K. Eeg-Olofsson

Level of physical activity associated with risk of cardiovascular diseases and mortality in patients with type-2 diabetes: report from the Swedish National Diabetes Register:

Aims To estimate risks of coronary heart disease (CHD), cardiovascular disease (CVD), and total mortality with low or higher levels of physical activity (PA) assessed with questionnaire, in an observational study of patients with type-2 diabetes from the Swedish National Diabetes Register. Subjects and methods A total of 15,462 patients (60 years), were followed for 5 years from baseline in 2004 until 2009, with 760 CVD events and 427 total mortality events based on 54,344 person-years. Results Comparing 6963 patients with low baseline PA (never or 1–2 times/week for 30u2009min) and 8499 patients with higher baseline PA (regular 3 times/week or more), hazard ratios for fatal/nonfatal CHD, fatal/nonfatal CVD, fatal CVD, and total mortality were 1.25 (95% CI 1.05–1.48; pu2009=u20090.01), 1.26 (95% CI 1.09–1.45; pu2009=u20090.002), 1.69 (95% CI 1.18–2.41; pu2009=u20090.004), and 1.48 (95% CI 1.22–1.79; pu2009<u20090.001), adjusting for age, sex, diabetes duration, diabetes treatment, and smoking (model 1). Adjusting also for HbA1c, systolic blood pressure, low- and high-density lipoprotein cholesterol, triglycerides, body mass index, and albuminuria (model 2), HRs were 1.19 (95% CI 1.00–1.42; pu2009=u20090.049), 1.18 (95% CI 1.02–1.36; pu2009=u20090.04), 1.54 (95% CI 1.07–2.22; pu2009=u20090.02), and 1.41 (95% CI 1.16–1.72; pu2009<u20090.001), respectively. Corresponding results (model 2), comparing 4166 patients having low PA both baseline and at follow up with all other 11,296 patients were 1.68 (95% CI 1.41–2.01), 1.68 (95% CI 1.45–1.96), 2.12 (95% CI 1.48–3.03), and 2.03 (95% CI 1.66–2.48) (all pu2009<u20090.001) and compared to 2797 patients with low baseline PA and higher PA at follow up were 2.51 (95% CI 1.87–3.38), 2.54 (95% CI 1.98–3.27), 3.26 (95% CI 1.74–6.10), and 2.91 (95% CI 2.08–4.07) (all pu2009<u20090.001). Conclusions This large observational study of patients with type-2 diabetes showed considerably increased risks for CVD and mortality with low PA.

Long-term mortality in patients with type 2 diabetes undergoing coronary angiography: the impact of glucose-lowering treatment.

Aims/hypothesisThe aim of this study was to analyse whether the increased mortality rates observed in insulin-treated patients with type 2 diabetes and coronary artery disease are explained by comorbidities and complications.MethodsA retrospective analysis of data from two Swedish registries of type 2 diabetic patients (nu2009=u200912,515) undergoing coronary angiography between the years 2001 and 2009 was conducted. The association between glucose-lowering treatment and long-term mortality was studied after extensive adjustment for cardiovascular- and diabetes-related confounders. Patients were classified into four groups, according to glucose-lowering treatment: diet alone; oral therapy alone; insulin in combination with oral therapy; and insulin alone.ResultsAfter a mean follow-up time of 4.14xa0years, absolute mortality rates for patients treated with diet alone, oral therapy alone, insulin in combination with oral therapy and insulin alone were 19.2%, 17.4%, 22.9% and 28.1%, respectively. Compared with diet alone, insulin in combination with oral therapy (HR 1.27; 95% CI 1.12, 1.43) and insulin alone (HR 1.62; 95% CI 1.44, 1.83) were associated with higher mortality rates. After adjustment for baseline differences, insulin in combination with oral glucose-lowering treatment (HR 1.22; 95% CI 1.06, 1.40; pu2009<u20090.005) and treatment with insulin only (HR 1.17; 95% CI 1.02, 1.35; pu2009<u20090.01) remained independent predictors for long-term mortality.Conclusions/interpretationType 2 diabetes patients treated with insulin and undergoing coronary angiography have a higher long-term mortality risk after adjustment for measured confounders. Further research is needed to evaluate the optimal glucose-lowering treatment for these high-risk patients.

LDL-cholesterol versus non-HDL-to-HDL-cholesterol ratio and risk for coronary heart disease in type 2 diabetes:

Aims We assessed the association between different blood lipid measures and risk of fatal/nonfatal coronary heart disease (CHD), which has been less analysed previously in type 2 diabetes. Design, methods Observational study of 46,786 patients with type 2 diabetes, aged 30–70 years, from the Swedish National Diabetes Register, followed for a mean of 5.8 years until 2009. Baseline and updated mean low-density lipoprotein (LDL)-, high-density lipoprotein (HDL)-, non-HDL-cholesterol, and non-HDL-to-HDL-cholesterol ratio were measured. Results Hazard ratios (HR) for CHD with quartiles 2–4 of baseline lipid measures, with lowest quartile 1 as reference: 1.03–1.29–1.63 for LDL; 1.23–1.41–1.95 for non-HDL; 1.29–1.39–1.57 for HDL; and 1.31–1.67–2.01 for non-HDL:HDL, all pu2009<u20090.001 except for quartile 2 of LDL, when adjusted for clinical characteristics and nonlipid risk factors. A similar picture was seen with updated mean values. Splines with absolute 6-year CHD rates in a Cox model showed decreasing rates only down to around 3u2009mmol/l for LDL, with linearly decreasing rates to the lowest level of non-HDL:HDL. Non-HDL and HDL were independent additive risk factors for CHD risk. HRs per 1u2009SD continuous decrease in baseline or updated mean HDL were 1.14–1.17 when fully adjusted as above, and 1.08–1.13 when also adjusted for non-HDL (pu2009<u20090.001). HRs were 1.13–1.16 adjusted for LDL, and 1.22–1.26 adjusted for total cholesterol and triglycerides (pu2009<u20090.001). Splines showed progressively increasing 6-year CHD rates with lower HDL down to 0.5u2009mmol/l. Conclusions This study suggests that lower levels of non-HDL:HDL are a better risk marker for CHD than LDL-cholesterol below 3u2009mmol/l.

Mortality and extent of coronary artery disease in 2776 patients with type 1 diabetes undergoing coronary angiography: A nationwide study

Background In a modern perspective there is limited information on mortality by affected coronary vessels assessed by coronary angiography in patients with type 1 diabetes. The aim of the present study was to characterise distribution of coronary artery disease and impact on long-term mortality in patients with type 1 diabetes undergoing coronary angiography. Design The design of this research was a nationwide population-based cohort study. Methods Individuals (nu2009=u20092776) with type 1 diabetes undergoing coronary angiography 2001–2013 included in the Swedish National Diabetes Registry and Swedish Coronary Angiography and Angioplasty Registry were followed for mortality until 31 December 2013 (mean 7.1 years). In 79% the indication was stable or acute coronary artery disease. Coronary artery disease was categorised into normal (21%), one- (23%), two- (18%), three- (29%) and left main-vessel disease (8%). Results Mean age was 57 years and 58% were male. Mean diabetes duration was 35 years, glycated haemoglobin was 67 mmol/mol and 44% had normal or one-vessel disease. In multivariate Cox proportional analyses hazard ratio for mortality compared with normal findings was 1.09 (95% confidence interval 0.80–1.48) for one, 1.43 (1.05–1.94) for two, 1.47 (1.10–1.96) for three and 1.90 (1.35–2.68) for left main-vessel disease. Renal failure 2.29 (1.77–2.96) and previous heart failure 1.76 (1.46–2.13) were highly associated with mortality. Standard mortality ratio the first year was 5.55 (4.65–6.56) and decreased to 2.80 (2.18–3.54) after five years. Conclusions In patients with type 1 diabetes referred for coronary angiography mortality is influenced by numbers of affected coronary vessels. The overall mortality rate was higher compared with the general population. These results support early intensive prevention of coronary artery disease in this population.

Refill adherence and persistence to lipid-lowering medicines in patients with type 2 diabetes: A nation-wide register-based study

This study aimed to describe and compare refill adherence and persistence to lipid‐lowering medicines in patients with type 2 diabetes by previous cardiovascular disease (CVD).

Body mass index as a risk factor for coronary events and mortality in patients with type 1 diabetes

Objective To investigate the potential relationship between body mass index (BMI) and the risk for myocardial infarction and coronary death in patients with type 1 diabetes. Methods We studied patients with type 1 diabetes included in the Swedish National Diabetes Registry during 2002–2004 and followed them until a discharge diagnosis for myocardial infarction, acute coronary event, death or until 31 December 2011. Cox regression was used to estimate relative risks. Results In 17u2009499 patients with type 1 diabetes (mean age 39.4 years; mean BMI 25.2u2009kg/m2), 819 were diagnosed with myocardial infarction as a primary or secondary diagnosis during a mean follow-up of 8.5 years (maximum 9.9 years). Estimated with Cox regression, there was no significant effect of increased BMI on the risk of myocardial infarction (HR 1.4 (95% CI 0.7 to 2.5) in the group with BMI >35u2009kg/m2 compared with BMI 18.5–25u2009kg/m2. There was no association between BMI and coronary mortality, acute coronary events or all-cause mortality after adjusting for other known risk factors. Underweight patients (BMI <18.5u2009kg/m2) had increased hazard for coronary (HR 5.0 (95%u2009CI 1.5 to 16.9)) and all-cause mortality (HR 5.4 (95%u2009CI 3.1 to 9.6)) compared with BMI 18.5–25u2009kg/m2. Conclusions Among patients with type 1 diabetes, increased BMI is not a significant independent risk factor for myocardial infarction or coronary death after adjustment for other risk factors. Low BMI (less than 18.5u2009kg/m2) is associated with mortality from coronary or any cause.

Association between refill adherence to lipid-lowering medications and the risk of cardiovascular disease and mortality in Swedish patients with type 2 diabetes mellitus: a nationwide cohort study

Objectives To analyse the association between refill adherence to lipid-lowering medications, and the risk of cardiovascular disease (CVD) and mortality in patients with type 2 diabetes mellitus. Design Cohort study. Setting National population-based cohort of Swedish patients with type 2 diabetes mellitus. Participants 86u2009568 patients aged ≥18 years, registered with type 2 diabetes mellitus in the Swedish National Diabetes Register, who filled at least one prescription for lipid-lowering medication use during 2007–2010, 87% for primary prevention. Exposure and outcome measures Refill adherence of implementation was assessed using the medication possession ratio (MPR), representing the proportion of days with medications on hand during an 18-month exposure period. MPR was categorised by five levels (≤20%, 21%–40%, 41%–60%, 61%–80% and >80%). Patients without medications on hand for ≥180 days were defined as non-persistent. Risk of CVD (myocardial infarction, ischaemic heart disease, stroke and unstable angina) and mortality by level of MPR and persistence was analysed after the exposure period using Cox proportional hazards regression and Kaplan-Meier, adjusted for demographics, socioeconomic status, concurrent medications and clinical characteristics. Results The hazard ratios for CVD ranged 1.33–2.36 in primary prevention patients and 1.19–1.58 in secondary prevention patients, for those with MPR ≤80% (p<0.0001). The mortality risk was similar regardless of MPR level. The CVD risk was 74% higher in primary prevention patients and 33% higher in secondary prevention patients, for those who were non-persistent (p<0.0001). The mortality risk was 6% higher in primary prevention patients and 18% higher in secondary prevention patients, for non-persistent patients (p<0.0001). Conclusions Higher refill adherence to lipid-lowering medications was associated with lower risk of CVD in primary and secondary prevention patients with type 2 diabetes mellitus.

A disease-specific questionnaire for measuring patient-reported outcomes and experiences in the Swedish National Diabetes Register: Development and evaluation of content validity, face validity, and test-retest reliability

OBJECTIVEnTo describe the development and evaluation of the content and face validity and test-retest reliability of a disease-specific questionnaire that measures patient-reported outcomes and experiences for the Swedish National Diabetes Register for adult patients who have type 1 or type 2 diabetes.nnnMETHODSnIn this methodological study, a questionnaire was developed over four phases using an iterative process. Expert reviews and cognitive interviews were conducted to evaluate content and face validity, and a postal survey was administered to evaluate test-retest reliability.nnnRESULTSnThe expert reviews and cognitive interviews found the disease-specific questionnaire to be understandable, with relevant content and value for diabetes care. An item-level content validity index ranged from 0.6-1.0 and a scale content validity/average ranged from 0.7-1.0. The fourth version, with 33 items, two main parts and seven dimensions, was answered by 972 adults with type 1 and type 2 diabetes (response rate 61%). Weighted Kappa values ranged from 0.31-0.78 for type 1 diabetes and 0.27-0.74 for type 2 diabetes.nnnCONCLUSIONSnThis study describes the initial development of a disease-specific questionnaire in conjunction with the NDR. Content and face validity were confirmed and test-retest reliability was satisfactory.nnnPRACTICE IMPLICATIONSnWith the development of this questionnaire, the NDR becomes a clinical tool that contributes to further understanding the perspectives of adult individuals with diabetes.

Electrical atrial vulnerability and renal complications in type 2 diabetes. Reply to Montaigne D, Coisne A, Sosner P et al [letter]

Electrical atrial vulnerability and renal complications in type 2 diabetes. Reply to Montaigne D, Coisne A, Sosner P et al [letter]

Systolic Blood Pressure And Risk Of Cardiovascular Disease In Type 2 Diabetic Patients, On Antihypertensive Treatment Or Not: National Data

Objectives: At present the blood pressure goal for patients with diabetes is disputed. We estimated the risks of fatal/non-fatal coronary heart disease (CHD), stroke and cardiovascular disease (CVD) in relation to baseline systolic blood pressure (SBP) in an observational study of type 2 diabetic patients from the National Diabetes Register (NDR) of Sweden. Methods: Sample 1 (n = 15,042, without previous CVD), and Sample 2 (in addition also including 2626 with a history of CVD), aged 30–70 years, stratified whether on antihypertensive drug treatment (AHT) or not, followed for 5 years. Results: In all 17,668 patients, hazard ratios for CHD, stroke and CVD per 10 mmHg SBP increase at Cox regression, adjusting for several cardiovascular risk factors, were 1.08 (95%CI: 1.03–1.12), 1.13 (1.07–1.20), 1.09 (1.06–1.13), all p < 0.001. In Sample 1 on AHT, no J-shaped curve was seen relating adjusted CHD or stroke rates to SBP across 110–180 mmHg, although the increase in CHD rate was very small from 110 to 125–130 mmHg. Analysing by quartiles of SBP, mean CHD rates were similar in the lowest quartiles 1 and 2, while the mean stroke rate was lower in quartile 1. In Sample 2 on AHT, a J-shaped curve with nadir of around 130 mmHg was found for the CHD rate, although not for the stroke rate. The mean CHD rate was 12% higher (p < 0.001) comparing quartile 1 (110–131 mmHg) with quartile 2 (132–140 mmHg). Conclusions: An increased CHD risk at the lowest SBP values below around 130 mmHg was observed in high-risk patients on AHT with 19% previous CHD/stroke and 5% congestive heart failure, although not seen on AHT without previous CVD, and not regarding the stroke risk.