The significant effect of diabetes duration on coronary heart disease mortality: the Framingham Heart Study

Metabolic syndrome-associated murine aortic wall stiffening is associated with premature elastic fibers aging

Type 2 diabetes (T2D) constitutes a major public health problem, and despite prevention efforts, this pandemic disease is one of the deadliest diseases in the world. In 2022, 6.7 million patients with T2D died prematurely from vascular complications. Indeed, diabetes increases the risk of myocardial infarction or stroke eightfold. The identification of the molecular factors involved in the occurrence of cardiovascular complications and their prevention are therefore major axes. Our hypothesis is that factors brought into play during physiological aging appear prematurely with diabetes progression. Our study focused on the aging of the extracellular matrix (ECM), a major element in the maintenance of vascular homeostasis. We characterized the morphological and functional aspects of aorta, with a focus on the collagen and elastic fibers of diabetic mice aged from 6 mo to nondiabetic mice aged 6 mo and 20 mo. The comparison with the two nondiabetic models (young and old) highlighted an exacerbated activity of proteases, which could explain a disturbance in the collagen accumulation and an excessive degradation of elastic fibers. Moreover, the generation of circulating elastin-derived peptides reflects premature aging of the ECM. These extracellular elements contribute to the appearance of vascular rigidity, often the origin of pathologies such as hypertension and atherosclerosis. In conclusion, we show that diabetic mice aged 6 mo present the same characteristics of ECM wear as those observed in mice aged 20 mo. This accelerated aortic wall remodeling could then explain the early onset of cardiovascular diseases and, therefore, the premature death of patients with T2D.NEW & NOTEWORTHY Aortic elastic fibers of young (6-mo old) individuals with diabetes degrade prematurely and exhibit an appearance like that found in aged (20-mo old) nondiabetic mice. Exacerbated elastolysis and elastin-derived peptide production are characteristic elements, contributing to early aortic wall rigidity and hypertension development. Therefore, limiting this early aging could be a judicious therapeutic approach to reduce cardiovascular complications and premature death in patients with diabetes.

Changes in serum lipids following consumption of coconut oil and palm olein oil: A sequential feeding crossover clinical trial

BACKGROUND

High incidence of cardiovascular disease (CVD) in South Asia is linked to genetic predisposition and diets high in saturated fatty acids (SFAs). Increased CVD prevalence correlates with rising palm oil consumption in some South Asian countries, where coconut oil and palm olein oil are primary SFA sources.

OBJECTIVE

Compare the effects of coconut oil and palm olein oil on serum lipoprotein lipids and biochemical parameters in healthy adults.

METHODS

A sequential feeding crossover clinical trial with two feeding periods of 8 weeks each was conducted among 40 healthy adults. Participants were provided palm olein oil in the first feeding period followed by coconut oil with a 16-week washout period in between. The outcomes measured were the difference in serum low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC) and high-density lipoprotein cholesterol (HDL-C), TC/HDL-C ratio, triglycerides (TG), very-low-density lipoprotein cholesterol (VLDL-C), fasting plasma glucose (FPG), and liver enzymes.

RESULTS

Thirty-seven participants completed the study. LDL-C decreased by 13.0 % with palm olein oil (p < 0.001) and increased by 5.6 % with coconut oil (p = 0.044), showing a significant difference (p < 0.001). TC decreased by 9.9 % with palm olein oil (p < 0.001) and increased by 4.0 % with coconut oil (p = 0.044).

CONCLUSION

Palm olein oil consumption resulted in more favorable changes in lipid-related CVD risk factors (TC, LDL-C, TC:HDL-C, and FPG) compared to coconut oil. Clinical Trial Registry number and website where it was obtained: (SLCTR/2019/034); https://slctr.lk/trials/slctr-2019-034.

An application of the Bayesian network model based on the EN-ESL-GA algorithm: Exploring the predictors of heart disease in middle-aged and elderly people in China

BACKGROUND

The morbidity and mortality of heart disease are increasing in middle-aged and elderly people in China. It is necessary to explore relationships and interactive associations between heart disease and its risk factors in order to prevent heart disease.

OBJECTIVE

To establish a Bayesian network model of heart disease and its influencing factors in middle-aged and elderly people in China, and explore the applicability of the elite-based structure learner using genetic algorithm based on ensemble learning (EN-ESL-GA) algorithm in etiology analysis and disease prediction.

METHODS

Based on the 2013 national tracking survey data from China Health and Retirement Longitudinal Study (CHARLS) database, EN-ESL-GA algorithm was used to learn the Bayesian network structure. Then we input the data and the learned network structure into the Netica software for parameter learning and inference analysis.

RESULTS

The Bayesian network model based on the EN-ESL-GAalgorithm can effectively excavate the complex network relationships and interactive associations between heart disease and its risk factors in middle-aged and elderly people in China.

CONCLUSIONS

The Bayesian network model based on the EN-ESL-GA algorithm has good applicability and application prospect in the prediction of diseases prevalence risk.

Trends in Survival After First Myocardial Infarction in People With Diabetes

BACKGROUND

The aim of this study was to investigate temporal trends in survival and subsequent cardiovascular events in a nationwide myocardial infarction population with and without diabetes.

METHODS AND RESULTS

Between 2006 and 2020, we identified 2527 individuals with type 1 diabetes, 48 321 individuals with type 2 diabetes and 243 170 individuals without diabetes with first myocardial infarction in national health care registries. Outcomes were trends in all-cause death after 30 and 365 days, cardiovascular death and major adverse cardiovascular events (ie, nonfatal stroke, nonfatal myocardial infarction, cardiovascular death, and heart failure hospitalization). Pseudo-observations were used to estimate the mortality risk, with 95% CIs, using linear regression, adjusted for age and sex. Individuals with type 1 diabetes were younger (62±12.2 years) and more often women (43.6%) compared with individuals with type 2 diabetes (75±10.8 years; women, 38.1%), and individuals without diabetes (73±13.2 years; women, 38.4%). Early death decreased in people without diabetes from 23.1% to 17.5%, (annual change -0.48% [95% CI, -0.52% to -0.44%]) and in people with type 2 diabetes from 22.6% to 19.3% (annual change, -0.33% [95% CI, -0.43% to -0.24%]), with no such significant trend in people with type 1 diabetes from 23.8% to 21.7% (annual change, -0.18% [95% CI, -0.53% to 0.17%]). Similar trends were observed with regard to 1-year death, cardiovascular death, and major adverse cardiovascular events.

CONCLUSIONS

During the past 15 years, the trend in survival and major adverse cardiovascular events in people with first myocardial infarction without diabetes and with type 2 diabetes have improved significantly. In contrast, a similar improvement was not seen in people with type 1 diabetes.

Impact of Duration of Diabetes Mellitus on Long-Term Outcome in Type 2 Diabetic Patients with Primary Percutaneous Coronary Intervention after the First Myocardial Infarction

BACKGROUND

Diabetes mellitus (DM) increases the risk of mortality in patients with acute myocardial infarction (AMI). The impact of the diabetes duration on the long-term outcome of those with percutaneous coronary intervention (PCI) after the first AMI is unclear. In this study, we evaluated the predictive value of diabetes duration in the occurrence of major adverse cardiovascular and cerebrovascular events (MACCEs).

METHODS

A total of 394 type 2 DM patients with PCI after the first AMI were enrolled and were divided into two groups by the diabetes duration: a short-DM group with diabetes duration of <5 years and a long-DM group with a duration of ≥5 years. The clinical endpoint was MACCEs.

RESULTS

Multivariate Cox regression analysis found that the diabetes duration was independently associated with increased occurrence of MACCEs (HR: 1.512, 95% CI: 1.033, 2.215, p = 0.034), along with hypertension, Killip class III or IV, creatinine, multivessel disease, and continuous hypoglycemic therapy. After adjusting for the confounding variables, a nested Cox model showed that diabetes duration was still an independent risk factor of MACCEs (HR: 1.963, 95% CI: 1.376, 2.801, p < 0.001). The Kaplan-Meier survival curve illustrated a significantly high risk of MACCEs (HR: 2.045, p < 0.0001) in long-duration DM patients. After propensity score matching, a longer diabetes duration was associated with an increased risk of MACCE occurrence.

CONCLUSION

Long-duration diabetes was independently associated with poor clinical outcomes after PCI in patients with their first myocardial infarction. Despite the diabetes duration, continuous hypoglycemic therapy significantly improved long-term clinical outcomes.

Determinants of health and mortality in undiagnosed diabetes: A nationally representative US adult, 2011-2020

AIM

This study examines the determinants of health and mortality associated with undiagnosed diabetes among a nationally representative sample of US adults.

METHODS

Data are from the National Health and Nutrition Examination Survey between 2011 and 2012 and 2019-2020. Diabetes status is categorized into three groups: undiagnosed diabetes, diagnosed diabetes, and no diabetes. Multiple logistic regression is used to estimate the association between undiagnosed diabetes and three domains of risk factors, including sociodemographic and health behavioral and clinical factors. Cox proportional hazards models are performed to compare excess mortality risk between the three groups.

RESULTS

Young adults, racial minorities, the foreign-born, and individuals with limited access to health care are more likely to be unaware of their diabetes. Moreover, adults without a family history of diabetes and chronic conditions have a higher chance of undiagnosed diabetes. No health behavioral factors are found to be associated with undiagnosed diabetes. Adults with undiagnosed diabetes have a lower risk of all-cause and cardiovascular disease mortality compared to those with diagnosed diabetes, but a higher risk of all-cause mortality than those with no diabetes.

CONCLUSION

Targeted public health approaches should address sociodemographic and clinical factors to reduce the burden of undiagnosed diabetes.

CD8+ T and NK cells characterized by upregulation of NPEPPS and ABHD17A are associated with the co-occurrence of type 2 diabetes and coronary artery disease

Background

Coronary artery disease (CAD) and type 2 diabetes mellitus (T2DM) are closely related. The function of immunocytes in the pathogenesis of CAD and T2DM has not been extensively studied. The quantitative bioinformatics analysis of the public RNA sequencing database was applied to study the key genes that mediate both CAD and T2DM. The biological characteristics of associated key genes and mechanism of CD8+ T and NK cells in CAD and T2DM are our research focus.

Methods

With expression profiles of GSE66360 and GSE78721 from the Gene Expression Omnibus (GEO) database, we identified core modules associated with gene co-expression relationships and up-regulated genes in CAD and T2DM using Weighted Gene Co-expression Network Analysis (WGCNA) and the 'limma' software package. The enriched pathways of the candidate hub genes were then explored using GO, KEGG and GSEA in conjunction with the immune gene set (from the MSigDB database). A diagnostic model was constructed using logistic regression analysis composed of candidate hub genes in CAD and T2DM. Univariate Cox regression analysis revealed hazard ratios (HRs), 95% confidence intervals (CIs), and p-values for candidate hub genes in diagnostic model, while CIBERSORT and immune infiltration were used to assess the immune microenvironment. Finally, monocytes from peripheral blood samples and their immune cell ratios were analyzed by flow cytometry to validate our findings.

Results

Sixteen candidate hub genes were identified as being correlated with immune infiltration. Univariate Cox regression analysis revealed that NPEPPS and ABHD17A were highly correlated with the diagnosis of CAD and T2DM. The results indicate that CD8+ T cells (p = 0.04) and NKbright cells (p = 3.7e-3) are significantly higher in healthy controls than in individuals with CAD or CAD combined with T2DM. The bioinformatics results on immune infiltration were well validated by flow cytometry.

Conclusions

A series of bioinformatics studies have shown ABHD17A and NPEPPS as key genes for the co-occurrence of CAD and T2DM. Our study highlights the important effect of CD8+ T and NK cells in the pathogenesis of both diseases, indicating that they may serve as viable targets for diagnosis and therapeutic intervention.

Diabetes duration, cholesterol levels, and risk of cardiovascular diseases in individuals with type 2 diabetes

OBJECTIVE

To investigate the association of diabetes duration with cardiovascular disease (CVD) risk and to examine the relationship between lipid levels and CVD risk over the duration.

METHODS

Using the Korean National Health Insurance Service Cohort database, we identified 2,359,243 subjects with type 2 DM aged ≥20 years in 2015-2016. Baseline lipid levels and diabetes duration were evaluated, and followed up until December 2020 (mean follow-up, 3.9 years). Subjects were categorized according to diabetes duration (new-onset, <5 years, 5-9 years, or ≥10 years). We analyzed the new-onset diabetes group with low-density lipoprotein cholesterol (LDL-C), <70 mg/dL, as the reference group. The hazard ratios (HRs) and 95% confidence intervals (CIs) of myocardial infarction (MI), and ischemic stroke (IS) were estimated using a Cox proportional hazards model adjusted for potential confounders.

RESULTS

During follow-up, 45,883 cases of MI and 53,538 cases of IS were identified. The risk of MI or IS began to increase at LDL-C ≥160 mg/dL in the new-onset diabetes group, and at LDL-C ≥130 mg/dL in the diabetes duration <5 years group. Among subjects with a diabetes duration of 5-9 years, LDL-C 100-129 mg/dL, LDL-C 130-159 mg/dL, and ≥160 mg/dL were significantly associated with the risk of MI, with HRs (95% CI) of 1.13 (1.04-1.22), 1.28 (1.17-1.39), and 1.58 (1.42-1.76), respectively. The risk of MI in the diabetes duration ≥10 years group was increased by 16%, even in the LDL-C 70-99 mg/dL population (HR [95% CI] 1.16 [1.08-1.25]).

CONCLUSIONS

This population-based longitudinal study revealed that the LDL-C cutoff level for increasing the risk of cardiovascular disease varied with diabetes duration, and that the target LDL-C level should depend on the duration.

Green tea consumption and incidence of cardiovascular disease in type 2 diabetic patients with overweight/obesity: a community-based cohort study

BACKGROUND

Green tea has been reported to be potentially protective against the development of cardiovascular disease (CVD). This study aimed to investigate the association between green tea consumption and incident CVD in type 2 diabetes (T2D) patients with overweight/obesity.

METHODS

A total of 4756 Chinese overweight/obese T2D patients were recruited and followed up for 6.27 years. Information on green tea consumption was collected at baseline using interviewer-administered questionnaires. Hazard ratios (HRs) and 95% confidence intervals (CIs) for incident CVD according to green tea consumption were estimated using the Cox proportional hazards model.

RESULTS

Compared with non-habitual consumers, participants who consumed > 5 g/day of green tea leaves reduced the risk of CVD by 29% (95%CI: 0.55-0.92), stroke by 30% (95%CI: 0.51-0.95) and coronary heart disease (CHD) by 40% (95%CI: 0.40-0.89). Similarly, participants who consumed green tea for ≥ 40 years reduced the risk of CVD by 31% (95%CI: 0.54-0.88), stroke by 33% (95%CI: 0.50-0.90) and CHD by 39% (95%CI: 0.42-0.88). Among participants with < 5-year history of T2D, > 5 g/day of tea leaves and > 40 years of tea consumption were associated with 59% (95%CI: 0.23-0.72) and 57% (95%CI: 0.26-0.74) reduced risk of stroke, respectively. However, among participants with ≥ 5-year history of T2D, > 5 g/day of tea leaves and > 40 years of tea consumption were associated with a 50% (95%CI: 0.30-0.82) and 46% (95%CI: 0.35-0.85) reduced risk of CHD, respectively.

CONCLUSIONS

Green tea consumption is associated with reduced risk of CVD, stroke, and CHD in overweight/obese T2D patients.

Precision prognostics for cardiovascular disease in Type 2 diabetes: a systematic review and meta-analysis

BACKGROUND

Precision medicine has the potential to improve cardiovascular disease (CVD) risk prediction in individuals with Type 2 diabetes (T2D).

METHODS

We conducted a systematic review and meta-analysis of longitudinal studies to identify potentially novel prognostic factors that may improve CVD risk prediction in T2D. Out of 9380 studies identified, 416 studies met inclusion criteria. Outcomes were reported for 321 biomarker studies, 48 genetic marker studies, and 47 risk score/model studies.

RESULTS

Out of all evaluated biomarkers, only 13 showed improvement in prediction performance. Results of pooled meta-analyses, non-pooled analyses, and assessments of improvement in prediction performance and risk of bias, yielded the highest predictive utility for N-terminal pro b-type natriuretic peptide (NT-proBNP) (high-evidence), troponin-T (TnT) (moderate-evidence), triglyceride-glucose (TyG) index (moderate-evidence), Genetic Risk Score for Coronary Heart Disease (GRS-CHD) (moderate-evidence); moderate predictive utility for coronary computed tomography angiography (low-evidence), single-photon emission computed tomography (low-evidence), pulse wave velocity (moderate-evidence); and low predictive utility for C-reactive protein (moderate-evidence), coronary artery calcium score (low-evidence), galectin-3 (low-evidence), troponin-I (low-evidence), carotid plaque (low-evidence), and growth differentiation factor-15 (low-evidence). Risk scores showed modest discrimination, with lower performance in populations different from the original development cohort.

CONCLUSIONS

Despite high interest in this topic, very few studies conducted rigorous analyses to demonstrate incremental predictive utility beyond established CVD risk factors for T2D. The most promising markers identified were NT-proBNP, TnT, TyG and GRS-CHD, with the highest strength of evidence for NT-proBNP. Further research is needed to determine their clinical utility in risk stratification and management of CVD in T2D.

Cumulative HbA1c exposure as a CVD risk in patients with type 2 diabetes: A post hoc analysis of ACCORD trial

AIMS

The study aimed to investigate the relationship between cumulative HbA1c exposure and cardiovascular events in patients with type 2 diabetes (T2D).

METHODS

This study included 9307 participants from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Cumulative HbA1c exposure was calculated as the area under the curve during exposure time.

RESULTS

After adjusting for covariates, a 1-SD increase in cumulative HbA1c exposure was significantly associated with a higher risk of the primary outcome (HR 1.32, 95 % CI: 1.22-1.43, P < 0.001), all-cause mortality (HR 1.33, 95 % CI: 1.21-1.46, P < 0.001), and cardiovascular death (HR 1.45, 95 % CI: 1.27-1.67, P < 0.001). These associations were independent of baseline HbA1c and the first HbA1c level after enrollment. Cross-tabulation analysis showed that participants in the intensive-therapy group with high baseline HbA1c and cumulative HbA1c exposure had a significantly higher risk of primary outcome, all-cause mortality and cardiovascular death.

CONCLUSIONS

Higher cumulative HbA1c exposure was significantly associated with an increased risk of the primary outcome, all-cause mortality and cardiovascular death among T2D patients. Patients with T2D should strive for stable glycemic control to reduce their risk of cardiovascular events, and that those with high baseline HbA1c may require more intensive therapy to achieve this goal.

10-Year Cardiovascular Risk in Patients With Newly Diagnosed Type 2 Diabetes Mellitus

BACKGROUND

Contemporary data on cardiovascular disease (CVD) risk in patients with newly diagnosed type 2 diabetes mellitus (T2DM) is needed to guide appropriate preventive management.

OBJECTIVES

The authors sought to investigate sex- and age-specific 10-year CVD risk in patients with newly diagnosed T2DM compared with the general population.

METHODS

A cohort study was conducted of all Danish patients with T2DM diagnosed between 2006 and 2013 (n = 142,587) and sex- and age-matched individuals from the general population (n = 388,410), all without prior atherosclerotic CVD. Ten-year CVD risk (myocardial infarction, stroke, and fatal CVD) was estimated.

RESULTS

A total of 52,471 CVD events were recorded. Compared with the general population, the 10-year CVD risks were higher in patients with T2DM in both sexes and across all age groups, especially among younger individuals. For example, patients aged 40 to 49 years had the largest 10-year CVD risk difference (T2DM 6.1% vs general population 3.3%; risk difference: 2.8%, subdistribution HR: 1.91; 95% CI: 1.76-2.07). The age when a given CVD risk was reached differed substantially between the cohorts. Thus, a 10-year CVD risk of 5% was reached at age 43 in men with T2DM compared with 12 years later, at age 55, in men without T2DM. A 10-year CVD risk of 5% was reached at age 51 in women with T2DM and 10 years later, at age 61, in women without T2DM.

CONCLUSIONS

Newly diagnosed T2DM increased 10-year CVD risk across both sexes and all age groups, especially among younger patients, with CVD occurring ≤12 years earlier than in general population individuals.

Ten-Year Cardiovascular Risk as Predicted by the QRISK®3 Calculator in Diabetic Patients Attending a Tertiary Care Teaching Hospital in Central India and Its Application to Stratify Statin Over-Users and Under-Users

BACKGROUND

Cardiovascular disease (CVD) is an important cause of morbidity and mortality in diabetic patients. As such, risk stratification is essential to identify the risk factors of CVD and provide early intervention. The QRISK®3 tool, recommended by the National Institute for Health and Care Excellence (NICE) guidelines, has the option to choose the patient's ethnicity, which is not available in other tools. However, there is a paucity of data regarding the use of this tool in the Indian population. Therefore, this study was planned to predict 10-year CVD risk using the QRISK®3 tool and to determine statin eligibility in diabetic patients.

METHODS

We enrolled diabetic patients visiting our general medicine outpatient department and diabetic clinic in the study. We collected data from clinical and prescription records, as well as through patient interviews. We analyzed the data to determine the 10-year CVD risk using the QRISK®3 risk tool, which is available online. A cut-off QRISK score of 10%, as recommended by the NICE guidelines (2014), was used to stratify patients as "over-users" and "under-users." We also analyzed the data to determine any correlation between other risk factors and QRISK scores.

RESULTS

Of the 134 diabetic patients recruited in this study, 43 (32.09%) had a CVD risk score of <10%, of which 16 (37.21%) were categorized as "over-users." Of the patients, 91 had a CVD risk score of ≥10%, of which 17 (18.68%) were categorized as "under-users." Risk factors showing a positive correlation with QRISK score included duration of diabetes, age, blood pressure treatment, waist circumference, and non-high-density lipoprotein cholesterol level.

CONCLUSION

QRISK score can be useful to predict 10-year CVD risk in the Indian population and to stratify patients as statin over-users and under-users. This tool can be used in the Indian set-up to identify potential candidates for statin initiation.

Organ-specific model of simulated ischemia/reperfusion and hyperglycemia based on engineered heart tissue

Here we aimed to establish an in vitro engineered heart tissue (EHT) co-morbidity mimicking model of ischemia-reperfusion injury and diabetes. EHTs were generated from primary neonatal rat cardiomyocytes. Hyperglycemic conditions or hyperosmolar controls were applied for one day to model acute hyperglycemia and for seven days to model chronic hyperglycemia. 120 min' simulated ischemia (SI) was followed by 120 min' reperfusion (R) and 1-day follow-up reperfusion (FR). Normoxic controls (N) were not subjected to SI/R. Half of the EHTs was paced, the other half was left unpaced. To assess cell injury, lactate-dehydrogenase (LDH) concentration was measured. Beating force and activity (frequency) were monitored as cardiomyocyte functional parameters. LDH-release indicated relevant cell injury after SI/N in each experimental condition, with much higher effects in the chronically hyperglycemic/hyperosmolar groups. SI stopped beating of EHTs in each condition, which returned during reperfusion, with weaker recovery in chronic conditions than in acute conditions. Acutely treated EHTs showed small LDH-release and ∼80% recovery of force during reperfusion and follow-up, while chronically treated EHTs showed a marked LDH-release, only ∼30% recovery with reperfusion and complete loss of beating activity during 24 h follow-up reperfusion. We conclude that EHTs respond differently to SI/R injury in acute and chronic hyperglycemia/hyperosmolarity, and that our EHT model is a novel in vitro combination of diabetes and ischemia-reperfusion.

Risk of atrial fibrillation in individuals with dysglycemia and diabetes

OBJECTIVE

Diabetes is a risk factor for atrial fibrillation (AF), and increases the risk of thromboembolic events in persons with AF. However, the link between the two conditions is not fully elucidated. Few studies have investigated the association of dysglycemia and incident AF. We investigated the risk of incident AF and prognosis according to diabetes status.

RESEARCH DESIGN AND METHODS

The Copenhagen Primary Care Laboratory Database was merged with data on medical prescriptions, in- and outpatient contacts and vital status. The risk of AF according to diabetes status was investigated by use of Cox regression models.

RESULTS

Of 354.807 individuals with a hemoglobin A1c (HbA1c) measurement, 28.541 (8 %) had known diabetes, 13.038 (4 %) had new onset diabetes and 27.754 (8 %) had prediabetes (HbA1c 42-47 mmol/mol). Persons with dysglycemia (HbA1c > 42 mmol/mol) and diabetes were older, more were men, they had lower level of education and were more likely to be living alone. We observed a gradual increase in risk of developing AF from HbA1c levels of 40 to 60 mmol/mol. In adjusted analyses we found a stepwise increase in hazard of AF from normoglycemia over prediabetes to persons with diabetes (no diabetes: 1.00 [ref.]; prediabetes: 1.12 [1.08-1.16]; new-onset diabetes: 1.16 [1.10-1.22]; known diabetes: 1.15 [1.11-1.20]). Persons with known diabetes had a significant higher hazard of stroke, cardiovascular and all-cause mortality.

CONCLUSION

Increasing levels of HbA1c were associated with an increased hazard of developing AF. Persons with new onset of diabetes and those with known diabetes had similar hazard of developing AF, however persons with known diabetes had a significant higher hazard of stroke, cardiovascular- and all-cause mortality.

Precision Prognostics for Cardiovascular Disease in Type 2 Diabetes: A Systematic Review and Meta-analysis

Background Precision medicine has the potential to improve cardiovascular disease (CVD) risk prediction in individuals with type 2 diabetes (T2D). Methods We conducted a systematic review and meta-analysis of longitudinal studies to identify potentially novel prognostic factors that may improve CVD risk prediction in T2D. Out of 9380 studies identified, 416 studies met inclusion criteria. Outcomes were reported for 321 biomarker studies, 48 genetic marker studies, and 47 risk score/model studies. Results Out of all evaluated biomarkers, only 13 showed improvement in prediction performance. Results of pooled meta-analyses, non-pooled analyses, and assessments of improvement in prediction performance and risk of bias, yielded the highest predictive utility for N-terminal pro b-type natriuretic peptide (NT-proBNP) (high-evidence), troponin-T (TnT) (moderate-evidence), triglyceride-glucose (TyG) index (moderate-evidence), Genetic Risk Score for Coronary Heart Disease (GRS-CHD) (moderate-evidence); moderate predictive utility for coronary computed tomography angiography (low-evidence), single-photon emission computed tomography (low-evidence), pulse wave velocity (moderate-evidence); and low predictive utility for C-reactive protein (moderate-evidence), coronary artery calcium score (low-evidence), galectin-3 (low-evidence), troponin-I (low-evidence), carotid plaque (low-evidence), and growth differentiation factor-15 (low-evidence). Risk scores showed modest discrimination, with lower performance in populations different from the original development cohort. Conclusions Despite high interest in this topic, very few studies conducted rigorous analyses to demonstrate incremental predictive utility beyond established CVD risk factors for T2D. The most promising markers identified were NT-proBNP, TnT, TyG and GRS-CHD, with the highest strength of evidence for NT-proBNP. Further research is needed to determine their clinical utility in risk stratification and management of CVD in T2D.

Impact of modifiable risk factors on prediction of 10-year cardiovascular disease utilizing framingham risk score in Southwest Iran

BACKGROUND

This cohort study was conducted to examine the association between modifiable risk factors, including hypertension, smoking, physical activity, diabetes, cholesterol, and high-density lipoprotein with Framingham risk score in the prediction of 10-year-risk of cardiovascular diseases (CVD) between men and women in an Arab community of Southwest Iran, Hoveyzeh.

MATERIALS AND METHODS

A total of 8,526 people aged 35-70 participated in this cohort study. Framingham was used to estimate the 10-year risk of CVD. Also, the linear regression models were used to assess the relationship between modifiable risk factors and the 10-year risk of CVD. Finally, the area under the receiver operating characteristic curve (AUC) was used to measure the ability of modifiable risk factors to predict the 10-year risk of CVD.

RESULTS

Our results of linear regression models showed that hypertension, smoking, PA, diabetes, cholesterol, and HDL were independently associated with the CVD risk in men and women. Also, AUC analysis showed that hypertension and diabetes have the largest AUC in men 0.841; 0.778 and in women 0.776; 0.715, respectively. However, physical activity had the highest AUC just in women 0.717.

CONCLUSION

Hypertension and diabetes in both gender and physical activity in women are the most important determinant for the prediction of CVD risk in Hoveyzeh. Our cohort study may be useful for adopting strategies to reduce CVD progression through lifestyle changes.

Duration-dependent impact of cardiometabolic diseases and multimorbidity on all-cause and cause-specific mortality: a prospective cohort study of 0.5 million participants

BACKGROUND

The association of incident cardiometabolic multimorbidity (CMM) with mortality risk is rarely studied, and neither are the durations of cardiometabolic diseases (CMDs). Whether the association patterns of CMD durations with mortality change as individuals progress from one CMD to CMM is unclear.

METHODS

Data from China Kadoorie Biobank of 512,720 participants aged 30-79 was used. CMM was defined as the simultaneous presence of two or more CMDs of interest, including diabetes, ischemic heart disease, and stroke. Cox regression was used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for the duration-dependent associations of CMDs and CMM with all-cause and cause-specific mortality. All information on exposures of interest was updated during follow-up.

RESULTS

During a median follow-up of 12.1 years, 99,770 participants experienced at least one incident CMD, and 56,549 deaths were documented. Among 463,178 participants free of three CMDs at baseline, compared with no CMD during follow-up, the adjusted HRs (95% CIs) between CMM and all-cause mortality, mortality from circulatory system diseases, respiratory system diseases, cancer, and other causes were 2.93 (2.80-3.07), 5.05 (4.74-5.37), 2.72 (2.35-3.14), 1.30 (1.16-1.45), and 2.30 (2.02-2.61), respectively. All CMDs exhibited a high mortality risk in the first year of diagnosis. Subsequently, with prolonged disease duration, mortality risk increased for diabetes, decreased for IHD, and sustained at a high level for stroke. With the presence of CMM, the above association estimates inflated, but the pattern of which remained.

CONCLUSION

Among Chinese adults, mortality risk increased with the number of the CMDs and changed with prolonged disease duration, the patterns of which varied among the three CMDs.

Impact of diabetes duration on left ventricular mass regression with empagliflozin

AIMS

The duration of type 2 diabetes mellitus (T2DM) is an important determinant of diabetes severity. The EMPA-HEART CardioLink-6 trial reported significant left ventricular (LV) mass indexed to body surface area (LVMi) regression in patients treated with the sodium-glucose cotransporter 2 inhibitor (SGLT2i) empagliflozin for 6 months. This exploratory sub-analysis of the same trial investigated the association between T2DM duration and LVMi regression.

METHODS AND RESULTS

A total of 97 individuals with T2DM and coronary artery disease (CAD) were randomly assigned to receive empagliflozin 10 mg daily or placebo. LVMi was measured at the baseline and 6 month visit using cardiac magnetic resonance imaging. The study population was divided into those with a baseline T2DM duration <10 years (n = 40) or ≥10 years (n = 57). A linear model adjusting for baseline values in each of the subgroups (ANCOVA) was used to assess the treatment effect of 6 month change in LVMi, LV end systolic volume indexed to body surface area, LV end diastolic volume indexed to body surface area and LV ejection fraction. Patients in the T2DM duration <10 years group (38 males [95.0%], median age 63 [IQR: 55 years to 70 years]) had a median T2DM duration of 4 years (IQR: 2.0 years to 7.0 years). Those in the T2DM duration ≥10 years group (52 males [91.2%], median age 65 [IQR: 57 years to 71 years]) had a median duration of 15 years (IQR: 12 years to 20 years). There was no significant difference in baseline LVMi according to T2DM duration (median 62 g/m² [IQR: 53.1 g/m² to 70.0 g/m² ] for T2DM duration <10 years; median 57.5 g/m² [IQR: 52.1 g/m² to 66.2 g/m² ] for T2DM duration ≥10 years; P = 0.11). Empagliflozin was associated with reductions in LVMi irrespective of duration of T2DM above and below 10 years (T2DM duration <10 years group, mean adjusted difference -2.90 g/m² [95% CI: -6.64 g/m² to 0.84 g/m² ]; T2DM duration ≥10 years group, mean adjusted difference -3.69 g/m² [95% CI: -0.14 g/m² to -7.24 g/m² ]; P_interaction  = 0.07).

CONCLUSIONS

In the EMPA-HEART CardioLink-6 trial, empagliflozin treatment was associated with reductions in LVMi in people with T2DM and CAD irrespective of the duration of diabetes assessed categorically above and below 10 years.

An updated review on cell signaling pathways regulated by candidate miRNAs in coronary artery disease

MicroRNAs (miRNAs) are small endogenous non-coding RNA, size range from 17 to 25 nucleotides that regulate gene expression at the post-transcriptional level. More than 2000 different types of miRNAs have been identified in humans which regulate about 60% of gene expression, since the discovery of the first miRNA in 1993. MicroRNA performs many functions such as being involved in the regulation of various biological pathways for example cell migration, cell proliferation, cell differentiation, disease progression, and initiation. miRNAs also play an important role in the development of atherosclerosis lesions, cardiac fibroblast, cardiac hypertrophy, cancer, and neurological disorders. Abnormal activation of many cell signaling pathways has been observed in the development of coronary artery disease. Abnormal expression of these candidate miRNA genes leads to up or downregulation of specific genes, these specific genes play an important role in the regulation of cell signaling pathways involved in coronary artery disease. Many studies have found that miRNAs play a key role in the regulation of crucial signaling pathways that are involved in the pathophysiology of coronary artery disease. This review is designed to investigate the role of cell signaling pathways regulated by candidate miRNAs in Coronary artery disease.

Prediction of microvascular complications in diabetic patients without obstructive coronary stenosis based on peri-coronary adipose tissue attenuation model

OBJECTIVES

To investigate the predictive value of peri-coronary adipose tissue (PCAT) attenuation for microvascular complications in diabetic patients without significant stenosis and to develop a prediction model for early risk stratification.

METHODS

This study retrospectively included patients clinically identified for coronary computed tomography angiography (CCTA) and type 2 diabetes between January 2017 and December 2020. All patients were followed up for at least 1 year. The clinical data and CCTA-based imaging characteristics (including PCAT of major epicardial vessels, high-risk plaque features) were recorded. In the training cohort comprising of 579 patients, two models were developed: model 1 with the inclusion of clinical factors and model 2 incorporating clinical factors + RCA_PCAT using multivariable logistic regression analysis. An internal validation cohort comprising 249 patients and an independent external validation cohort of 269 patients were used to validate the proposed models.

RESULTS

Microvascular complications occurred in 69.1% (758/1097) of the current cohort during follow-up. In the training cohort, model 2 exhibited improved predictive power over model 1 based on clinical factors (AUC = 0.820 versus 0.781, p = 0.003) with lower prediction error (Brier score = 0.146 versus 0.164) compared to model 1. Model 2 accurately categorized 78.58% of patients with diabetic microvascular complications. Similar performance of model 2 in the internal validation cohort and the external validation cohort was further confirmed.

CONCLUSIONS

The model incorporating clinical factors and RCA_PCAT predicts the development of microvascular complications in diabetic patients without significant coronary stenosis.

KEY POINTS

• Hypertension, HbA1c, duration of diabetes, and RCA_PCAT were independent risk factors for microvascular complications. • The prediction model integrating RCA_PCAT exhibited improved predictive power over the model only based on clinical factors (AUC = 0.820 versus 0.781, p = 0.003) and showed lower prediction error (Brier score=0.146 versus 0.164).

The Association Between Diabetes Duration and Domain-Specific Cognitive Impairment: A Population-Based Study

BACKGROUND

Diabetes is a risk factor for cognitive impairment, and disease duration is associated with geriatric decline and functional disabilities.

OBJECTIVE

This study aimed to examine the association of diabetes duration with domain-specific cognitive impairment in elderly.

METHODS

A total of 3,142 participants from the National Health and Nutrition Examination Survey (NHANES) from the period between 2011 and 2014 were included. We assessed cognitive function using the Digit Symbol Substitution Test (DSST), the CERAD Word Learning (CERAD-WL) test, the CERAD Delayed Recall (CERAD-DR) test and animal fluency (AF) test.

RESULTS

After adjusting for age, sex, race/ethnicity, education level, and annual household income, we found that diabetes with a duration longer than 20 years were at 3.32-fold increased risk of DSST impairment (OR = 3.32, 95% CI: 1.95 to 5.67), 1.72-fold increased risk of CERAD-WL impairment (OR = 1.72, 95% CI: 1.13 to 2.62), and 1.76-fold increased risk of AF impairment (OR = 1.76, 95% CI: 1.23 to 2.53), compared with those with no diabetes. Associations were generally stronger in women than in men. Participants with diabetes, who were diagnosed at 50-59 years old were at increased risk of DSST impairment, CERAD-WL impairment, CERAD-DR impairment, and AF impairment per 5 years longer duration of diabetes.

CONCLUSION

Longer diabetes duration was associated with the increased risk of cognitive impairment, especially in processing speed and attention. The presence of chronic kidney disease was associated with the increased risk of DSST impairment.

Diabetes mellitus is associated with a higher relative risk for venous thromboembolism in females than in males

AIMS

The risk for developing venous thromboembolism (VTE) is about equal in both sexes. Research suggests diabetes mellitus (DM) is a risk factor for pulmonary embolism and deep vein thrombosis, both forms of VTE. We aimed at investigating the sex-specific impact of DM on VTE risk.

MATERIALS AND METHODS

Medical claims data were analyzed in a retrospective, population-level cohort study in Austria between 1997 and 2014. 180,034 patients with DM were extracted and compared to 540,102 sex and age-matched controls without DM in terms of VTE risk and whether specific DM medications might modulate VTE risk.

RESULTS

The risk to develop VTE was 1.4 times higher amongst patients with DM than controls (95% CI 1.36-1.43, p < 0.001). The association of DM with newly diagnosed VTE was significantly greater in females (OR = 1.52, 95% CI 1.46-1.58, p < 0.001) resulting in a relative risk increase of 1.17 (95% CI 1.11-1.23) across all age groups with a peak of 1.65 (95% CI 1.43-1.89) between 50 and 59 years. Dipeptidyl peptidase 4 inhibitors were associated with a higher risk for VTE amongst female DM patients (OR = 2.3, 95% CI 1.3-4.3, p = 0.0096).

CONCLUSION

Amongst DM patients, females appear to be associated with a higher relative risk increase in VTE than males, especially during perimenopause.

Ten-Year Effectiveness of the Multidisciplinary Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM) on Macrovascular and Microvascular Complications and All-Cause Mortality: A Population-Based Cohort Study

OBJECTIVE

The Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM) is a protocol-driven, risk-stratified, and individualized management program offered by a multidisciplinary team in addition to usual care for primary care patients with diabetes. This study aimed to evaluate the effectiveness of RAMP-DM for preventing complications and mortality over 10 years.

RESEARCH DESIGN AND METHODS

A population-based, prospective cohort study of adult patients with type 2 diabetes managed in the Hong Kong public primary health care system between 2009 and 2010 was conducted. RAMP-DM participants and usual care patients were matched using one-to-one propensity score matching and followed for 10 years. Risks of macrovascular and microvascular complications and all-cause mortality were estimated by Cox proportional hazards regression.

RESULTS

A total of 36,746 patients (18,373 in each group) were included after propensity score matching, with a median follow-up of 9.5 years and 306,802 person-years. RAMP-DM participants had significantly lower risks of macrovascular (hazard ratio [HR] 0.52, 95% CI 0.50-0.54) and microvascular (HR 0.68, 95% CI 0.64-0.72) complications and all-cause mortality (HR 0.45, 95% CI 0.43-0.47) than patients who received usual care only. However, the effect of RAMP-DM on macrovascular and microvascular complications attenuated after the 9th and 8th year of follow-up, respectively. RAMP-DM participants also showed better control of hemoglobin A1c, blood pressure, triglycerides, and BMI and a slower decline in renal function.

CONCLUSIONS

Significant reductions in diabetes-related complications and all-cause mortality were observed among RAMP-DM participants over a 10-year follow-up, yet the effect of preventing complications attenuated after 8 years.

Remnant cholesterol and the risk of cardiovascular disease in type 2 diabetes: a nationwide longitudinal cohort study

BACKGROUND

Elevated remnant cholesterol (remnant-C) is considered a risk factor for cardiovascular disease (CVD); however, whether this notion applies to the East Asian population with type 2 diabetes (T2D) has not been established. This study investigated the association between remnant-C concentrations and the risk of CVD in Korean patients with T2D.

METHODS

By using the Korean National Health Insurance Service database, 1,956,452 patients with T2D and without atherosclerotic CVD who underwent regular health checks between 2009 and 2012 were included. Cox regression analyses were conducted to assess the association between remnant-C concentrations and incident CVD comprising myocardial infarction (MI) and ischemic stroke.

RESULTS

In total, 50,120 (2.56%) cases of MI and 73,231 (3.74%) cases of ischemic strokes occurred during a median follow-up of 8.1 years. The adjusted hazard ratios for MI and stroke in the highest remnant-C quartile were 1.281 (95% confidence interval [CIs], 1.249-1.314) for MI and 1.22 (1.195-1.247) for ischemic stroke, compared to those in the lowest quartiles. The results were similar, based on stratified analysis by age, sex, use of statin or fibrate, and levels of other cholesterol. The increased risk of CVD in the highest remnant-C quartile was profound in patients who had a longer T2D duration. A remnant-C concentration ≥ 30 mg/dL differentiated patients who were at a higher risk of CVD, compared to patients with a lower concentrations, regardless of whether LDL-C levels were or were not on target at ≤ 100 mg/dL.

CONCLUSION

In Korean patients with T2D, remnant-C was associated with CVD, independent of the LDL-C level or other conventional CVD risk factors. Our finding confirmed evidence of the causal role of remnant-C on CVD, as a residual risk of CVD, in East Asian patients with T2D.

Cumulative Consumption of Sulfur Amino Acids and Risk of Diabetes: A Prospective Cohort Study

BACKGROUND

Cross-sectional studies have suggested that consumption of sulfur amino acids (SAAs), including methionine and cysteine, is associated with a higher risk of type 2 diabetes (T2D) in humans and with T2D-related biomarkers in animals. But whether higher long-term SAA intake increases the risk of T2D in humans remains unknown.

OBJECTIVES

We aimed to investigate the association between long-term dietary SAA intake and risk of T2D.

METHODS

We analyzed data collected from 2 different cohorts of the Framingham Heart Study, a long-term, prospective, and ongoing study. The Offspring cohort (1991-2014) included participants from fifth through ninth examinations, and the Third-Generation cohort (2002-2011) included participants from first and second examinations. After excluding participants with a clinical history of diabetes, missing dietary data, or implausible total energy intake, 3222 participants in the Offspring cohort and 3205 participants in the Third-Generation cohort were included. Dietary intake was assessed using a validated FFQ. The relations between energy-adjusted total SAA (methionine and cysteine) intake or individual SAA intake (in quintiles) and risk of incident T2D were estimated via Cox proportional hazards models after adjusting for dietary and nondietary risk factors. Associations across the 2 cohorts were determined by direct combination and meta-analysis.

RESULTS

During the 23 y of follow-up, 472 participants reported a new diagnosis of T2D in the 2 cohorts. In the meta-analysis, the HRs of T2D comparing the highest with the lowest intake of total SAAs, methionine, and cysteine were 1.8 (95% CI: 1.3, 2.5), 1.7 (95% CI: 1.2, 2.3), and 1.4 (95% CI: 1.0, 2.1), respectively. The association of SAA intake with T2D was attenuated after adjusting animal protein intake in sensitivity analyses.

CONCLUSIONS

Our findings show that excess intake of SAAs is associated with higher risk of T2D. Dietary patterns that are low in SAAs could help in preventing T2D.

Neuropathy scale score as an independent risk factor for myocardial infarction in patients with type 2 diabetes

AIMS

To investigate whether peripheral neuropathy scale scores are associated with myocardial infarction (MI) in patients with type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

In this cross-sectional study, 32,463 T2DM patients were enroled from 103 tertiary hospitals in 25 Chinese provinces. Based on a history of MI, participants were divided into the MI group (n = 4170) and the non-MI group (n = 28,293). All patients were assessed using four neuropathy scales, namely, Neurological Symptom Score (NSS), Neurological Disability Score (NDS), Toronto Clinical Scoring System (TCSS), and Michigan Neuropathy Screening Instrument (MNSI), and some of the patients underwent evaluation of nerve conduction velocity (NCV) (n = 20,288). The relationship between these scores and myocardial infraction was analysed.

RESULTS

The neuropathy scale scores in the MI group were higher than those in the non-MI group (p < 0.001). After dividing patients into four groups based on the grading criteria, our results showed that, in addition to aggravating the degree of neuropathy signs, the incidence of MI increased (p < 0.001). Logistic regression analysis results showed that neuropathy scale scores and NCV were both independent risk factors for MI (p < 0.001). Furthermore, among the scales used, MNSI presented a higher odds ratio and area under the curve (AUC; 0.625, p < 0.001) than the other three scales (AUC_NSS  = 0.575, AUC_NDS  = 0.606, and AUC_TCSS  = 0.602, p < 0.001) for MI.

CONCLUSIONS

Increased scores on these neuropathy scales (NSS, NDS, TCSS, and MNSI) and NCV were significantly associated with increased risk of MI and were considered independent risk factors.

Associations of Age at Diagnosis and Duration of Diabetes With Morbidity and Mortality Among Older Adults

Importance

Older adults vary widely in age at diagnosis and duration of type 2 diabetes, but treatment often ignores this heterogeneity.

Objectives

To investigate the associations of diabetes vs no diabetes, age at diagnosis, and diabetes duration with negative health outcomes in people 50 years and older.

Design, Setting, and Participants

This cohort study included participants in the 1995 through 2018 waves of the Health and Retirement Study (HRS), a population-based, biennial longitudinal health interview survey of older adults in the US. The study sample included adults 50 years or older (n = 36 060) without diabetes at entry. Data were analyzed from June 1, 2021, to July 31, 2022.

Exposures

The presence of diabetes, specifically the age at diabetes diagnosis, was the main exposure of the study. Age at diagnosis was defined as the age when the respondent first reported diabetes. Adults who developed diabetes were classified into 3 age-at-diagnosis groups: 50 to 59 years, 60 to 69 years, and 70 years and older.

Main Outcomes and Measures

For each diabetes age-at-diagnosis group, a propensity score-matched control group of respondents who never developed diabetes was constructed. The association of diabetes with the incidence of key outcomes-including heart disease, stroke, disability, cognitive impairment, and all-cause mortality-was estimated and the association of diabetes vs no diabetes among the age-at-diagnosis case and matched control groups was compared.

Results

A total of 7739 HRS respondents developed diabetes and were included in the analysis (4267 women [55.1%]; mean [SD] age at diagnosis, 67.4 [9.9] years). The age-at-diagnosis groups included 1866 respondents at 50 to 59 years, 2834 at 60 to 69 years, and 3039 at 70 years or older; 28 321 HRS respondents never developed diabetes. Age at diagnosis of 50 to 59 years was significantly associated with incident heart disease (hazard ratio [HR], 1.66 [95% CI, 1.40-1.96]), stroke (HR, 1.64 [95% CI, 1.30-2.07]), disability (HR, 2.08 [95% CI, 1.59-2.72]), cognitive impairment (HR, 1.30 [95% CI, 1.05-1.61]), and mortality (HR, 1.49 [95% CI, 1.29-1.71]) compared with matched controls, even when accounting for diabetes duration. These associations significantly decreased with advancing age at diagnosis. Respondents with diabetes diagnosed at 70 years or older only showed a significant association with the outcome of elevated mortality (HR, 1.08 [95% CI, 1.01-1.17]).

Conclusions and Relevance

The findings of this cohort study suggest that age at diabetes diagnosis was differentially associated with outcomes and that younger age groups were at elevated risk of heart disease, stroke, disability, cognitive impairment, and all-cause mortality. These findings reinforce the clinical heterogeneity of diabetes and highlight the importance of improving diabetes management in adults with earlier diagnosis.

Mortality differentials by previous diagnosis of diabetes and glycemic status in the United States

AIMS

This study examines mortality differences associated with current glycemic status in mortality by current glycemic status among adults with a previously diagnosed diabetes. Using previous clinical diagnosis of diabetes (diagnosed diabetes) and laboratory measures of hemoglobin A1c (HbA1c) measured at baseline, we estimated mortality differentials simultaneously by diagnosed diabetes and baseline glycemic status in the United States.

METHODS

Data were from 39,491 adults aged 30-84 years assessed in the National Health and Nutrition Examination Survey (NHANES) III and continuous NHANES 1999-2014 linked to mortality data. We categorized participants into four mutually exclusive groups based on diagnosed diabetes and glycemic control measured by HbA1c ≥6.5 % at baseline. Relative hazard ratio (HR) of all-cause death among these four groups were estimated using Cox proportional models.

RESULTS

There was no significant difference in mortality by glycemic control status among adults with diagnosed diabetes. The same finding was observed among adults without diagnosed diabetes. Adults with diagnosed diabetes had higher mortality than adults without diagnosed diabetes independent of their baseline glycemic control.

CONCLUSIONS

Once diagnosed with diabetes, US adults with normal- and hyper-glycemia showed no significant difference in all-cause mortality. This finding emphasizes the importance of primary prevention interventions among adults with a sign of early-stage diabetes.

The association of attained age, age at diagnosis, and duration of type 2 diabetes with the long-term risk for major diabetes-related complications

AIM

We evaluated the associations of age and duration of type 2 diabetes with major diabetes-related complications.

METHODS

We included 1.1 million people with type 2 diabetes from the Australian diabetes registry, followed from 2010 to 2019. We estimated the incidence of hospitalization or death from myocardial infarction (MI), stroke, and heart failure (HF), and hospitalisation for lower extremity amputation (LEA); end-stage kidney disease (ESKD; kidney replacement therapy or death from ESKD); and all-cause mortality. Poisson regression was used to model incidence by attained age, age at diabetes diagnosis, and duration of diabetes.

RESULTS

Risk for complications increased exponentially with diabetes duration. Effects of attained age differed for each complication: age was a strong risk factor for MI, stroke, HF, and mortality, while diabetes duration, not age, was the predominant determinant of LEA and ESKD. At a given age, a 10-year longer diabetes duration was associated with a 1.1-1.5-fold increased risk of stroke and mortality, a 1.5-2.0-fold increased risk of MI and HF, and a 2-4-fold increased risk of LEA and ESKD.

CONCLUSIONS

Duration of diabetes is a stronger risk factor for ESKD and LEA than it is for cardiovascular disease or mortality.

Impact of Diabetes Duration on Clinical Outcome in Patients Receiving Rotational Atherectomy in Calcified Lesions in Korea-Results from ROCK Registry

There are limited data regarding the clinical impact of diabetes duration for patients with heavy calcified coronary lesions. We sought to determine the clinical impact of diabetes duration on clinical outcomes in patients with heavily calcified lesions who required rotational atherectomy during percutaneous coronary intervention (PCI). A total of 540 diabetic patients (583 lesions) were enrolled between January 2010 and October 2019. Patients were classified into three subgroups: patients with no diabetes mellitus (non-DM), shorter duration (S-DM), and longer duration (L-DM), of which duration was divided at 10 years. During 18 months of follow-up-duration, diabetes duration was significantly associated with the primary outcome. The incidence rate of target-vessel failure (TVF), the primary outcome, was significantly higher in the L-DM group compared with non-DM or S-DM. Among secondary outcomes, any repeat revascularization (RR) was frequently observed in the L-DM compared with other groups. In multivariate analysis, the risk of TVF and any RR was 1.9 times and 2.4 times higher in L-DM than in non-DM, respectively. This study firstly demonstrated that there is an association between a longer DM duration and poor clinical outcomes in patients with severe calcified CAD after PCI. More careful monitoring for recurrence is needed during follow-up in those patients.

Duration of diabetes and the risk of major cardiovascular events in women and men: A prospective cohort study of UK Biobank participants

AIMS

Diabetes has been associated with a greater excess risk of cardiovascular disease (CVD) in women than men. We investigated whether there are also sex differences in the association of diabetes duration and the risk of CVD.

METHODS

Data were used from 18,961 (40% women) individuals with type 2 diabetes, without a history of CVD, in the UK Biobank. Sex-specific incidence rates were calculated by diabetes duration. Cox proportional hazards analyses estimated multiple-adjusted sex-specific hazard ratios (HR) and women-to-men ratio of HRs (RHR).

RESULTS

Over a median follow-up of 11 years, 1,506 (29% women) CVD events were documented. Compared with men, women had lower multiple-adjusted incidence rates of CVD per 10,000 person-years for all categories of diabetes duration. Duration of diabetes was associated with an increased risk of CVD in both sexes. A 5-year increase in diabetes duration was associated with an approximately similar excess risk of about 20% for each of the three endpoints, in both sexes.

CONCLUSIONS/INTERPRETATION

The increased risk of CVD associated with longer duration of diabetes is similar in women and men, and thus cannot explain the higher excess risk from diabetes in women in this study population.

The association between age at diagnosis of type 2 diabetes and albuminuria in Chinese adults: A nationwide population study

BACKGROUND

Type 2 diabetes is increasingly diagnosed at a younger age worldwide and in China. Limited data are available regarding the association between age at diabetes diagnosis and risks of albuminuria. This study sought to examine the independent effect of age at diagnosis of type 2 diabetes on the risk of albuminuria.

METHODS

We used data from a nationwide multicenter study with 207 961 participants in mainland China. Age, sex, and study site were matched for 31 366 screen-detected type 2 diabetes cases and 31 366 normal controls. Age, sex, study site, and diabetes duration were matched for 7490 self-reported type 2 diabetes cases and 7490 normal controls. Risks of having albuminuria in matched type 2 diabetes vs controls were examined using multivariable logistic regression analysis in strata of age at diabetes diagnosis.

RESULTS

Although the absolute rate of albuminuria is higher in older adults, the odds ratio of albuminuria in type 2 diabetes vs matched controls decreased with increasing age at diagnosis. For participants with diabetes diagnosed at an age of <50, 50 to 59, 60 to 69, or ≥70 years, the multivariable adjusted risk of albuminuria increased by 81%, 60%, 45%, and 33% for screen-detected diabetes, and 135%, 121%, 90%, and 58% for self-reported diabetes compared with their normal controls, respectively.

CONCLUSIONS

A younger age at diagnosis of type 2 diabetes is associated with a more significantly elevated risk of albuminuria than an older age at diagnosis in Chinese adults.

Assessment of structural and functional myocardial characteristics in patients with chronic coronary artery disease and various glycemic status

Aim. To study the structural and functional myocardial characteristics in patients with exertional angina and type 2 diabetes in comparison with those without diabetes to identify combined hemodynamic changes.

Material and methods. Patients were divided into two groups depen - ding on the glycemic status. The first group consisted of 49 patients (mean age, 57,9±1,04 years; male/female, 35/14) with coronary artery disease (CAD) and type 2 diabetes, while the second one (control)  — 51 patients (60,2±0,9 years, 34/17) with CAD and without diabetes. Patients were surveyed using a standard questionnaire that included socio-demographic parameters, behavioral risk factors, clinical status, medications received, and comorbidities. Diagnostic investigations were carried out, including resting electrocardiography, transthoracic echocardiography and cycle ergometry.

Results. Among patients with CAD and type 2 diabetes, hypertension occurred 20% more often compared with the control group  — 98 vs 78% (p<0,004). According to the electrocardiography, the combination of diabetes and CAD was characterized by various arrhythmias, which were recorded 2,8 times more often than in the group without diabetes. According to echocardiography, signs of left ventricular hypertrophy, systolic and diastolic dysfunction prevailed in people with diabetes. Mean pulmonary artery pressure in patients with diabetes were higher than in patients without carbohydrate metabolism disorders (p<0,004). According to the stress test, exercise tolerance in experimental group patients was lower than in patients in the control group.

Conclusion. The combination of chronic CAD and type 2 diabetes is cha - racterized by a more common combination with hypertension, impaired central and intracardiac hemodynamics, as well as left ventricular hypertrophy. In people with diabetes, impaired systolic and diastolic myocardial function is combined with reduced exercise tolerance.

Predicting Depression and Post-Traumatic Stress Symptoms Following Burn Injury: A Risk Scoring System

Depression and post-traumatic stress are common psychiatric comorbidities following burn injury. The purpose of this study was to develop an admission scoring system that assesses the risk of development of depression or post-traumatic symptoms in the burn population. This study is a retrospective review of the prospectively collected Burn Model System National Database. Adult burn survivors enrolled from 2014-2018 (n=486) were included. The primary outcome was the presence of depression or post-traumatic stress symptoms at 6, 12, or 24 months post-injury. Logistic regression analysis was used to identify demographic and clinical predictors of depression and post-traumatic stress symptoms. A risk scoring system was then created based on assigning point values to relevant predictor factors. The study population had a mean age of 46.5±15.8 years, mean burn size of 18.3±19.7%, and was 68.3% male. Prior to injury, 71.3% of the population was working, 47.9% were married, and 50.8% had completed more than a high school education. An 8-point risk scoring system was developed using the following predictors of depression or post-traumatic stress symptom development: gender, psychiatric treatment in the past year, graft size, head/neck graft, etiology of injury, and education level. This study is the first to develop a depression and post-traumatic stress symptom risk scoring system for burn injury. This scoring system will aid in identifying burn survivors at high risk of long-term psychiatric symptoms that may be used to improve screening, monitoring, timely diagnosis and interventions.

Outcomes of Participants With Diabetes in the ISCHEMIA Trials

BACKGROUND

Among patients with diabetes and chronic coronary disease, it is unclear if invasive management improves outcomes when added to medical therapy.

METHODS

The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trials (ie, ISCHEMIA and ISCHEMIA-Chronic Kidney Disease) randomized chronic coronary disease patients to an invasive (medical therapy + angiography and revascularization if feasible) or a conservative approach (medical therapy alone with revascularization if medical therapy failed). Cohorts were combined after no trial-specific effects were observed. Diabetes was defined by history, hemoglobin A1c ≥6.5%, or use of glucose-lowering medication. The primary outcome was all-cause death or myocardial infarction (MI). Heterogeneity of effect of invasive management on death or MI was evaluated using a Bayesian approach to protect against random high or low estimates of treatment effect for patients with versus without diabetes and for diabetes subgroups of clinical (female sex and insulin use) and anatomic features (coronary artery disease severity or left ventricular function).

RESULTS

Of 5900 participants with complete baseline data, the median age was 64 years (interquartile range, 57-70), 24% were female, and the median estimated glomerular filtration was 80 mL·min-1·1.73-2 (interquartile range, 64-95). Among the 2553 (43%) of participants with diabetes, the median percent hemoglobin A1c was 7% (interquartile range, 7-8), and 30% were insulin-treated. Participants with diabetes had a 49% increased hazard of death or MI (hazard ratio, 1.49 [95% CI, 1.31-1.70]; P<0.001). At median 3.1-year follow-up the adjusted event-free survival was 0.54 (95% bootstrapped CI, 0.48-0.60) and 0.66 (95% bootstrapped CI, 0.61-0.71) for patients with diabetes versus without diabetes, respectively, with a 12% (95% bootstrapped CI, 4%-20%) absolute decrease in event-free survival among participants with diabetes. Female and male patients with insulin-treated diabetes had an adjusted event-free survival of 0.52 (95% bootstrapped CI, 0.42-0.56) and 0.49 (95% bootstrapped CI, 0.42-0.56), respectively. There was no difference in death or MI between strategies for patients with diabetes versus without diabetes, or for clinical (female sex or insulin use) or anatomic features (coronary artery disease severity or left ventricular function) of patients with diabetes.

CONCLUSIONS

Despite higher risk for death or MI, chronic coronary disease patients with diabetes did not derive incremental benefit from routine invasive management compared with initial medical therapy alone. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01471522.

Cardiovascular risk factor management in patients with diabetes: Does management differ with disease duration?

AIMS

Our objective was to examine risk factor modification targets and treatment in relation to duration of diabetes.

METHODS

The Diabetes Mellitus Status in Canada (DM-SCAN) study collected data on 5109 patients with type 2 diabetes mellitus (T2DM) in 2012 in primary care. We compared the prevalence of vascular complications, treatment targets, and interventions between patients with diagnosed diabetes duration ≤10 and > 10 years.

RESULTS

Physicians more frequently assigned HbA1c (glycated hemoglobin) targets of 7.1-8.5% (54-69 mmol/mol) to patients with longer duration of diabetes (n = 1647) (19.8% vs 9.5%, p < 0.001). Patients with longer duration of diabetes were less likely to achieve HbA1c targets of ≤7.0% (53 mmol/mol) (39% vs. 55%, p < 0.001), had similar likelihood of achieving blood pressure targets of ≤130/80 mmHg (38% vs. 36%, p = 0.26) and were more likely to achieve LDL-C targets of ≤2.0 mmol/L (≤77.3 mg/dL) (63% vs. 53%, p < 0.001) compared to patients with shorter duration of diabetes (n = 3462). Achievement of all three targets between both groups were similar (13% vs. 13%, p = 0.82). Overall, patients with longer duration of diabetes were more likely to be prescribed anti-hyperglycemic, anti-hypertensive, lipid-lowering medications and referred for diabetes education.

CONCLUSIONS

Only 13% of patients achieved glycemic, blood pressure, and LDL-C targets irrespective of duration of diabetes. Despite being managed with more medications, patients with longer duration of diabetes were less likely to achieve glycemic targets. More focus is needed on developing methods to bridge best care and real-world practice.

Assessing the prevalence and predicting factors of an abnormal gated myocardial perfusion SPECT in asymptomatic patients with type 2 diabetes

Considering the significant prevalence of silent myocardial ischemia and its related morbidity and mortality in asymptomatic type 2 diabetic patients, it is not well known whether early screening with MPI is cost-effective and predicting factors are not well elucidated. This was a cross-sectional study including 63 asymptomatic patients with type 2 diabetes mellitus (T2DM), with normal ECG and ejection fraction. Patients with any history of documented valvular, congestive or ischemic heart disease, renal or hepatic failure were excluded. At first all patients were interviewed and checked for risk factors and then patients underwent a two-day rest/stress 99mTc-MIBI gated MPI SPECT. Data was assessed by QPS/QGS and 4DM software and evaluated by a nuclear medicine specialist with summed stress score (SSS) of more than 4 defined as CAD. There were 42 females (67%) and 21 males (33%), with a mean age of 61.33 ± 6.98 years and 7.97 ± 4.86 years history of T2DM. CAD was detected in 26 (41.3%) patients and was significantly associated with male gender, smoking and requiring insulin therapy (P-value = 0.019, 0.046, 0.05, respectively). A significant association was found between the duration of diabetes, especially when > 15 years, and the probability of having CAD. Multivariable logistic regression revealed that smoking; male gender and diabetes duration were the strongest independent predictors of abnormal MPI results. We found a high (46%) prevalence of abnormal stress MPI SPECT in patients with type 2 diabetes mellitus, despite being asymptomatic. Asymptomatic patients with a history of smoking, long duration of diabetes, being under insulin treatment and male gender might benefit from MPI for early detection of silent ischemia.

Duration of Diabetes and Incident Heart Failure: The ARIC (Atherosclerosis Risk In Communities) Study

OBJECTIVES

This study assessed the association of diabetes duration with incident heart failure (HF).

BACKGROUND

Diabetes increases HF risk. However, the independent effect of diabetes duration on incident HF is unknown.

METHODS

We included 9,734 participants (mean age 63 years, 58% women, 22% Black) at ARIC (Atherosclerosis Risk In Communities) Visit 4 (1996-1998) without HF or coronary heart disease. We calculated diabetes duration at Visit 4 (baseline), utilizing diabetes status at the first 4 ARIC visits spaced 3 years apart, and self-reported diagnosis date for those with diabetes diagnosed before Visit 1. We used Cox regression to estimate associations of diabetes duration with incident HF, accounting for intercurrent coronary heart disease and other risk factors. We performed analyses stratified by age (<65 years or ≥65 years), race, sex, and glycemic control (hemoglobin A1C [HbA1C] consistently <7%, vs HbA1C ≥7%), with tests for interaction.

RESULTS

Over 22.5 years of follow-up, there were 1,968 HF events. Compared to those without diabetes, HF risk rose with longer diabetes duration, with the highest risk among those with ≥15 y diabetes duration (HR: 2.82; 95% CI: 2.25-3.63). Each 5-year increase in diabetes duration was associated with a 17% (95% CI: 11-22) relative increase in HF risk. Similar results were observed across HF subtypes. The HF and diabetes duration associations were stronger among those aged <65 years, those with HbA1C ≥7%, those with a body mass index ≥30 kg/m2, women, and Blacks (all P interactions <0.05).

CONCLUSIONS

Delaying diabetes onset may augment HF prevention efforts, and therapies to improve HF outcomes might target those with long diabetes duration.

Comparing left ventricular mechanical dyssynchrony between diabetic and non-diabetic patients with normal gated SPECT MPI

The aim of this study was to employ phase analysis to diagnose left ventricular mechanical dyssynchrony (LVMD) in asymptomatic patients with diabetes mellitus type 2 and normal perfusion study which may help prevent diabetic cardiomyopathy. Ninety-three consecutive patients with known type 2 diabetes and 81 age- and gender- matched patients without diabetes who were candidates for SPECT-MPI were considered as the control group. The presence of LVMD as an possible risk factor for cardiomyopathy- was determined using phase analysis for each scan with quantitative gated SPECT (QGS) and corridor4DM (4DM) software. All outcomes such as phase bandwidth (PBW) and phase standard deviation (PSD) were compared between the two groups. A total of 174 patients were included in the study. There were no statistically significant difference regarding demographic factors between the two groups (P > 0.05). PBW showed statistically significant differences (increased in diabetics) between the control and diabetic patients (P < 0.05). Kruskal Wallis analysis revealed that as the duration of diabetes is prolonged, especially more than 15 years, the probability of LVMD is increased as well (P = 0.021). Fraction of asymptomatic diabetic patients with normal ejection fraction and gated SPECT MPI-especially those with prolonged diabetes- might have some degrees of LVMD. Phase analysis can detect this which in turn may prevent progress into heart failure.

Intensity of Glycemic Exposure in Early Adulthood and Target Organ Damage in Middle Age: The CARDIA Study

AIM

To determine whether long-term intensity of glycemic exposure (IGE) during young adulthood is associated with multiple target organs function at midlife independent of single fasting glucose (FG) measurement.

METHODS

We included 2,859 participants, aged 18-30 years at Y0, in the Coronary Artery Risk Development in Young Adults (CARDIA) Study. IGE was calculated as the sum of (average FG of two consecutive examinations × years between the examinations) over 25 years. Target organs function was indicated by cardiac structure, left ventricular (LV) systolic function, LV diastolic function, coronary artery calcium (CAC), and urine albumin-to-creatinine ratio (UACR) at Y25. We evaluated the associations between IGE with target organs function using linear regression models and estimated the associations between IGE with numbers of organs involved (0, 1, or ≥ 2 organs) using multinomial logistic regression models.

RESULTS

A 1-SD increment of IGE was significantly associated with worse target organs function after multivariable adjustment: left ventricular mass (β [SE], 5.468 [1.175]); global longitudinal strain (β [SE], 0.161 [0.071]); E/e' ratio (β[SE], 0.192 [0.071]); CAC score (β [SE], 27.948 [6.116]); and log UACR (β [SE], 0.076 [0.010]). Besides, IGE was independently associated with having ≥ 2 organs involved in both overall population (OR [95% CI], 1.48 [1.23, 1.41], P < 0.001) and subgroups stratified by diabetes at Y25.

CONCLUSION

Higher intensity of glycemic exposure during young adulthood was independently associated with subclinical alterations of target organs function at midlife. Our findings highlight the importance of early screening and management of IGE in youth.

Microvascular and macrovascular complications in type 2 diabetes in a multi-ethnic population based in Amsterdam. The HELIUS study

OBJECTIVE

To assess ethnic differences in diabetes-related microvascular and macrovascular complication rates in a multi-ethnic population in the Netherlands.

STUDY, DESIGN AND SETTING

Data from the HELIUS study comprising of 165 Dutch, 591 South-Asian Surinamese, 494 African Surinamese, 272 Ghanaian, 368 Turkish, and 444 Moroccan participants with diabetes were analyzed. Logistic regression was used to assess ethnic differences in microvascular (nephropathy) and macrovascular (coronary heart disease (CHD), peripheral artery disease (PAD) and stroke) complications, with adjustments for age, sex, education, and the conventional risk factors.

RESULTS

In an age-sex adjusted model, ethnic minorities had higher odds of nephropathy than Dutch except for Ghanaians and African Surinamese. The difference remained statistically significant in South-Asian Surinamese (odds ratio: 2.29; 95% CI, 1.09-4.80), but not in the Turkish (1.01; 0.43-2.38) and Moroccan (1.56; 0.68-3.53) participants. The odds of CHD was higher in all ethnic minorities than in Dutch, with the odds ratios ranging from 2.73 (1.09-6.84) in Ghanaians to 6.65 (2.77-15.90) in Turkish in the fully-adjusted model. There were no ethnic differences in the odds of PAD and stroke.

CONCLUSIONS

The findings suggest ethnic inequalities in macrovascular and microvascular complications in diabetes, with nephropathy and CHD being the most common complications affecting ethnic minorities.

Diabetes duration and glycaemic control as predictors of cardiovascular disease and mortality

AIMS

To assess the associations of diabetes duration and glycaemic control (defined by plasma glycated haemoglobin [HbA1c] level) with the risks of cardiovascular disease (CVD) and all-cause mortality and to determine whether the addition of either or both to the established CVD risk factors can improve predictions.

MATERIALS AND METHODS

A total of 435 679 participants from the UK Biobank without CVD at baseline were included. Cox models adjusting for classic risk factors (sociodemographic and anthropometric characteristics, lipid profiles and medication use) were used, and predictive utility was determined by the C-index and net reclassification improvement (NRI).

RESULTS

Compared with participants without diabetes, participants with longer diabetes durations and poorer glycaemic control had a higher risk of fatal/nonfatal CVD. Among participants with diabetes, the fully-adjusted hazard ratios (HRs) for diabetes durations of 5 to <10 years, 10 to <15 years and ≥15 years were 1.15 (95% confidence interval [CI] 0.99, 1.34), 1.50 (95% CI 1.26, 1.79) and 2.22 (95% CI 1.90, 2.58; P-trend <0.01), respectively, compared with participants with diabetes durations <5 years. In addition, those with the longest disease duration (≥15 years) and poorer glycaemic control (HbA1c ≥64 mmol/mol [8%]) had the highest risk of fatal/nonfatal CVD (HR 3.12, 95% CI 2.52, 3.86). Among participants with diabetes, the addition of both diabetes duration and glycaemic control levels significantly improved both the C-index (change in C-index +0.0254; 95% CI 0.0111, 0.0398) and the overall NRI for fatal/nonfatal CVD (0.0992; 95% CI 0.0085, 0.1755) beyond the use of the classic risk factors.

CONCLUSIONS

Both longer diabetes duration and poorer glycaemic control were associated with elevated risks of CVD and mortality. Clinicians should consider not only glycaemic control but also diabetes duration in CVD risk assessments for participants with diabetes.

Outcomes of pancreas transplantation in older versus younger recipients: a comparative analysis

PURPOSE

The feasibility of pancreas transplantation (PT) in older recipients remains a matter of debate. We examined the influence of recipient age on PT outcomes and identified the prognostic factors for older recipients.

METHODS

We compared the outcomes of PT in recipients aged < 50 years (younger group; n = 285) with those in recipients aged ≥ 50 years (older group; n = 94). Prognostic factors in the older group were analyzed by a logistic regression model and the influence of recipient age on survival outcomes were analyzed using propensity score matching.

RESULTS

The patient survival rate was significantly worse in the older group (P < 0.001). Patient death from infection or/and multiple organ failure or cardiac/cerebrovascular events was also more frequent in the older group than in the younger group (P = 0.012 and P = 0.045, respectively). A longer duration of diabetes was an independent risk factor of 1-year mortality in the older group. In a propensity score-matched comparison, the older recipients (n = 77) had significantly poorer survival than the younger recipients (n = 77) (P = 0.026).

CONCLUSIONS

PT should be considered with appropriate caution, especially for older recipients with a long duration of diabetes.

Peripheral Neuropathy and All-Cause and Cardiovascular Mortality in U.S. Adults : A Prospective Cohort Study

BACKGROUND

Growing evidence indicates that peripheral neuropathy (PN) is common even in the absence of diabetes. However, the clinical sequelae of PN have not been quantified in the general population.

OBJECTIVE

To assess the associations of PN with all-cause and cardiovascular mortality in the general adult population of the United States.

DESIGN

Prospective cohort study.

SETTING

NHANES (National Health and Nutrition Examination Survey), 1999 to 2004.

PARTICIPANTS

7116 adults aged 40 years or older who had standardized monofilament testing for PN.

MEASUREMENTS

Cox regression to evaluate the associations of PN with all-cause and cardiovascular mortality after adjustment for demographic and cardiovascular risk factors, overall and stratified by diabetes status.

RESULTS

The overall prevalence of PN (±SE) was 13.5% ± 0.5% (27.0% ± 1.4% in adults with diabetes and 11.6% ± 0.5% in adults without diabetes). During a median follow-up of 13 years, 2128 participants died, including 488 of cardiovascular causes. Incidence rates (per 1000 person-years) of all-cause mortality were 57.6 (95% CI, 48.4 to 68.7) in adults with diabetes and PN, 34.3 (CI, 30.3 to 38.8) in adults with PN but no diabetes, 27.1 (CI, 23.4 to 31.5) in adults with diabetes but no PN, and 13.0 (CI, 12.1 to 14.0) in adults with no diabetes and no PN. In adjusted models, PN was significantly associated with all-cause mortality (hazard ratio [HR], 1.49 [CI, 1.15 to 1.94]) and cardiovascular mortality (HR, 1.66 [CI, 1.07 to 2.57]) in participants with diabetes. In those without diabetes, PN was significantly associated with all-cause mortality (HR, 1.31 [CI, 1.15 to 1.50]), but the association between PN and cardiovascular mortality was not statistically significant after adjustment (HR, 1.27 [CI, 0.98 to 1.66]).

LIMITATION

Prevalent cardiovascular disease was self-reported, and PN was defined by monofilament testing only.

CONCLUSION

Peripheral neuropathy was common and was independently associated with mortality in the U.S. population, even in the absence of diabetes. These findings suggest that decreased sensation in the foot may be an underrecognized risk factor for death in the general population.

PRIMARY FUNDING SOURCE

National Institute of Diabetes and Digestive and Kidney Diseases and National Heart, Lung, and Blood Institute of the National Institutes of Health.