Why and when do patients with heart failure and normal left ventricular ejection fraction die? Analysis of >600 deaths in a community long-term study.

BACKGROUND: The aim of the study was to examine the causes of the death of patients with heart failure (HF) and evaluate the differences in this respect between patients with and without depression of left ventricular ejection fraction (LVEF). METHOD: All patients hospitalized with HF between 1995 and 2002 in the cardiology service of a tertiary hospital were assessed. LVEF was evaluated by echocardiography during hospitalization and was considered normal when it was > or =50%. After a mean follow-up time of 3.7 +/- 2.8 years, 615 cases had terminated in death. RESULTS: The most common cause was refractory HF, both in the whole group (39%) and in both the subgroups defined with respect to LVEF (normal and depressed). There was no statistically significant difference between the normal and depressed subgroups as regard the distribution of deaths, although the depressed group showed a somewhat greater incidence of sudden death (21% as against 16% in the normal group) and a somewhat smaller incidence of death due to refractory HF (37% as against 47%). However, in the depressed LVEF group, the cumulative risk of death due to acute myocardial infarction in the first 1.5 years first increased rapidly and then more slowly, whereas the reverse pattern was held in the normal left ventricular systolic function group, in which it was the cumulative risks of death from noncardiovascular or vascular noncardiac causes that initially increased more rapidly than later. CONCLUSIONS: The spectrum of causes of death among patients with HF who have been hospitalized is independent of LVEF in the long term. In the short term, there are differences between patients with normal LVEF and depressed LVEF as regard the dynamics of the risks of death from acute myocardial infarction, noncardiac vascular causes, and noncardiovascular causes. These results may help orient the short-term and long-term management of HF, especially for patients with normal LVEF, for whom there is still no well-established consensus strategy.

[Changes in lipid profile after regular intake of canned fish. The influence of addition of isoflavones, omega-3 fatty acids and fitosterols]. / Modificaciones en el perfil lipídico tras el consumo regular de conservas de pescado. Influencia de la adición de isoflavonas, ácidos grasos omega-3 y fitoesteroles.

BACKGROUND AND OBJECTIVE: Changes in dietary habits are associated with an improvement of lipid profile. We decided to assess changes in lipid profile reached with a dietary enrichment with canned tuna in olive oil and compared them with those reached with canned tuna with additional supplementation. SUBJECTS AND METHOD: In a prospective, randomized, single blind study, 400 participants were assigned to a daily intake of canned tuna in olive oil alone (control group) or enriched with: isoflavones, omega-3 fatty acids of phytosterols, during three months. Plasmatic lipid levels were measured before and after intervention. Changes of lipid levels between basal and final visits and differences between the 4 types of supplementations were evaluated. RESULTS: The mean age of the study population was 53 years, 45% of them being males. In all 4 groups a significant reduction of total cholesterol, low-density lipoprotein (LDL)-cholesterol levels and total cholesterol/high-density lipoprotein (HDL)-cholesterol ratio was observed after 3 months of follow-up; there were no significant changes of triglycerides nor HDL-cholesterol levels. The comparison between different types of supplementation revealed that only phytosterols addition reached a greater reduction of total cholesterol and LDL-cholesterol levels than canned tuna in olive oil alone (p < 0.05), and the differences between the remaining 2 supplementations and the control group were not significant. CONCLUSIONS: Regular intake of enrichment with canned tuna supplementation is associated with improvement of lipid profile. The addition of isoflavones, omega-3 fatty acids or phytosterols supplementations increases fish consume effect, although only the enrichment with phytosterols reaches significantly better results.

[High prevalence of left ventricular hypertrophy in patients with hypertension of long course]. / Elevada prevalencia de hipertrofia ventricular izquierda en pacientes con hipertensión arterial de larga evolución.

BACKGROUND AND OBJECTIVE: Left ventricular hypertrophy (LVH) is the most frequent manifestation of cardiac damage in hypertension. The objective of this study was to evaluate the prevalence of LVH in hypertensive patients of long evolution at Primary Care (PC) and to describe their epidemiological profile. PATIENTS AND METHOD: 915 hypertensive patients treated for more than 5 years with antihypertensive drugs, who were attended in a consecutive way by de PC physicians, were evaluated in a multicentral and descriptive study. Clinical evaluation data together with electrocardiographic (EKG) and laboratory results were recorded. LVH was assessed by the Cornell and/or Sokolow-Lyon criteria. RESULTS: Study population was characterized by a mean age of 68.7 years, 63% women, 31.6% diabetics, and 37.5% presented controlled blood pressure levels. 30.5% of them presented LVH criteria on EKG, being more prevalent among women, and on the other hand, women with LVH were of a greater age. 30% of patients presented history of cardiovascular disease and heart failure was more frequent among those with LVH. 54% were polymedicated with blood pressure lowering drugs, however there were no differences between groups of patients with and without LVH regarding their treatment. The Cornell criterion and the Sokolow-Lyon criterion alone were presented in a 77% and 12% of patients, respectively, and 11% of them were positive for both criteria. Patients with positivity for only the Cornell criterion were characterized by a greater prevalence of women and obesity. CONCLUSIONS: The prevalence of LVH assessed by EKG criteria is high among hypertensive population of long evolution. A greater effort is needed to guarantee a periodic EKG performance in hypertensive patients together with a therapeutic strategy improvement.

Outcomes of a contemporary sample of patients with atrial fibrillation taking digoxin: results from the AFBAR study.

INTRODUCTION AND OBJECTIVES: We aimed to assess and compare the effect of digoxin on clinical outcomes in patients with atrial fibrillation vs those under beta-blockers or none of these drugs. METHODS: AFBAR is a prospective registry study carried out by a team of primary care physicians (n=777 patients). Primary endpoints were survival, survival free of admission due to any cause, and survival free of admission due to cardiovascular causes. The mean follow up was 2.9 years. Four groups were analyzed: patients receiving digoxin, beta-blockers, or digoxin plus beta-blockers, and patients receiving none of these drugs. RESULTS: Overall, 212 patients (27.28%) received digoxin as the only heart control strategy, 184 received beta-blockers (23.68%), 58 (7.46%) were administered both, and 323 (41.57%) received none of these drugs. Digoxin was not associated with all-cause mortality (estimated hazard ratio=1.42; 95% confidence interval, 0.77-2.60; P=.2), admission due to any cause (estimated hazard ratio=1.03; 95% confidence interval, 0.710-1.498; P=.8), or admission due to cardiovascular causes (estimated hazard ratio=1.193; 95% confidence interval, 0.725-1.965; P=.4). No association was found between digoxin use and all-cause mortality, admission due to any cause, or admission due to cardiovascular causes in patients without heart failure. There was no interaction between digoxin use and sex in all-cause mortality or in survival free of admission due to any cause. However, an association was found between sex and admission due to cardiovascular causes. CONCLUSIONS: Digoxin was not associated with increased all-cause mortality, survival free of admission due to any cause, or admission due to cardiovascular causes, regardless of underlying heart failure.

Exploring The Obesity Paradox In Atrial Fibrillation. AFBAR (Atrial Fibrillation Barbanza Area) Registry Results.

INTRODUCTION AND OBJECTIVES: Previous studies have described an inverse relationship between obesity and adverse events in a variety of conditions. Our aim was to investigate the relationship between obesity and prognosis in patients with atrial fibrillation. METHODS: We studied 746 patients who were prospectively included, between January and April 2008, in the AFBAR (Atrial Fibrillation in BARbanza area) registry. Patients were categorized into 3 body mass index groups using baseline measurements: normal (< 25 kg/m2), overweight (25-30 kg/m2), and obese (≥30 kg/m2). Survival free from the composite endpoint hospitalization for cardiovascular causes or all-cause mortality was compared across the 3 body mass index groups. A multivariable Cox proportional hazard regression was also performed to determine the independent effect of obesity as well as overweight, with respect to normal body mass index as a reference category, regarding the study endpoint. Median follow-up time was 36 (28-36) months. RESULTS: 49.3% were obese and 38.2% had overweight. The composite endpoint rate was 70.9%, 67.5%, and 57.6% for obese, overweight, and normal weight patients, respectively (log rank test; p=0.02). An inverse association of obesity with a favorable prognosis persisted even after multivariable adjustment: hazard ratio 0.668; 95% confidence interval 0.449-0.995; p=0.047. Hazard ratio of overweight, however, was 0.741; 95% confidence interval: 0.500-1.098; p=0.096. CONCLUSIONS: Obesity, defined as a body mass index ≥ 30 kg/m2, is associated with better prognosis in a community-based cohort of patients with atrial fibrillation.

The change in the atrial fibrillation type as a prognosis marker in a community study: long-term data from AFBAR (Atrial Fibrillation in the BARbanza) study.

BACKGROUND: The aim is to describe the prognosis role of the change in the atrial fibrillation (AF) type in an unselected population of patients with AF currently attending primary care in a single health-service area in Galicia, north-western Spain. METHODS: AFBAR is a cohort study that was carried out by 35 primary care providers in 2008. Participants were followed up for a mean of 2.8 ± 0.7 years. 798 patients with the diagnosis of AF who presented at their clinics during a three-month period were recruited. Primary endpoint was mortality or hospital admission. RESULTS: 778 patients (413 male) were analyzed; mean age 74.8 years old. Hypertension was the most prevalent risk factor (76.5%). Permanent AF was diagnosed in 529 patients (68.0%). Change of AF status occurred in 76 patients (9.8%). During follow-up 52.1% of the patients underwent a primary endpoint and the overall survival was 83.4%. The following independent determinants of primary endpoint were identified: change in AF status (Hazard Ratio (HR) 1.41 (95%-confidence interval (CI) 1.04-1.92); p=0.026); previous heart failure (HR 1.28 (95%-CI 1.00-1.65); p=0.050); previous cardiovascular admission (HR 1.54 (95%-CI 1.16-2.03); p=0.002); stroke (HR 2.02 (95%-CI 1.35-3.03); p=0.001);ischemic heart disease (HR 1.28 (95%-CI 1.00-1.65); p=0.050); chronic obstructive pulmonary disease (HR 1.28 (95%-CI 1.00-1.64);p=0.042); anemia (HR 1.37 (95% CI 1.08-1.75); p=0.010); or AF-related complications (HR 1.45 (95%-CI 1.18-1.78); p<0.001). CONCLUSIONS: The change in AF status showed to be an important prognosis marker for death or hospital admissions in a primary care cohort.

Determinants of cardiovascular mortality in a cohort of primary care patients with chronic ischemic heart disease. BARBANZA Ischemic Heart Disease (BARIHD) study.

BACKGROUND: Prognosis of chronic patients with established ischemic heart disease (IHD) is not fully understood. The objective was to determine which factors are related to cardiovascular death and hospitalizations in patients with IHD within a primary care network. MATERIALS AND METHODS: A cohort study was carried out by 69 primary care providers in Spain in 2007. Participants were followed up for a mean of 2.2 ± 0.3 years. 1095 patients were recruited if they had established (at least 1 year of known disease) IHD (myocardial infarction or and stable or unstable angina). Several hypothesized determinants of cardiovascular mortality were studied, using Cox proportional hazard regression models. Subgroup analysis was also performed for participants without cardiovascular admissions within the last year. RESULTS: Mean time since first IHD diagnosis was 7.6 ± 6.0 years. Annual all-cause mortality rate was 3.25%, with 44 cardiovascular deaths and 119 cardiovascular admissions. The main prognostic factor for cardiovascular death was previous heart failure (hazard ratio [HR] 4.32, 95% confidence interval [CI] 2.30 to 8.11, p<0.001). Recent cardiovascular admission doubled the risk for death (HR 2.01, CI 1.06 to 3.81, p=0.031). Results showed that use of beta blockers and increased physical activity were the main protective factors. Patients without a recent cardiovascular admission showed previous heart failure as the main significant factor for cardiovascular death. CONCLUSIONS: Patients with chronic IHD in a primary care setting may need a closer follow-up in the presence of previous conditions such as heart failure. Physical activity and treatment with beta blockers were the factors giving these patients the greatest protection.

Prognostic impact of atrial fibrillation progression in a community study: AFBAR Study (Atrial Fibrillation in the Barbanza Area Study).

INTRODUCTION: The aim of the study is to describe the natural history of an unselected population of patients with atrial fibrillation (AF) currently attending primary care services in a single health-service area in Galicia, north-western Spain. METHODS: AFBAR is a transverse prospective study in which 35 general practitioners within one health-service area have enrolled patients diagnosed with AF who presented at their clinics during a three-month recruiting period. Primary endpoints are mortality or hospital admission. Here we report the results of the first 7-month follow-up period. RESULTS: 798 patients (421 male) were recruited; mean age of cohort was 75 years old. Hypertension was the most prevalent risk factor (77%). 87% of the patients were both overweight and obese. Permanent AF was diagnosed in 549 patients (69%). In the follow-up period, 16.4% of the patients underwent a primary endpoint and the overall survival was 98%. The following independent determinants of primary endpoint were identified: change in AF status (Hazard Ratio (HR) 2.89 (95% confidence interval (CI) 1.28-6.55); p=0.011); ischemic heart disease (IHD) (HR 2.78 (95% CI 1.51-5.13); p=0.001); pre-recruitment hospital admission (HR 2.22 (95% CI 1.18-4.19); p=0.013); left ventricular systolic dysfunction (HR 2.19 (95% CI 1.11-4.32); p=0.023); or AF-related complications (HR 1.98 (95% CI 1.10-3.56); p=0.022). CONCLUSIONS: In the first 7-month follow-up period of patients with AF in a primary care setting the study identified several independent risk factors for mortality or hospital admission, i.e. change in AF status, ischemic heart disease, left ventricular systolic dysfunction, previous AF-related complications and hospital admission.

[Clinical features and prognosis of patients with chronic cerebrovascular disease (ICBAR study)]. / Características clínicas y pronóstico de pacientes con enfermedad cerebrovascular crónica (estudio ICBAR).

INTRODUCTION: Patients with cerebrovascular disease (CVD) are a group with a very high cardiovascular risk, in addition to that arising from their own vascular pathology, probably due to an inadequate control of risk factors and owing to the presence of comorbidities. PATIENTS AND METHODS: This research consisted in a multi-centre study involving the collaboration of 34 primary care physicians and recording of the features of 473 patients with a previous history of a CVD event that required hospitalisation. After a clinical follow-up of the cohort, hospital readmissions, mortality and causes were analysed. RESULTS: The mean age of patients (52% males) was 75 ± 10 years and the most prevalent risk factors were arterial hypertension (79%), dyslipidaemia (66%), obesity (43%) and diabetes (29%). Sixty-eight per cent of patients had been diagnosed with stroke and 32% with transient ischaemic attack. The mean amount of time elapsed since the first CVD event was 6.6 ± 5.5 years. Twenty-nine per cent of patients had a situation of dependence and only one third showed good blood pressure and lipid control. During a follow-up lasting 8.2 ± 2.3 months, 7.2% of patients suffered some kind of cardio-vascular event (death or hospitalisation), which independent determinants were found to be previous heart failure (hazard ratio, HR = 2.74; 95% confidence interval, CI 95% = 1.3-5.9); cardiomyopathy (HR = 3.32; CI 95% = 1.4-8.2); anaemia (HR = 3.09; CI 95% = 1.6-6.2); renal failure (HR = 2.4; CI 95% = 1.0-5.6); the situation of dependence (HR = 2.57; CI 95% = 1.3-5.7) and cardiovascular admissions over the past year (HR = 3.05; CI 95% = 1.5-5.6). CONCLUSIONS: Patients with CVD followed up in the area of primary care present a high prevalence of arterial hypertension and little is done to control it. Their prognosis is conditioned by cardiovascular comorbidities and sequelae of their cerebro-vascular disease.

Sex does not influence prognosis in diabetic patients. The Barbanza Diabetes study.

INTRODUCTION AND OBJECTIVES: To determine the influence of sex on cardiovascular complications in diabetic patients. METHODS: This multicenter prospective cohort study involved 1423 consecutive patients with diabetes mellitus who were recruited during consultations with 31 primary care physicians. The patients' characteristics were recorded and they were followed up for 45 + or - 10 months. RESULTS: The mean age of the patients (50% female) was 66 years, 64% had hypertension, 70% had dyslipidemia, and 26% had had a previous cardiovascular event. Cardiovascular disease, predominantly ischemic heart disease, was observed more frequently in men and a higher percentage had end-organ damage (57.7% of males versus 45.4% of females; P< .0001). Women had poorer glycemic control, higher total cholesterol levels and lower high-density lipoprotein cholesterol levels. By the end of follow-up, 81 patients had died (5.7% of males versus 6.7% of females; P=.513). There were no sex differences in cardiovascular complications during follow up (15.8% in males versus 13.7% in females; P=.368). Multivariate analysis identified the following factors as independent predictors of morbidity or mortality: age (hazard ratio [HR]=1.04; 95% confidence interval [CI], 1.02-1.06), existing cardiovascular disease (HR=1.96; 95% CI, 1.38-2.79), diuretic treatment (HR=1.62; 95% CI, 1.10-2.38), and albuminuria (HR=1.86; 95% CI, 1.33-2.61). CONCLUSIONS: No difference was observed in mediumterm prognosis, with regard to mortality and cardiovascular selecmorbidity, between male and female diabetics from the same geographical area, despite the presence of clinical differences between the sexes.

Effect of diabetes on the clinical characteristics and prognosis of patients with chronic ischemic heart disease. The CIBAR study.

The aim of this study was to evaluate the effect of diabetes mellitus on the prognosis of patients with chronic ischemic heart disease. The multicenter prospective cohort study involved 1108 outpatients with ischemic heart disease whose clinical characteristics were recorded by 69 primary care physicians. Morbidity and mortality were recorded during a mean follow-up period of 6.9 months. Overall, 29% of patients were diabetic; they were older than non-diabetics, presented with more risk factors, had poorer blood pressure control, and had more comorbid conditions. In addition, diabetics were more likely to be prescribed renin-angiotensin system blockers, calcium channel blockers, diuretics and lipid-lowering drugs. Cardiovascular mortality and hospitalization rates were higher in diabetics. On multivariate analysis, diabetes was found to be an independent predictor of a cardiovascular event (hazard ratio=1.81; 95% confidence interval, 1.17-2.82). Prognosis in chronic ischemic heart disease is relatively good, although it is worse in diabetics, which means that treatment and disease controls targets must be more rigorously applied in these patients.

Nuevos datos sobre fibrilación auricular, observaciones al estudio OFRECE / New Data About Atrial Fibrillation, Comment to the OFRECE Study

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Seguimiento clínico de una muestra contemporánea de pacientes con fibrilación auricular en tratamiento con digoxina: resultados del estudio AFBAR / Outcomes of a contemporary sample of patients with atrial fibrillation taking digoxin: results from the AFBAR study

Introducción y objetivos: Evaluar el efecto de la digoxina en los resultados clínicos de los pacientes con fibrilación auricular con y sin tratamiento con bloqueadores beta. Métodos El AFBAR es un registro prospectivo llevado a cabo por un equipo de médicos de atención primaria (n = 777 pacientes). Los objetivos principales fueron la supervivencia, la supervivencia libre de hospitalización por cualquier causa y la supervivencia libre de hospitalización por causas cardiovasculares. La media de seguimiento fue 2,9 años. Se analizaron cuatro grupos: pacientes tratados con digoxina, bloqueadores beta o digoxina más bloqueadores beta, y pacientes que no recibían ninguno de estos fármacos. Resultados En total, 212 pacientes (27,28%) recibieron digoxina como única estrategia de control de frecuencia; 184 recibieron bloqueadores beta (23,68%); 58 (7,46%), ambos fármacos y 323 (41,57%), ninguno de ellos. El tratamiento con digoxina no se asoció a la mortalidad por todas las causas (razón de riesgos estimada = 1,42; intervalo de confianza del 95%, 0,710-1,498; p = 0,2), la hospitalización por todas las causas (razón de riesgos estimada = 1,03; intervalo de confianza del 95%, 0,71-1,49; p = 0,8) ni la hospitalización por causas cardiovasculares (razón de riesgos estimada = 1,193; intervalo de confianza del 95%, 0,725-1,965; p = 0,4). No se observó asociación entre el empleo de digoxina y la mortalidad por cualquier causa, la hospitalización por cualquier causa o la hospitalización por causas cardiovasculares en los pacientes sin insuficiencia cardiaca. No hubo interacción entre el uso de digoxina y el sexo en cuanto a la mortalidad por todas las causas o la supervivencia sin hospitalización por todas las causas. Sin embargo, sí se observó una asociación entre el sexo y la hospitalización por causa cardiovascular. Conclusiones: La digoxina no se asoció a un aumento de la mortalidad por cualquier causa, la supervivencia libre de hospitalización por cualquier causa ni la supervivencia libre de hospitalización por causas cardiovasculares, con independencia de la presencia de insuficiencia cardiaca subyacente (AU)

Introduction and objectives We aimed to assess and compare the effect of digoxin on clinical outcomes in patients with atrial fibrillation vs those under beta-blockers or none of these drugs. We compared the incidence of ventricular arrhythmias in patients who were undergoing cardiac resynchronization therapy with an implantable cardioverter-defibrillator in terms of the degree of echocardiographic response to resynchronization. Patients were classified in 3 subgroups; super-responders, responders, and nonresponders. Methods AFBAR is a prospective registry study carried out by a team of primary care physicians (n = 777 patients). Primary endpoints were survival, survival free of admission due to any cause, and survival free of admission due to cardiovascular causes. The mean follow up was 2.9 years. Four groups were analyzed: patients receiving digoxin, beta-blockers, or digoxin plus beta-blockers, and patients receiving none of these drugs. Conclusions Digox in was not associated with increased all-cause mortality, survival free of admission due to any cause, or admission due to cardiovascular causes, regardless of underlying heart failure(AU)

Morbidity and mortality among heart failure patients in Galicia, N.W. Spain: the GALICAP Study.

OBJECTIVE: Characterization of current morbidity and mortality among heart failure (HF) outpatients in Galicia (N.W. Spain), together with their main determinants. DESIGN: Prospective multicentre study involving 149 primary care physicians. SETTING: Primary care physicians selected randomly from among all (1959) primary care physicians in Galicia. PATIENTS: Clinical and epidemiological information for 1195 outpatients with HF were collected in 2006, with a mean follow-up of 6.5+/-1.5 months. MAIN OUTCOME MEASURES: Survival rates were calculated by Cox's proportional hazard model. RESULTS: Mean patient age was 76 years, 48% were male, 82% had a history of arterial hypertension, and 32% ischaemic cardiopathy. Echocardiography had been performed in 67%, showing preserved systolic function in 61%. Ninety-two (8%) died during follow-up [74 (80%) of them from cardiac causes], and 313 (29%) were re-admitted to hospital [230 (73%) of them for cardiac reasons]. Multivariate analysis identified the following independent predictors of cardiovascular death and/or readmission: ischaemic cardiopathy [hazard ratio (HR) 1.76, 95% confidence interval (CI) 1.29-4.40], stroke (HR 1.79, CI 1.18-2.73), oedema (HR 1.49, CI 1.10-2.03), anaemia (HR 1.66, CI 1.21-2.27), deteriorated systolic function (HR 1.62, CI 1.19-2.20), and previous cardiovascular admissions (HR 2.33, CI 1.67-3.24). Residence in the Barbanza district was identified as an independent predictor of survival free from cardiovascular admission (HR 0.56, CI 0.37-0.86). CONCLUSION: Morbidity and mortality are currently high among Galician HF patients, and their best single predictor is previous hospitalization for cardiovascular reasons.

[Effect of the location of previous atherosclerotic disease on prognosis in diabetic patients. The Barbanza Diabetes Study]. / Impacto pronóstico de la localización de la enfermedad aterosclerosa previa en pacientes diabéticos. Estudio Barbanza-diabetes.

INTRODUCTION AND OBJECTIVES: To assess the effect of different forms of atherosclerotic disease on prognosis in diabetic patients. METHODS: This multicenter prospective cohort study involved 1423 consecutive patients with diabetes mellitus who were recruited by 31 primary care physicians. The patients' characteristics were recorded and they were followed up for 45 +/- 10 months. RESULTS: The mean age of the patients (50% male) was 66 years, 64% had hypertension, 70% had dyslipidemia, and 26% had had a previous cardiovascular event. By the end of follow-up, 81 (6.2%) had died, 40 (3%) of whom due to cardiovascular causes, and 393 (30%) had been hospitalized, 179 (14%) of whom for cardiovascular disease. Multivariate analysis identified the following factors as independent predictors of mortality: age (hazard ratio [HR]=1.08; 95% confidence interval [CI],1.05-1.11), previous cardiovascular disease (HR=2.15; 95% CI, 1.12-4.14) and diuretic treatment (HR=3.40; 95% CI, 1.76-6.56), while the prescription of an angiotensin-converting enzyme inhibitor or an angiotensin-receptor antagonist had a protective effect (HR=0.48; 95% CI, 0.25-0.93). Compared with diabetics without a previous cardiovascular event, the risk of a cardiovascular event during follow-up was greater in those with a history of either ischemic heart disease (HR=2.48; 95% CI, 1.51-4.07), cerebrovascular disease (HR=2.51; 95% CI, 1.28-4.92), or peripheral vascular disease (HR=1.46; 95% CI, 0.81-2.60). CONCLUSIONS: The increase in the risk of a cardiovascular event was similar in diabetics with ischemic heart disease and those with cerebrovascular disease. In both cases, the risk was more than double that in patients without a history of cardiovascular disease.