Preventable Major Cardiovascular Events Associated With Uncontrolled Glucose, Blood Pressure, and Lipids and Active Smoking in Adults With Diabetes With and Without Cardiovascular Disease: A Contemporary Analysis

Abstract

OBJECTIVEThe objective of this study was to assess the incidence of major cardiovascular (CV) hospitalization events and all-cause deaths among adults with diabetes with or without CV disease (CVD) associated with inadequately controlled glycated hemoglobin (A1C), high LDL cholesterol (LDL-C), high blood pressure (BP), and current smoking.RESEARCH DESIGN AND METHODSStudy subjects included 859,617 adults with diabetes enrolled for more than 6 months during 2005–2011 in a network of 11 U.S. integrated health care organizations. Inadequate risk factor control was classified as LDL-C ≥100 mg/dL, A1C ≥7% (53 mmol/mol), BP ≥140/90 mm Hg, or smoking. Major CV events were based on primary hospital discharge diagnoses for myocardial infarction (MI) and acute coronary syndrome (ACS), stroke, or heart failure (HF). Five-year incidence rates, rate ratios, and average attributable fractions were estimated using multivariable Poisson regression models.RESULTSMean (SD) age at baseline was 59 (14) years; 48% of subjects were female, 45% were white, and 31% had CVD. Mean follow-up was 59 months. Event rates per 100 person-years for adults with diabetes and CVD versus those without CVD were 6.0 vs. 1.7 for MI/ACS, 5.3 vs. 1.5 for stroke, 8.4 vs. 1.2 for HF, 18.1 vs. 40 for all CV events, and 23.5 vs. 5.0 for all-cause mortality. The percentages of CV events and deaths associated with inadequate risk factor control were 11% and 3%, respectively, for those with CVD and 34% and 7%, respectively, for those without CVD.CONCLUSIONSAdditional attention to traditional CV risk factors could yield further substantive reductions in CV events and mortality in adults with diabetes.

Relation of Smoking With Total Mortality and Cardiovascular Events Among Patients With Diabetes Mellitus

“…One study 15 reported results separately for type 1 diabetes (T1D) and type 2 diabetes (T2D), and one study 16 reported results separately for those with and without baseline CVD, and thus 50 reports from 48 studies were included with a total of 1,132,700 participants and 109,966 deaths. Of the 48 studies, most were conducted in European countries ( n =24) and US ( n =14).…”

“…In particular, they had missed 6 eligible studies 23–28 in the analysis of total mortality that were published before 2011. Our current meta-analysis included those studies together with many newly published articles (particularly some recent large studies 16,29,30 ), thus providing the most accurate and comprehensive estimates of smoking related adverse health outcomes among diabetic patients. We included almost double the number of studies, and ten-fold more study participants.…”

Cardiovascular Risk Factor Targets and Cardiovascular Disease Event Risk in Diabetes: A Pooling Project of the Atherosclerosis Risk in Communities Study, Multi-Ethnic Study of Atherosclerosis, and Jackson Heart Study

“…Also, applying UK Prospective Diabetes Study risk engine estimates to combined control of HbA 1c , BP, total cholesterol, HDL-C, and smoking among U.S. adults with DM in the National Health and Nutrition Examination Survey, statistically “controlling” all risk factors to goal was projected to prevent an estimated 36–42% of CHD events and, in the case of aggressive control, was projected to prevent 54–60% of CHD events (22). Finally, a recently published 5-year follow-up study (23) of 859,617 adults with DM among 11 U.S. integrated health care organizations showed inadequate risk factor control to be responsible for 11–34% of CVD events. While control of BP, LDL-C, and HbA 1c has improved over recent years in U.S. adults with DM, only about one-fourth of such individuals are at control for all three of these factors, according to recent U.S. data (14).…”

Effect of Multifactorial Treatment Targets and Relative Importance of Hemoglobin A1c, Blood Pressure, and Low‐Density Lipoprotein‐Cholesterol on Cardiovascular Diseases in Chinese Primary Care Patients With Type 2 Diabetes Mellitus: A Population‐Based Retrospective Cohort Study

“…To date, there have only been a few studies that have explored the association between multifactorial risk factors and CVD . These studies have typically examined the number of factors controlled as none, any 1, any 2, or all 3 risk factors, but the relative importance of these 3 risk factors remains unclear.…”

“…Evidence on the relative importance of treating each factor or combinations of factors can help clinicians make the most informed decisions and can also be used for shared decision making in diabetic patients with multimorbidity. Previous studies included both type 1 diabetes mellitus (DM) and type 2 DM (T2DM) subjects, have included patients recruited from hospital‐based settings, have had inadequate sample sizes to observe sufficient end‐point events, or have been performed under very structured but artificial settings such as randomized clinical trials . Given the potential difference in pathophysiology of CVD in type 1 DM and T2DM, and difference in disease severity in hospital‐based patients and primary care patients, findings from these previous studies may not be applicable to T2DM patients managed in a real‐world primary care outpatient setting.…”