Newly diagnosed abnormal glucose tolerance determines post-MI prognosis in patients with hospital related hyperglycaemia but without known diabetes

AIMS

Investigate if abnormal glucose tolerance (AGT) affects post-myocardial infarction (MI) prognosis in patients with hospital-related hyperglycaemia (HRH) but without known diabetes mellitus (KDM).

METHODS

Post-MI survivors without KDM underwent pre-discharge oral glucose tolerance test. Cardiovascular death and non-fatal re-infarction (MACE) were recorded. We compare the ability of admission (APG), fasting (FPG) and 2 h post-load (2 h-PG) plasma glucose to predict MACE in patients with (HRH) and without HRH (NoHRH).

RESULTS

50.2% and 73% of NoHRH and HRH had AGT respectively. MACE occurred in 19.5% and 18.1% in HRH and NoHRH groups. MACE-free survival was lower in patient with AGT in both groups (NoHRH: HR 1.82, 95% CI 1.19-2.78, p = 0.005; HRH: HR 2.48, 95% CI 1.24-4.96, p = 0.010). AGT predicted MACE-free survival (NoHRH: HR 1.60, 95% CI 1.02-2.51, p = 0.042; HRH: HR 3.09, 95% CI 1.07-8.94, p = 0.037). 2 h-PG, but not FPG or APG, independently predicted MACE free survival (NoHRH: HR 1.17, 95% CI 1.07-1.27, p ≤0.001 and HRH: HR 1.18, 95% CI 1.03-1.37, p = 0.020). Addition of AGT and 2 h-PG, not FPG or APG, improved net reclassification of events in both groups.

CONCLUSION

Post-MI prognosis is worse with AGT irrespective of presence of HRH. 2 h-PG, predicts prognosis in HRH and NoHRH groups.

Impaired glucose tolerance and albuminuria in patients with chronic heart failure: a subanalysis of the SUPPORT trial

AIMS

The study aims to evaluate the prognostic significance of impaired glucose tolerance (IGT) with reference to albuminuria in patients with chronic heart failure (CHF).

METHODS AND RESULTS

We examined 535 CHF patients (mean 66 years, women 25%) in the control arm of our SUPPORT trial, in which we examined additive impact of olmesartan in hypertensive patients with symptomatic CHF treated with β-blockers and/or angiotensin-converting enzyme inhibitors. We examined the association between glycaemic abnormality (assessed by 75 g of oral glucose tolerance test) and albuminuria for a composite outcome of all-cause death, myocardial infarction, stroke, and HF hospitalization. IGT patients (N = 113, mean 67.2 years) were older and more frequently treated with β-blockers compared with those with normal glucose regulation (N = 142, mean 64.0 years) and those with diabetes mellitus (N = 280, mean 65.7 years). Multivariable Cox proportional hazard models revealed that, as compared with normal glucose regulation (NGR), IGT was associated with increased risk of the outcome when complicated by albuminuria [hazard ratio (HR) 2.25; 95% confidence interval (CI) 1.14-4.42; P = 0.019] but not when uncomplicated by albuminuria (HR 0.76; 95% CI 0.35-1.60, P = 0.47) (P for interaction = 0.041). This was also the case for diabetes mellitus and albuminuria (HR 2.06; 95% CI 1.17-3.61; P = 0.012). Among IGT patients without albuminuria, 21 (29%) developed albuminuria at 1-year visit, which was again associated with poor prognosis (HR 7.36; 95% CI 1.39-38.98, P = 0.019).

CONCLUSIONS

These results indicate that IGT is associated with poor prognosis when complicated by albuminuria in CHF patients, demonstrating the importance of combined early stages of glucose intolerance and renal dysfunction in the management of CHF.

HbA1c predicts long-term postoperative mortality in patients with unknown glycemic status at admission for vascular surgery: An exploratory study

BACKGROUND

Peripheral arterial disease (PAD) and diabetes mellitus (DM) represent major public health challenges and are tightly associated. To facilitate early diagnosis, HbA1c has been implemented as the preferred diagnostic tool for the diagnosis of type 2 DM. In this study, we compared and evaluated HbA1c, fasting plasma glucose (FPG), and 2-hour post-load glucose values to determine which test best predicted mortality in patients with PAD.

METHODS

In all, 273 PAD patients with unknown glycemic status admitted to Haukeland University Hospital for elective surgery between October 2006 and September 2007 were included in the study. All 273 patients underwent a standard oral glucose tolerance test (OGTT) in addition to determination of HbA1c; patients were then grouped into those with DM, intermediate hyperglycemia, and normoglycemia according to World Health Organization and International Expert Committee criteria.

RESULTS

All-cause mortality was 40% over a 9-year follow-up period. After adjusting for age, sex, and relevant medication, HbA1c was a predictor for mortality (hazard ratio [HR] 1.54; 95% confidence interval [CI] 1.03-2.32]; P = 0.04). The association did not achieve statistical significance in a fully adjusted Cox regression model, although the effect estimation of HbA1c on all-cause mortality remained largely unchanged (HR 1.39; 95% CI 0.92-2.09; P = 0.13). The OGTT was not a predictor of long-term mortality.

CONCLUSIONS

The results indicate that HbA1c is a useful marker in the preoperative screening of patients of unknown glycemic status at the time of admission for vascular surgery, and may identify people at high risk of long-term mortality following surgical treatment for PAD.

Incident Diabetes in Survivors of Critical Illness and Mechanisms Underlying Persistent Glucose Intolerance: A Prospective Cohort Study

OBJECTIVES

Stress hyperglycemia occurs in critically ill patients and may be a risk factor for subsequent diabetes. The aims of this study were to determine incident diabetes and prevalent prediabetes in survivors of critical illness experiencing stress hyperglycemia and to explore underlying mechanisms.

DESIGN

This was a prospective, single center, cohort study. At admission to ICU, hemoglobin A1c was measured in eligible patients. Participants returned at 3 and 12 months after ICU admission and underwent hemoglobin A1c testing and an oral glucose tolerance test. Blood was also collected for hormone concentrations, whereas gastric emptying was measured via an isotope breath test. β-cell function was modeled using standard techniques.

SETTING

Tertiary-referral, mixed medical-surgical ICU.

PATIENTS

Consecutively admitted patients who developed stress hyperglycemia and survived to hospital discharge were eligible.

MEASUREMENTS AND MAIN RESULTS

Consent was obtained from 40 patients (mean age, 58 yr [SD, 10], hemoglobin A1c 36.8 mmol/mol [4.9 mmol/mol]) with 35 attending the 3-month and 26 the 12-month visits. At 3 months, 13 (37%) had diabetes and 15 (43%) had prediabetes. At 12 months, seven (27%) participants had diabetes, whereas 11 (42%) had prediabetes. Mean hemoglobin A1c increased from baseline during the study: +0.7 mmol/mol (-1.2 to 2.5 mmol/mol) at 3 months and +3.3 mmol/mol (0.98-5.59 mmol/mol) at 12 months (p = 0.02). Gastric emptying was not significantly different across groups at either 3 or 12 months.

CONCLUSIONS

Diabetes and prediabetes occur frequently in survivors of ICU experiencing stress hyperglycemia. Based on the occurrence rate observed in this cohort, structured screening and intervention programs appear warranted.

All-Cause Mortality Risk in Australian Women with Impaired Fasting Glucose and Diabetes

AIMS

Impaired fasting glucose (IFG) and diabetes are increasing in prevalence worldwide and lead to serious health problems. The aim of this longitudinal study was to investigate the association between impaired fasting glucose or diabetes and mortality over a 10-year period in Australian women.

METHODS

This study included 1167 women (ages 20-94 yr) enrolled in the Geelong Osteoporosis Study. Hazard ratios for all-cause mortality in diabetes, IFG, and normoglycaemia were calculated using a Cox proportional hazards model.

RESULTS

Women with diabetes were older and had higher measures of adiposity, LDL cholesterol, and triglycerides compared to the IFG and normoglycaemia groups (all p < 0.001). Mortality rate was greater in women with diabetes compared to both the IFG and normoglycaemia groups (HR 1.8; 95% CI 1.3-2.7). Mortality was not different in women with IFG compared to those with normoglycaemia (HR 1.0; 95% CI 0.7-1.4).

CONCLUSIONS

This study reports an association between diabetes and all-cause mortality. However, no association was detected between IFG and all-cause mortality. We also showed that mortality in Australian women with diabetes continues to be elevated and women with IFG are a valuable target for prevention of premature mortality associated with diabetes.

Copeptin in patients with acute myocardial infarction and newly detected glucose abnormalities - A marker of increased stress susceptibility? A report from the Glucose in Acute Myocardial Infarction cohort

OBJECTIVE

To characterize copeptin levels and to explore its prognostic importance in patients with acute myocardial infarction with newly detected glucose abnormalities.

METHODS

Copeptin was measured in 166 patients with acute myocardial infarction without known diabetes and in 168 age- and gender-matched controls. Participants were classified as having normal glucose tolerance or abnormal glucose tolerance (impaired glucose tolerance + type 2 diabetes mellitus) by oral glucose tolerance test. Study participants were followed over a decade for major cardiovascular event (acute myocardial infarction/stroke/congestive heart failure/cardiovascular death), cardiovascular and total death.

RESULTS

Median copeptin level was higher in patients (10.5 pmol/L) than controls (5.9 pmol/L; p < 0.01). Patients with abnormal glucose tolerance had higher copeptin (12.2 pmol/L) than those with normal glucose tolerance (7.9 pmol/L; p < 0.01) but levels of copeptin did not differ in controls with abnormal glucose tolerance or normal glucose tolerance. Copeptin predicted major cardiovascular events [ n = 64; hazard ratio = 1.15 (1.01-1.32; p = 0.04)], cardiovascular mortality [ n = 29; hazard ratio = 1.24 (1.06-1.46; p = 0.01)] and total death [ n = 51; hazard ratio = 1.21 (1.05-1.40; p = 0.01)] in unadjusted Cox regression analyses in the patient cohort. In controls, copeptin predicted major cardiovascular events [ n = 26; hazard ratio = 1.17 (1.01-1.36; p = 0.03)].

CONCLUSION

Copeptin levels are highest among acute myocardial infarction patients with glucose disturbances and predict an adverse prognosis in unadjusted analyses. These findings imply that raised copeptin reflects stress rather than acting as a pathogenic factor for glucose abnormalities.

Elevated levels of adipokines predict outcome after acute myocardial infarction: A long-term follow-up of the Glucose Tolerance in Patients with Acute Myocardial Infarction cohort

OBJECTIVE

Adiponectin and leptin are associated with insulin resistance and cardiovascular disease. Information on the prognostic value after an acute myocardial infarction is still conflicting.

METHODS

Patients (n = 180) without known diabetes and with admission glucose of <11 mmol/L admitted for an acute myocardial infarction in 1998-2000 were followed for mortality and cardiovascular events (first of cardiovascular mortality/acute myocardial infarction/stroke/heart failure) until the end of 2011 (median: 11.6 years). Plasma adiponectin and leptin were related to outcome in Cox proportional-hazard regression analyses.

RESULTS

Median age was 64 years and 69% were male. Total mortality was 34% (n = 61) and 44% (n = 80) experienced a cardiovascular event. Adiponectin at discharge predicted cardiovascular events (hazard ratio; 95% confidence interval; 1.45; 1.02-2.07, p = 0.038), total mortality (2.53; 1.64-3.91, p < 0.001) and cancer mortality (3.64; 1.51-8.74, p = 0.004). After adjustment for age, sex, body mass index, previous myocardial infarction and heart failure, adiponectin predicted total mortality (1.79; 1.07-3.00, p = 0.027) but not cardiovascular events. High levels of leptin were associated with cardiovascular events during the first 7 years, after which the association was attenuated. Leptin did not predict total mortality.

CONCLUSION

In patients with acute myocardial infarction but without previously known diabetes, high levels of adiponectin at discharge predicted total mortality. The present results support the hypothesis that high rather than low levels of adiponectin predict mortality after acute myocardial infarction.

Diabetes, glucose tolerance, and the risk of sudden cardiac death

BACKGROUND

Diabetes predisposes to sudden cardiac death (SCD). However, it is uncertain whether greater proportion of cardiac deaths are sudden among diabetes patients than other subjects. It is also unclear whether the risk of SCD is pronounced already early in the course of the disease. The relationship of impaired glucose tolerance (IGT) and SCD is scarcely documented.

METHODS

A general population cohort of 10594 middle-aged subjects (mean age 44 years, 52.6 % male, follow-up duration 35-41 years) was divided into diabetes patients (n = 82), subjects with IGT (n = 3806, plasma glucose ≥9.58 mmol/l in one-hour glucose tolerance test), and controls (n = 6706).

RESULTS

Diabetes patients had an increased risk of SCD after adjustment confounders (hazard ratio 2.62, 95 % confidence interval 1.46-4.70, p = 0.001) but risk for non-sudden cardiac death was similarly increased and the proportion of SCD of cardiac deaths was not increased. The SCD risk persisted after exclusion of subjects with baseline cardiac disease or non-fatal cardiac events during the follow-up. Subjects with IGT were at increased risk for SCD (univariate hazard ratio 1.51; 95 % confidence interval 1.31-1.74; p < 0.001) and also for non-sudden cardiac deaths and non-fatal cardiac events but adjustments for other risk factors attenuated these effects.

CONCLUSIONS

Diabetes was associated with increased risk of SCD but also the risk of non-sudden cardiac death was similarly increased. The proportion of cardiac deaths being sudden in subjects with diabetes was not increased. The higher SCD risk in diabetes patients was independent of known cardiac disease at baseline or occurrence of non-fatal cardiac event during the follow-up.

Cardiovascular and All-Cause Mortality Over a 23-Year Period Among Chinese With Newly Diagnosed Diabetes in the Da Qing IGT and Diabetes Study

OBJECTIVE

Despite its growing prevalence in China, the extent to which diabetes leads to excess cardiovascular disease (CVD) mortality and all-cause mortality is unclear.

RESEARCH DESIGN AND METHODS

We compared death rates and causes of death among 630 people with newly diagnosed diabetes (NDD) and 519 with normal glucose tolerance (NGT) who, in 1986, were identified as a result of screening 110,660 adults aged 25-74 years for diabetes in Da Qing, China.

RESULTS

During 23 years of follow-up, 338 (56.5%) participants with NDD and 100 (20.3%) with NGT died. CVD was the predominant cause of death in those with diabetes (47.5% in men and 49.7% in women), almost half of which was due to stroke (52.3% in men and 42.3% in women). The age-standardized incidence of all-cause death was three times as high in those with NDD as in those with NGT with incidences (per 1,000 person-years) of 36.9 (95% CI 31.5-42.3) vs. 13.3 (10.2-16.5) in men (P < 0.0001) and 27.1 (22.9-31.4) vs. 9.2 (7.8-10.6) in women (P < 0.0001). The incidence of CVD deaths in men and women with NDD (17.5 [13.8-21.2] vs. 13.5 [10.5-16.5]) did not differ significantly. Significantly higher death rates attributable to renal disease and infection were also found in the NDD group.

CONCLUSIONS

Diabetes is associated with a substantially increased risk of death in Chinese adults, especially from CVD, almost half of which is due to stroke.

Dysglycemia and long-term mortality: observations from the Israel study of glucose intolerance, obesity and hypertension

BACKGROUND

We describe the relationship between dysglycemia and long-term mortality and elucidate the relationship between blood glucose levels during an oral glucose tolerance test (OGTT) and haemoglobin A1 (HbA1) and mortality.

METHODS

A cohort of 1410 individuals was followed for 33 years since 1980. Fasting and post-OGTT glucose parameters were used to categorize the cohort according to baseline glycemic status.

RESULTS

The mortality rate increased from 43% in normoglycemic individuals to 53.3, 61.7, 72.9 and 88.0% in those with impaired fasting glucose (IFG), impaired glucose tolerance (IGT), IFG/IGT and diabetes, respectively. The highest mortality rate, compared with the normoglycemic category, was observed in individuals with IFG/IGT and diabetes according to a Cox proportional hazard model (HR = 1.38, 95%CI 1.10-1.74 and HR = 2.14, 95%CI 1.70-2.70, respectively), followed by individuals with IGT and IFG, but this did not reach statistical significance. We speculate that the IFG group may represent a mixture of individuals en route from normal to the next two categories as well as another cohort whose glucose levels are stably set at the upper reaches of the normal distribution. Significant differences were found between 1 and 2 h glucose values (p < 0.001). Fasting, 60 and 120 min glucose values were positively associated with increasing HbA1 quintiles (p < 0.05). The mean HbA1 was significantly higher in those who died (p = 0.01). The highest mortality (58.8%) was observed in the upper HbA1 quintile that was also associated with the highest prevalence of the metabolic syndrome (17.2%).

CONCLUSIONS

This study shows a continuous relationship between the severity of dysglycemia and long-term mortality and should promote the early recognition of prediabetes. The 1 h post-load glucose level was continuously associated with increasing HbA1 concentrations and may therefore serve as an early marker for abnormalities in glucose tolerance. An elevated 1 h post-load glucose level may potentially identify at-risk individuals well before the traditional 2 h glucose value.

Subclinical abnormal glucose tolerance is a predictor of death in liver cirrhosis

AIM: To determine if subclinical abnormal glucose tolerance (SAGT) has influence on survival of non-diabetic patients with liver cirrhosis.

METHODS: In total, 100 patients with compensated liver cirrhosis and normal fasting plasma glucose were included. Fasting plasma insulin (FPI) levels were measured, and oral glucose tolerance test (OGTT) was performed. According to OGTT results two groups of patients were formed: those with normal glucose tolerance (NGT) and those with SAGT. Patients were followed every three months. The mean follow-up was 932 d (range of 180-1925). Survival was analyzed by the Kaplan-Meyer method, and predictive factors of death were analyzed using the Cox proportional hazard regression model.

RESULTS: Of the included patients, 30 showed NGT and 70 SAGT. Groups were significantly different only in age, INR, FPI and HOMA2-IR. Patients with SAGT showed lower 5-year cumulated survival than NGT patients (31.7% vs 71.6%, P = 0.02). Differences in survival were significant only after 3 years of follow-up. SAGT, Child-Pugh B, and high Child-Pugh and Model for End-Stage Liver Disease (MELD) scores were independent predictors of death. The causes of death in 90.3% of cases were due to complications related to liver disease.

CONCLUSION: SAGT was associated with lower survival. SAGT, Child-Pugh B, and high Child-Pugh and MELD scores were independent negative predictors of survival.

Association between glucose tolerance level and cancer death in a general Japanese population: the Hisayama Study

The authors examined the associations of glucose tolerance status and fasting and 2-hour postload glucose levels with the risk of cancer death in a 19-year follow-up study of 2,438 Japanese subjects aged 40-79 years who underwent a 75-g oral glucose tolerance test (1988-2007). During follow-up, 229 subjects died of cancer. The risk of cancer death was significantly higher in subjects with fasting plasma glucose levels of ≥5.6 mmol/L or 2-hour postload glucose levels of ≥11.1 mmol/L than in those with the lowest fasting or 2-hour postload glucose levels, after adjustment for potentially confounding factors. According to glucose tolerance status, not only diabetes but also impaired fasting glycemia and impaired glucose tolerance were significant risk factors for cancer death (for impaired fasting glycemia, multivariable-adjusted hazard ratio (HR) = 1.49 (95% confidence interval (CI): 1.05, 2.11); for impaired glucose tolerance, HR = 1.52 (95% CI: 1.05, 2.22); and for diabetes, HR = 2.10 (95% CI: 1.41, 3.12)). With regard to site-specific cancers, elevated fasting or 2-hour postload glucose levels were associated with the risks of death from stomach, liver, and lung cancer. These findings suggest that both prediabetic hyperglycemia and diabetes are significant risk factors for cancer death in the general Japanese population.

Impaired fasting glucose in combination with silent myocardial ischaemia is associated with poor prognosis in healthy individuals

AIM

As both impaired fasting glucose and silent myocardial ischaemia are risk factors for cardiovascular disease and death, we hypothesized that these risk factors in combination would identify those subjects at the highest risk of adverse events.

METHODS

Healthy individuals without diabetes (n=596, 55-75 years) were examined for silent myocardial infarction (≥ 1 mm ST-interval during ≥ 1 min) by ambulant 48-h continuous electrocardiogram monitoring and impaired fasting glucose (fasting plasma glucose 5.6-6.9 mmol/l).

RESULTS

After 6.3 years, 77 subjects met the endpoint of myocardial infarction and/or death. The prevalence of silent myocardial ischaemia at inclusion was 12.3% in subjects with impaired fasting glucose and 11.7% in subjects with normal fasting glucose, P=0.69. Subjects with impaired fasting glucose/silent myocardial ischaemia more often met the endpoint (36%) than subjects with impaired fasting glucose/no silent myocardial ischaemia (15%), subjects with normal fasting glucose/silent myocardial ischaemia (12%), and subjects with normal fasting glucose/no silent myocardial ischaemia (10%), respectively, (P<0.001). In a Cox model including these four study groups of interest, gender, age, smoking habits, blood pressure and total cholesterol, only subjects with impaired fasting glucose/silent myocardial ischaemia exhibited an increased risk of death or myocardial infarction (hazard ratio 2.5, P=0.016).

CONCLUSION

The combination of impaired fasting glucose and silent myocardial ischaemia was associated with the poorest prognosis in middle-aged and older subjects without previously known glucose metabolic aberration and heart disease.

30 Year patterns of mortality in Tobago, West Indies, 1976-2005: impact of glucose intolerance and alcohol intake

Objectives

To determine the main predictors of all-cause and cardiovascular (CV) mortality in a rural West Indian population in Plymouth, Tobago over 30 years.

Methods

Questionnaire survey for CV risk factors and alcohol consumption patterns administered at baseline in 1976 with 92.5% response rate. 831/832 patients were followed up until 2005 or death.

Results

Hypertension (>140/90 mm Hg) was prevalent in 48% of men and 44% of women, and 21% of men and 17% of women had diabetes. Evidence showed most predictors for all cause and cardiovascular mortality having the main effects at ages <60 years, (p-value for interaction<0.01) but no risk factors having sex-specific effects on mortality. The main predictors of all-cause mortality at age <60 years in the fully adjusted model were high sessional alcohol intake (hazard ratio (HR) 2.04, 95% CI 1.10-3.80), severe hypertension >160/95 mm Hg (HR 1.68, 95% CI 1.09-2.60), diabetes (HR 3.28, 95% CI 1.89-5.69), and BMI (HR 1.04, 95% CI 1.00-1.07). The main predictors of cardiovascular mortality were similar in the fully adjusted model: high sessional alcohol intake (HR 2.47 95% CI 1.10-5.57), severe hypertension (HR 2.78 95% CI 1.56-4.95), diabetes (HR 3.68 95% CI 1.77-7.67) and additionally LVH, (HR 5.54 95% CI 1.38-22.26), however BMI did not show independent effects. For men, high sessional alcohol intake explains 27% of all cause mortality, and 40% of cardiovascular mortality at age <60 yrs. In adults aged <60 years, the attributable risk fraction for IGT/Diabetes and all cause mortality and cardiovascular mortality is 28% in women vs. 11% in men, and 22% in women vs. 6% in men respectively.

Conclusions

In this Afro-Caribbean population we found that a major proportion of deaths are attributable to high sessional alcohol intake (in males), diabetes, and hypertension and these risk factors primarily operate in those below 60 years.

Assessment of cardiovascular risk and prevention of cardiovascular disease in women with the polycystic ovary syndrome: a consensus statement by the Androgen Excess and Polycystic Ovary Syndrome (AE-PCOS) Society

OBJECTIVE

Women with polycystic ovary syndrome (PCOS) often have cardiovascular disease (CVD) risk factors. The Androgen Excess and Polycystic Ovary Syndrome (AE-PCOS) Society created a panel to provide evidence-based reviews of studies assessing PCOS-CVD risk relationships and to develop guidelines for preventing CVD.

PARTICIPANTS

An expert panel in PCOS and CVD reviewed literature and presented recommendations.

EVIDENCE

Only studies comparing PCOS with control patients were included. All electronic databases were searched; reviews included individual studies/databases, systematic reviews, abstracts, and expert data. Articles were excluded if other hyperandrogenic disorders were not excluded, PCOS diagnosis was unclear, controls were not described, or methodology precluded evaluation. Inclusion/exclusion criteria were confirmed by at least two reviewers and arbitrated by a third.

CONSENSUS PROCESS

Systematic reviews of CVD risk factors were compiled and submitted for approval to the AE-PCOS Society Board.

CONCLUSIONS

Women with PCOS with obesity, cigarette smoking, dyslipidemia, hypertension, impaired glucose tolerance, and subclinical vascular disease are at risk, whereas those with metabolic syndrome and/or type 2 diabetes mellitus are at high risk for CVD. Body mass index, waist circumference, serum lipid/glucose, and blood pressure determinations are recommended for all women with PCOS, as is oral glucose tolerance testing in those with obesity, advanced age, personal history of gestational diabetes, or family history of type 2 diabetes mellitus. Mood disorder assessment is suggested in all PCOS patients. Lifestyle management is recommended for primary CVD prevention, targeting low-density and non-high-density lipoprotein cholesterol and adding insulin-sensitizing and other drugs if dyslipidemia or other risk factors persist.

The prognosis of glycoregulation disturbances and insulin secretion in alcoholic and C virus liver cirrhosis

We studied 49 alcoholic and viral C liver cirrhosis, over a period of 5 years, we evaluated OGTT, HOMA-IR, HOMA-beta, child score, diabetes mellitus and liver cirrhosis complications and survival. Both insulin resistance and lower insulin secretion in liver cirrhosis are important determinants of the degree of oral glucose tolerance. There is a correlation between the bad prognosis in patients with cirrhosis and glycoregulation disturbances, especially in those with alcoholic etiology.

Nature and prognostic importance of abnormal glucose tolerance and diabetes in acute heart failure

OBJECTIVE

To investigate the nature and importance of blood glucose abnormalities in an unselected heart failure (HF) population.

DESIGN

Cohort study.

SETTING

Urban University hospital.

PATIENTS

All index emergency HF admissions to one University hospital during the year 2000 were studied.

RESULTS

454 consecutive index admissions had blood chemistry, diabetic status and follow-up information recorded. 390 (86%) patients had an echocardiogram, of whom 117 (30%) had preserved left ventricular systolic function and 110 (24%) had diabetes. Sixty (13%) patients had abnormal glucose tolerance (8.0-10.99 mmol/l), and 284 (63%) patients had a normal admission blood glucose (<8 mmol/l). 51 (11.2%) patients died in hospital. After adjustment for other prognostic attributes, abnormal glucose tolerance (Cox hazard ratio HR, 95% CI: 5.920, 1.03 to 34.00; p = 0.046) but not diabetes (HR 3.46, 0.75 to 16.02; p = 0.112) predicted in-hospital mortality. During follow-up (median 812 (range 632-978) days), 104 (36.6%), 30 (50.0%) and 55 (50%) patients with a normal admission blood glucose concentration, abnormal glucose tolerance and diabetes, respectively, died (log rank test p = 0.0037, adjusted p = 0.075). Compared with patients with normal admission blood glucose, abnormal glucose tolerance (adjusted HR: 1.41 (0.92 to 2.16); p = 0.12) and diabetes (adjusted HR: 2.02 (1.41 to 2.88); p = 0.0001) predicted mortality. Considering glucose on admission as a continuous covariate, a 2 mmol/l increase was associated with a HR of 1.08 (1.03 to 1.13), p = 0.0010, which after adjustment for the above covariates became 1.08 (1.03 to 1.13), p = 0.0023.

CONCLUSIONS

Admission blood glucose concentration and diabetes are prognostically important in HF and could help target some patients for more intensive therapy.

Effect of ramipril on the incidence of diabetes

BACKGROUND

Previous studies have suggested that blockade of the renin-angiotensin system may prevent diabetes in people with cardiovascular disease or hypertension.

METHODS

In a double-blind, randomized clinical trial with a 2-by-2 factorial design, we randomly assigned 5269 participants without cardiovascular disease but with impaired fasting glucose levels (after an 8-hour fast) or impaired glucose tolerance to receive ramipril (up to 15 mg per day) or placebo (and rosiglitazone or placebo) and followed them for a median of 3 years. We studied the effects of ramipril on the development of diabetes or death, whichever came first (the primary outcome), and on secondary outcomes, including regression to normoglycemia.

RESULTS

The incidence of the primary outcome did not differ significantly between the ramipril group (18.1%) and the placebo group (19.5%; hazard ratio for the ramipril group, 0.91; 95% confidence interval [CI], 0.81 to 1.03; P=0.15). Participants receiving ramipril were more likely to have regression to normoglycemia than those receiving placebo (hazard ratio, 1.16; 95% CI, 1.07 to 1.27; P=0.001). At the end of the study, the median fasting plasma glucose level was not significantly lower in the ramipril group (102.7 mg per deciliter [5.70 mmol per liter]) than in the placebo group (103.4 mg per deciliter [5.74 mmol per liter], P=0.07), though plasma glucose levels 2 hours after an oral glucose load were significantly lower in the ramipril group (135.1 mg per deciliter [7.50 mmol per liter] vs. 140.5 mg per deciliter [7.80 mmol per liter], P=0.01).

CONCLUSIONS

Among persons with impaired fasting glucose levels or impaired glucose tolerance, the use of ramipril for 3 years does not significantly reduce the incidence of diabetes or death but does significantly increase regression to normoglycemia. (ClinicalTrials.gov number, NCT00095654 [ClinicalTrials.gov].).

Diabetes and impaired fasting glucose as predictors of morbidity and mortality in male coronary artery disease patients with reduced left ventricular function

OBJECTIVES

To evaluate the prognostic value of impaired fasting glucose and diabetes mellitus in male patients with coronary artery disease and poor left ventricular function.

METHODS AND RESULTS

From a prospective database on patients referred for gated myocardial perfusion imaging between 1998 and 2002 all male patients with a history of coronary artery disease and poor left ventricular function were selected. Poor function was defined as left ventricular ejection fraction < or = 40%. Subjects were classified as non-diabetics with fasting blood glucose levels < 110 mg/dL, non-diabetics with impaired fasting glucose (fasting blood glucose between 110 and 125 mg/dL) and diabetics. Median follow-up was 2.7years. End points were all-cause mortality, cardiac death and hospitalization for heart failure. One hundred and sixty patients were selected (age 65 +/- 9 years and left ventricular ejection fraction 29 +/- 8%). In univariate analysis atrial fibrillation, NYHA class, glycaemia and diabetes mellitus discriminated between survivors and non-survivors. In Cox multivariate regression analysis for all-cause mortality only NYHA class and diabetes mellitus remained significant. Kaplan Meier analysis showed that diabetics had the worst survival and non-diabetics with glucose < 110 mg/dL had the best survival. Non-diabetics with impaired fasting glucose had intermediate survival. Analysis for cardiac death/hospitalization for heart failure showed similar results.

CONCLUSION

In male patients with coronary artery disease and impaired left ventricular function diabetes mellitus and fasting glucose are strongly predictive of poor outcome. Diabetics have the worst prognosis but non-diabetics with impaired fasting glucose also are at higher risk compared to nondiabetics with low fasting blood glucose.

Glucose intolerance and all-cause mortality in Japanese migrants

OBJECTIVE

To assess all-cause mortality in a Japanese-Brazilian community according to the categories of glucose tolerance.

STUDY DESIGN AND SETTING

The cohort consisted of participants examined in two phases of a follow-up study started in 1993 (n=647). They were interviewed and submitted to an oral glucose tolerance test. Student's t-test was used to compare baseline parameters between alive and dead subjects. Cox proportional hazards model was used to estimate crude and adjusted hazard ratios (HR).

RESULTS

Seventy-one deaths occurred during the study period and a higher proportion of men (62%) was detected. Crude all-cause mortality rate was 16.2/1000 person-year. Vascular disease and cancer were the most frequent causes of deaths (77.3%). A higher mortality rate was observed in subjects with diabetes when compared with the normal glucose tolerant ones (HR: 2.0; 95% CI: 1.1-3.6), independently of age, systolic blood pressure, smoking and history of myocardial infarction.

CONCLUSION

Also among Japanese living in the Western world, a deleterious role of fasting and 2-h plasma glucose was found on mortality especially among younger subjects.

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.

The carboxypeptidase E knockout mouse exhibits endocrinological and behavioral deficits

A carboxypeptidase E (CPE) knockout (KO) mouse was generated by deletion of exons 4 and 5 from the CPE gene, and its phenotype was characterized. KO mice became obese by 10-12 wk of age and reached 60-80 g by 40 wk. At this age, body fat content was more than double that in the wild-type (WT) controls. The null animals consumed more food overall, were less physically active during the light phase of the light-dark cycle, and burned fewer calories as fat than WT littermates. Fasting levels of glucose and insulin-like immunoreactivity in plasma were elevated in both male and female KO mice at approximately 20 wk; males recovered fully and females partially from this state by 32 wk. At this time, insulin-like immunoreactivity in the plasma, identified as proinsulin, was 50-100 times higher than that of the WT animals. The KO mice showed impaired glucose clearance and were insulin resistant. High levels of leptin and no circulating fully processed cocaine- and amphetamine-related transcript, a peptide that is responsive to leptin-induced feedback inhibition of feeding, were found in serum. The KO mice were subfertile and showed deficits in GnRH processing in the hypothalamus. Behavioral analyses revealed that KO animals showed diminished reactivity to stimuli and had reduced muscle strength and coordination, as well as visual placing and toe-pinch reflexes. These data demonstrate that CPE KO mice display a wide range of neural and endocrine abnormalities and suggest that CPE may have additional physiological roles beyond those ascribed to peptide processing and sorting of prohormones in cells.

Fasting plasma leptin, tumor necrosis factor-alpha receptor 2, and monocyte chemoattracting protein 1 concentration in a population of glucose-tolerant and glucose-intolerant women: impact on cardiovascular mortality

OBJECTIVE

Leptin and tumor necrosis factor (TNF)-alpha are associated with insulin resistance and cardiovascular disease. In vitro studies suggested that these effects may be mediated via overproduction of monocyte chemoattracting protein (MCP)-1/CCL2, which is a chemokine involved in the pathogenesis of atherosclerosis.

RESEARCH DESIGN AND METHODS

In this study, fasting plasma leptin, soluble TNF-alpha receptor 2 (TNF-alpha-R2), and MCP-1/CCL2 concentrations were measured in 207 middle-aged women (age 61 +/- 12 years, BMI 30.1 +/- 6.6 kg/m(2)), including 53 patients with type 2 diabetes, 42 with impaired glucose tolerance, and 112 with normal glucose tolerance, to assess cross-sectionally their relationship with markers of atherosclerosis and, longitudinally over 7 years, whether their circulating levels were associated with cardiovascular disease (CVD) mortality.

RESULTS

At baseline, leptin and TNF-alpha-R2 were not different among groups; meanwhile, MCP-1/CCL2 was increased in type 2 diabetes (P < 0.05). All showed significant associations with biochemical risk markers of atherosclerosis. In a univariate analysis, age, fasting insulin, leptin, and MCP-1/CCL2 were associated with CVD mortality at 7 years. When a multivariate analysis was performed, only age, leptin, and insulin retained an independent association with CVD mortality, with leptin showing a protective effect (hazard ratio 0.88; P < 0.02).

CONCLUSIONS

In middle-aged women, MCP-1/CCL2, leptin, and TNF-alpha-R2 were all related to biochemical risk markers of atherosclerosis. MCP-1/CCL2 concentration was the only one to be increased in type 2 diabetes with respect to nondiabetic women and the only one to be associated with increased risk of CVD mortality after a 7-year follow-up period in the univariate analysis. In the multivariate analysis, neither MCP-1/CCL2 nor TNF-alpha-R2 was associated with CVD mortality, and inspection of the data showed that leptin, in both the univariate and multivariate analysis, was associated with a protective effect.

Predictive properties of impaired glucose tolerance for cardiovascular risk are not explained by the development of overt diabetes during follow-up

OBJECTIVE

To evaluate the relationship of impaired glucose tolerance (IGT) at baseline to coronary heart disease (CHD) incidence, and cardiovascular disease (CVD) and total mortality at follow-up, and to analyze whether the relationship is independent of the subsequent development of diabetes during follow-up.

RESEARCH DESIGN AND METHODS

A baseline screening survey for diabetes was performed in 1987 using a 2-h 75-g oral glucose tolerance test. A total of 1234 men and 1386 women aged 45-64 years, who were free of diabetes at baseline, were followed up for 10 years. During the follow-up, 153 subjects had an incident CHD event, 224 died, and 100 deaths were due to cardiovascular causes. Multivariate adjusted (adjusted for age, sex, waist-to-hip ratio, systolic blood pressure, cholesterol, HDL cholesterol, and smoking) hazard ratio (HR) was estimated using Cox regression analysis.

RESULTS

In subjects who had IGT at baseline and who did not progress to diabetes during the follow-up, the multivariate adjusted HR (95% CI) was 1.49 (0.95-2.34) for CHD incidence, 2.34 (1.42-3.85) for CVD mortality, and 1.65 (1.13-2.40) for all-cause mortality.

CONCLUSIONS

Baseline IGT was an independent risk predictor for cardiovascular morbidity and mortality and for total mortality, which was not confounded by the subsequent development of overt diabetes.

Secondary prevention of cardiovascular events with long-term pravastatin in patients with diabetes or impaired fasting glucose: results from the LIPID trial

OBJECTIVE

Diabetes, a major health problem worldwide, increases the risk of cardiovascular disease and its associated mortality: The Long-Term Intervention with Pravastatin in Ischemic Disease (LIPID) trial showed that cholesterol-lowering treatment with pravastatin reduced mortality and coronary heart disease (CHD) events in 9014 patients aged 31-75 years with CHD and total cholesterol 4.0-7.0 mmol/l. We measured the effects of pravastatin therapy, 40 mg/day over 6.0 years, on the risk of CHD death or nonfatal myocardial infarction and other cardiovascular outcomes in 1,077 LIPID patients with diabetes and 940 patients with impaired fasting glucose (IFG).

RESULTS

In patients allocated to placebo, the risk of a major CHD event was 61% higher in patients with diabetes and 23% higher in the IFG group than in patients with normal fasting glucose, and the risk of any cardiovascular event was 37% higher in the diabetic group and 19% higher in the IFG group. Pravastatin therapy reduced the risk of a major CHD event overall from 15.9 to 12.3% (relative risk reduction [RRR] 24%, P < 0.001) and from 23.4 to 19.6% in the diabetic group (19%, P = 0.11); in the diabetic group, the reduction was not significantly different from the reductions in the other groups. Pravastatin reduced the risk of any cardiovascular event from 52.7 to 45.2% (21%, P < 0.008) in patients with diabetes and from 45.7 to 37.1% (26%, P = 0.003) in the IFG group. Pravastatin reduced the risk of stroke from 9.9 to 6.3% in the diabetic group (RRR 39%, CI 7-61%, P = 0.02) and from 5.4 to 3.4% in the IFG group (RRR 42%, CI -9 to 69%, P = 0.09). Pravastatin did not reduce the incidence of diabetes. Over 6 years, pravastatin therapy prevented one major CHD event (CHD death or nonfatal myocardial infarction) in 23 patients with IFG and 18 patients with diabetes. A meta-analysis of other major trials confirmed the high absolute risks of diabetes and IFG and the absolute benefits of statin therapy in these patients.

CONCLUSIONS

Cholesterol-lowering treatment with pravastatin therapy prevents cardiovascular events, including stroke, in patients with diabetes or IFG and established CHD.

[Mortality among individuals diagnosed with glucose intolerance by the 75 g oral glucose tolerance test in rural Japanese communities]

OBJECTIVE

To examine mortality among individuals confirmed to have glucose intolerance by the 75 g oral glucose tolerance test (OGTT) in rural communities.

METHODS

Subjects were 1,639 residents of seven rural communities in Japan (total population size = 54,000) who underwent an OGTT as a secondary screening test for diabetes during 1987-95 and had received no medication for diabetes at baseline. OGTT results were classified as diabetes (n = 471), impaired glucose tolerance (IGT) (n = 408), or normal glucose tolerance (NGT) (n = 760), according to the recommendations of the American Diabetes Association. Indirect age-adjusted mortality rates and standardized mortality ratios (SMRs) for diabetes and IGT groups were calculated using age-stratified mortality rates for people aged 40-89 in the communities as the standard population. Relative risks of death and 95% confidence intervals (CI) for diabetes and IGT were calculated using Cox's proportional models, adjusted for age and baseline factors such as body mass index (BMI), total cholesterol, hypertension, smoking, alcohol drinking, history of diabetes, and family history of diabetes.

RESULTS

During 9.4 years of follow-up, we recorded 70 deaths for the NGT, 46 for the IGT, and 71 for the diabetes group. The SMRs for IGT and diabetic men and women were not significantly increased in comparison with the standard population values. However, when analyzed in our cohort, age-adjusted relative risks of death for IGT and diabetes versus NGT men were 1.10 (9.5% CI: 0.72-1.67) and 1.54 (95% CI: 1.05-2.24), respectively, whereas, the risks among women did not significantly vary. Finally, multivariate analysis, further adjusted for the baseline factors, indicated the relative risk of mortality with diabetes in men to be significantly increased (relative risk = 1.74, 95% CI: 1.11-2.75).

CONCLUSION

During follow-up, mortality rates among screened IGT and diabetes were not significantly higher than those in general. Nonetheless, we found that diabetes elevated the risk of death in our cohort, primarily in men.

Aortic pulse-wave velocity and its relationship to mortality in diabetes and glucose intolerance: an integrated index of vascular function?

BACKGROUND

Arterial distensibility measures, generally from pulse-wave velocity (PWV), are widely used with little knowledge of relationships to patient outcome. We tested whether aortic PWV predicts cardiovascular and all-cause mortality in type 2 diabetes and glucose-tolerance-tested (GTT) multiethnic population samples.

METHODS AND RESULTS

Participants were randomly sampled from (1) a type 2 diabetes outpatient clinic and (2) primary care population registers, from which nondiabetic control subjects were given a GTT. Brachial blood pressures and Doppler-derived aortic PWV were measured. Mortality data over 10 years' follow-up were obtained. At any level of systolic blood pressure (SBP), aortic PWV was greater in subjects with diabetes than in controls. Mortality risk doubled in subjects with diabetes (hazard ratio 2.34, 95% CI 1.5 to 3.74) and in those with glucose intolerance (2.12, 95% CI 1.11 to 4.0) compared with controls. For all groups combined, age, sex, and SBP predicted mortality; the addition of PWV independently predicted all-cause and cardiovascular mortality (hazard ratio 1.08, 95% CI 1.03 to 1.14 for each 1 m/s increase) but displaced SBP. Glucose tolerance status and smoking were other independent contributors, with African-Caribbeans experiencing reduced mortality risk (hazard ratio 0.41, 95% CI 0.25 to 0.69).

CONCLUSIONS

Aortic PWV is a powerful independent predictor of mortality in both diabetes and GTT population samples. In displacing SBP as a prognostic factor, aortic PWV is probably further along the causal pathway for arterial disease and may represent a useful integrated index of vascular status and hence cardiovascular risk.

Two hour plasma glucose is not unequivocally predictive for early death in men with impaired fasting glucose: more results from the Paris Prospective Study

AIMS/HYPOTHESIS

We examined whether the 2-h plasma glucose (2 hPG) concentration after a 75 g OGTT is predictive of death in men with a diabetic, an impaired or a normal fasting plasma glucose concentration (DM-FPG: > or =7.0 mmol/l; IFG: 6.1-6.9 mmol/l; normal-FPG: <6.1 mmol/l).

METHODS

The 17-year mortality of 7018 men, aged 44 to 55 years, from the Paris Prospective Study, who were not known to be diabetic at baseline was studied.

RESULTS

The 2 hPG was not associated with early mortality in men with a DM-FPG in contrast to men with an IFG or a normal-FPG; for an increase from 10 to 11 mmol/l in the 2 hPG, the age-adjusted hazards ratios were 1.01 (95% CI 0.95-1.08), 1.15 (1.03-1.28) and 1.24 (1.18-1.31) respectively. Coronary heart disease mortality and within this category sudden death but not ischaemic heart disease death, were related with 2 hPG but only in the men with normal FPG. However, the prediction by 2 hPG did not differ between the men with DM-FPG, an IFG or a normal-FPG: the overall age-adjusted hazards ratios for these three causes of death were 1.09 (1.00-1.18), 1.13 (1.02-1.26) and 1.13 (0.99-1.29), respectively.

CONCLUSION/INTERPRETATION

2 hPG is unequivocally prognostic for all-cause mortality only in men with normal FPG. Screening men with an IFG by using a 75 g OGTT is of limited benefit.

Physical activity and cause-specific mortality in men with Type 2 diabetes/impaired glucose tolerance: evidence from the Whitehall study

AIMS

Given that studies of individuals with Type 2 diabetes or impaired glucose tolerance indicate that physical activity has a normalizing effect on several indices of coronary heart disease (CHD) risk-including body weight, blood pressure, blood lipids, and cardiorespiratory fitness-it is plausible that activity may reduce CHD incidence in this group in the long term. The aim of the present analysis was to explore this hypothesis using data from a prospective observational study.

METHODS

We examined the relation of two indices of physical activity-walking pace and leisure activity-to total mortality, CHD, and other cardiovascular diseases in a 25-year follow-up of 6408 male British Civil Servants who underwent an oral glucose tolerance test at study entry.

RESULTS

In 352 men who were identified as having Type 2 diabetes or impaired glucose tolerance (diabetes/IGT) at baseline, 215 had died at follow-up and, in 6056 normoglycaemics, 2550 deaths had occurred. The two indices of physical activity were inversely related to all-cause, CHD, and other cardiovascular disease mortality in both normoglycaemics and in men with diabetes/IGT. Although these associations were attenuated somewhat after statistical adjustment for a range of covariates, the majority held, suggesting an independent effect for physical activity. The gradient of the activity-mortality association was steeper in individuals with diabetes/IGT in comparison with the normoglycaemics, with the linear trend across activity levels for CHD risk differing markedly in the analyses of both walking pace (P-value for interaction test = 0.05) and leisure activity (P-value = 0.02).

CONCLUSIONS

The findings of the present analysis of men with Type 2 diabetes/IGT provide support for those from a small number of other studies of persons with Type 2 diabetes suggesting that this group may benefit from physical activity in terms of CHD risk reduction.

Moderate alcohol consumption is associated with lower risk for incident diabetes and mortality: the Hoorn Study

In the present study we examined the association between baseline alcohol consumption and 10-year mortality in subjects with normal and abnormal glucose levels (diabetes, impaired fasting glucose (IFG) or impaired glucose tolerance (IGT)). Furthermore, we assessed the 6-year cumulative incidence of diabetes in categories of alcohol consumption. In the Hoorn Study, which started in 1989, alcohol intake was assessed by questionnaire in 2393 subjects who were subsequently categorised into four groups of alcohol consumption (non-drinkers, up to 10 g per day, 10-30 and >or=30 g per day). Glucose tolerance status by oral glucose tolerance test was classified according to the WHO-1999 diagnostic criteria. Subjects who drank up to 10 g per day of alcohol had the lowest mortality risk. The age- and sex-adjusted mortality risks for non-drinkers were 1.55 (1.04-2.32) for subjects with normal glucose levels and 1.72 (1.05-2.82) for subjects with abnormal glucose levels. The risk of diabetes was also lowest for subjects who consumed up to 10 g per day: 8.0 versus 12.9% for non-drinkers (P<0.05). Higher alcohol intakes were associated with increasing risks for mortality and diabetes. Adjustment for classical cardiovascular risk factors and other lifestyle variables did not materially affect the estimates. In conclusion, moderate alcohol consumption was associated with a lower risk for mortality and diabetes.

Brachial artery pulse pressure and common carotid artery diameter: mutually independent associations with mortality in subjects with a recent history of impaired glucose tolerance

BACKGROUND

Decreased large artery function, as reflected by increased brachial artery pulse pressure and increased carotid artery diameter and stiffness, may contribute to the increased mortality risk that is observed in subjects with impaired glucose tolerance. We therefore investigated the association between brachial artery pulse pressure and carotid artery diameter and stiffness, which are estimates of central artery stiffness and arterial remodelling, respectively, and mortality in subjects with a recent history of impaired glucose tolerance.

DESIGN

A prospective, population-based cohort study. We measured brachial artery pulse pressure by oscillometric blood pressure measurements, and common carotid artery diameter and distensibility and compliance coefficients by ultrasound in 140 subjects with a recent history of impaired glucose tolerance. During a median 6.6-year follow-up, 16 subjects died.

RESULTS

Brachial artery pulse pressure and common carotid artery diameter were positively related to all-cause mortality [hazard ratios per standard deviation, 1.7 (1.2-2.5) and 2.1 (1.3-3.3), respectively]. Results were similar after adjustment for gender, age, waist-to-hip ratio, body mass index, total cholesterol concentration, pre-existent cardiovascular disease, and hypertension, and after additional mutual adjustment. Common carotid artery distensibility and compliance coefficients were not statistically significantly associated with mortality.

CONCLUSIONS

Among subjects with a recent history of impaired glucose tolerance, brachial artery pulse pressure and common carotid artery diameter are independently associated with mortality risk. Stiffness of the central arteries may explain the association between pulse pressure and mortality risk. The association between carotid diameter and mortality risk is more likely to reflect arterial remodelling in response to atherosclerosis than that in response to increased local stiffness.

Postchallenge hyperglycemia and mortality in a national sample of U.S. adults

OBJECTIVE

Although postchallenge hyperglycemia is a well-established feature of type 2 diabetes, its association with risk of mortality is uncertain. Therefore, the aim of this study was to assess the independent association of fasting and 2-h glucose levels with all-cause and cardiovascular disease (CVD) mortality.

RESEARCH DESIGN AND METHODS

We analyzed data from the Second National Health and Nutrition Examination Survey (NHANES II) Mortality Study, a prospective cohort study of U.S. adults examined in the NHANES II, and focused on the 3,092 adults aged 30-74 years who underwent an oral glucose tolerance test at baseline (1976-1980). Deaths were identified from U.S. national mortality files from 1976 to 1992. To account for the complex survey design, we used SUDAAN statistical software for weighted analysis.

RESULTS

Compared with their normoglycemic counterparts (fasting glucose [FG] < 7.0 and 2-h glucose < 7.8 mmol/l), adults with fasting and postchallenge hyperglycemia (FG > or =7.0 and 2-h glucose > or =11.1 mmol/l) had a twofold higher risk of death after 16 years of follow-up (age- and sex-adjusted relative hazard [RH] 2.1, 95% CI 1.4-3.2). However, adults with isolated postchallenge hyperglycemia (FG < 7.0 and 2-h glucose > or =11.1 mmol/l) were also at higher risk of death (1.6, 1.0-2.6). In proportional hazards analysis, FG (fully adjusted RH 1.10 per 1 SD; 95% CI 1.01, 1.22) and 2-h glucose (1.14, 1.00-1.29) showed nearly identical predictive value for mortality. Similar trends were observed for CVD mortality.

CONCLUSIONS

These results suggest that postchallenge hyperglycemia is associated with increased risk of all-cause and CVD mortality independently of other CVD risk factors.

Diagnostic criteria of glucose intolerance and mortality

In 1997 American Diabetes Association (ADA) Expert Committee approved changing the diagnostic criteria for diabetes. The major change is to lower fasting plasma glucose from 7.8 mmol/l to 7.0 mmol/l for diabetes and did not recommend the use of 2-hour 75 g oral glucose tolerance test (OGTT). The decision by the ADA not to recommend the OGTT has been criticised based on the findings of several recent studies, in particularly those from the Diabetes Epidemiology: Collaborative Analysis of Diagnostic Criteria in Europe (DECODE) and in Asia (DECODA) Studies. These studies have reported that only 29% of all newly screened diabetic subjects qualified for diabetes on both the fasting and the 2-hour glucose criteria in European and 37% in Asian populations. It has now been clearly shown that elderly and less obese patients are more likely to have diagnostic 2-hour values, whereas fasting hyperglycaemia is more common among obese subjects. Analysis of the prospective DECODE data showed that elevated 2-hour glucose was a better predictor of mortality from all-cause and from cardiovascular and non-cardiovascular diseases than elevated fasting glucose alone. The largest absolute number of excess deaths was observed in subjects with impaired glucose tolerance (IGT), especially in those whose fasting glucose was normal.

Subclinical states of glucose intolerance and risk of death in the U.S

OBJECTIVE

Although clinically evident type 2 diabetes is a well-established cause of mortality, less is known about subclinical states of glucose intolerance.

RESEARCH DESIGN AND METHODS

Data from the Second National Health and Nutrition Examination Survey Mortality Study, a prospective study of adults, were analyzed. This analysis focused on a nationally representative sample of 3,174 adults aged 30-75 years who underwent an oral glucose tolerance test at baseline (1976-1980) and who were followed up for death through 1992.

RESULTS

Using 1985 World Health Organization criteria, adults were classified as having previously diagnosed diabetes (n = 248), undiagnosed diabetes (n = 183), impaired glucose tolerance (IGT) (n = 480), or normal glucose tolerance (n = 2,263). For these groups, cumulative all-cause mortality through age 70 was 41, 34, 27, and 20%, respectively (P < 0.001). Compared with those with normal glucose tolerance, the multivariate adjusted RR of all-cause mortality was greatest for adults with diagnosed diabetes (RR 2.11, 95% CI 1.56-2.84), followed by those with undiagnosed diabetes (1.77, 1.13-2.75) and those with IGT (1.42, 1.08-1.87; P < 0.001). A similar pattern of risk was observed for cardiovascular disease mortality.

CONCLUSIONS

In the U.S., there was a gradient of mortality associated with abnormal glucose tolerance ranging from a 40% greater risk in adults with IGT to a 110% greater risk in adults with clinically evident diabetes. These associations were independent of established cardiovascular disease risk factors.

Impaired fasting glucose concentrations in nondiabetic patients with ischemic heart disease: a marker for a worse prognosis

BACKGROUND

The issue of whether glucose concentrations below the diabetic threshold may be predictive of increased cardiovascular risk has not yet been fully elucidated. The current study evaluates the prognosis of nondiabetic patients with ischemic heart disease (IHD) and impaired fasting glucose (IFG) over a 7.7-year follow-up period.

METHODS

A total of 11,853 patients with documented coronary artery disease aged between 45 and 74 years were examined. Patients were divided into 3 groups on the basis of their fasting blood glucose levels at screening: nondiabetic individuals, patients with IFG, and undiagnosed diabetic patients. Patients who were on any type of pharmacologic antidiabetic treatment were excluded from the study. Mortality rates were assessed separately for each group.

RESULTS

The population comprised 9773 nondiabetic patients (82.4%, glucose up to 109 mg/dL), 1258 patients with IFG levels (10.6%, glucose 110-125 mg/dL), and 822 diabetic subjects (7%, glucose > or =126 mg/dL). Patients were followed up from 6.2 to 9.0 years (mean follow-up period 7.7 +/- 1.5 years). Crude mortality was lower in the nondiabetic subjects than in the 2 other groups. All-cause mortality in the nondiabetic group was 14.3% compared to 20.1% in patients with IFG and 24.3% in the undiagnosed (P <.001). Multivariate adjustment showed the lowest mortality in nondiabetic subjects, who exhibited a survival rate of 0.86 at the end of the follow-up, whereas the lowest survival-0.75-was seen among undiagnosed diabetic patients (P =.0001). An intermediate value of 0.78 was documented for patients with IFG (P <.01). After multivariate analysis, with nondiabetic patients as the reference group, IFG was identified as a consistent predictor of increased all-cause and IHD mortality with hazard ratios of 1.39 (95% confidence interval 1.21-1.59) and 1.29 (95% confidence interval 1.01-1.64), respectively.

CONCLUSIONS

The main finding of this study is the substantially increased mortality rate among nondiabetic coronary patients with IFG, who had fasting glucose levels markedly lower than hitherto acknowledged as defining overt diabetes.

No excess 12-year mortality in men with impaired glucose tolerance who participated in the Malmö Preventive Trial with diet and exercise

Impaired glucose tolerance (IGT) is associated with increased mortality due to ischaemic heart disease (IHD), but as it is not known whether this excess mortality can be reduced by preventing or delaying the development of non-insulin-dependent diabetes mellitus (NIDDM), a long-term NIDDM prevention trial of dietary counselling and physical exercise was launched at Malmö, Sweden, the 12-year follow-up of which is reported here. At 12-year follow-up of 6956 men who underwent health screening at 48 years of age, an IGT intervention group (n = 288) who participated in a long-term NIDDM prevention programme were compared with an IGT non-randomised routine treatment group (n = 135), a diabetic group (n = 144), and the remainder, the normal glucose tolerance (NGT) group (n = 6389). The variables studied included the levels of blood glucose, plasma insulin, blood pressure, blood lipids, lung function and maximum oxygen uptake. Subjects with IGT were characterised by overweight, poor vital capacity, hypertension, hypertriglyceridaemia and hyperinsulinaemia. The mortality rate in the IGT intervention group was similar to that in the NGT group (6.5 vs 6.2 per 1000 person years at risk) and lower than that in the IGT routine treatment group (6.5 vs 14.0, p = 0.009). In the two IGT groups taken together, intervention but not body mass index, systolic blood pressure, smoking, cholesterol or the 2-h glucose level predicted mortality. Systolic blood pressure was a predictor of IHD mortality among IGT subjects; and in the cohort as a whole, body mass index, systolic blood pressure, hypercholesterolaemica, diabetes and smoking were predictors of IHD mortality. The findings suggest that a long-term intervention programme, with an emphasis on lifestyle changes, including dietary counselling and physical exercise, will reduce mortality in subjects with IGT who are at an increased risk of both developing NIDDM and of premature death due to IHD and other causes.

Glucose tolerance and mortality in an elderly Finnish population

The aim of this study was to describe the association between glucose tolerance status and mortality in an elderly (> 70 years) Finnish community-living population (n = 379, of whom 141 were men). The baseline examination in 1991-1992 consisted of a postal questionnaire, a physical examination, and a 2-h oral glucose tolerance test. The follow-up was continued until death or 31 May 1996. The deaths were ascertained from official death certificates; 31% (n = 44) of the men and 18% (n = 40) of the women died within 4 years. The cumulative 4-year mortalities were 42% in previously diagnosed diabetic men, 25% in previously undiagnosed diabetic men, 27% in men with impaired glucose tolerance (IGT), and 31% in men with normal glucose tolerance (NGT). The corresponding figures for women were: 26%, 29%, 19%, and 8%, respectively. After adjusting for age, gender, smoking, body mass index and exercise by the Cox proportional hazards model in the total population, the estimated relative mortality rate was 2.2 (95% confidence interval (CI) 1.2 to 4.1) in previously diagnosed diabetic subjects, 1.7 (95% CI 0.8 to 3.7) in subjects with previously undiagnosed diabetes, and 1.2 (95% CI 0.7 to 2.1) in the IGT group, respectively, all in comparison to the NGT subjects. In separate modelling by gender these relative mortalities were higher in women than in men, but the gender difference could well be explained by chance variation. In conclusion, the results suggest that previously diagnosed diabetes is associated with increased mortality among the elderly and, particularly among elderly women, undiagnosed diabetes and even IGT may be associated with increased mortality.

Glucose tolerance and mortality, including a substudy of tolbutamide treatment

Mortality according to glucose tolerance was studied to determine the prognosis of impaired glucose tolerance. Among 2500 persons tested in a community screening programme in 1962-1965 and followed-up for mortality to the end of 1987, age-sex-adjusted mortality rates were 37.9 +/- 1.9, 53.6 +/- 4.2, and 70.1 +/- 3.6 deaths per 1000 person-years (+/-SE) in those with normal glucose tolerance, impaired glucose tolerance, and diabetes by World Health Organization criteria at baseline. Age-sex-adjusted mortality rates due to ischaemic heart disease were 14.3 +/- 1.1, 16.3 +/- 2.4, and 25.8 +/- 2.0 deaths per 1000 person-years, respectively. Using criteria predating those of the World Health Organization 147 men with abnormal glucose tolerance were entered into a randomized clinical trial in which 49 were treated with tolbutamide for approximately 10 years. Those treated had lower mortality rates from all causes (mortality rate ratio = 0.66, 95% confidence interval = 0.39, 1.10) and from ischaemic heart disease (mortality rate ratio = 0.42, 95% confidence interval = 0.16, 1.12) than those not receiving tolbutamide. Thus mortality rates are increased in persons with impaired glucose tolerance and diabetes, and the small clinical trial suggests that tolbutamide may be beneficial in men with abnormal glucose tolerance.

The pituitary-gonadal axis and health in elderly men: a study of men born in 1913

The results of recent studies suggest that a relative hypogonadism in men is associated with several established risk factors for prevalent diseases. Therefore, we determined total and free testosterone, luteinizing hormone (LH), and sex-hormone binding globulin (SHBG) in a cohort of randomly selected men (n = 659) at 67 years of age. These data were analyzed cross-sectionally in relation to blood glucose and serum insulin, which were measured while fasting and after an oral glucose tolerance test, in addition to plasma lipids and blood pressure. The data were also analyzed in relation to impaired glucose tolerance (IGT) and diabetes, which were discovered at examination or earlier diagnosis. Risk factors for the development of diabetes up to 80 years of age were analyzed with univariate and multivariate statistics. Total and free testosterone and SHBG concentrations correlated negatively with glucose and insulin values; total testosterone and SHBG, with triglycerides; and SHBG, with blood pressure (from P < 0.05 to P < 0.01). Men with IGT or newly diagnosed diabetes had higher BMI values (26.2 +/- 0.31 and 27.0 +/- 0.59 [mean +/- SE], respectively) and waist circumference (99.0 +/- 1.03 and 100.5 +/- 1.57) than nondiabetic men (BMI, 25.1 +/- 0.14; waist circumference, 95.4 +/- 0.47; P < 0.05), indicating abdominal obesity. Such men and men with previously diagnosed diabetes had, in general, lower total and free testosterone and SHBG levels, while those for LH were not different. In multivariate analyses that included BMI, waist-to-hip ratio, total and free testosterone, and SHBG, the remaining independent predictors for the development of diabetes were low total testosterone (P = 0.015) and, on the borderline, low SHBG (P = 0.053). In relation to nondiabetic men, the risk ratio for mortality, myocardial infarction, and stroke increased gradually and significantly from 1.18 to 1.68, from 1.51 to 1.78, and from 1.72 to 2.46 in men with IGT, newly diagnosed diabetes, and previously known diabetes, respectively. It was concluded that low testosterone and SHBG concentrations in elderly men are associated with established risk factors for diabetes and in established diabetes. Moreover, low testosterone levels independently predict the risk of developing diabetes. In different degrees of expression, the diabetic state predicts strongly (and gradually mortality from) myocardial infarction and stroke. It has been suggested that a relative hypogonadism might be a primary event, because other studies have shown that testosterone deficiency is followed by insulin resistance, which is ameliorated by testosterone substitution. The data suggest that the relative hypogonadism involved might be of both central and peripheral origin.

Impaired glucose tolerance and unidentified diabetes

The epidemiology of impaired glucose tolerance and undiagnosed non-insulin-dependent diabetes mellitus is reviewed and the implications for screening strategies discussed.

[The survival rate of impaired glucose tolerance groups in the elderly]

We analyzed a total of 468 cases, all inmates of the Yokufukai Home for the Aged who had undergone a 50-gram oral glucose tolerance test (OGTT) from January 1980 to December 1981 and who were followed up to the end of March 1994. All cases were divided into different normal, borderline and diabetic categories according to glucose tolerance. 1) Normal cases accounted for 39.6% of males and 39.2% of females, 50% and 52.5% were borderline cases in males and female and these were 10.4% and 8.3% diabetic cases, respectively. 2) The overall survival rate of females was significantly higher than that of males groups (p < 0.05). 3) There was no significant difference in survival rate of males and females in the normal and impaired glucose tolerance groups (border and diabetic). CONCLUSION. Mildly impaired glucose tolerance could be considered as part of the normal aging process.