2207Cardiovascular outcome in THEMIS -like type 2 diabetes patients in Sweden: a nationwide observational study

Background

The THEMIS study (NCT01991795; in analysis phase; n=19,349) compares the effect of dual antiplatelet therapy (DAPT) vs ASA alone for the prevention of major cardiovascular (CV) events in type 2 diabetes (T2D) patients with coronary artery disease (CAD) at high CV risk, but without prior myocardial infarction (MI) or stroke. However, there is a lack of real-life data on CV risk in a THEMIS-like population compared to MI patients, where treatment with DAPT is guideline standard. The aim of this study was to investigate the CV risk in a THEMIS-like population vs an MI population

Methods

Patients invasively managed in Sweden (2006–2014) were identified using the SWEDEHEART registry and the National Patient Registry. Two populations were studied: a THEMIS-like population including patients with CAD and T2D, ≥1 vessel disease or elective percutaneous coronary intervention [PCI], and no prior stroke or MI), and a MI patient population alive at discharge. The cumulative incidence of the primary composite outcome (CV death (CVD)/MI/stroke) was estimated 3 years after index using the Kaplan-Meier method, and with probability plots adjusted for age, sex, atrial fibrillation, and heart failure. A 30 days blanking period for outcome was added to ensure capture of new events (index THEMIS-pop.: after angiography; index MI-pop.: after discharge).

Results

Overall, 6,534 THEMIS-like patients and 96,638 MI patients were included. At index, the THEMIS-like patients (CAD and T2D without previous MI/stroke) were aged 67.1 years (mean), 26.6% women, 9.2% AF, and 4.7% HF, while the MI patients were aged 67.3 years (mean), 30.7% women, 15.5% T2D, 17.9% previous MI, 5.2% stroke, 6.4% AF, and 4.8% HF. Three-year cumulative incidence for the composite outcome CVD/MI/stroke was 0.149 (95% CI 0.140, 0.158) for THEMIS-like patients, and 0.148 (95% CI 0.145, 0,15) for MI patients (p=0.88 log rank test) (Figure). Corresponding adjusted probably plots: 0.135 (95% CI 0.127, 0.143) and 0.131 (95% CI 0.128, 0.133). MI was the main risk driver with greatest cumulative incidence in both populations (0.091 vs 0.087) (Figure).

Figure 1

Conclusions

In this Swedish real-life setting, THEMIS-like patients, followed from 30 days after invasive intervention, had a similar long-term risk for CV events compared with MI patients surviving 30 days after discharge, with MI as the main risk driver, despite having no previous ischemic events. The present data indicate that long-term ischemic risk prevention should be a key strategy in coronary artery disease patients with diabetes requiring elective invasive intervention.

Acknowledgement/Funding

AstraZeneca

Outcomes of antibiotic prophylaxis in acute cholecystectomy in a population-based gallstone surgery registry

Background

The aim of this study was to assess the effect of antibiotic prophylaxis (AP) on postoperative infections in acute cholecystectomy.

Methods

The study was based on acute cholecystectomies registered in the nationwide Swedish Register for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks) between 2006 and 2010. The association between AP and the risk of postoperative infectious complications was tested in a multivariable regression analysis, with stepwise addition of age, sex, duration of operation, indication for surgery, surgical approach (laparoscopic versus open) and American Society of Anesthesiologists (ASA) fitness grade as co-variables. Postoperative infections requiring antibiotic treatment and postoperative abscesses were defined as outcome measures.

Results

AP was given to 9549 (68·6 per cent) of 13 911 patients. Postoperative infections requiring antibiotic treatment occurred following 1070 procedures (7·7 per cent), including 805 patients (8·4 per cent) who received AP (P < 0·001 versus patients without AP). Postoperative abscesses developed after 273 procedures (2·0 per cent), including 208 patients (2·2 per cent) who received AP (P = 0·007). In univariable analysis, the odds ratio for development of infectious complications necessitating treatment with antibiotics was 1·42 (95 per cent confidence interval 1·23 to 1·64) for those who received APversus those who did not, and for postoperative abscesses it was 1·47 (1·11 to 1·95). In multivariable analysis, adjusting for confounders, the odds ratios were 0·93 (0·79 to 1·10) and 0·88 (0·64 to 1·21) respectively.

Conclusion

The present study suggests that AP provides no benefit in acute cholecystectomy.

Changes in body mass index following newly diagnosed type 2 diabetes and risk of cardiovascular mortality: a cohort study of 8486 primary-care patients

AIMS

Elevated body mass index (BMI) is associated with an increased risk of type 2 diabetes and cardiovascular disease (CVD). This study explored the association between BMI changes in the first 18 months of newly diagnosed type 2 diabetes and the risk of long-term CVD mortality.

METHODS

A total of 8486 patients with newly diagnosed type 2 diabetes and no previous history of CVD or cancer were identified from 84 primary-care centres in Sweden. During the first year after diagnosis, patients were grouped according to BMI change: 'Increase', or ≥+1 BMI unit; 'unchanged', or between +1 and-1 BMI unit; and 'decrease', or ≤-1 BMI unit. Associations between BMI change and CVD mortality, defined as death from stroke, myocardial infarction or sudden death, were estimated using adjusted Cox proportional hazards models (NCT 01121315).

RESULTS

Baseline mean age was 60.0 years and mean BMI was 30.2kg/m(2). Patients were followed for up to 9 years (median: 4.6 years). During the first 18 months, 53.4% had no change in their BMI, while 32.2% decreased and 14.4% increased. Compared with patients with unchanged BMI, those with an increased BMI had higher risks of CVD mortality (hazard ratio: 1.63, 95% CI: 1.11-2.39) and all-cause mortality (1.33, 1.01-1.76). BMI decreases had no association with these risks compared with unchanged BMI: 1.06 (0.76-1.48) and 1.06 (0.85-1.33), respectively.

CONCLUSION

Increased BMI within the first 18 months of type 2 diabetes diagnosis was associated with an increased long-term risk of CVD mortality. However, BMI decrease did not lower the long-term risk of mortality.

Associations of HbA1c and educational level with risk of cardiovascular events in 32,871 drug-treated patients with Type 2 diabetes: a cohort study in primary care

AIMS

To explore the association of HbA1c and educational level with risk of cardiovascular events and mortality in patients with Type 2 diabetes.

METHODS

A cohort of 32 871 patients with Type 2 diabetes aged 35 years and older identified by extracting data from electronic patient records for all patients who had a diagnosis of Type 2 diabetes and had glucose-lowering agents prescribed between 1999 and 2009 at 84 primary care centres in Sweden. Associations of mean HbA1c levels and educational level with risks of cardiovascular events and all-cause mortality were analysed.

RESULTS

The associations of HbA1c with risk of all-cause and cardiovascular mortality were J-shaped, with the lowest risk observed for cardiovascular mortality at an HbA1c level of 51 mmol/mol (6.8%) for subjects on oral agents and 56 mmol/mol (7.3%) in insulin-treated patients. The lowest risk observed for all-cause mortality was at an HbA1c level of 51 mmol/mol (6.8%) for subjects on oral agents and 56 mmol/mol (7.3%) in insulin-treated patients. There was an increased risk for cardiovascular death [hazard ratio 1.6 (1.2-2.1), P = 0.0008] at the lowest HbA1c decile for subjects in the low education category. For subjects with higher education there was no evident J curve for cardiovascular death [hazard ratio 1.2 (0.8-1.6), P = 0.3873].

CONCLUSIONS

Our results lend support to the recent American Diabetes Association/ European Association for the Study of Diabetes position statement that emphasizes the importance of additional factors, including the propensity for hypoglycaemia, which should influence HbA1c targets and treatment choices for individual patients. (Clinical Trials Registry No; NCT 01121315).

Risk of bleeding associated with use of systemic thromboembolic prophylaxis during laparoscopic cholecystectomy

BACKGROUND

The extent to which systemic perioperative thromboembolic prophylaxis affects peroperative and postoperative bleeding during cholecystectomy is not known. This article reports on risk of bleeding in a national cohort of cholecystectomies.

METHODS

All cholecystectomies registered in the Swedish Register of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks) between 2005 and 2010 were reviewed. Peroperative bleeding was defined as bleeding that could not be controlled by standard surgical techniques, necessitated conversion to an open procedure or required peroperative blood transfusion. Postoperative bleeding was defined as bleeding that necessitated reoperation, transfusion or a prolonged hospital stay. Risk estimates were performed using univariable and multiple logistic regression, and reported as odds ratios (ORs).

RESULTS

A total of 51 621 procedures were registered in GallRiks. Some 48 010 patients were included in the analyses, of whom 21 259 (44·3 per cent) received thromboembolic prophylaxis. Peroperative bleeding complications occurred in 400 (1·9 per cent) and postoperative bleeding in 296 (1·4 per cent) given thromboembolic prophylaxis, compared with 189 (0·7 per cent) and 195 (0·7 per cent) respectively without thromboprophylaxis. After adjusting for age, sex, indication for surgery, American Society of Anesthesiologists grade, mode of admission, operative approach, duration of surgery and hospital volume, the OR for peroperative or postoperative bleeding complications in the group receiving prophylaxis was 1·35 (95 per cent confidence interval 1·17 to 1·55). However, in a subgroup analysis the risk was increased in laparoscopic surgery only. At 30-day follow-up, a total of 74 patients (0·2 per cent) had developed postoperative thromboembolism, 43 (0·2 per cent) of those who received thromboembolic prophylaxis compared with 31 (0·1 per cent) of those who did not.

CONCLUSION

Thromboprophylaxis in patients undergoing laparoscopic cholecystectomy increased the risk of bleeding, but the occurrence of thromboembolic events was not significantly reduced. Identification of high- and low-risk patients is needed to guide clinical decisions regarding medical thromboprophylaxis.