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Risk Factors, Mortality, and Cardiovascular Outcomes in Patients with Type 2 Diabetes

Journal article
Authors Aidin Rawshani
Araz Rawshani
Stefan Franzén
N. Sattar
Björn Eliasson
Ann-Marie Svensson
B. Zethelius
Mervete Miftaraj
D. K. McGuire
Annika Rosengren
Soffia Gudbjörnsdottir
Published in New England Journal of Medicine
Volume 379
Issue 7
Pages 633-644
ISSN 0028-4793
Publication year 2018
Published at Institute of Medicine, Department of Molecular and Clinical Medicine
Institute of Medicine, Department of Public Health and Community Medicine, Health Metrics
Pages 633-644
Language en
Links dx.doi.org/10.1056/NEJMoa1800256
Keywords accord randomized-trial, multifactorial intervention, microvascular, outcomes, follow-up, disease, association, mellitus, complications, hyperglycemia, management, General & Internal Medicine
Subject categories Clinical Medicine

Abstract

BACKGROUND Patients with diabetes are at higher risk for death and cardiovascular outcomes than the general population. We investigated whether the excess risk of death and cardiovascular events among patients with type 2 diabetes could be reduced or eliminated. In a cohort study, we included 271,174 patients with type 2 diabetes who were registered in the Swedish National Diabetes Register and matched them with 1,355,870 controls on the basis of age, sex, and county. We assessed patients with diabetes according to age categories and according to the presence of five risk factors (elevated glycated hemoglobin level, elevated low-density lipoprotein cholesterol level, albuminuria, smoking, and elevated blood pressure). Cox regression was used to study the excess risk of outcomes (death, acute myocardial infarction, stroke, and hospitalization for heart failure) associated with smoking and the number of variables outside target ranges. We also examined the relationship between various risk factors and cardiovascular outcomes. The median follow-up among all the study participants was 5.7 years, during which 175,345 deaths occurred. Among patients with type 2 diabetes, the excess risk of outcomes decreased stepwise for each risk-factor variable within the target range. Among patients with diabetes who had all five variables within target ranges, the hazard ratio for death from any cause, as compared with controls, was 1.06 (95% confidence interval [CI], 1.00 to 1.12), the hazard ratio for acute myocardial infarction was 0.84 (95% CI, 0.75 to 0.93), and the hazard ratio for stroke was 0.95 (95% CI, 0.84 to 1.07). The risk of hospitalization for heart failure was consistently higher among patients with diabetes than among controls (hazard ratio, 1.45; 95% CI, 1.34 to 1.57). In patients with type 2 diabetes, a glycated hemoglobin level outside the target range was the strongest predictor of stroke and acute myocardial infarction; smoking was the strongest predictor of death. Patients with type 2 diabetes who had five risk- factor variables within the target ranges appeared to have little or no excess risk of death, myocardial infarction, or stroke, as compared with the general population. (Funded by the Swedish Association of Local Authorities and Regions and others.)

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