History of heart failure and chronic kidney disease and the risk for all-cause death after COVID-19 during the three first waves in comparison to influenza outbreaks in Sweden

Background

Infection with SARS-CoV-2 (COVID-19) affects people globally causing hospitalisation and reduced life expectancy. To improve future preventive measures there is a need of extensive analysis on contributing risk factors for severe COVID-19 outcome.

Purpose

To explore how cardiorenal disease (CRD; heart failure and/or chronic kidney disease) impacted mortality in patients hospitalised for COVID-19 during the three first waves in Sweden in comparison to previous influenza outbreaks and with a sex perspective.

Methods

All patients in Sweden with a main hospital diagnosis of COVID-19 (January 2020-September 2021) or influenza (January 2015-December 2019) with previous CRD were identified in registries and compared with a reference group free from CRD but with COVID-19 or influenza. Associated risk of all-cause death during the first year was analysed using adjusted Cox proportional hazards models.

Results

In COVID-19 patients with and without prior history of CRD (n=44,866) mean age was 79.8 years (SD 11.8) and 43% were women. In influenza patients (n=8897) mean age was 80.6 (SD 11.5) years and 45% were women. COVID-19 vs. influenza was associated with higher mortality risk the first two waves (HR 1.53; 95% CI 1.45–1.62, p<0.001 and 1.52; 1.44–1.61, p<0.001) but not in the third wave (1.07; 0.99–1.14, p=0.072). The cumulative incidence of all-cause death was increased in COVID-19 patients and in influenza patients if CRD was present (Figure 1). Further, CRD was an independent risk factor for all-cause death after COVID-19 in men and women (men: 1.37; 1.31–1.44, p<0.001, women: 1.46; 1.38–1.54, p<0.001). At ages <70 years women with CRD had a similar mortality rate as men with CRD while at ages ≥70 years mortality rate was higher in men (Figure 2).

Conclusions

Outcome after COVID-19 is worse if CRD is present. In women at ages <70 years the presence of CRD attenuates the protective effect of female sex. Further COVID-19 was associated with higher mortality risk than influenza during the first two waves.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The Family Kamprad FoundationAstraZeneca (study sponsor)

Measures of insulin resistance as a screening tool for dysglycaemia in patients with coronary artery disease. A report from the EUROASPIRE V population

Background

The optimal screening strategy for dysglycaemia, including type 2 diabetes (T2DM) and impaired glucose tolerance (IGT), in patients with coronary artery disease (CAD) is debated.

Purpose

We tested the hypothesis that measures of insulin resistance by homeostasis model assessment (HOMA) indexes may constitute accurate screening methods in a CAD population.

Methods

Insulin, C-peptide, glycated haemoglobin A1c (HbA1c) and an oral glucose tolerance test (OGTT) were centrally assessed in 3534 CAD patients without known dysglycaemia from the EUROASPIRE V survey. Three different HOMA indexes were calculated: HOMA-IR, HOMA2 based on insulin (HOMA2-ins), and HOMA2 based on C-peptide (HOMA2-Cpep). Dysglycaemia was diagnosed based on the two-hour postload glucose (2hPG) value obtained from the OGTT. Information on study participants was obtained by standardised visits. The optimal thresholds of the three HOMA indexes for dysglycaemia diagnosis were obtained by the maximum value of Youden's J statistic on receiver operator characteristics curves. The diagnostic performance of such thresholds was tested for both T2DM (i.e. in reference to a 2hPG value ≥11 mmol/L) and dysglycaemia (i.e. in reference to 2hPG value ≥7.8 mmol/L) and their correlation with several clinical parameters was assessed by Spearman's coefficients.

Results

The mean age of the patients was 63 years and 25% were women. Fifty-four percent of the patients had central obesity, 18% were current smokers, mean blood pressure was 133/80 mmHg and mean LDL-cholesterol 2.4 mmol/L. The OGTT revealed that 41% were dysglycaemic (IGT = 24% and T2DM = 16%). Mean insulin, C-peptide and HOMA indexes were significantly higher in patients with vs. without newly detected dysglycaemia (all p&lt;0.0001). Sensitivity and specificity of the three HOMA indexes for the diagnosis of dysglycaemia were low and the associations between 2hPG and the other parameters in the total sample were weak, with Spearman correlation coefficients of 0.15 for fasting insulin, 0.19 for C-peptide, 0.24 for HOMA-IR, 0.18 for HOMA2-ins and 0.22 for HOMA2-Cpep. HOMA-IR, HOMA2-ins and C-peptide were strongly correlated with body mass index and waist circumference (Spearman correlation coefficients ranging 0.43–0.47).

Conclusion

Screening for dysglycaemia in CAD patients by insulin, C-peptide, HOMA-IR, HOMA2-ins and HOMA2-Cpep had insufficient diagnostic performance to detect dysglycaemia with reference to the yield of an OGTT, which should still be prioritized. Further studies are warranted to assess whether measures of insulin resistance might be better markers of unfavourable metabolic derangement beyond dysglycaemia.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): European Society of CardiologyErling-Perssons Stiftelse

Periodontitis and cardiovascular outcome – a prospective follow-up of the PAROKRANK cohort

Background

There is an association between periodontitis (PD) and myocardial infarction (MI). Whether that is related to shared risk factors or it is causal is debated. The Periodontitis and Its Relation to Coronary Artery Disease (PAROKRANK) case-control study previously reported on an independent association between PD and a first MI.

Purpose

This follow-up of the PAROKRANK study tests the hypothesis that PD increases the risk for new cardiovascular (CV) events.

Methods

Between 2010–2014 805 patients (age &lt;75 years; females 19%) with a first MI and 805 controls without MI, matched for gender, age (mean 62±8 years) and living area underwent a CV and dental examination including panoramic x-ray. The PD was categorised in three grades: healthy (≥80% remaining alveolar bone height), moderate (79–66%) or severe (&lt;66%). The composite primary endpoint was the first of all-cause death, non-fatal MI or stroke, or severe heart failure until December 2018. The first of CV-death, non-fatal MI or stroke, or severe heart failure served as a secondary CV-endpoint. Data on outcomes were provided via linkage to the National Patient Registries and the Cause of Death Registry. Cumulative event rates, stratified by PD status at baseline in the combined cohort of cases and controls, were calculated using logistic regression and the Kaplan-Meier method.

Results

A total of 1587 participants with evaluated PD-status were followed for a mean of 6.2 (range 0.2–8.5) years. The total number of primary events and CV-events was 205 and 158 respectively. The number of deaths was 68. Baseline PD-status was healthy in 985 (mean age 60.4 years), moderate in 489 (mean age 65.1 years) and severe in 113 (mean age 64.3 years) participants. The figure presents the time to primary event by the three PD grades in the combined cohort (patients and controls). Time to the primary endpoint differed between the three PD grades (log-rank test 0.0148), however, significant only for patients (log-rank test patients vs. controls: 0.0382 vs. 0.608). Replacing the primary endpoint with the secondary CV-endpoint just changed the outcome slightly (log-rank 0.0976), possibly due to a low number of CV-deaths within the CV-event. Compared to participants without PD, the presence of PD at baseline was associated with the primary endpoint in the total cohort (Odds Ratio (OR): 1.49; 95% Confidence Interval (CI): 1.11–2.00) as well as the CV-endpoint (OR 1.42; 95% CI 1.02–1.98). PD was not associated with total mortality (OR 1.57; 95% CI 0.97–2.56).

Conclusion

In this up to 8-years follow up of the PAROKRANK cohort there was a graded increase in the risk for new CV-events by the presence of PD. This was in particular seen in the MI-patients. Together with the previous case-control based report from PAROKRANK, on an association between PD and a first MI, the findings during the follow-up supports the assumption that there may be a causal relationship between PD and CV-disease.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The PAROKRANK study was supported by grants from AFA Insurance, Swedish Heart-Lung Foundation, Swedish Research Council, Swedish Society of Medicine, Stockholm County Council (ALF project and Steering committee KI/SLL for odontological research), and The Baltic Child Foundation. Figure 1

Long term outcome after a first myocardial infarction

Background

Prognosis after a myocardial infarction (MI) have improved consistently over the last decades. In parallel, the incidence of cardiovascular (CV) events has been reduced and life expectancy in people free from CV disease improved.

Purpose

To explore the long-term mortality and burden of cardiovascular disease in patients after a first MI compared to matched controls in a contemporary setting.

Methods

The Swedish case-control study PAROKRANK recruited 805 patients &lt;75 years with a first MI and 805 age-, gender- and area-matched controls from 2010 to 2014. All participants were followed by means of registry-based information. The primary endpoint was the first of a composite of all-cause death, non-fatal MI, non-fatal stroke and heart failure hospitalization. Data on the outcomes were provided via linkage to the National Patient Registries and the Cause of Death Registry. Hazard Ratios (HR) for the first composite event were calculated by means of a Cox regression model, subsequently adjusted for smoking, education level and marital status at baseline. Event curves for the time-to-first event in patients and controls were computed by Kaplan-Meier curves and the two groups were compared by means of the log-rank test.

Results

Data from 804 patients and 800 controls (mean age in both groups 62 years; women 19%) were complete for an average period of 6.2 years (0.2–8.5 years). The total number of events was 211. Patients had a higher event rate than controls (log rank p&lt;0.0001). Unadjusted HR for the primary outcome was 2.08 (95% confidence interval (CI) 1.56–2.77) while the adjusted HR was 2.04 (95% CI 1.52–2.73). Mortality did not differ significantly between patients (n=38; 4.7%) and controls (n=35; 4.4%). In total, 82.5% of the patients and 91.3% of the controls were event-free during follow-up.

Conclusion

This long-term follow-up of a contemporary, nationwide case-control cohort illustrates that the likelihood for CV events is higher in patients with a first MI compared to their matched controls while mortality did not differ. The access to high quality of care and cardiac rehabilitation might explain the low rates of adverse outcomes.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): AFA Insurance, Swedish Heart-Lung Foundation, Swedish Research Council, Swedish Society of Medicine, Stockholm County Council (ALF project and Steering committee KI/SLL for odontological research), and The Baltic Child Foundation. Figure 1. Kaplan-Meier curves

Time trends in risk factor control and use of secondary preventive medication among patients with myocardial infarction attending cardiac rehabilitation: data from the SWEDEHEART registry 2006–2017

Background

Systematically monitoring results within cardiac rehabilitation (CR) has been highlighted as a possible way to improve CR outcomes. The nationwide SWEDEHEART registry has monitored quality of care post myocardial infarction (MI) in Sweden since the 1990s. Follow-up data describing treatment and outcomes within CR has been collected since 2006.

Purpose

To describe changes in risk factor control and use of secondary preventive medication for post MI patients after completion of CR in Sweden 2006–2017, and to compare with trends in the EUROASPIRE surveys.

Methods

All patients who suffered an MI and attended a one-year CR follow-up visit registered in SWEDEHEART 2006–2017 were included (n=66 666, 18–74 years, 75% men). Trends in risk factor control and secondary preventive medication were collected yearly and analyzed over the time period using Cochran-Armitage trend test. Comparisons were made to data from the EUROASPIRE III (2006–2007), IV (2012–2013) and V (2016–2017) surveys, where patients with coronary artery events or interventions were interviewed at approximately 1.2 years after the index event (n=25 225, 18–80 years, 74% men).

Results

Trends in blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) control, smoking, and central obesity are shown in the Figure. The proportion of patients achieving BP goal &lt;140/90 mmHg and LDL-C goal &lt;1.8 mmol/L increased by 16% and 29% from 2006 to 2017 in SWEDEHEART (p for trend &lt;0.0001 for both), compared to 14% and 8% between EUROASPIRE III and V. Of patients who were active smokers at the time of the index event, the proportion still smoking at one-year remained unchanged in SWEDEHEART (43% in 2006 and 2017) while increasing from 52% to 55% in the EUROASPIRE surveys. An increase in prevalence of central obesity from approximately 50% to 60% was observed in both cohorts. The proportion of patients with obesity (BMI ≥30kg/m2) and diabetes increased in SWEDEHEART during the observed period from 23% to 29% (obesity) and 18% to 25% (diabetes) (p for trend &lt;0.0001 for both). The proportions in 2017 were considerably lower than in EUROASPIRE V (2016–2017), where 38% were obese and 29% had diabetes. The use of statins increased from 89% to 93%, ezetimibe from 5% to 21%, and ACE/ARB from 65% to 82% in SWEDEHEART (p for trend &lt;0.0001 for all). In comparison, in EUROASPIRE V the proportion treated with lipid lowering medication of any kind was 84% and with ACE/ARB was 75%.

Conclusion

Between 2006–2017, considerable improvements were achieved in risk factor control and use of secondary preventive medication for MI patients completing CR in Sweden, where all patients were monitored through the SWEDEHEART registry. The improvements were larger than observed in the EUROASPIRE surveys during the same time period. Continuous and nationwide auditing of CR outcomes, as well as local review of performance, could be possible explanations for some of the observed differences.

Figure 1

Funding Acknowledgement

Type of funding source: None

P6400Risk for heart failure after acute myocardial infarction, a nationwide report on 73 303 patients with and without diabetes 2012–2017 in the SWEDEHEART-SCAAR registry

Background

Impressive improved one-year survival rates after acute myocardial infarction (AMI) have been achieved the last decades while long-term cardiovascular events still are a challenge particularly when diabetes is present. Recently several glucose lowering drugs with preventive effects on heart failure (HF) and MACE have entered the market however still used in low proportion by cardiologists.

Purpose

To explore the real-life complication rates of HF after AMI in patients with and without diabetes.

Methods

All patients with AMI admitted for coronary angiography in Sweden 2012–2017 were followed for time to first hospitalisation with HF diagnosis (ICD-10 code I50) until December 2017. Kaplan-Meier curves were used to estimate the cumulative heart failure event stratified by previous MI. Hazard ratios (HR) were calculated in a Cox proportional hazard regression model adjusting for age, gender, smoking, creatinine, previous CABG/cancer/dementia/dialysis/hypertension/COPD/renal failure/stroke, year, indication, hospital, angiographic findings, primary decision after angiography, cardiac chock, medications at discharge.

Results

Of 73 303 patients, mean age was 69 years (SD±12), 69% were men and 24% had diabetes. In all, HF occurred in 14% with a higher rate in patients with diabetes than those without (22% vs 12%). The highest HF rates were seen in patients with previous MI (33% if diabetes was present vs. 23% if no diabetes). After adjustments, patients with diabetes without previous MI had about the same HF risk (HR 1.52 [95% CI 1.44–1.61]) as patients without diabetes with previous MI (1.48 [1.40–1.57]) where patients without diabetes and previous MI served as a reference. The same pattern was seen regardless of STEMI/NSTEMI and also after excluding patients with previous HF (n=4567, 6%; Figure; patients with diabetes without previous MI 1.48 [1.40–1.57] and patients without diabetes with previous MI 1.27 [1.19–1.36]).

Conclusion

Heart failure is a common complication after AMI in patients with diabetes, particularly if previous MI, and regardless of previous reported heart failure. Diabetes increases the risk of heart failure by 30–50% compared to those without diabetes. These data indicate the existence of a large diabetes population at heart failure risk after AMI where heart failure protective glucose lowering drugs could be suitable.

Acknowledgement/Funding

The Swedish Heart and Lung foundation, Department of Research and Development Region Kronoberg, the Kamprad Family Foundation

209Glucose is associated with future atrial fibrillation and heart failure already at prediabetes levels, a 19 year follow up of 243,665 subjects

Background

Dysglycaemia is associated with cardiovascular disease even below the diagnostic diabetes threshold. Atrial fibrillation (AF) has been found to be associated with the metabolic syndrome and life-style changes after AF have been found to reduce recurrence of AF.

Purpose

We explored the association glucose and risk of first event of AF, HF and combined event.

Methods

Subject with fasting glucose in the AMORIS cohort, obtained 1985–1996 at routine occupational health check-ups or primary care in the Stockholm area were included. Subjects with prevalent AF, HF, ischemic heart disease, revascularization and cerebrovascular disease were excluded. Glucose levels were categorised as low (<3.9 mmol/L), normal (3.9–6.0mmol/L), impaired (IFG; 6.1–6.9 mmol/L) and diabetes (≥7.0 mmol/L or a diabetes diagnosis) according to WHO definition in 2006. First events of AF, HF or a combined event was identified until December 2011 by linkage to national registries. Information on co-morbidities was obtained from the National Patient Register. Hazard ratios (HR and 95% CI) by glucose group for AF and heart failure were calculated using Cox proportional hazards with attained age as timescale and adjusting for gender, total cholesterol and triglycerides. The change in AF risk by increasing glucose level was described by using splines (Figure).

Results

243 665 subjects with mean age 48.3 at index date, 54% male were included. During a mean follow-up time of 19.1 years and 4,7 million person years, 23 522 events of AF, 21 411 events of HF and 35 131 combined events occurred. The proportion with IFG and diabetes were 3.2% and 3.3% respectively. In the diabetes group about half were diagnosed prevalent cases (1.5%). Glucose was continuously associated with developement of AF (Table and Figure) and even more of HF (Table).

Events (n) and HR by glucose category Atrial fibrillation Heart failure Combined event Event HR [95% CI] Event HR [95% CI] Event HR [95% CI] Low 405 0.97 [0.88–1.08] 326 0.97 [0.87–1.08] 598 1.00 [0.92–1.09] Normal 20 663 1.00 17 811 1.00 30 159 1.00 IFG 1185 1.20 [1.13–1.28] 1319 1.43 [1.35–1.51] 1901 1.30 [1.24–1.36] Diabetes 1269 1.28 [1.20–1.35] 1955 2.19 [2.08–2.29] 2473 1.73 [1.66–1.81] Events (n) of AF, HF and combined and HR (95% CI) by fasting glucose category.

HR for AF by glucose level spline graph

Conclusion

Dysglycaemia, including glucose levels below the diabetes threshold, is continuously associated with future risk of both AF and HF. These data are important considering the large population with undetected dysglycaemia at risk for AF and HF where preventive measures including life-style changes could be of importance even before the onset of overt diabetes.

Acknowledgement/Funding

Swedish Heart and Lung foundation

Invasive Dental Treatment and Risk for a First Myocardial Infarction

Invasive dental treatment is suggested to be associated with an increased risk for the development of cardiovascular events. We tested the hypothesis that the incidence of a first myocardial infarction (MI) within 4 wk after invasive dental treatments is increased. A registry-based case-control study within nationwide health care and population registries in Sweden was performed. The case patients included 51,880 individuals with a first fatal or nonfatal MI between January 2011 and December 2013. For each case, 5 control subjects, free from prior MI and matched for age, sex, and geographic area of residence, were randomly selected from the national population registry through risk set sampling with replacement, resulting in 246,978 control subjects. Information on dental treatments was obtained from the Dental Health Register, and the procedures were categorized into invasive dental treatments or other dental treatments. Conditional logistic regression was used to estimate odds ratios (ORs) for MI with corresponding 95% confidence intervals (CIs). In addition to the matching variables, adjustments were made for the following confounders: diabetes, previous cardiovascular disease (CVD), CVD drug treatment, education, and income. The mean age for case patients and controls subjects was 72.6 ± 13.0 y and 72.3 ± 13.0 y, respectively. Case patients more often had previous CVD (49% vs. 23%; P < 0.001) and diabetes (19% vs. 11%; P < 0.001) and received more treatment with CVD drugs (68% vs. 56%; P < 0.001) than control subjects. There was no association between invasive dental treatments during the 4 wk preceding the MI index date (crude OR = 0.99; 95% CI, 0.92 to 1.06; adjusted for confounders OR = 0.98; 95% CI, 0.91 to 1.06). This study did not support the hypothesis of an increased incidence of MI after recent invasive dental treatment.

Severe Periodontitis Is Associated with Myocardial Infarction in Females

The aim of the present study was to test the hypothesis that there is a sex difference in the association between periodontitis (PD) and a first myocardial infarction (MI). The analysis in the case-control study was based on 785 patients (147 females and 638 males) with a first MI and 792 matched controls (147 females and 645 males), screened for cardiovascular risk factors and subjected to a panoramic dental X-ray. Periodontal status was defined by alveolar bone loss and diagnosed as no PD (≥80% remaining alveolar bone), mild to moderate PD (66% to 79%), or severe PD (<66%). Logistic regression was used when analyzing PD as a risk factor for MI, adjusting for age, smoking, diabetes, education, and marital status. The mean age was 64 ± 7 y for females and 62 ± 8 y for males. Severe PD was more common in female patients than female controls (14 vs. 4%, P = 0.005), with an increased risk for severe PD among female patients with a first MI (odds ratio [OR] = 3.92, 95% confidence interval [CI] =1.53 to 10.00, P = 0.005), which remained (OR = 3.72, 95% CI = 1.24 to 11.16, P = 0.005) after adjustments. Male patients had more severe PD (7% vs. 4%; P = 0.005) than male controls and an increased risk for severe PD (OR = 1.88, 95% CI = 1.14 to 3.11, P = 0.005), but this association did not remain following adjustment (OR = 1.67, 95% CI = 0.97 to 2.84, NS). Severe PD was associated with MI in both females and males. After adjustments for relevant confounders, this association did, however, remain only in females. These data underline the importance of considering poor dental health when evaluating cardiovascular risk, especially in females.

Mortality and extent of coronary artery disease in 2776 patients with type 1 diabetes undergoing coronary angiography: A nationwide study

Background In a modern perspective there is limited information on mortality by affected coronary vessels assessed by coronary angiography in patients with type 1 diabetes. The aim of the present study was to characterise distribution of coronary artery disease and impact on long-term mortality in patients with type 1 diabetes undergoing coronary angiography. Design The design of this research was a nationwide population-based cohort study. Methods Individuals ( n = 2776) with type 1 diabetes undergoing coronary angiography 2001-2013 included in the Swedish National Diabetes Registry and Swedish Coronary Angiography and Angioplasty Registry were followed for mortality until 31 December 2013 (mean 7.1 years). In 79% the indication was stable or acute coronary artery disease. Coronary artery disease was categorised into normal (21%), one- (23%), two- (18%), three- (29%) and left main-vessel disease (8%). Results Mean age was 57 years and 58% were male. Mean diabetes duration was 35 years, glycated haemoglobin was 67 mmol/mol and 44% had normal or one-vessel disease. In multivariate Cox proportional analyses hazard ratio for mortality compared with normal findings was 1.09 (95% confidence interval 0.80-1.48) for one, 1.43 (1.05-1.94) for two, 1.47 (1.10-1.96) for three and 1.90 (1.35-2.68) for left main-vessel disease. Renal failure 2.29 (1.77-2.96) and previous heart failure 1.76 (1.46-2.13) were highly associated with mortality. Standard mortality ratio the first year was 5.55 (4.65-6.56) and decreased to 2.80 (2.18-3.54) after five years. Conclusions In patients with type 1 diabetes referred for coronary angiography mortality is influenced by numbers of affected coronary vessels. The overall mortality rate was higher compared with the general population. These results support early intensive prevention of coronary artery disease in this population.

Type 2 diabetes and cardiovascular disease in women

Cardiovascular disease is the leading cause of death in both men and women. This is also true for patients with diabetes. In general, differences between the sexes are present in several areas, such as epidemiology, pathophysiology, diagnostics, treatment response and prognosis, as well as the way in which disease is experienced and expressed. Cardiovascular disease presents later in life in women, who are therefore more likely to suffer from comorbidities. However, this age-related difference is attenuated in women with diabetes, who suffer their first myocardial infarction at about the same age as men with diabetes. Diabetes mellitus increases the risk of cardiovascular disease by three to four times in women and two to three times in men, after adjusting for other risk factors. This paper describes the differences in cardiovascular disease in men and women and the special situation of women with type 2 diabetes when it comes to risk factors, symptoms and the setting of acute coronary syndromes. Furthermore, it highlights the importance of sex-specific analyses in clinical research to improve our knowledge of cardiovascular disease in women in general and in women with diabetes in particular. The importance of taking sex into account when treating women and men at risk of cardiovascular disease is discussed.

Long-term mortality in patients with type 2 diabetes undergoing coronary angiography: the impact of glucose-lowering treatment

AIMS/HYPOTHESIS

The aim of this study was to analyse whether the increased mortality rates observed in insulin-treated patients with type 2 diabetes and coronary artery disease are explained by comorbidities and complications.

METHODS

A retrospective analysis of data from two Swedish registries of type 2 diabetic patients (n = 12,515) undergoing coronary angiography between the years 2001 and 2009 was conducted. The association between glucose-lowering treatment and long-term mortality was studied after extensive adjustment for cardiovascular- and diabetes-related confounders. Patients were classified into four groups, according to glucose-lowering treatment: diet alone; oral therapy alone; insulin in combination with oral therapy; and insulin alone.

RESULTS

After a mean follow-up time of 4.14 years, absolute mortality rates for patients treated with diet alone, oral therapy alone, insulin in combination with oral therapy and insulin alone were 19.2%, 17.4%, 22.9% and 28.1%, respectively. Compared with diet alone, insulin in combination with oral therapy (HR 1.27; 95% CI 1.12, 1.43) and insulin alone (HR 1.62; 95% CI 1.44, 1.83) were associated with higher mortality rates. After adjustment for baseline differences, insulin in combination with oral glucose-lowering treatment (HR 1.22; 95% CI 1.06, 1.40; p < 0.005) and treatment with insulin only (HR 1.17; 95% CI 1.02, 1.35; p < 0.01) remained independent predictors for long-term mortality.

CONCLUSIONS/INTERPRETATION

Type 2 diabetes patients treated with insulin and undergoing coronary angiography have a higher long-term mortality risk after adjustment for measured confounders. Further research is needed to evaluate the optimal glucose-lowering treatment for these high-risk patients.

Prognostic implications of glucose-lowering treatment in patients with acute myocardial infarction and diabetes: experiences from an extended follow-up of the Diabetes Mellitus Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) 2 Study

AIMS/HYPOTHESIS

This post hoc analysis from the Diabetes Mellitus Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) 2 trial reports on extended long-term outcome in relation to glucose-lowering agents in patients with myocardial infarction and type 2 diabetes.

METHODS

Patients were randomised as follows: group 1, insulin-based treatment; group 2, insulin during hospitalisation followed by conventional glucose control; and group 3, conventional treatment. Treatment according to the above protocol lasted 2.1 years. Using the total DIGAMI 2 cohort as an epidemiological database, this study presents mortality rates in the randomised groups, and mortality and morbidity rates by glucose-lowering treatment during an extended period of follow-up (median 4.1 and max 8.1 years).

RESULTS

Follow-up data were available in 1,145 of the 1,253 patients. The mortality rate was 31% (72% cardiovascular) without significant differences between treatment groups. The total number of fatal malignancies was 37, with a trend towards a higher risk in group 1. The HR for death from malignant disease, compared with group 2, was 1.77 (95% CI 0.87-3.61; p = 0.11) and 3.60 (95% CI 1.24-10.50; p = 0.02) compared with group 3. Insulin treatment was associated with non-fatal cardiovascular events (OR 1.89 95% CI 1.35-2.63; p = 0.0002), but not with mortality (OR 1.30, 95% CI 0.93-1.81; p = 0.13). Metformin was associated with a lower mortality rate (HR 0.65, 95% CI 0.47-0.90; p = 0.01) and a lower risk of death from malignancies (HR 0.25, 95% CI 0.08-0.83; p = 0.02).

CONCLUSIONS/INTERPRETATION

Patients with type 2 diabetes and myocardial infarction have a poor prognosis. Glucose-lowering drugs appear to be of prognostic importance. Insulin may be associated with an increased risk of non-fatal cardiac events, while metformin seems to be protective against risk of death.

Effect of gender on prognosis in patients with myocardial infarction and type 2 diabetes

BACKGROUND

Diabetes is associated with a markedly increased cardiovascular risk, but the role of gender on the combined effects of diabetes and myocardial infarction has been less well explored.

METHODS

The Diabetes Mellitus and Insulin Glucose Infusion in Acute Myocardial Infarction 2 (DIGAMI2) trial recruited 837 men and 416 women with type 2 diabetes hospitalized due to myocardial infarction and followed for a median of 2.1 years. The effects of gender on diabetes-specific risk factors and conventional cardiovascular risk predictors of unfavourable outcome were analysed using a Cox proportional hazards model.

RESULTS

Women were older, more frequently had hypertension and previous heart failure than men, and were more often treated with diuretics. More men were smokers. Treatment during hospitalization, at discharge and during follow-up, did not differ significantly, apart from the more frequent use of diuretics in women. Total mortality did not differ between genders, but the combined cardiovascular end-point of death, re-infarction or stroke was more common in women (38.9% vs. 32.1%). This difference disappeared after age adjustment. Age and previous heart failure were independent risk predictors in both genders, whereas diabetes complications were an additional risk factor in women only. Blood glucose level at randomization and updated glucose concentration during follow-up were independent predictors of poor outcome in men but not in women.

CONCLUSIONS

Age and not gender itself explained the increased cardiovascular event rate seen in women compared with men. A heavier risk factor burden was seen amongst women. Improved risk factor control instituted before the development of a myocardial infarction should be attempted as a possible means of improving the outcome.

Leptin: a predictor of abnormal glucose tolerance and prognosis in patients with myocardial infarction and without previously known Type 2 diabetes

AIMS

High levels of leptin and low adiponectin are associated with Type 2 diabetes mellitus (T2DM) and cardiovascular (CV) disease. We studied the prognostic implications of leptin and adiponectin in patients with acute myocardial infarction (AMI) without previously known Type 2 DM.

METHODS

One hundred and eighty-one patients were included. Based on an oral glucose tolerance test at hospital discharge (day 4-5), 168 (67% men) had normal or abnormal glucose tolerance (AGT), defined as impaired glucose tolerance or T2DM. Sex- and age-matched healthy persons served as control subjects (n = 185). The associations between fasting serum leptin and adiponectin (day 2) and newly discovered AGT and CV events (CV mortality, non-fatal stroke, reinfarction or severe heart failure) during a median follow-up of 34 months were investigated.

RESULTS

Compared with control subjects, patients of both genders had significantly higher levels of leptin 2 days after an AMI. These levels were higher than those obtained at hospital discharge and 3 months later. Circulating levels of (ln) leptin 2 days after the AMI predicted AGT at discharge (odds ratio 2.03, P = 0.042). Ln leptin at day 2 was the only biochemical variable that significantly predicted CV events both on univariate [hazard ratio (HR) 1.60, P = 0.018] and on multivariate analysis (HR 1.75, P = 0.045). Adiponectin levels did not differ between patients and control subjects and did not relate to AGT or CV events.

CONCLUSIONS

Elevated circulating levels of leptin on the first morning after an AMI are associated with the presence of AGT at discharge and with a poorer long-term prognosis.

Women younger than 65 years with diabetes mellitus are a high-risk group after myocardial infarction: a report from the Swedish Register of Information and Knowledge about Swedish Heart Intensive Care Admission (RIKS-HIA)

OBJECTIVE

To analyse gender differences in prognosis, risk factors and evidence-based treatment in patients with diabetes and myocardial infarction.

METHODS

Mortality in 1995-2002 was analysed in 70 882 Swedish patients (age <80) with a first registry-recorded acute myocardial infarction stratified by gender and age. Owing to gender differences in mortality, specifically characterising patients below the age of 65 years, a more detailed analysis was performed within this cohort of 25 555 patients. In this group, 5786 (23%) were women and 4473 (18%) had diabetes. Differences in clinical and other parameters were adjusted for using a propensity score model.

RESULTS

Long-term mortality in diabetic patients aged <65 years was significantly higher in women than men (RR 1.34; 95% CI 1.16 to 1.55). Compared with diabetic men, women had an increased risk factor burden (hypertension 49 vs 43%; RR 1.12; 95% CI 1.05 to 1.20; heart failure 10 vs 8%; RR 1.25; 95% CI 1.03 to 1.53). Diabetic women aged <65 years were less frequently treated with intravenous beta-blockade during the acute hospital phase and with angiotensin-converting enzyme inhibitors at hospital discharge. However, this under-use was not associated with the mortality differences, nor was female gender by itself.

CONCLUSION

Women below 65 years of age with diabetes have a poorer outcome than men after a myocardial infarction. This relates to an increased risk factor burden. It is suggested that greater awareness of this situation and improved prevention have the potential to improve what is an unfavourable situation for these women.

Hyperglycaemia and cardiovascular disease

Coronary artery disease and type 2 diabetes are chronic diseases of substantial and growing prevalence. Their coincidence is common, markedly enhancing mortality and morbidity. The risk for cardiovascular disease increases along a spectrum of blood glucose concentrations already apparent at levels regarded as normal. Accordingly, strategies for the early detection of glucometabolic disturbances are needed to find ways to prevent the occurrence of cardiovascular complications or to treat them already at an early stage. More specifically, abnormal glucose tolerance is almost twice as common amongst patients with a myocardial infarction as in population-based controls and a normal glucose regulation is indeed less common than abnormal glucose metabolism also amongst patients with stable coronary artery disease. Already an abnormal glucose tolerance is a strong risk factor for future cardiovascular events after an acute myocardial infarction. An oral glucose tolerance test should, therefore, be a part of the evaluation of total risk in all patients with coronary artery disease. As glucose disturbances are common and easy to detect, they may be suitable targets for novel secondary preventive efforts.

Insulin-like growth factor I: a predictor of long-term glucose abnormalities in patients with acute myocardial infarction

AIMS/HYPOTHESIS

Low levels of IGF-I are associated with increased risk of cardiovascular disease and type 2 diabetes. The aim of this study was to investigate the IGF-I system in patients with acute myocardial infarction (AMI) without previously known diabetes.

MATERIALS AND METHODS

One hundred and sixty-eight AMI patients were classified before hospital discharge by means of an OGTT as having NGT, IGT or newly detected type 2 diabetes. Age- and sex-matched subjects from the background population (n=185) served as the control group. The associations between fasting levels of IGF-I and IGF binding proteins 1 and 3 (IGFBP-1, IGFBP-3) and glucose metabolism during a follow-up period of 12 months were studied.

RESULTS

At hospital discharge, age-adjusted IGF-I (IGF-I SD) was significantly lower in patients with abnormal glucose tolerance (AGT=IGT or type 2 diabetes) compared with patients with NGT (p=0.014) and control subjects (p<0.001). IGF-I was strongly correlated with IGFBP-3 (r=0.730, p<0.001), which was significantly lower in patients with AGT compared with patients with NGT (p=0.009) and control subjects (p<0.001). Fasting levels of IGFBP-1 did not differ significantly between patients with NGT and AGT or between patients and control subjects. In a multiple logistic regression analysis in patients, IGF-I at hospital discharge was a significant predictor of AGT at discharge and after 12 months (adjusted odds ratio 0.29, p=0.022, and adjusted odds ratio 0.29, p=0.034, respectively).

CONCLUSIONS/INTERPRETATION

Low levels of IGF-I may be a useful predictor of abnormal glucose metabolism in patients with AMI.

Beta cell dysfunction in patients with acute myocardial infarction but without previously known type 2 diabetes: a report from the GAMI study

AIMS/HYPOTHESIS

Patients with acute myocardial infarction (AMI) but without previously known type 2 diabetes have a high prevalence of undiagnosed IGT and type 2 diabetes. Such perturbations have dismal prognostic implications. The aim of this study was to characterise AMI patients in terms of insulin resistance and beta cell function.

METHODS

A total of 168 consecutive AMI patients were classified by means of an OGTT before hospital discharge as having NGT, IGT or type 2 diabetes. The homeostasis model assessment (HOMA-IR) was used to estimate insulin resistance. Beta cell responsiveness was quantified as insulinogenic index (IGI) at 30 min (DeltaI(30)/DeltaG(30)).

RESULTS

According to the HOMA-IR, patients with type 2 diabetes were more insulin resistant than those with IGT or NGT (p=0.003). Beta cell responsiveness deteriorated with decreasing glucose tolerance as measured by the IGI (median [quartile 1, quartile 3] in pmol/mmol: NGT, 70.1 [42.7, 101.4]; IGT, 48.7 [34.7, 86.8], type 2 diabetes, 38.1 [25.7, 61.6]; p<0.001). The IGI was significantly related to admission capillary blood glucose (r=-0.218, p=0.010) and to the area under the curve for glucose (r=-0.475, p<0.001).

CONCLUSIONS/INTERPRETATION

Glucose abnormalities are very common in patients with AMI but without previously known type 2 diabetes. To a significant extent, this seems to be related to impaired beta cell function and implies that dysglycaemia immediately after an infarction is not a stress epiphenomenon but reflects stable disturbances of glucose regulation preceding the AMI. Early beta cell dysfunction may have important pathophysiological implications and may serve as a future target for treatment strategies.

Newly detected abnormal glucose tolerance: an important predictor of long-term outcome after myocardial infarction

AIMS

Recent data revealed that patients with myocardial infarction (MI) have a high prevalence of previously unknown diabetes mellitus (DM) and impaired glucose tolerance (IGT). The added prognostic importance of this finding has not been prospectively explored. To investigate whether a newly detected abnormal glucose tolerance (IGT or DM) assessed early after an MI, is related to long-term prognosis.

METHODS AND RESULTS

Patients (n=168; age 63.5+/-9.3 years) with MI, no previous DM and admission blood glucose <11.0 mmol/l were followed for major cardiovascular events defined as the composite of cardiovascular death, non-fatal MI, non-fatal stroke or severe heart failure (HF). According to an oral glucose tolerance test (OGTT) before hospital discharge, 55 patients had normal and 113 abnormal glucose tolerance (GT). During the follow-up of median 34 months there were eight cardiovascular deaths, 15 patients had a recurrent MI, six had a stroke and ten severe HF. All patients who died from cardiovascular causes had abnormal GT. The composite cardiovascular event occurred in 31 (18%) patients. The probability of remaining free from cardiovascular events was significantly higher in patients with normal than abnormal GT (p=0.002). Together with previous MI, abnormal GT was the strongest predictor of future cardiovascular events (hazard ratio 4.18; CI 1.26-13.84; p=0.019).

CONCLUSIONS

Abnormal glucose tolerance is a strong risk factor for future cardiovascular events after myocardial infarction. Since it is common and possible to detect even during the hospital phase it may be a target for novel secondary preventive efforts.

Abnormal glucose tolerance--a common risk factor in patients with acute myocardial infarction in comparison with population-based controls

BACKGROUND

A high prevalence of newly detected diabetes and impaired glucose tolerance (abnormal glucose tolerance) was recently reported in patients with acute myocardial infarction. It is important to verify whether this finding is specific for the patients or attributable to the population, from which they were recruited.

OBJECTIVE

To verify whether abnormal glucose tolerance is more prevalent in patients than in controls chosen from the same population and to compare metabolic characteristics between the two groups.

DESIGN AND SUBJECTS

The metabolic state was assessed in patients (n = 181) admitted with acute myocardial infarction and no history of diabetes before discharge and after 3 months. Sex- and age-matched controls (n = 185) without previously known diabetes or cardiovascular disease except hypertension were recruited from the general population.

MAIN OUTCOME MEASURES

Oral glucose tolerance test, glucosylated haemoglobin A1c (HbA1c), insulin, proinsulin, lipid profile, fibrinolytic function and inflammatory markers.

RESULTS

Abnormal glucose tolerance was more common (number/all classified) in patients at discharge 113/168 (67%) and after 3 months 95/145 (66%) than in controls 65/185 (35%) (P < 0.001). Dyslipidaemia (70% vs. 29%; P < 0.001) and previously treated hypertension (32% vs. 18%; P = 0.028) were more frequent amongst patients whilst obesity (18% vs. 24%) did not differ significantly. Blood glucose, HbA1c, proinsulin, proinsulin/insulin ratio, triglycerides, insulin resistance (by HOMA) and fibrinogen were consistently higher in patients than controls (P < 0.01).

CONCLUSIONS

Abnormal glucose tolerance was almost twice as common amongst patients with acute myocardial infarction as in matched controls. Impaired glycaemic control accompanied by insulin resistance, dyslipidaemia, hypertension, together with increased plasma fibrinogen and proinsulin levels were main features characterizing patients.

Glycometabolic state at admission: important risk marker of mortality in conventionally treated patients with diabetes mellitus and acute myocardial infarction: long-term results from the Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study

BACKGROUND

The Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study addressed prognostic factors and the effects of concomitant treatment and glycometabolic control in diabetic patients with myocardial infarction (AMI).

METHODS AND RESULTS

Of 620 diabetic patients with AMI, 306 were randomly assigned to a >/=24-hour insulin-glucose infusion followed by multidose subcutaneous insulin. Three hundred fourteen patients were randomized as controls, receiving routine antidiabetic therapy. Thrombolysis and beta-blockers were administered when possible. Univariate and multivariate statistical analyses were applied to study predictors of long-term mortality. During an average follow-up of 3.4 years (range, 1.6 to 5.6 years), 102 patients (33%) in the intensive insulin group and 138 (44%) in the control group died (P=0. 011). Old age, previous heart failure, diabetes duration, admission blood glucose, and admission Hb AIc were independent predictors of mortality in the total cohort, whereas previous AMI, hypertension, smoking, or female sex did not add independent predictive value. Metabolic control, mirrored by blood glucose and Hb AIc, improved significantly more in patients on intensive insulin treatment than in the control group. beta-Blockers improved survival in control subjects, whereas thrombolysis was most efficient in the intensive insulin group.

CONCLUSIONS

Mortality in diabetic patients with AMI is predicted by age, previous heart failure, and severity of the glycometabolic state at admission but not by conventional risk factors or sex. Intensive insulin treatment reduced long-term mortality despite high admission blood glucose and Hb AIc.