Risk factors for atrial fibrillation in type 2 diabetes: report from the Swedish National Diabetes Register (NDR).

AIMS/HYPOTHESIS: Atrial fibrillation (AF) is more frequent in patients with diabetes than in the general population. However, characteristics contributing to AF risk in diabetes remain speculative. METHODS: Observational study of 83,162 patients with type 2 diabetes, aged 30-79 years, with no baseline AF, 17% had history of cardiovascular disease (CVD) and 3.3% history of congestive heart failure (CHF), followed up for development of AF during mean 6.8 years from 2005-2007 to 2012. A subgroup of 67,780 patients without history of CVD or CHF was also analysed. RESULTS: Using Cox regression, cardiovascular risk factors associated with risk for AF were updated mean BMI (HR 1.31 per 5 kg/m(2)) or obesity (HR 1.51), updated mean systolic BP (SBP; HR 1.13 per 10 mmHg) or hypertension (HR 1.71), and cumulative microalbuminuria (HR 1.21), p < 0.001 for all analyses. Male sex, increasing age and height were also significant predictors. HRs were 1.76 for a history of CHF and 2.56 for in-study CHF, while 1.32 for history of CVD and 1.38 for in-study CHD (p < 0.001). Among patients without history of CVD or CHF, significant predictors were similarly BMI, SBP, and cumulative microalbuminuria and CHF. The risk of AF differed in the subgroups achieving or not achieving a target BP < 140/85 mmHg. The HRs for AF were (per 10 mmHg increase) 0.88 and 1.24, respectively. CONCLUSIONS/INTERPRETATION: The modifiable risk factors high BP, high BMI and albuminuria were strongly associated with AF in type 2 diabetes. CVD, advancing age and height were also associated with AF in type 2 diabetes.

Risk factors for the development of albuminuria and renal impairment in type 2 diabetes--the Swedish National Diabetes Register (NDR).

BACKGROUND: The aim of this study was to identify clinical risk factors associated with the development of albuminuria and renal impairment in patients with type 2 diabetes (T2D). In addition, we evaluated if different equations to estimate renal function had an impact on interpretation of data. This was done in a nationwide population-based study using data from the Swedish National Diabetes Register. METHODS: Three thousand and six hundred sixty-seven patients with T2D aged 30-74 years with no signs of renal dysfunction at baseline (no albuminuria and eGFR >60 mL/min/1.73 m(2) according to MDRD) were followed up for 5 years (2002-2007). Renal outcomes, development of albuminuria and/or renal impairment [eGFR < 60 mL/min/1.73 m(2) by MDRD or eCrCl > 60 mL/min by Cockgroft-Gault (C-G)] were assessed at follow-up. Univariate regression analyses and stepwise regression models were used to identify significant clinical risk factors for renal outcomes. RESULTS: Twenty percent of patients developed albuminuria, and 11% renal impairment; thus, ~6-7% of all patients developed non-albuminuric renal impairment. Development of albuminuria or renal impairment was independently associated with high age (all P < 0.001), high systolic BP (all P < 0.02) and elevated triglycerides (all P < 0.02). Additional independent risk factors for albuminuria were high BMI (P < 0.01), high HbA1c (P < 0.001), smoking (P < 0.001), HDL (P < 0.05) and male sex (P < 0.001), and for renal impairment elevated plasma creatinine at baseline and female sex (both P < 0.001). High BMI was an independent risk factor for renal impairment when defined by MDRD (P < 0.01), but low BMI was when defined by C-G (P < 0.001). Adverse effects of BMI on HbA1c, blood pressure and lipids accounted for ~50% of the increase risk for albuminuria, and for 41% of the increased risk for renal impairment (MDRD). CONCLUSIONS: Distinct sets of risk factors were associated with the development of albuminuria and renal impairment consistent with the concept that they are not entirely linked in patients with type 2 diabetes. Obesity and serum triglycerides are semi-novel risk factors for development of renal dysfunction and BMI accounted for a substantial proportion of the increased risk. The equations used to estimate renal function (MDRD vs. C-G) had an impact on interpretation of data, especially with regard to body composition and gender.

Blood lipids in 75,048 type 2 diabetic patients: a population-based survey from the Swedish National diabetes register.

BACKGROUND: Type 2 diabetes and diabetic dyslipidemia are high-risk conditions for cardiovascular disease. However, the description of the distribution of blood lipids in diabetic patients has not been based on population-based surveys. The aim of this study was to describe diabetic dyslipidemia in a large unselected sample of patients from the Swedish National Diabetes Register. METHODS: Blood lipid profiles and clinical characteristics in 75,048 type 2 diabetic patients (57% men) were studied. RESULTS: Pronounced hypertriglyceridemia (triglycerides >4.0mmol/l) was seen in 3.4% of the patients. Total cholesterol (TC), LDL-cholesterol (LDL-C), HDL-cholesterol (HDL-C) and non-HDL-C were generally higher, and LDL-C/HDL-C and Non-HDL-C/HDL-C ratios were lower in women. Mean TC, LDL-C as well as HDL-C values were lower in patients treated with lipid-lowering agents, whereas triglycerides was higher than in the untreated patients. In patients not treated with lipid-lowering agents all blood lipids increased in women and decreased in men (except HDL-C) at higher ages. Patients with LDL-C/HDL-C ratio ≥ 3 were slightly younger, less frequently used lipid-lowering drugs and had not so often a history of coronary heart disease or stroke. CONCLUSION: The distribution of blood lipids in this large sample of unselected type 2 diabetic patients challenges the previous conception of diabetic dyslipidemia, and calls for new studies to explain the roles of LDL-C and HDL-C as strong cardiovascular risk factors in type 2 diabetes.

Trends in blood pressure control in patients with type 2 diabetes: data from the Swedish National Diabetes Register (NDR).

We assessed blood pressure (BP) trends in patients with type 2 diabetes from a national diabetes register using three cross-sectional samples (aged 30?85 years) in 2005, 2007 and 2009, and in patients from 2005 followed individually until 2009. The prevalence of hypertension was 87% among all 180 369 patients in 2009, although lower in subgroups with ages 30?39, 40?49 and 50?59 years: 40%, 60% and 77%. In the three cross-sectional surveys, mean BP decreased (141/77?136/76 mmHg), uncontrolled BP? 140/90 mmHg decreased (58?46%), and antihypertensive drug treatment (AHT) increased (73?81%). Comparatively in 79 185 patients followed individually for 5 years, mean BP decreased (141/77?137/75 mmHg), uncontrolled BP ?140/90 mmHg decreased (58?47%) and AHT increased (73?82%). Independent predictors of BP decrease were BMI decrease (stronger) and increase in AHT. AHT occurred among 81% of all patients in 2009. In 57 645 patients on AHT followed individually, mean BP decreased (143/77?138/75 mmHg) and uncontrolled BP ?140/90 mmHg decreased (63?50%). Among 5164 patients with nephropathy on AHT followed individually, BP <130/80 mmHg increased (12?21%). In conclusion, BP control improved from 2005 to 2009, relative to BMI decrease and AHT increase, although still about half had BP ?140/90 mmHg.

Smoking as an independent risk factor for myocardial infarction or stroke in type 2 diabetes: a report from the Swedish National Diabetes Register.

BACKGROUND: Few earlier studies have analysed smoking as a risk factor for myocardial infarction (MI) or stroke in type 2 diabetic patients. DESIGN AND METHODS: A longitudinal study involved 13 087 female and male patients with type 2 diabetes from the Swedish National Diabetes Register with no previous MI or stroke at baseline, aged 30-74 years, and with data available for all analysed variables, followed up for mean 5.7 years. RESULTS: Adjusted hazard ratios (HRs) for smoking and first-incident fatal/nonfatal MI, stroke and total mortality were 1.7 [95% confidence interval (CI): 1.4-2.0; P<0.001], 1.3 (95% CI: 1.1-1.6; P = 0.006) and 1.8 (95% CI: 1.5-2.2; P<0.001), respectively, by Cox regression analysis, adjusted for age, sex, diabetes duration, hypoglycaemic treatment, haemoglobin A1c, blood pressure, body mass index, microalbuminuria, antihypertensive and lipid-lowering drugs. Adjusted HR was higher for fatal MI, 2.1 (95% CI: 1.7-2.7; P<0.001), than for nonfatal MI, 1.4 (95% CI: 1.2-1.7; P<0.001). The highest HRs were observed in more frequently smoking (22%), middle-aged patients (age <60 years) for fatal/nonfatal MI, 2.3 (95% CI: 1.8-3.1; P<0.001) and for total mortality, 2.5 (95% CI: 1.6-3.8, P<0.001), whereas lower HRs were observed in older and less smoking patients. With predicted cessation of smoking in patients aged below 60 years, 24% (95% CI: 15-33%) of cases of fatal/nonfatal MI and 24% (11-37%) of cases of total mortality may have been prevented. CONCLUSION: The risk for MI and total mortality associated with smoking is high in type 2 diabetes, especially in more frequently smoking, middle-aged patients, and was higher for MI than for stroke, and also higher for fatal than for nonfatal events. Smoking cessation would strongly affect risk reduction.

SPISE and other fasting indexes of insulin resistance: risks of coronary heart disease or type 2 diabetes. Comparative cross-sectional and longitudinal aspects.

Background: Fasting insulin resistance indexes are used extensively nowadays. We intended to analyze a new recently presented fasting index, SPISE (sensitivity formula: 600 × HDL-cholesterol0.185/triglycerides0.2/BMI1.338), in comparison with three previously known fasting indexes, regarding correlation with the insulin clamp index, and for the predictive effects of future long-term risks of coronary heart disease (CHD) or manifest type 2 diabetes.Methods: A total of 1049 71-year-old male subjects from the Swedish ULSAM study, median follow-up 8 years, were included. All subjects performed the euglycemic insulin clamp, and analyses of four fasting insulin resistance indexes: SPISE-IR (= 10/SPISE), QUICKI-IR, Log HOMA-IR, and Revised QUICKI-IR.Results: Spearman correlation coefficients with the insulin clamp were 0.60-0.62 for all indexes. Area under curve at ROC analysis was 0.80 for SPISE-IR, and 0.84 for QUICKI-IR, Log HOMA-IR, and Rev QUICKI-IR. Adjusted hazard ratios per 1 SD index increase for long-term risk CHD were similar in all patients: 1.20-1.24 (p = 0.02-0.03). However, comparing the highest quartile (recommended to define insulin resistance) with the lower quartiles, SPISE-IR was the strongest and the only statistically significant insulin resistance index: HR 1.53 (p = 0.02). Adjusted odds ratios per 1 SD index increase for long-term risk of type 2 diabetes were fairly similar (p < 0.001) in all patients: 1.62 for SPISE-IR, 1.97 for QUICKI-IR and Log HOMA-IR, and 2.04 for Rev QUICKI-IR, and also when comparing the highest versus the lower quartiles: 2.8-3.1 (p < 0.001).Conclusion: SPISE, easily applicable, performed equally well as other fasting insulin indexes previously recommended for clinical use, regarding correlation with the insulin clamp, and as predictor for future long-term risks of CHD or type 2 diabetes.

Considerably decreased risk of cardiovascular disease with combined reductions in HbA1c, blood pressure and blood lipids in type 2 diabetes: Report from the Swedish National Diabetes Register.

OBJECTIVES: Assess the effect of risk factors changes on risk for cardiovascular disease and mortality in patients with type 2 diabetes selected from the Swedish National Diabetes Register. METHODS: Observational study of 13,477 females and males aged 30-75 years, with baseline HbA1c 41-67 mmol/mol, systolic blood pressure 122-154 mmHg and ratio non-HDL:HDL 1.7-4.1, followed for mean 6.5 years until 2012. Four groups were created: a reference group (n = 6757) with increasing final versus baseline HbA1c, systolic blood pressure and non-HDL:HDL cholesterol during the study period, and three groups with decreasing HbA1c (n = 1925), HbA1c and systolic blood pressure (n = 2050) or HbA1c and systolic blood pressure and non-HDL:HDL (n = 2745). RESULTS: Relative risk reduction for fatal/nonfatal cardiovascular disease was 35% with decrease in HbA1c only (mean 6 to final 49 mmol/mol), 56% with decrease in HbA1c and systolic blood pressure (mean 12 to final 128 mmHg) and 75% with combined decreases in HbA1c, systolic blood pressure and non-HDL:HDL (mean 0.8 to final 2.1), all p < 0.001 adjusting for clinical characteristics, other risk factors, treatments and previous cardiovascular disease. Similar risk reductions were found for fatal/nonfatal coronary heart disease, fatal cardiovascular disease, all-cause mortality and also in a subgroup of 3038 patients with albuminuria. CONCLUSION: Considerable risk reductions for cardiovascular disease and mortality were seen with combined long-term risk factor improvement.

Predictors of successful long-term blood pressure control in type 2 diabetic patients: data from the Swedish National Diabetes Register (NDR).

BACKGROUND: Hypertension in patients with diabetes is a well recognized cardiovascular risk factor for which the benefits of treatment are strongly evidence based. Less is known about predictors for successful long-term blood pressure control in these patients, including the potential role of body mass index (BMI), glycaemic control, microalbuminuria and smoking. MATERIAL AND METHODS: We used longitudinal data on risk factor levels from repeated clinical surveys of 1759 type 2 diabetic patients in the Swedish National Diabetes Register (NDR), a nationwide annual registration of quality indicators in diabetes care. Subjects with successful blood pressure (BP) control (systolic BP < 135 mmHg and diastolic BP < 85 mmHg) at baseline in 1997, in 2001, and at follow-up in 2003, were compared to subjects with BP control >or= 135/85 mmHg. RESULTS: Logistic regression analysis disclosed that successful BP control during the study period was predicted by lower BMI (P < 0.001), a lower frequency of microalbuminuria (P = 0.002), and lower age (P < 0.001) at baseline in 1997, and was still associated with lower BMI (P < 0.001), a lower frequency of microalbuminuria (P = 0.01) and lower age (P < 0.001) at follow-up. Successful BP control was also associated at follow-up with a lower frequency of the metabolic syndrome (30 versus 75%) and lower predicted 10-year risks [United Kingdom Prospective Diabetes Study (UKPDS) Risk Engine] of coronary heart disease (14 versus 29%) and stroke (10 versus 22%) (all P < 0.001). CONCLUSION: A lower BMI and absence of microalbuminuria were strong independent predictors of long-term successful BP control in type 2 diabetic patients, also characterized by a lower frequency of the metabolic syndrome and lower 10-year risk of cardiovascular disease. This implies the long-term benefits on BP control of lifestyle measures as well as control of microalbuminuria.

The National Diabetes Register in Sweden: an implementation of the St. Vincent Declaration for Quality Improvement in Diabetes Care.

OBJECTIVE: To monitor glycemic control, treatable risk factors, and treatment profile for quality assessment of diabetes care on a national scale. RESEARCH DESIGN AND METHODS: Four samples of 23,546, 32,903, 30,311, and 29,769 patients with diabetes (1996-1999) were studied based on a repeated national screening and quality assessment of diabetes care by the National Diabetes Register, Sweden, with participation of both hospitals and primary health care. Clinical characteristics included were age, sex, diabetes duration and treatment, glycemic control (HbA(1c)), office blood pressure (BP), BMI, smoking habits, and use of lipid-lowering drugs in patients with type 1 or type 2 diabetes. RESULTS: Favorable decreases of mean HbA(1c) and BP values were registered during the 4-year study period for both type 1 (HbA(1c) 7.5-7.3% and BP 130/75-130/74 mmHg) and type 2 diabetic patients (HbA(1c) 7.0-6.7% and BP 151/82-147/80 mmHg). Treatment aims of HbA(1c) and BP levels were also achieved in increasing proportions for type 1 (HbA(1c) <7.5%: 50-58% and BP

Comparison between indexes of insulin resistance for risk prediction of cardiovascular diseases or development of diabetes.

AIM: The predictive effect of various insulin resistance indexes for risk of cardiovascular diseases (CVD) or type 2 diabetes (T2DM) is still unclear. METHODS: One thousand and forty-nine 71-years-old male subjects from the Swedish ULSAM study, mean follow-up 9 years. All subjects performed the euglycemic insulin clamp for M/I [glucose disposal/mean insulin], and 75-g oral glucose tolerance test for Ceder-IR: 1/glucose uptake rate/[mean glucose×log mean insulin]; Matsuda-IR: 1/10,000/square root [glucose0×insulin0×glucose120×insulin120]; Belfiore-IR: 1/([glucose0+glucose120]/normal mean glucose×[insulin0+insulin120]/normal mean insulin)+1); and HOMA-IR: [glucose0×insulin0]/22.5. RESULTS: Bland-Altman plots showed best agreement between M/I versus Belfiore-IR and Ceder-IR with mean difference near zero, -0.21 to -0.46, while -0.68 to -0.77 for the other indexes. ISI-Ceder was the strongest predictor for incident nonfatal/fatal ischemic heart disease (CHD) or CVD at Cox regression in all subjects, and for incident T2DM at logistic regression in 1024 subjects with no baseline T2DM, with significantly higher hazard ratios or odds ratios than with all other indexes, also with best model fit, after adjusting for clinical characteristics and the traditional cardiovascular risk factors, including metabolic syndrome for CVD risk. CONCLUSION: Ceder-IR performed strongest as independent predictor for incidences of CHD/CVD and T2DM.

Insulin pump therapy, multiple daily injections, and cardiovascular mortality in 18,168 people with type 1 diabetes: observational study.

OBJECTIVE: To investigate the long term effects of continuous subcutaneous insulin infusion (insulin pump therapy) on cardiovascular diseases and mortality in people with type 1 diabetes. DESIGN: Observational study. SETTING: Swedish National Diabetes Register, Sweden 2005-12. PARTICIPANTS: 18,168 people with type 1 diabetes, 2441 using insulin pump therapy and 15,727 using multiple daily insulin injections. MAIN OUTCOME MEASURES: Cox regression analysis was used to estimate hazard ratios for the outcomes, with stratification of propensity scores including clinical characteristics, risk factors for cardiovascular disease, treatments, and previous diseases. RESULTS: Follow-up was for a mean of 6.8 years until December 2012, with 114,135 person years. With multiple daily injections as reference, the adjusted hazard ratios for insulin pump treatment were significantly lower: 0.55 (95% confidence interval 0.36 to 0.83) for fatal coronary heart disease, 0.58 (0.40 to 0.85) for fatal cardiovascular disease (coronary heart disease or stroke), and 0.73 (0.58 to 0.92) for all cause mortality. Hazard ratios were lower, but not significantly so, for fatal or non-fatal coronary heart disease and fatal or non-fatal cardiovascular disease. Unadjusted absolute differences were 3.0 events of fatal coronary heart disease per 1000 person years; corresponding figures were 3.3 for fatal cardiovascular disease and 5.7 for all cause mortality. When lower body mass index and previous cardiovascular diseases were excluded, results of subgroup analyses were similar to the results from complete data. A sensitivity analysis of unmeasured confounders in all individuals showed that an unmeasured confounders with hazard ratio of 1.3 would have to be present in >80% of the individuals treated with multiple daily injections versus not presence in those treated with pump therapy to invalidate the significantly lower hazard ratios for fatal cardiovascular disease. Data on patient education and frequency of blood glucose monitoring were missing, which might have influenced the observed association. CONCLUSION: Among people with type 1 diabetes use of insulin pump therapy is associated with lower cardiovascular mortality than treatment with multiple daily insulin injections.

Durability of oral hypoglycemic agents in drug naïve patients with type 2 diabetes: report from the Swedish National Diabetes Register (NDR).

OBJECTIVE: To analyze the durability of monotherapy with different classes of oral hypoglycemic agents (OHAs) in drug naïve patients with type 2 diabetes mellitus (T2DM) in real life. METHODS: Men and women with T2DM, who were new users of OHA monotherapy and registered in the Swedish National Diabetes Register July 2005-December 2011, were available (n=17 309) and followed for up to 5.5 years. Time to monotherapy failure, defined as discontinuation of continuous use with the initial agent, switch to a new agent, or add-on treatment of a second agent, was analyzed as a measure of durability. Baseline characteristics were balanced by propensity score matching 1:5 between groups of sulfonylurea (SU) versus metformin (n=4303) and meglitinide versus metformin (n=1308). HRs with 95% CIs were calculated using Cox regression models. RESULTS: SU and meglitinide, as compared with metformin, were associated with increased risk of monotherapy failure (HR 1.74; 95% CI 1.56 to 1.94 and 1.66; 1.37 to 2.00 for SU and meglitinide, respectively). When broken down by type of monotherapy failure, SU and meglitinide were associated with an increased risk of add-on treatment of a second agent (HR 3.14; 95% CI 2.66 to 3.69 and 2.52; 1.89 to 3.37 for SU and meglitinide, respectively) and of switch to a new agent (HR 2.81; 95% CI 2.01 to 3.92 and 3.78; 2.25 to 6.32 for SU and meglitinide, respectively). The risk of discontinuation did not differ significantly between the groups. CONCLUSIONS: In this nationwide observational study reflecting clinical practice, SU and meglitinide showed substantially increased risk of switch to a new agent or add on of a second agent compared with metformin. These results indicate superior glycemic durability with metformin compared with SU and also meglitinide in real life.

[Diabetes and tobacco--a double health hazard]. / Diabetes och tobak--dubbla hot mot hälsan.

Smoking is a serious risk factor for cardiovascular disease, retinopathy, and nephropathy in patients with diabetes. Furthermore, epidemiological studies have shown that heavy smokers run an increased prospective risk of developing type 2 diabetes, probably due both to the fact that smoking is a marker for an unhealthy lifestyle and that smoking via nicotine may deteriorate glucose metabolism by negatively influencing insulin sensitivity. In Sweden, data from the National Diabetes Register (NDR) has shown that the prevalence of smoking in type 2 diabetes patients followed in primary health care is almost as high as in the non-diabetic population, at least in middle-aged subjects (about 20%). This alarming situation must be dealt with by using new and effective methods to promote anti-smoking. If support by group sessions can be organised for patients with type 2 diabetes who are smokers, in combination with pharmacological approaches (nicotine, bupropion) it is hoped that the rate of smoking cessation can substantially increase. Such projects are currently under-way within the primary health care in southern Sweden.

[The National Diabetes Registry 1996-2003. Quality assessment shows improved diabetic care]. / Nationella diabetesregistret 1996-2003. Kvalitetsvärdering visar att diabetesvården har förbättrats.

The Swedish National Diabetes Register presents results during the period 1996-2003. Quality of care data from more than 75,000 diabetic patients (2003) treated at medical departments and primary health care centres are evaluated concerning national goals of HbA1c < 6.5% and BP < 140/85 mm Hg, the prevalence of lipid treatment, smoking etc. The national goals of HbA1c and BP were reached with increasing degree in cross-sectional analysis during the period, and were achieved by 33% and 71% at medical departments, and by 61% and 48% in primary health care in 2003. A similar tendency was also seen in longitudinal analysis of subgroups 1996-2003. The use of antihypertensive and lipid-lowering drugs was also considerably increased. This should imply a reduction of the risk for diabetic complications. As the national goals are still difficult to reach, individual goals should be set for the treatment.

Excess body weight and cancer risk in patients with type 2 diabetes who were registered in Swedish National Diabetes Register--register-based cohort study in Sweden.

AIM: To assess the association between excess body weight and cancer risk in patients with type 2 diabetes (T2D) who were registered in the Swedish National Diabetes Register (NDR). METHODS: This is a cohort study based on 25,268 patients with T2D and baseline BMI≥18.5 kg/m(2) from NDR 1997-1999. Subjects were grouped according to BMI into normal weight (18.5 to 24.9), overweight (25 to 29.9) or obesity (30 or more). All subjects were followed until the first occurrence of cancer, or death, or the end of follow-up (December 31, 2009). Adjusted hazard ratios (HRs) and 95% confidence interval (CI) for cancer risks were estimated by Cox regression. RESULTS: In men with T2D, overweight was associated with increased risks of all cancer [1.13 (1.02-1.27)], gastrointestinal cancer [1.34 (1.07-1.72)] and colorectal cancer [1.59 (1.18-2.13)]; obesity was related to higher risks of all cancer [1.17 (1.04-1.33)], gastrointestinal cancer [1.40 (1.08-1.82)] and colorectal cancer [1.62 (1.17-2.24)]. In women with T2D, obesity was associated with increased risk of all cancer [1.30 (1.12-1.51)], gastrointestinal cancer [1.40 (1.03-1.91)] and postmenopausal breast cancer [1.39 (1.00-1.91)]. CONCLUSIONS: Excess body weight was associated with increased risks of all cancer, gastrointestinal cancer and colorectal cancer in men with T2D. Obesity was related with elevated risks of all cancer, gestational cancer and postmenopausal breast cancer in women with T2D.

The triglycerides-to-HDL-cholesterol ratio and cardiovascular disease risk in obese patients with type 2 diabetes: an observational study from the Swedish National Diabetes Register (NDR).

AIMS: Assessing the association between BMI and risk of coronary heart disease (CHD), cardiovascular disease (CVD) and mortality in patients with type 2 diabetes, also with regard to higher or lower levels of the ratio triglycerides-to-HDL-cholesterol (TG:HDL). METHODS: 54,061 patients with BMI≥18.5kg/m(2), mean age and duration 61.5±8 and 6.9±6 years, 59% males, 14% with CVD history, from the Swedish National Diabetes Register, followed for mean 4.8 years. RESULTS: Adjusting at Cox regression for non-BMI-linked (age, sex, smoking, CVD history) and BMI-linked (blood lipids, blood pressure, HbA1c, albuminuria) covariates, hazard ratios (HR) for fatal/nonfatal CHD and CVD were mainly increased with prominent obesity (BMI≥35kg/m(2)), 1.19 (p=0.01) and 1.17 (p=0.009), compared to normal weight (BMI 18.5-24.9kg/m(2)), although increased also with obesity (BMI 30-34.9kg/m(2)), 1.34 and 1.30 (p<0.001), when adjusting only for non-BMI-linked covariates. Stratifying by 75th percentile of TG:HDL, with normal weight and TG:HDL<1.9 as reference, obese and prominently obese with TG:HDL≥1.9 had considerably increased HR around 1.7 for fatal/nonfatal CHD and 1.6 for CVD (p<0.001), while obese and prominently obese with TG:HDL<1.9 only had HR 1.2-1.3 for CHD and CVD (p0.003-<0.01). CONCLUSION: Obese T2D patients with high TG:HDL, associated with increased insulin resistance, had considerably increased risk of CHD and CVD.

Albuminuria and renal function as predictors of cardiovascular events and mortality in a general population of patients with type 2 diabetes: a nationwide observational study from the Swedish National Diabetes Register.

OBJECTIVE: Reduced renal function and albuminuria predict cardiovascular (CV) events and mortality in type 2 diabetes (T2D). In addition, we evaluated the role of co-existing congestive heart failure (CHF) and other CV risk factors on CV events in a large observational population-based cohort of T2D patients. RESEARCH DESIGN AND METHODS: We included 66,065 patients with T2D who were reported to the National Diabetes Register (NDR) in Sweden between 2003-2006 with a follow-up of 5.7 years. Data on outcomes were collected from the cause of death and hospital discharge registers. RESULTS: A total of 10% of patients experienced a CV event and 3.7% of these were fatal. Increasing levels of albuminuria and renal impairment were independently associated with increasing risk of CV events and all-cause mortality also when adjusting for CHF. In normoalbuminuric patients, a reduction in renal function is an important predictor of CV events and all-cause mortality. Glycaemic control (high HbA1c), smoking and hyperlipidaemia had important effects on risk for CV events in patients with albuminuria, while high blood pressure, but not glycaemic control, had an effect in patients with normoalbuminuric renal impairment. CONCLUSION: Albuminuria and renal impairment are independent risk factors for CV outcomes and mortality in T2D, albuminuria being the strongest risk factor and relevant at all levels of renal function. In normoalbuminuric patients, a reduction in renal function is an important predictor of CV events and all-cause mortality.