Sex differences in the impact of coexistent diabetes on survival in patients with coronary heart disease

Sex Differences in the Mortality Risk of Elderly Patients with Systolic Heart Failure in Taiwan

Background

Sex differences in heart failure mortality might be affected by age, race, and treatment response. Many large studies in Western countries have shown conflicting results, however few studies have been conducted in Asian patients.

Objectives

We prospectively investigated the mortality risk in a multicenter cohort of 1,093 male and 416 female heart failure patients with reduced ejection fraction (HFrEF) hospitalized for worsening symptoms in Taiwan between 2013 and 2015.

Methods

Kaplan-Meier curve and Cox proportional regression analyses were used to determine the one-year mortality risk by sex.

Results

There were no significant differences in major adverse cardiovascular events, re-admission rate, and mortality between sexes in the overall cohort and the young subgroup during one-year of follow-up. In the elderly subgroup, the overall and cardiac mortality rate of the male patients were higher than those of the female patients (p = 0.035, p = 0.049, respectively). We found that the prognostic effect of old age on overall mortality rate appeared to be stronger in the male patients (p < 0.0001) than in the female patients (p = 0.69) in Cox regression analysis and Kaplan-Meier survival curves. Male sex was a risk factor for all-cause mortality in the elderly (hazard ratio: 1.50, 95% confidence interval 1.02-2.25) independently of systolic blood pressure, diabetes mellitus, hemoglobin concentration, kidney function, and medications.

Conclusions

In the Taiwan HFrEF registry, the highest mortality risk was observed in male patients aged 65 years or more. Clinicians need to pay more attention to these patients.

The attributes of hospital-based coronary artery diseases registries with a focus on key registry processes: A systematic review

BACKGROUND

The management of data on coronary artery disease (CAD) plays a significant role in controlling the disease and reducing the mortality of patients. The diseases registries facilitate the management of data.

OBJECTIVE

This study aimed to identify the attributes of hospital-based CAD registries with a focus on key registry processes.

METHOD

In this systematic review, we searched for studies published between 2000 and 2019 in PubMed, Scopus, EMBASE and ISI Web of Knowledge. The search terms included coronary artery disease, registry and data management (MeSH terms) at November 2019. Data gathering was conducted using a data extraction form, and the content of selected studies was analysed with respect to key registry processes, including case finding, data gathering, data abstracting, data quality control, reporting and patient follow-up.

RESULTS

A total of 17,604 studies were identified in the search, 55 of which were relevant studies that addressed the 21 registries and were selected for the analysis. Results showed that the most common resources for case finding included admission and discharge documents, physician's reports and screening results. Patient follow-up was mainly performed through direct visits or via telephone calls. The key attributes used for checking the data quality included data accuracy, completeness and definition.

CONCLUSION

CAD registries aim to facilitate the assessment of health services provided to patients. Putting the key registry processes in place is crucial for developing and implementing the CAD registry. The data quality control, as a CAD registry process, requires developing standard tools and applying appropriate data quality attributes.

IMPLICATIONS

The findings of the current study could lay the foundation for successful design and development of CAD registries based on the key registry processes for effective data management.

Mapping the Gaps: Gender Differences in Preventive Cardiovascular Care among Managed Care Members in Four Metropolitan Areas

BACKGROUND

Prior research documents gender gaps in cardiovascular risk management, with women receiving poorer quality routine care on average, even in managed care systems. Although population health management tools and quality improvement efforts have led to better overall care quality and narrowing of racial/ethnic gaps for a variety of measures, we sought to quantify persistent gender gaps in cardiovascular risk management and to assess the performance of routinely used commercial population health management tools in helping systems narrow gender gaps.

METHODS

Using 2013 through 2014 claims and enrollment data from more than 1 million members of a large national health insurance plan, we assessed performance on seven evidence-based quality measures for the management of coronary artery disease and diabetes mellitus, a cardiac risk factor, across and within four metropolitan areas. We used logistic regression to adjust for region, demographics, and risk factors commonly tracked in population health management tools.

FINDINGS

Low-density lipoprotein (LDL) cholesterol control (LDL < 100 mg/dL) rates were 5 and 15 percentage points lower for women than men with diabetes mellitus (p < .0001), and coronary artery disease (p < .0001), respectively. Adjusted analyses showed women were more likely to have gaps in LDL control, with an odds ratio of 1.31 (95% confidence interval, 1.27-1.38) in diabetes mellitus and 1.88 (95% confidence interval, 1.65-2.10) in coronary artery disease.

CONCLUSIONS

Given our findings that gender gaps persist across both clinical and geographic variation, we identified additional steps health plans can take to reduce disparities. For measures where gaps have been consistently identified, we recommend that gender-stratified quality reporting and analysis be used to complement widely used algorithms to identify individuals with unmet needs for referral to population health and wellness behavior support programs.

Exploring differences in Canadian adult men and women with diabetes management: results from the Canadian Community Health Survey

BACKGROUND

Over 2 million Canadians are known to have diabetes. In addition to the economic burden placed on the healthcare system, the human cost associated with diabetes poses a heavy burden on those living with diabetes. The literature shows that apparent differences exist in diabetes complications and diabetes management between men and women. How self-care management and utilization of health services differ by sex is not clearly understood.The purpose of this study was to explore sex differences in diabetes self-care and medical management in the Canadian population, using a nationally representative sample.

METHODS

Data collected from the cross-sectional, population-based Canadian Community Health Survey (2007-2008) were used in these analyses. A bootstrap variance estimation method and bootstrap weights provided by Statistics Canada were used to calculate 95% confidence intervals. Bivariate analyses identified variables of interest between females and males that were used in subsequent multivariate analyses.

RESULTS

A total of 131,959 respondents were surveyed for the years of 2007 and 2008, inclusive. Fully adjusted multinomial and logistic regression analyses revealed sex differences for those living with diabetes. Compared to men with diabetes, women were more likely to be in the lowest income quintiles than the highest (OR: 1.8, 95% CI: 1.3-2.6) and were more likely not to have a job in the previous week (OR: 1.8, 95% CI: 1.4-2.4). Women were also more likely to avoid foods with fats or high calories (OR: 2.1, 95% CI: 1.4-3.0 and OR: 2.2, 95% CI: 1.6-3.0, respectively), to be concerned about heart disease (OR: 1.6, 95% CI: 1.1-2.2), and to be non-smokers (OR: 2.2, 95% CI: 1.6-3.0). However, despite their increased concern, women checked their blood-glucose less frequently on a daily basis than men (μwomen = 1.7, 95% CI: 1.7-1.8; μmen = 3.1, 95% CI: 2.9-3.2). Women were more likely to have an anxiety disorder (OR: 2.3, 95% CI: 1.7-3.2) and a mood disorder (OR: 2.4, 95% CI: 1.8-3.1), and more likely to be physically inactive (OR: 1.5, 95% CI: 1.2-1.8).

CONCLUSIONS

Our findings underscore the importance of addressing sex differences which may interfere with diabetes self-care. In women, addressing socioeconomic and psychological barriers, as well as limitations to active living are important; in men, the benefit of more effective nutrition therapy and smoking cessation interventions are suggested. The results for this study highlight the need to further investigate and eliminate disparities between the sexes in order to optimize health outcomes among Canadians with diabetes.

A systematic literature review of diabetes self-management education features to improve diabetes education in women of Black African/Caribbean and Hispanic/Latin American ethnicity

OBJECTIVE

This systematic literature review aims to identify diabetes self-management education (DSME) features to improve diabetes education for Black African/Caribbean and Hispanic/Latin American women with Type 2 diabetes mellitus.

METHODS

We conducted a literature search in six health databases for randomized controlled trials and comparative studies. Success rates of intervention features were calculated based on effectiveness in improving glycosolated hemoglobin (HbA1c), anthropometrics, physical activity, or diet outcomes. Calculations of rate differences assessed whether an intervention feature positively or negatively affected an outcome.

RESULTS

From 13 studies included in our analysis, we identified 38 intervention features in relation to their success with an outcome. Five intervention features had positive rate differences across at least three outcomes: hospital-based interventions, group interventions, the use of situational problem-solving, frequent sessions, and incorporating dietitians as interventionists. Six intervention features had high positive rate differences (i.e. ≥50%) on specific outcomes.

CONCLUSION

Different DSME intervention features may influence broad and specific self-management outcomes for women of African/Caribbean and Hispanic/Latin ethnicity.

PRACTICAL IMPLICATIONS

With the emphasis on patient-centered care, patients and care providers can consider options based on DSME intervention features for its broad and specific impact on outcomes to potentially make programming more effective.

High-density lipoprotein subclass and particle size in coronary heart disease patients with or without diabetes

BACKGROUND

A higher prevalence of coronary heart disease (CHD) in people with diabetes. We investigated the high-density lipoprotein (HDL) subclass profiles and alterations of particle size in CHD patients with diabetes or without diabetes.

METHODS

Plasma HDL subclasses were quantified in CHD by 1-dimensional gel electrophoresis coupled with immunodetection.

RESULTS

Although the particle size of HDL tend to small, the mean levels of low density lipoprotein cholesterol(LDL-C) and total cholesterol (TC) have achieved normal or desirable for CHD patients with or without diabetes who administered statins therapy. Fasting plasma glucose (FPG), triglyceride (TG), TC, LDL-C concentrations, and HDL₃ (HDL(3b) and (3a)) contents along with Gensini Score were significantly higher; but those of HDL-C, HDL(2b+preβ2), and HDL(2a) were significantly lower in CHD patients with diabetes versus CHD patients without diabetes; The preβ₁-HDL contents did not differ significantly between these groups. Multivariate regression analysis revealed that Gensini Score was significantly and independently predicted by HDL(2a), and HDL(2b+preβ2).

CONCLUSIONS

The abnormality of HDL subpopulations distribution and particle size may contribute to CHD risk in diabetes patients. The HDL subclasses distribution may help in severity of coronary artery and risk stratification, especially in CHD patients with therapeutic LDL, TG and HDL levels.

Effect of gender on repeated coronary artery revascularization after intra-coronary stenting: a meta-analysis

BACKGROUND

As a risk factor of coronary artery disease (CAD), gender might be associated with the prognosis of percutaneous coronary intervention (PCI). However, there are conflicting reports in the literature regarding the role of gender on repeated coronary artery revascularization after PCI.

OBJECTIVE

This meta-analysis aimed to determine whether gender influenced the incidence of repeated coronary artery revascularization after intra-coronary stenting.

METHODS

We performed a meta-analysis including 13 randomized controlled trials (a total of 156,798 patients, including 107,697 men and 49,101 women) that assessed the results of target vessel revascularization (TVR), target lesion revascularization (TLR) and major adverse cardiac events (MACE) after PCI. PUBMED, MEDLINE, EMBASE and the Cochrane Database were searched for articles published in the last 10 years.

RESULTS

There was no difference in the long-term incidence of TVR between males and females after PCI (16.68% vs. 16.41%; odds ratio (OR)=0.94; 95% confidence intervals (CI): 0.82-1.07; P=0.36). However, the short-term rate of TVR after PCI was significantly higher in women than that in men (4.25% vs. 3.83%; OR=0.91; 95% CI: 0.86-0.97; P<0.01). Moreover, women had higher short-term and long-term incidences of MACE than men after PCI (short-term: 8.02% vs. 5.57%; P<0.01; long-term: 16.14% vs. 13.72%, P<0.01).

CONCLUSIONS

The present data suggested that female sex could increase the short-term incidence of repeated coronary revascularization after PCI. However, the long-term rate of repeated coronary revascularization was similar between male and female patients.

Disparity in management of diabetes and coronary heart disease risk factors by sex in DCCT/EDIC

AIMS

Coronary heart disease (CHD) is a major cause of morbidity and mortality in patients with diabetes. Sex disparity in the treatment of modifiable CHD risk factors in patients with Type 2 diabetes has been reported previously; however, there is little comparable information in Type 1 diabetes.

METHODS

We performed a cross-sectional analysis of 1153 subjects with Type 1 diabetes in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) cohort to compare achievement of metabolic and CHD risk factor goals and use of recommended risk factor interventions between the sexes.

RESULTS

Women were less likely than men to achieve glycated haemoglobin (HbA1c)<7.0% [adjusted odds ratio (AOR) 0.76, 95% confidence interval (CI) 0.57-0.995] or<8.0% (AOR 0.74, 95% CI 0.58-0.95). Achievement of target lipid levels was not significantly different between the sexes. As in the non-diabetic population, men had higher blood pressure. Women were significantly less likely than men to report using aspirin (AOR 0.77, 0.60-0.99) and angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) (AOR 0.62, 0.49-0.80) and statins (AOR 0.56, 0.43-0.73), even after adjusting for blood pressure and lipid levels, respectively. Reported use of statins was also lower in women than men in the subset that developed a low-density lipoprotein (LDL) cholesterol level>3.4 mmol/l (39% vs. 60%, P<0.05).

CONCLUSIONS

In Type 1 diabetes, women report lower frequency than men in the use of interventions that decrease CHD risk. These findings are consistent with reports in the Type 2 diabetic population, showing that risk-reducing measures are underused in women with diabetes.

Sex does not influence prognosis in diabetic patients. The Barbanza Diabetes study

INTRODUCTION AND OBJECTIVES

To determine the influence of sex on cardiovascular complications in diabetic patients.

METHODS

This multicenter prospective cohort study involved 1423 consecutive patients with diabetes mellitus who were recruited during consultations with 31 primary care physicians. The patients' characteristics were recorded and they were followed up for 45 + or - 10 months.

RESULTS

The mean age of the patients (50% female) was 66 years, 64% had hypertension, 70% had dyslipidemia, and 26% had had a previous cardiovascular event. Cardiovascular disease, predominantly ischemic heart disease, was observed more frequently in men and a higher percentage had end-organ damage (57.7% of males versus 45.4% of females; P< .0001). Women had poorer glycemic control, higher total cholesterol levels and lower high-density lipoprotein cholesterol levels. By the end of follow-up, 81 patients had died (5.7% of males versus 6.7% of females; P=.513). There were no sex differences in cardiovascular complications during follow up (15.8% in males versus 13.7% in females; P=.368). Multivariate analysis identified the following factors as independent predictors of morbidity or mortality: age (hazard ratio [HR]=1.04; 95% confidence interval [CI], 1.02-1.06), existing cardiovascular disease (HR=1.96; 95% CI, 1.38-2.79), diuretic treatment (HR=1.62; 95% CI, 1.10-2.38), and albuminuria (HR=1.86; 95% CI, 1.33-2.61).

CONCLUSIONS

No difference was observed in mediumterm prognosis, with regard to mortality and cardiovascular selecmorbidity, between male and female diabetics from the same geographical area, despite the presence of clinical differences between the sexes.

Macrovascular complications of diabetes in atherosclerosisprone mice

The well-established relationship between diabetes and cardiovascular complications, combined with the rapidly increasing prevalence of diabetes, has created a pressing need for better understanding of the mechanisms of diabetic atherosclerosis. Multiple metabolic and diabetes-specific factors have been associated with accelerated atherosclerosis, including dyslipidemia, oxidative stress, inflammation, vascular cell dysfunction and coagulopathy. This discussion highlights selected studies in which researchers have employed mouse models of diabetic atherosclerosis in an attempt to examine these mechanisms and test potential therapeutic and preventative measures.

Does Quality of Care for Cardiovascular Disease and Diabetes Differ by Gender for Enrollees in Managed Care Plans?

PURPOSE

To assess gender differences in the quality of care for cardiovascular disease and diabetes for enrollees in managed care plans.

METHODS

We obtained data from 10 commercial and 9 Medicare plans and calculated performance on 6 Health Employer Data and Information Set (HEDIS) measures of quality of care (beta-blocker use after myocardial infarction [MI], low-density lipoprotein cholesterol [LDL-C] check after a cardiac event, and in diabetics, whether glycosylated hemoglobin [HgbA1c], LDL cholesterol, nephropathy, and eyes were checked) and a 7th HEDIS-like measure (angiotensin-converting enzyme [ACE] inhibitor use for congestive heart failure). A smaller number of plans provided HEDIS scores on 4 additional measures that require medical chart abstraction (control of LDL-C after cardiac event, blood pressure control in hypertensive patients, and HgbA1c and LDL-C control in diabetics). We used logistic regression models to adjust for age, race/ethnicity, socioeconomic status, and plan.

MAIN FINDINGS

Adjusting for covariates, we found significant gender differences on 5 of 11 measures among Medicare enrollees, with 4 favoring men. Similarly, among commercial enrollees, we found significant gender differences for 8 of 11 measures, with 6 favoring men. The largest disparity was for control of LDL-C among diabetics, where women were 19% less likely to achieve control among Medicare enrollees (relative risk [RR] = 0.81; 95% confidence interval [CI] = 0.64-0.99) and 16% less likely among commercial enrollees (RR = 0.84; 95%CI = 0.73-0.95).

CONCLUSION

Gender differences in the quality of cardiovascular and diabetic care were common and sometimes substantial among enrollees in Medicare and commercial health plans. Routine monitoring of such differences is both warranted and feasible.

The Impact of Reclassifying Moderate CKD as a Coronary Heart Disease Risk Equivalent on the Number of US Adults Recommended Lipid-Lowering Treatment

BACKGROUND

The Third National Cholesterol Education Program Adult Treatment Panel (ATP-III) guidelines recommend consideration of lipid-lowering therapy at lower low-density lipoprotein cholesterol levels (>or=100 mg/dL [>or=2.59 mmol/L]) for adults with coronary heart disease risk equivalents. Chronic kidney disease is associated with increased coronary heart disease risk but is not included as a risk equivalent in these guidelines.

METHODS

The impact of including moderate chronic kidney disease (estimated glomerular filtration rate, 30 to 59 mL/min/1.73 m(2) [0.50 to 0.98 mL/s]) as a coronary heart disease risk equivalent on the percentage and number of US adults with chronic kidney disease recommended lipid-lowering therapy was estimated by using data from the Third National Health and Nutrition Examination Survey.

RESULTS

Of adults with moderate chronic kidney disease, 53.0% had a history of coronary heart disease or a risk equivalent, 24.7% reported a history of myocardial infarction or stroke, 17.7% had diabetes, 9.6% had angina, and 26.9% had a 10-year coronary heart disease risk greater than 20%. Using current ATP-III guidelines, lipid-lowering therapy is recommended for 61.4% of adults with moderate chronic kidney disease. If moderate chronic kidney disease was reclassified as a coronary heart disease risk equivalent, this percentage would increase to 87.7%, representing an increase in number of adults with moderate chronic kidney disease recommended lipid-lowering treatment from 4.5 to 6.5 million adults.

CONCLUSION

This analysis shows that a majority of adults with moderate chronic kidney disease have coronary heart disease or risk equivalents. Nonetheless, a substantially greater proportion of US adults with moderate chronic kidney disease would be recommended lipid-lowering therapy through its reclassification as a coronary heart disease risk equivalent.

The synergistic effect of heart disease and diabetes on self-management, symptoms, and health status

BACKGROUND

Coronary heart disease (CHD) and diabetes may have synergistic effects on symptoms, self-management, and general and cardiac-specific health status.

PURPOSE

We compared symptom distress, self-management difficulties, and general and cardiac-specific health status in patients with CHD by the presence and severity of diabetes.

METHODS

We performed a cross-sectional study of 1013 patients enrolled in the COURAGE trial, with the use of clinical data, the Symptom Distress Scale, the Self-Management Difficulties Scale, the Short-Form 36, and the Seattle Angina Questionnaire.

RESULTS

Patients with diabetes and greater severity of diabetes had worse findings in symptom distress, self-management difficulties, and general and cardiac-specific health status than patients without diabetes.

CONCLUSIONS

A robust effect of diabetes on symptom distress and self-management difficulties was found in patients with CHD. The results from the Seattle Angina Questionnaire illustrate difficulty in attributing physical limitations to specific symptoms or conditions, and show the experience of comorbid conditions to be synergistic. Clinicians' understanding of this synergy and integration of condition-specific care with general treatment and self-management practices are needed.

Should all diabetic patients receive statins?

Diabetes is known to play a causal role in promoting both microvascular and macrovascular complications. Reducing rates of end-organ damage has been a key objective of multiple clinical trials. In addition to the roles of glycemic and blood pressure control, it is evident that lipid reduction via statin therapy independently helps to reduce the risk of primary and secondary vascular events. This effect seems to remain intact across a broad range of lipid levels, suggesting additional mechanisms for efficacy of statin medications beyond cholesterol reduction. The demonstrated safety and data from recent trials lend support to the argument that all people with diabetes should be started on statin therapy regardless of their cholesterol level. It is also plausible that treating the underlying mechanisms of vascular dysfunction, inflammation, and injury so prevalent in diabetic patients would have similar implications for the patient identified as having insulin resistance or metabolic syndrome.

Sex disparities in treatment of cardiac risk factors in patients with type 2 diabetes

OBJECTIVE

Diabetes eliminates the protective effect of female sex on the risk of coronary heart disease (CHD). We assessed sex differences in the treatment of CHD risk factors among patients with diabetes.

RESEARCH DESIGN AND METHODS

A cross-sectional analysis included 3,849 patients with diabetes treated in five academic internal medicine practices from 2000 to 2003. Outcomes were stratified by the presence of CHD and included adjusted odds ratios (AORs) that women (relative to men) were treated with hypoglycemic, antihypertensive, lipid-lowering medications or aspirin (if indicated) and AORs of reaching target HbA(1c), blood pressure, or lipid levels.

RESULTS

Women were less likely than men to have HbA(1c) <7% (without CHD: AOR 0.84 [95% CI 0.75-0.95], P = 0.005; with CHD: 0.63 [0.53-0.75], P < 0.0001). Women without CHD were less likely than men to be treated with lipid-lowering medication (0.82 [0.71-0.96], P = 0.01) or, when treated, to have LDL cholesterol levels <100 mg/dl (0.75 [0.62-0.93], P = 0.004) and were less likely than men to be prescribed aspirin (0.63 [0.55-0.72], P < 0.0001). Women with diabetes and CHD were less likely than men to be prescribed aspirin (0.70 [0.60-0.83], P < 0.0001) or, when treated for hypertension or hyperlipidemia, were less likely to have blood pressure levels <130/80 mmHg (0.75 [0.69-0.82], P < 0.0001) or LDL cholesterol levels <100 mg/dl (0.80 [0.68-0.94], P = 0.006).

CONCLUSIONS

Women with diabetes received less treatment for many modifiable CHD risk factors than diabetic men. More aggressive treatment of CHD risk factors in this population offers a specific target for improvement in diabetes care.

Influence of diabetes and diabetes-gender interaction on the risk of death in patients hospitalized with congestive heart failure

OBJECTIVES

The purpose of this study was to investigate the influence of diabetes on long-term mortality in a large cohort of patients hospitalized with heart failure (HF).

BACKGROUND

Diabetes is common in HF patients, but information on the prognostic effect of diabetes is sparse.

METHODS

The study is an analysis of survival data comprising 5,491 patients consecutively hospitalized with new or worsening HF and screened for entry into the Danish Investigations of Arrhythmia and Mortality on Dofetilide (DIAMOND). Screening, which included obtaining an echocardiogram in 95% of the patients, took place at Danish hospitals between 1993 and 1995. The follow-up time was five to eight years.

RESULTS

A history of diabetes was found in 900 patients (16%), 41% of whom were female. Among the diabetic patients, 755 (84%) died during follow-up, compared with 3,200 (70%) among the non-diabetic patients, resulting in a risk ratio (RR) of death in diabetic patients of 1.5 (95% confidence interval [CI] 1.4 to 1.6, p < 0.0001). In a multivariate analysis, the RR of death in diabetic patients was 1.5 (CI 1.3 to 1.76, p < 0.0001), but a significant interaction between diabetes and gender was found. Diabetes increased the mortality risk more in women than in men, with the RR for diabetic men being 1.4 (95% CI 1.3 to 1.6, p < 0.0001) and 1.7 for diabetic women (95% CI 1.4 to 1.9, p < 0.0001). The effect of diabetes on mortality was similar in patients with depressed and normal left ventricular systolic function.

CONCLUSIONS

Diabetes is a potent, independent risk factor for mortality in patients hospitalized with HF. The excess risk in diabetic patients appears to be particularly prominent in females.

Coronary heart disease: the female heart is vulnerable

During the past decade, an overall theme has emerged, validating the exploration of gender-based differences in coronary heart disease (CHD) as a basis for clinical strategies to improve outcomes for women. Underrepresentation of women in most of CHD and lack of gender-specific reporting in many clinical trials continue to limit the available knowledge and evidence-based medicine needed to devise optimal managements for women with CHD. Control of conventional coronary risk factors provides comparable cardioprotection for men and women. Current evidence fails to show cardiac protection from menopausal hormone therapy. Clinical presentations of coronary heart disease (CHD) and management strategies differ between the sexes. Underutilization of proven beneficial therapies is a contributor to less-favorable outcomes in women. The contemporary increased application of appropriate diagnostic, therapeutic, and interventional managements has favorably altered the prognosis for women, particularly when the data are adjusted for baseline characteristics. Better education of women during office visits, earlier and more aggressive control of coronary risk factors, and a greater index of suspicion regarding chest pain and its appropriate evaluation may help to reverse the trend of late referral and late intervention. Research indicates that behavioral changes on the part of women and reshaping of practice patterns by their health care providers may dramatically reduce the number of women disabled and killed by CHD each year.

Cardiovascular risk in women with type 2 diabetes

Type 2 DM appears to eliminate the relative survival advantage experienced by premenopausal nondiabetic women compared with men with regard to CVD. The role of traditional cardiovascular risk factors, while important, cannot fully account for the disparate increase in CVD among women with type 2 DM compared with nondiabetic women. The interplay between type 2 DM and female hormones may prove important. Other less traditional risk factors such as endothelial dysfunction and impaired fibrinolysis may also play a role. Impairments in cardiovascular exercise performance in women with type 2 DM may provide insight in the future as representative of a pre-CVD state. Future research should focus on the specific causes of CVD in women with DM. In the meantime, it is important to aggressively treat modifiable risk factors in this population (Table 1). The impact of this health problem will continue to increase in our aging society, because a steadily increasing proportion of the population will be women; furthermore, an increasing percentage of these women will have diabetes if current trends continue.

Improving women’s quality of care for cardiovascular disease and diabetes: the feasibility and desirability of stratified reporting of objective performance measures

Despite growing recognition of significant morbidity and mortality among women from cardiovascular disease, management of primary and secondary cardiac risk factors continues to be suboptimal for many women. Although there is a good deal of room to improve the care for cardiovascular disease and diabetes in men, existing gender differences in performance suggest much can be gained by specifically assessing and monitoring quality of care for these conditions in women. In this paper, we describe recent work showing gender differences in quality of ambulatory care in managed care plans with some plans having substantial gender differences on widely used measures of the quality of primary and secondary prevention of cardiac disease. We then discuss potential benefits of and barriers to routine reporting of objective measures of the quality of care, such as Health Plan Employer Data and Information Set (HEDIS) measures, by health plans.

Molecular mechanisms of diabetic cardiovascular disease

Cardiovascular disease is a major cause of morbidity and mortality in persons with diabetes mellitus. This population represents an important target for preventive therapies aimed at reducing atherosclerosis. Recent molecular research has uncovered many of the cellular mechanisms that lead to atherosclerosis in the diabetic patient. This review, part 1 of a 2-part series, is geared toward clinicians and discusses these mechanisms as they pertain to prevention of cardiovascular disease in patients with diabetes.

Diabetes mellitus and cardiovascular disease

Diabetes is associated with a high incidence and poor prognosis of cardiovascular disease, and with high short- and long-term mortality. Adequate treatment of cardiovascular disorders and aggressive management of coexisting risk factors have proved to be at least as effective in diabetic as in nondiabetic patients in randomized, controlled studies. Indeed, treating diabetic patients with cardiovascular disease results in a larger absolute risk reduction than in nondiabetic subjects. Nevertheless, diabetic patients often receive inadequate therapy, which may, to a certain extent, explain their poor prognosis. Recommendations for the treatment of diabetic patients with acute myocardial infarction should include beta-blockers, aspirin, and ACE-inhibitors in all patients in whom no specific contraindications exist. Fibrinolysis should be administered when indicated, and the benefits of improving glycemic control should not be forgotten either. In patients with multi-vessel disease who need revascularization, when selecting the type of procedure, the superiority of surgical revascularization over angioplasty should be borne in mind. Even heart transplantation should be included as a therapeutic option since there are no data to support the exclusion of patients on account of their diabetes. Finally, coexisting risk factors should be intensively treated through lifestyle intervention, with or without drug therapy, in order to achieve secondary prevention goals.

Insulin resistance as a major determinant of increased coronary heart disease risk in postmenopausal women with Type 2 diabetes mellitus

AIM

To investigate the risk factors associated with clinically defined coronary heart disease (CHD) in women with Type 2 diabetes mellitus (DM).

METHODS

CHD status was assessed via standard history and resting electrocardiogram in 41 postmenopausal diabetic and 41 age- and body mass index-matched normoglycaemic women recruited from a community-based cohort. The following parameters were assessed: body composition by dual energy X-ray absorptiometry, blood pressure, metabolic and lipoprotein profile and haemostatic factors.

RESULTS

Diabetic women with CHD (n = 14) had greater insulin resistance, calculated by homeostasis model assessment (10.2 (7.0-14.8) vs. 6.5 (5.5-7.7), P = 0.010), and higher plasminogen activator inhibitor-1 (PAI-1) levels (45 (29-69) vs. 24 (19-32) ng/ml, P = 0.013), than those without CHD. They also had higher triglycerides (2.9 (2.2-3.8) vs. 2.1 (1.8-2.4) mmol/l, P = 0.016) and a trend towards reduced low-density lipoprotein particle size (25.5 +/- 0.6 vs. 25.8 +/- 0.5 nm, P = 0.097). In a logistic regression model, insulin resistance was a significant independent predictor of CHD status (odds ratio = 1.33, 95% confidence interval = 1.06-1.68, P = 0.015). In contrast, in normoglycaemic women the major risk factors for CHD were elevated cholesterol, apolipoprotein(a), apolipoprotein B and systolic blood pressure (P = 0.018, P = 0.016, P = 0.006 and P = 0.049, respectively).

CONCLUSIONS

Increased insulin resistance in association with elevated PAI-1 and dyslipidaemia appears to underpin the increased risk of CHD in women with Type 2 DM. Therapeutic approaches that increase insulin sensitivity may serve to reduce CHD risk in this vulnerable group. Diabet. Med. 18, 476-482 (2001)

Population-based estimates of mortality associated with diabetes: use of a death certificate check box in North Dakota

OBJECTIVES

Overall and cause-specific mortality among persons with diabetes in North Dakota was estimated and compared with estimates from previous population-based studies.

METHODS

Data were derived from North Dakota death certificate data, which included unique information on decedents' diabetes status and Behavioral Risk Factor Surveillance System estimates of the diabetic and nondiabetic adult populations of North Dakota.

RESULTS

The risk of death among adults with diabetes was 2.6 (2.2, 2.9) times that of adults without diabetes. Relative risks of death among adults with diabetes were at least twice as high for heart disease, cerebrovascular disease, accidents and adverse events, and kidney disease and 70% to 80% higher for pneumonia and influenza, malignant neoplasms, arterial disease, and other causes. Risks remained substantial in the oldest age group. These findings are comparable to results of other population-based studies.

CONCLUSIONS

Diabetes status information enhanced the usefulness of death certificate data in examining mortality associated with diabetes and confirms that the effect of diabetes on death is substantial.

Heart disease in women

Women face a disparity in the evaluation and treatment of coronary artery disease, even though coronary artery disease is the leading cause of death for women in the United States. Primary care physicians play an important role in the identification and treatment of risk factors and comorbidities. It is their obligation to ensure that women receive equal and appropriate care, and to advocate for their patients.

Diabetes, mortality and coronary heart disease in the prospective Dubbo study of Australian elderly

BACKGROUND

A prospective study of Australian elderly living in Dubbo has shown that diabetes is a significant predictor of all-causes mortality and coronary heart disease (CHD).

AIM

To examine and contrast clinical and socio-demographic predictors of these outcomes in those with and without diabetes.

METHODS

The data are derived from a community-based sample of subjects 60 years and older followed over 62 months since 1988. Of 1155 men and 1472 women, 9.2% and 6.9% respectively manifested diabetes at baseline, based on history or fasting hyperglycaemia.

RESULTS

In the presence of diabetes, all-causes mortality was increased twofold in both sexes, CHD incidence was increased twofold in men and threefold in women, stroke incidence was increased twofold in women but little changed in men. Proportional hazards models were derived separately for persons with and without diabetes and risk factors differentially predictive in diabetes were sought. Significant predictors of death in diabetes were old age and current smoking. Those factors differentially predictive were 'being married' (Relative Risk [RR] 1.60 with diabetes and 0.69 without diabetes) and higher body mass index (BMI) (RR 1.03 with diabetes and 0.79 without diabetes). Significant predictors of CHD in diabetes were old age, prior CHD, severe hypertension, low HDL cholesterol and self-rated health. Those factors differentially predictive were higher body mass index (RR 1.14 vs 0.83) and physical disability (RR 0.69 vs 1.55). Differential predictions with regard to BMI may relate in part to excess CHD and mortality at low BMI in non-diabetic subjects.

CONCLUSION

The vascular disease burden of diabetes in the elderly has been confirmed, especially in women. A number of conventional risk factors are contributing to this burden and may be amenable to treatment.

Left ventricular hypertrophy has a greater impact on survival in women than in men

BACKGROUND

Echocardiographically determined left ventricular hypertrophy (LVH) has a well-demonstrated association with cardiovascular morbidity and mortality. However, whether or not there is a sex differential in the impact of LVH on mortality has never been systematically explored.

METHODS AND RESULTS

This study enrolled 436 consecutive black patients (163 men and 273 women) free of angiographic coronary artery disease from a hospital registry. LVH (left ventricular [LV] mass/body surface area > or = 117 g/m2 in men and > or = 104 g/m2 in women) was present in 84 men (52%) and 119 women (44%). During a mean of 5 years' follow-up (range, 0 to 9), 49 patients (26 men and 23 women) died. The mortality rate was 5.40 per 100 patient-years in men with LVH and 2.58 in men without LVH (crude relative risk [RR] = 2.09) and 3.21 and 0.66, respectively, in women (RR = 4.87). In Cox regression analysis, adjusting for age, hypertension, and ejection fraction, the RR of total death for LVH versus non-LVH was 2.0 (95% confidence interval [CI], 0.8 to 5.0) in men and 14.3 (95% CI, 1.6 to 11.7) in women. For cardiac death, RR was 1.3 (95% CI, 0.4 to 3.7) and 7.5 (95% CI, 1.6 to 33.8) in men and women, respectively. Analyses using LV mass indexed by height or height with the use of different LVH cut points, comparing patients in the highest sex-specific tertile of mass index to those in the lower two tertiles, and the use of LV mass indexes as continuous variables similarly demonstrated a greater increase in risk of either fatal end point among women than men.

CONCLUSIONS

These findings indicate a sex difference in the contribution of LV mass and hypertrophy to mortality in the absence of coronary artery disease.

Diabetes mellitus--a priority health care issue for women

Diabetes occurs in more than 13 million persons in the United States, and approximately 60% of the new cases are diagnosed in women. This review examines health issues related to women with diabetes mellitus. The following issues are discussed in the review. The prevalence of diabetes is higher in Native-American, black, and Hispanic women than in white women. Women with upper-body obesity are at risk for developing non-insulin-dependent diabetes mellitus (NIDDM) and women with diabetes are at risk for developing heart disease. Diabetes, obesity, and heart disease are all modifiable by nutrition. White women with diabetes derive approximately 40% of energy from fat, which is 10% greater than the national goal. Women with a history of gestational diabetes are at risk for developing NIDDM. Women with insulin-dependent diabetes mellitus (IDDM) are at high risk of developing complications in pregnancy, and pregnancy outcomes improve with preconceptual counseling. Women with IDDM are at risk for developing eating disorders, although not to a greater extent than the nondiabetic population. Women with diabetes are at risk for developing endometrial cancer. Both IDDM and NIDDM prevention clinical trials are in progress, although none target women specifically. Dietetics practitioners are encouraged to use local and national diabetes resources.