Glucose Control and Vascular Complications in Veterans with Type 2 Diabetes

Duckworth, William C.; Abraira, Carlos; Möritz, Thomas; Reda, Domenic J.; Emanuele, Nicholas V.; Reaven, Peter D.; Zieve, Franklin J.; Marks, Jennifer B.; Davis, Stephen N.; Hayward, Rodney A.; Warren, Stuart; Goldman, Steven; McCarren, Madeline; Vitek, Mary Ellen; Henderson, William G.; Huang, Grant D.

doi:10.1056/nejmoa0808431

Cited by 4,274 publications

(2,753 citation statements)

References 23 publications

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“…Moreover, glycaemic goals were more often achieved by patients in the older subgroups regardless the presence of a CVD, in accordance with the results from clinical trials and observational studies suggesting that a global control of cardiovascular risk factors in older patients provides a greater benefit regarding morbidity and mortality than an intensive glycaemic control 13, 14, 15, 16, 17. Antihypertensive treatment, for instance, has benefits even in very old patients 18, 19, 20, 21, and there are also compelling evidences of the benefit of statins and antiplatelet agents in older adults in secondary prevention of CVD, while its use in primary prevention is controversial, and individual characteristics and the risk of related adverse events should be taken into account 5, 7, 22, 23, 24, 25.…”

Section: Discussionsupporting

confidence: 84%

Older type 2 diabetic patients are more likely to achieve glycaemic and cardiovascular risk factors targets than younger patients: analysis of a primary care database

et al. 2015

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SummaryBackgroundOlder subjects with type 2 diabetes mellitus (T2DM) have differential characteristics compared with middle‐aged or younger populations, and require tailored management of the disease.AimsTo evaluate how clinical characteristics, degree of control of glycaemia and cardiovascular risk factors, presence of chronic complications and treatments differ between older T2DM patients and younger adults.MethodsCross‐sectional study using data from a population‐based electronic database. We retrieved data from 318,020 patients ≥ 30 years diagnosed with T2DM, attended during 2011 in primary care centres in Catalonia, Spain. We performed descriptive and comparative analyses stratified by gender and age subgroups: ≤ 65, 66–75, 76–85 and >85 years.ResultsBoth men and women across older age subgroups (> 65 years) had longer diabetes duration than younger adults (8.0 vs. 5.6 in men and 8.4 vs. 6.9 years in women; p < 0.001), but better glycaemic control (mean glycated haemoglobin 7.1 vs. 7.7 in men and 7.1 vs. 7.4 in women; p < 0.001), and better combined control of different cardiovascular risk factors (p < 0.001). Moreover, older patients were more likely to achieve glycaemic targets irrespective of having cardiovascular disease. The use of oral antidiabetics decreased with increasing age, and insulin in monotherapy was more frequently prescribed among patients in the older age subgroups. Diabetes‐related complications were more frequent in men of all group ages. In the older age subgroups, patients of both sexes had a longer duration of T2DM but better glycaemic control. In this context, the prevalence of diabetic retinopathy decreased unexpectedly with increasing age.ConclusionControl of glycaemia and cardiovascular risk factors was better among older T2DM patients. There is a need for prospective studies to quantify the weight of risk factors in each complication to adapt the therapeutic and care approaches in elderly people.

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Section: Discussionsupporting

confidence: 84%

Older type 2 diabetic patients are more likely to achieve glycaemic and cardiovascular risk factors targets than younger patients: analysis of a primary care database

et al. 2015

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“…In the ADVANCE and Veterans Affairs Diabetes Trial, however, tight glycemic control did not lead to an improvement in cardiovascular outcomes, whereas in the ACCORD trial, in which patients had underlying cardiovascular disease, intensive treatment was associated with higher cardiovascular mortality risk 29, 30, 31. Findings from these recent studies have collectively raised the question of whether glycemic control in populations with an underlying cardiovascular risk may do more harm than good, which is particularly applicable to patients on hemodialysis in whom the risks of cardiovascular morbidity and mortality are high.…”

Section: Discussionmentioning

confidence: 95%

Associations of Glycemic Control With Cardiovascular Outcomes Among US Hemodialysis Patients With Diabetes Mellitus

Rhee

Zheng

Montez‐Rath

et al. 2017

JAHA

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BackgroundThere is a lack of data on the relationship between glycemic control and cardiovascular end points in hemodialysis patients with diabetes mellitus.Methods and ResultsWe included adult Medicare‐insured patients with diabetes mellitus who initiated in‐center hemodialysis treatment from 2006 to 2008 and survived for >90 days. Quarterly mean time‐averaged glycated hemoglobin (HbA1c) values were categorized into <48 mmol/mol (<6.5%) (reference), 48 to <58 mmol/mol (6.5% to <7.5%), 58 to <69 mmol/mol (7.5% to <8.5%), and ≥69 mmol/mol (≥8.5%). Medicare claims were used to identify outcomes of cardiovascular mortality, nonfatal myocardial infarction (MI), fatal or nonfatal MI, stroke, and peripheral arterial disease. We used Cox models as a function of time‐varying exposure to estimate multivariable adjusted hazard ratios and 95%CI for the associations between HbA1c and time to study outcomes in a cohort of 16 387 eligible patients. Patients with HbA1c 58 to <69 mmol/mol (7.5% to <8.5%) and ≥69 mmol/mol (≥8.5%) had 16% (CI, 2%, 32%) and 18% (CI, 1%, 37%) higher rates of cardiovascular mortality (P‐trend=0.01) and 16% (CI, 1%, 33%) and 15% (CI, 1%, 32%) higher rates of nonfatal MI (P‐trend=0.05), respectively, compared with those in the reference group. Patients with HbA1c ≥69 mmol/mol (≥8.5%) had a 20% (CI, 2%, 41%) higher rate of fatal or nonfatal MI (P‐trend=0.02), compared with those in the reference group. HbA1c was not associated with stroke, peripheral arterial disease, or all‐cause mortality.ConclusionsHigher HbA1c levels were significantly associated with higher rates of cardiovascular mortality and MI but not with stroke, peripheral arterial disease, or all‐cause mortality in this large cohort of hemodialysis patients with diabetes mellitus.

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“…Ford reported that compared with a two years period (1999–2000), the estimated 10‐year risk for developing coronary artery disease among people with diagnosed diabetes was 22% lower by 2007–2008 5. This improved risk factor control may be one reason explaining the failure of more aggressive hypoglycemic drugs to reduce macrovascular disease in diabetes 12, 13. Whether this improvement in CHD as a result of risk factor control translates to a reduction in mortality after revascularization has not previously been reported and our observational study provides data from a large cohort suggesting this may be the case and provides stimulus for further research.…”

Section: Discussionmentioning

confidence: 99%

Mortality after percutaneous coronary revascularization: Prior cardiovascular risk factor control and improved outcomes in patients with diabetes mellitus

Noman

Balasubramaniam

Alhous

et al. 2016

Cathet Cardio Intervent

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ObjectivesTo assess the mortality in patients with diabetes mellitus (DM) following percutaneous coronary intervention (PCI) according to their insulin requirement and PCI setting (elective, urgent, and emergency).BackgroundDM is a major risk factor to develop coronary artery disease (CAD). It is unclear if meticulous glycemic control and aggressive risk factor management in patients with DM has improved outcomes following PCI.MethodsRetrospective analysis of prospectively collected data on 9,224 patients treated with PCI at a regional tertiary center between 2008 and 2011.ResultsAbout 7,652 patients were nondiabetics (non‐DM), 1,116 had non‐insulin treated diabetes mellitus (NITDM) and 456 had ITDM. Multi‐vessel coronary artery disease, renal impairment and non‐coronary vascular disease were more prevalent in DM patients. Overall 30‐day mortality rate was 2.4%. In a logistic regression model, the adjusted odds ratios (95% confidence intervals [CI]) for 30‐day mortality were 1.28 (0.81–2.03, P = 0.34) in NITDM and 2.82 (1.61–4.94, P < 0.001) in ITDM compared with non‐DM. During a median follow‐up period of 641 days, longer‐term post‐30 day mortality rate was 5.3%. In the Cox's proportional hazard model, the hazard ratios (95% CI) for longer‐term mortality were 1.15 (0.88–1.49, P = 0.31) in NITDM and 1.88 (1.38–2.55, P < 0.001) in ITDM compared with non‐DM group. Similar result was observed in all three different PCI settings.ConclusionIn the modern era of aggressive cardiovascular risk factor control in diabetes, this study reveals higher mortality only in insulin‐treated diabetic patients following PCI for stable coronary artery disease and acute coronary syndrome. Importantly, diabetic patients with good risk factor control and managed on diet or oral hypoglycemics have similar outcomes to the non‐diabetic population. © 2016 The Authors Catheterization and Cardiovascular Interventions Published by Wiley Periodicals, Inc.

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Glucose Control and Vascular Complications in Veterans with Type 2 Diabetes

Cited by 4,274 publications

References 23 publications

Older type 2 diabetic patients are more likely to achieve glycaemic and cardiovascular risk factors targets than younger patients: analysis of a primary care database

Older type 2 diabetic patients are more likely to achieve glycaemic and cardiovascular risk factors targets than younger patients: analysis of a primary care database

Associations of Glycemic Control With Cardiovascular Outcomes Among US Hemodialysis Patients With Diabetes Mellitus

Mortality after percutaneous coronary revascularization: Prior cardiovascular risk factor control and improved outcomes in patients with diabetes mellitus

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