Long-Term Cardiovascular Outcomes in Diabetics

Study Questions:

What are long-term cardiovascular outcomes and predictors of these cardiovascular events in an international cohort of patients with diabetes?

Methods:

This was a post hoc analysis of the REACH registry, in which patients were enrolled between 2003-2004, and then followed until 2008. To be eligible, patients had to have established atherosclerosis (coronary artery disease, peripheral artery disease, or cerebrovascular disease) or three or more risk factors for atherosclerosis. The following were endpoints in the REACH registry: cardiovascular death, myocardial infarction, stroke, hospitalization for ischemia, and hospitalization for heart failure. Patients were categorized into those with and without diabetes. Those with diabetes were further stratified into patients with risk factors only or known atherothrombosis. Four-year event rates were determined using the corrected group prognosis method.

Results:

The analytic sample was comprised of 45,224 patients who were enrolled in the REACH registry and had follow-up at 4 years. Of these, 19,699 patients (43.6%) had diabetes. The overall hazard rate of cardiovascular death, myocardial infarction, or stroke (adjusted for age and sex) was greater in patients with diabetes as compared to patients without diabetes (16.5% vs. 13.1%, p < 0.001). Similar relationships were observed for cardiovascular death and nonfatal myocardial infarction, but there was no difference in rate of nonfatal stroke. In analyses adjusted for potential confounders and when compared to patients in REACH without diabetes, the presence of diabetes was associated with an increase in the odds of hospitalization for heart failure (9.4% vs. 5.9%; odds ratio, 1.33; 95% confidence interval, 1.18-1.50). A history of heart failure at baseline in patients with diabetes was independently associated with cardiovascular death (adjusted hazard ratio, 2.45; 95% confidence interval, 2.17-2.77; p < 0.001).

Conclusions:

In an international cohort of patients, the presence of diabetes significantly increased the risk of cardiovascular events in both patients with and at risk for atherothrombosis.

Perspective:

This is an important analysis of a large international cohort that offers convincing information to support the notion that diabetes significantly increases the risk of cardiovascular events. The presence of heart failure in patients with diabetes was associated with a particularly escalated risk of cardiovascular events. Diabetics with comorbid heart failure may be an especially vulnerable population, and there is a need for additional therapies in this group.

Clinical Topics: Acute Coronary Syndromes, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Atherosclerotic Disease (CAD/PAD), Acute Heart Failure

Keywords: Acute Coronary Syndrome, Atherosclerosis, Coronary Artery Disease, Diabetes Mellitus, Heart Failure, Metabolic Syndrome X, Myocardial Infarction, Risk Factors, Stroke


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