Diabetic Patients with AF at Increased Risk of Adverse Events

Diabetic patients with atrial fibrillation (AF) are at a significantly greater risk of adverse clinical outcomes than those without AF, a new analysis has shown. Compared with those without the rhythm disorder, diabetic patients with AF are more likely to die from all or cardiovascular causes, as well as have more cerebrovascular events and heart failure, report researchers.

“These findings are of direct relevance for the routine clinical management of diabetic patients and indicate that detection of AF in a patient with diabetes should prompt more aggressive treatment of cardiovascular risk factors,” writes lead author Dr Xin Du, University of Sydney, Australia.

The findings, from an analysis of the ADVANCE study, also showed that routine blood-pressure lowering with a fixed combination of perindopril and indapamide yielded similar relative risk reductions but greater absolute risk reductions in cardiovascular and all-cause mortality in patients with and without atrial fibrillation.

In this analysis, the ADVANCE investigators sought to evaluate the extent to which AF increases the already-elevated risk of cardiovascular disease in patients with diabetes and how these patients responded to blood-pressure–lowering therapy. AF is commonly observed in patients with diabetes, with prevalence rates at least twice those than among individuals without diabetes, according to the group.

Among the 11,140 patients with Type 2 diabetes, 7.6% had AF at baseline. These patients were older, had higher body-mass indexes, higher blood pressures, and more cardiovascular risk factors. During a mean follow-up of 4.3 years, patients with AF at baseline were at significantly greater risk of cardiovascular events and all-cause mortality than those without AF at baseline.

Association Between AF at Baseline and Occurrence of Clinical Outcomes

Clinical outcome	Multivariate-adjusted hazard ratio (95% CI)
All-cause mortality	1.61 (1.31–1.96)
Cardiovascular mortality	1.77 (1.36–2.30)
Major coronary events	1.27 (0.97–1.66)
Major cerebrovascular events	1.68 (1.24–2.26)
Heart failure	1.68 (1.27–2.21)

Active treatment with the drug combination resulted in similar relative risk reductions in all-cause death, cardiovascular death, and major coronary events in patients with and without AF. However, because of the higher baseline risk, the absolute benefits were larger in patients with AF.

“We estimate that five years of active treatment would prevent one death among every 39 patients with AF and cardiovascular death among every 42 patients with AF, compared with one among 84 and 120 patients without AF, respectively,” write Du and colleagues.

The presence of AF was associated with a greater increase in the relative risk of cardiovascular death in women than in men, a difference that could not be explained by differences in age, cardiovascular risk factors, or use of other drugs, including hormone-replacement therapy. The findings, however, are in line with other reports suggesting that women with AF are at a higher risk of stroke and cardiovascular mortality than men, report investigators.

Overall, the results highlight the importance of actively evaluating diabetic patients for the presence of AF, according to the group. “Routine administration of blood-pressure–lowering treatment, as well as greater use of antiplatelet agents, statins, and oral anticoagulants, may be expected to reduce the incidence of a broad range of adverse outcomes in these patients,” they write.

Du X, Ninomiya T, de Galan B, et al. Risks of cardiovascular events and effects of blood pressure lowering among patients with Type 2 diabetes and atrial fibrillation: results of the ADVANCE study. Eur Heart J 2009; DOI: 10.1093/eurheartj/ehp055. Available at: https://eurheartj.oxfordjournals.org. Abstract.  March 11, 2009 in the European Heart Journal.

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