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PAD, Heart Failure Shown Most Common Cardiovascular Disease Outcomes

Prevention methods differ from standard stroke and myocardial infarction presentations in T2DM patients…

Type 2 diabetes patients are considered to be at increased risk for cardiovascular diseases. While the incidence of stroke and myocardial infarction has been decreasing in type 2 diabetes patients, these disease states continue to be the most commonly used as endpoints in trials. Previous studies continue to focus on one or two disease states while neglecting other cardiovascular outcomes like heart failure and arrhythmias. This is typically because studies lack sample sizes large enough to demonstrate an association with rarer outcomes. Results also differ among previous studies depending on the sex of the participants and which cardiovascular outcome was selected.

This prospective cohort examined the association between type 2 diabetes and the risk of the most common initial cardiovascular diseases in both sexes. The data used was obtained from electronic health record sources. The 1,921,260 adult subjects were free of cardiovascular disease at baseline with 1.8% having type 2 diabetes. The median follow-up was 5.5 years. The primary endpoint was first record of 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. Cox models were used to calculate the cause-specific hazard ratios.

Type 2 diabetes patients were found to have peripheral arterial disease (16.2% of type 2 diabetes patients) and heart failure (14.1% of type 2 diabetes patients) as the most common initial presentations of a cardiovascular disease. Type 2 diabetes was also found to have a positive association with several cardiovascular disease states. A positive association was observed with stable angina (HR 1.62, 95%CI 1.49-1.77), unstable angina (HR1.53, 95%CI 1.32-176), non-fatal myocardial infarction (HR 1.54, 95%CI 1.42-1.67), heart failure (HR 1.56, 95% CI 1.45-1.69) and ischemic stroke (HR1.72, 95% CI 1.52-1.95). No association was observed between type 2 diabetes and arrhythmia or sudden cardiac death (HR 0.95, 95% CI 0.76-1.19). An inverse association was observed with abdominal aortic aneurysm (HR 0.46, 95% CI 0.35-0.59) and subarachnoid hemorrhage (HR 0.48, 95% CI 0.26-0.89).

The results of this study show that peripheral arterial disease and heart failure were the most common initial presentations of cardiovascular disease in type 2 diabetes patients. These disease states are often not studied in trials involving diabetes patients. Also, the strategies for preventing these outcomes differ from the more commonly studied risks, including myocardial infarction and stroke. Highlighting these diseases as a risk to type 2 diabetes patients could have an impact on the way future trials are conducted and alter cardiovascular disease risk prevention in this population.

Practice Pearls:

  • Type 2 diabetes patients are at an increased risk of cardiovascular disease, but previous studies are often limited by their choice of stroke and myocardial infarction as the disease state outcome
  • Peripheral arterial disease and heart failure were identified as the most common initial presentations of cardiovascular disease in patients with type 2 diabetes
  • A positive association was found between several cardiovascular disease states and type 2 diabetes, including angina, non-fatal myocardial infarction, heart failure and peripheral arterial disease

Shah AD, Langenber C, Rapsomaniki E, Denaxas S, Pujades-Rodriguez M et al. Type 2 diabetes incidence pf cardiovascular disease: a cohort study of 1.9 million people. Lancet Diabetes Endocrinol. 2014 Nov 11.