Type 2 Diabetes and Incidence of Cardiovascular Diseases: A Cohort Study in 1.9 Million People

Study Questions:

What are associations between type 2 diabetes and 12 initial manifestations of cardiovascular disease?


This was an analysis from the CALIBER programme (CArdiovascular disease research using LInked Bespoke studies and Electronic health records), which links the following four sources of electronic health data in England: primary care health records, coded hospital discharges, the Myocardial Ischemia National Audit Project (MINAP), and death registrations. Those with cardiovascular disease at baseline were excluded and the authors defined individuals as having diabetes at baseline or not. The primary endpoint was the first occurrence of one of the following 12 cardiovascular presentations: stable angina, unstable angina, myocardial infarction, unheralded coronary death, heart failure, transient ischemic attack, ischemic stroke, subarachnoid hemorrhage, intracerebral hemorrhage, peripheral arterial disease, abdominal aortic aneurysm, or a composite outcome classified as arrhythmia or sudden cardiac death.


The analytic sample included 1,921,260 individuals, of whom 98.2% did not have diabetes at baseline. Median follow-up was 5.5 years. The overall estimated risk of developing any cardiovascular disease by age 80 years was 30.7% (95% confidence interval [CI], 30.3-31.0) for women without diabetes and 44.3% (95% CI, 43.8-44.7) for men without diabetes, compared with 58.2% (95% CI, 54.9-61.4) for women with type 2 diabetes and 67.4% (95% CI, 64.4-70.4) for men with type 2 diabetes. The most common form of first cardiovascular presentation in those with type 2 diabetes was peripheral arterial disease (reported in 16.2% of patients), followed by heart failure (in 14.1% of patients). Type 2 diabetes was positively associated with peripheral arterial disease, ischemic stroke, stable angina, heart failure, and nonfatal myocardial infarction. Type 2 diabetes was inversely associated with abdominal aortic aneurysm and subarachnoid hemorrhage, and not associated with the composite of arrhythmia or sudden cardiac death.


The association between type 2 diabetes and various forms of cardiovascular disease differ in magnitude and direction. Importantly, the most common initial manifestations of cardiovascular disease in those with diabetes mellitus are peripheral arterial disease and heart failure.


This is an important, population-based study of nearly 2 million individuals. Perhaps the most relevant finding is that the most common presentations of cardiovascular disease are peripheral arterial disease and heart failure. The association with peripheral arterial disease persisted even in participants with adequate glycemic control with a glycated hemoglobin of <6.5%. These findings have important implications for clinical risk assessment and selection of clinical endpoints in drug trials of those with type 2 diabetes.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Stable Ischemic Heart Disease, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Chronic Angina

Keywords: Angina, Stable, Angina, Unstable, Aortic Aneurysm, Abdominal, Arrhythmias, Cardiac, Cerebral Hemorrhage, Death, Sudden, Cardiac, Diabetes Mellitus, Type 2, Electronic Health Records, England, Heart Failure, Hemoglobin A, Glycosylated, Ischemic Attack, Transient, Myocardial Infarction, Peripheral Arterial Disease, Primary Health Care, Risk Assessment, Stroke, Subarachnoid Hemorrhage

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