Glycated Hemoglobin, Prediabetes, and the Links to Cardiovascular Disease: Data From UK Biobank

Adding traditional and emerging biomarkers for risk assessment in secondary prevention: a prospective cohort study of 20 656 patients with cardiovascular disease

AIMS

This study aims to explore whether conventional and emerging biomarkers could improve risk discrimination and calibration in the secondary prevention of recurrent atherosclerotic cardiovascular disease (ASCVD), based on a model using predictors from SMART2 (Secondary Manifestations of ARTerial Disease).

METHODS AND RESULTS

In a cohort of 20 658 UK Biobank participants with medical history of ASCVD, we analysed any improvement in C indices and net reclassification index (NRI) for future ASCVD events, following addition of lipoprotein A (LP-a), apolipoprotein B, Cystatin C, Hemoglobin A1c (HbA1c), gamma-glutamyl transferase (GGT), aspartate aminotransferase (AST), alanine aminotransferase, and alkaline phosphatase (ALP), to a model with predictors used in SMART2 for the outcome of recurrent major cardiovascular event. We also examined any improvement in C indices and NRIs replacing creatinine-based estimated glomerular filtration rate (eGFR) with Cystatin C-based estimates. Calibration plots between different models were also compared. Compared with the baseline model (C index = 0.663), modest increments in C indices were observed when adding HbA1c (ΔC = 0.0064, P < 0.001), Cystatin C (ΔC = 0.0037, P < 0.001), GGT (ΔC = 0.0023, P < 0.001), AST (ΔC = 0.0007, P < 0.005) or ALP (ΔC = 0.0010, P < 0.001) or replacing eGFRCr with eGFRCysC (ΔC = 0.0036, P < 0.001) or eGFRCr-CysC (ΔC = 0.00336, P < 0.001). Similarly, the strongest improvements in NRI were observed with the addition of HbA1c (NRI = 0.014) or Cystatin C (NRI = 0.006) or replacing eGFRCr with eGFRCr-CysC (NRI = 0.001) or eGFRCysC (NRI = 0.002). There was no evidence that adding biomarkers modified calibration.

CONCLUSION

Adding several biomarkers, most notably Cystatin C and HbA1c, but not LP-a, in a model using SMART2 predictors modestly improved discrimination.

The use of continuous glucose monitoring in people living with obesity, intermediate hyperglycemia or type 2 diabetes

A global trend towards increased obesity, intermediate hyperglycemia (previously termed prediabetes) and type 2 diabetes, has prompted a range of international initiatives to proactively raise awareness and provide action-driven recommendations to prevent and manage these linked disease states. One approach, that has shown success in managing people already diagnosed with type 2 diabetes mellitus, is to use continuous glucose monitoring (CGM) devices to help them manage their chronic condition through understanding and treating their daily glucose fluctuations, in assocation with glucose-lowering medications, including insulin. However, much of the burden of type 2 diabetes mellitus is founded in the delayed detection both of type 2 diabetes mellitus itself, and the intermediate hyperglycemia that precedes it. In this review, we provide evidence that using CGM technology in people at-risk of intermediate hyperglycemia or type 2 diabetes mellitus can significantly improve the rate and timing of detection of dysglycemia. Earlier detection allows intervention, including through continued use of CGM to guide changes to diet and lifestyle, that can delay or prevent harmful progression of early dysglycemia. Although further research is needed to fully understand the cost-effectiveness of this intervention in people at-risk or with early dysglycemia, the proposition for use of CGM technology is clear.

Divergence in prediabetes guidelines - A global perspective

The global landscape of prediabetes diagnostic guidelines varies significantly, reflecting diverse healthcare priorities, population characteristics, and resource availability. Major international organisations, including the World Health Organisation (WHO), European Association for the Study of Diabetes (EASD), Italian Society of Diabetes (SID), American Diabetes Association (ADA), International Diabetes Federation (IDF), Diabetes UK, and Chinese Diabetes Society (CDS), adopt differing criteria for defining and diagnosing prediabetes. These discrepancies arise from variations in diagnostic tests-oral glucose tolerance test (OGTT), fasting plasma glucose (FPG), and glycated haemoglobin (HbA1c)-as well as differences in prevalence estimates, screening policies, and healthcare infrastructure. Ethnic variability in glucose metabolism further complicates standardisation, as some diagnostic tools, such as HbA1c, perform differently across populations. Additionally, individuals diagnosed via different criteria exhibit distinct metabolic risks and may respond differently to interventions. This heterogeneity poses challenges for global research, policy-making, and equitable access to care. While complete international harmonisation may be impractical, emerging diagnostic approaches, such as the 1-hour plasma glucose (1-h PG) test, offer a promising step toward improving diagnostic consistency. A hybrid model integrating universal standards with population-specific adaptations may offer a more effective global strategy for prediabetes identification and prevention.

Active Detection of Glucose Metabolism Disorders Prior to Coronary Artery Bypass Grafting: Associations with In-Hospital Postoperative Complications

Background/Objectives: Patients with coronary artery disease undergoing coronary artery bypass grafting (CABG) have a high prevalence of type 2 diabetes mellitus (T2DM) and prediabetes. Glucose metabolism disorders (GMDs) are often asymptomatic and remain undetected, but untreated they can have adverse effects. To evaluate the possibilities of active screening in identifying T2DM and prediabetes before CABG and to assess the impact of GMD on the incidence of postoperative complications. Methods: This study included 1021 patients who underwent CABG in 2016-2018 at the department of cardiovascular surgery, whose glycemic status was determined. All patients had their glycated hemoglobin (HbA1c) levels measured; those without a previous diagnosis of diabetes underwent an oral glucose tolerance test. The frequency of newly diagnosed diabetes and prediabetes was evaluated. Postoperative complication rates were analyzed among patient groups with various types of GMDs and normal blood glucose levels. Results: Screening before CABG increased the number of patients with established type 2 diabetes from 20.9 to 27.8% and the number of people with prediabetes from 2.7% to 31.7%. When analyzing hospital complications, patients with type 2 diabetes compared to patients with normoglycemia were significantly more likely to develop heart failure (p = 0.010), multiple organ failure (p = 0.002), require extracorporeal homeostasis correction (p = 0.011), and wound dehiscence (p = 0.004). Nine patients (0.9%) died following CABG without being discharged from the hospital, with 90% of these deaths occurring in patients with GMDs. Any GMD (diabetes or prediabetes) was associated with an increased incidence of postoperative heart failure (OR 1.259; p = 0.011), rhythm disturbances (OR 1.236; p = 0.010), major cardiovascular complications and/or heart failure (OR 1.193; p = 0.039), and all cardiovascular complications (OR 1.455; p = 0.002). In the presence of any GMD, the risk of multiple organ failure increased by 2.5 times (OR 2.506; p = 0.014), extracorporeal correction of homeostasis increased by 1.8 times (OR 1.821; p = 0.034), and diastasis of the wound edges increased by 1.3 times (OR 1.266; p = 0.005). It is important that, when adjusting for gender and age, the effect of GMD on the described complications remained significant. Conclusions: Active preoperative detection established an extremely high prevalence of GMD in patients with multivessel coronary artery disease (59.5%). T2DM and prediabetes are significant predictors of postoperative complications of coronary artery bypass grafting.

Epicardial Adipose Tissue Is Associated With Geometry Alteration and Diastolic Dysfunction in Prediabetic Cardiomyopathy

BACKGROUND

Diastolic dysfunction and alterations in cardiac geometry are early indicators of diabetic cardiomyopathy. However, the association between cardiac changes across the glucose continuum and the contribution of epicardial adipose tissue (EAT) to these changes has not yet been investigated.

PURPOSE

In this study, we aimed to investigate the EAT on cardiac diastolic function and structural alterations along the diabetic continuum using cardiac magnetic resonance imaging (CMRI).

METHODS

We enrolled individuals who were categorized into groups based on glucose tolerance status. Left ventricular structure and diastolic function were assessed using echocardiography and CMRI to determine the EAT, intramyocardial fat, and associated parameters. Multivariable logistic regression models were also used.

RESULTS

In a study of 370 patients (209 normal glucose tolerance, 82 prediabetes, 79 diabetes), those with prediabetes and diabetes showed increased heart dimensions and diastolic dysfunction, including the ratio of early mitral inflow velocity to mitral annular early diastolic velocity (7.9 ± 0.51 vs 8.5 ± 0.64 vs 10.0 ± 0.93, P = .010), left atrial volume index (28.21 ± 14.7 vs 33.2 ± 12.8 vs 37.4 ± 8.2 mL/m2, P < .001), and left ventricular peak filling rate (4.46 ± 1.75 vs 3.61 ± 1.55 vs 3.20 ± 1.30 mL/s, P < .001). EAT significantly increased in prediabetes and diabetes (26.3 ± 1.16 vs 31.3 ± 1.83 vs 33.9 ± 1.9 gm, P = .001), while intramyocardial fat did not differ significantly. Prediabetes altered heart geometry but not diastolic function (odds ratio [OR] 1.22 [1.02-1.83], P = .012; and 1.70 [0.79-3.68], P = .135). Diabetes significantly affected both heart structure and diastolic function (OR 1.42 [1.11-1.97], P = .032; and 2.56 [1.03-5.40], P = .034) after adjusting for covariates.

CONCLUSION

Elevated EAT was observed in patients with prediabetes and is associated with adverse alterations in cardiac structure and diastolic function, potentially serving as an underlying mechanism for the early onset of diabetic cardiomyopathy.

Association between estimated glucose disposal rate and future cardiovascular disease risk across glucose metabolism status: a prospective cohort study

BACKGROUND

Cardiovascular disease (CVD) remains a major global health challenge, particularly affected by glucose metabolism status. However, the relationship between estimated glucose disposal rate (eGDR) and future CVD risk across different glucose metabolism status remains unclear.

METHODS

We analyzed data from the China Health and Retirement Longitudinal Study (2011-2020) of participants aged ≥ 45 years. The eGDR was calculated using waist circumference, hypertension status, and HbA1c levels. CVD events (stroke or cardiac events) were the outcome. Participants were categorized by glucose metabolism status (normoglycemia, prediabetes, diabetes). Cox proportional hazards models and restricted cubic splines were used to assess associations and potential non-linear relationships.

RESULTS

Among 7,828 participants (52.84% male, mean age 59.01 ± 9.21 years) followed for an average of 8.29 years, 1,944 participants (24.83%) developed CVD. Higher eGDR was inversely associated with CVD risk across all glucose metabolism states. Below the inflection points (11.77, 11.15, and 11.56 mg/kg/min for normoglycemia, prediabetes, and diabetes, respectively), each 1-unit increase in eGDR reduced CVD risk by 14% (HR = 0.86, 95%CI: 0.83-0.89), 10% (HR = 0.90, 95%CI: 0.86-0.93), and 14% (HR = 0.86, 95%CI: 0.81-0.91), respectively.

CONCLUSION

The eGDR demonstrates a potentially non-linear inverse association with future CVD risk across different glucose metabolism states.

Strawberries Improve Insulin Resistance and Related Cardiometabolic Markers in Adults with Prediabetes: A Randomized Controlled Crossover Trial

BACKGROUND

Prediabetes, as a risk factor for type 2 diabetes, as well as cardiovascular disease, is a burgeoning public health concern in the United States and worldwide. Dietary supplementation of polyphenol-rich berries has been demonstrated to be a feasible nutritional intervention in improving multiple cardiometabolic risk factors in adults. However, reported clinical trials are quite heterogeneous in study findings, and focus on prediabetes is lacking.

OBJECTIVES

We examined the effects of a feasible dietary dose of strawberries (32 g freeze-dried strawberries ∼2.5 servings fresh strawberries) on glycemic control (primary) and cardiometabolic markers in adults with prediabetes in a 28-wk randomized controlled (no strawberry) crossover single-blinded study (12 wk/period).

METHODS

A total of 25 adults were recruited in each period of the study, and anthropometric, clinical, and dietary data and blood samples were collected at baseline, 6 wk, 12 wk, 16 wk (washout), 22 wk, and 28 wk of the crossover study. A mixed-model analysis of variance was used to examine treatment effects accounting for the fixed effects of treatment, time, order of randomization, age, sex, ethnicity, body mass index (in kg/m2), dietary calories, and physical activity over time, as well as the baseline value for each outcome.

RESULTS

Strawberry period significantly improved glycemic control (serum insulin, insulin resistance, fasting glucose and glycated hemoglobin) and serum total cholesterol in an adjusted model compared with control; [adjusted mean difference 95% confidence interval (CI): -6.9 μIU/mL (-3.2, -10.7) μIU/mL, -2.3 (-1.3, -3.4), -8.9 mg/dL (-4.7, -13.2) mg/dL, and -0.2% (-0.1, -0.3)%, and -7.0 mg/dL (-2.0, -12.0) mg/dL, respectively, all P < 0.05]. Strawberry period also decreased body weight, high sensitivity C-reactive protein, and interleukin-6 in the adjusted model (all P < 0.05).

CONCLUSIONS

These findings show that a 2.5-serving dose of strawberries consumed daily for 12 wk can improve prediabetes status and overall cardiometabolic profile in adults.

Tirzepatide for Obesity Treatment and Diabetes Prevention

BACKGROUND

Obesity is a chronic disease and causal precursor to myriad other conditions, including type 2 diabetes. In an earlier analysis of the SURMOUNT-1 trial, tirzepatide was shown to provide substantial and sustained reductions in body weight in persons with obesity over a 72-week period. Here, we report the 3-year safety outcomes with tirzepatide and its efficacy in reducing weight and delaying progression to type 2 diabetes in persons with both obesity and prediabetes.

METHODS

We performed a phase 3, double-blind, randomized, controlled trial in which 2539 participants with obesity, of whom 1032 also had prediabetes, were assigned in a 1:1:1:1 ratio to receive tirzepatide at a once-weekly dose of 5 mg, 10 mg, or 15 mg or placebo. The current analysis involved the participants with both obesity and prediabetes, who received their assigned dose of tirzepatide or placebo for a total of 176 weeks, followed by a 17-week off-treatment period. The three key secondary end points, which were controlled for type I error, were the percent change in body weight from baseline to week 176 and onset of type 2 diabetes during the 176-week and 193-week periods.

RESULTS

At 176 weeks, the mean percent change in body weight among the participants who received tirzepatide was -12.3% with the 5-mg dose, -18.7% with the 10-mg dose, and -19.7% with the 15-mg dose, as compared with -1.3% among those who received placebo (P<0.001 for all comparisons with placebo). Fewer participants received a diagnosis of type 2 diabetes in the tirzepatide groups than in the placebo group (1.3% vs. 13.3%; hazard ratio, 0.07; 95% confidence interval [CI], 0.0 to 0.1; P<0.001). After 17 weeks off treatment or placebo, 2.4% of the participants who received tirzepatide and 13.7% of those who received placebo had type 2 diabetes (hazard ratio, 0.12; 95% CI, 0.1 to 0.2; P<0.001). Other than coronavirus disease 2019, the most common adverse events were gastrointestinal, most of which were mild to moderate in severity and occurred primarily during the dose-escalation period in the first 20 weeks of the trial. No new safety signals were identified.

CONCLUSIONS

Three years of treatment with tirzepatide in persons with obesity and prediabetes resulted in substantial and sustained weight reduction and a markedly lower risk of progression to type 2 diabetes than that with placebo. (Funded by Eli Lilly; SURMOUNT-1 ClinicalTrials.gov number, NCT04184622.).

Dysglycaemia screening and its prognostic impact in patients with coronary artery disease: experiences from the EUROASPIRE IV and V cohort studies

BACKGROUND

Glucose perturbations can be detected by fasting plasma glucose (FPG), HbA1c, and the oral glucose tolerance test (OGTT). The highest yield is provided by OGTT. HbA1c is considered more practical. We compare the diagnostic and predictive performance of these glycaemic indicators based on combined data from the EUROASPIRE IV (EAIV) and V (EAV) studies.

METHODS

This cohort study was conducted in 79 centres in 24 European countries (EAIV) and 131 centres in 27 European countries (EAV). Eligible patients were aged 18-80 years, did not have diabetes, and were diagnosed with coronary artery disease 6-36 months (EAIV) or 6-24 months (EAV) before the investigation. Patients were investigated with OGTT (FPG and 2 h post-load glucose [2-hPG]) and HbA1c. Follow-up of subsequent cardiovascular events was done by means of a questionnaire at least 1 year after the baseline investigation. Analyses were done in patients with both OGTT and HbA1c data available. Outcome analysis in these patients was restricted to those with valid follow-up data available.

FINDINGS

16 259 patients were interviewed in EAIV (2012-13) and EAV (2016-17). 8364 patients had both OGTT and HbA1C data and were included in the analysis population (3932 in EAIV and 4432 in EAV). Information on cardiovascular events was available in 7892 patients. Follow-up was for a median 1·6 years (IQR 1·2-2·0). The average patient age was 63·3 years (SD 9·8), and 6346 (75·9%) of 8364 patients were men. At baseline, 1856 (22·5%) of 8263 patients were determined to have newly detected type 2 diabetes using OGTT alone, compared with 346 (4·2%) using HbA1c alone. New dysglycaemia, defined as newly detected type 2 diabetes or impaired glucose tolerance (IGT), was present in 3896 (47·1%) of the patients according to 2hPG. 2hPG 9 mmol/L or greater (162 mg/dL, adjusted hazard ratio [aHR] 1·58; 95% CI 1·27-1·95, p<0·0001), and HbA1c 5·9% or greater (41 mmol/mol, aHR 1·48, 1·19-1·84; p=0·0010) were the strongest predictors of cardiovascular events, while FPG did not predict. A multivariable model showed that the effect of HbA1c on cardiovascular events was mainly explained by 2hPG (aHR for 1 unit increase in HbA1c 1·13, 0·98-1·30; p=0·11; and aHR for 1 unit increase in Ln[2hPG] 1·37, 1·08-1·74; p=0·0042).

INTERPRETATION

2hPG appears better than HbA1c in detecting dysglycaemia and predicting its impact on future cardiovascular events in patients with coronary artery disease and should be recommended as the primary screening tool.

FUNDING

Swedish Heart-Lung Foundation, Region Stockholm (ALF), the Erling Persson Foundation, the Baltic Child Foundation.

Routine measurement of cardiometabolic disease risk factors in primary care in England before, during, and after the COVID-19 pandemic: A population-based cohort study

BACKGROUND

This study estimated to what extent the number of measurements of cardiometabolic risk factors (e.g., blood pressure, cholesterol, glycated haemoglobin) were impacted by the COVID-19 pandemic and whether these have recovered to expected levels.

METHODS AND FINDINGS

A cohort of individuals aged ≥18 years in England with records in the primary care-COVID-19 General Practice Extraction Service Data for Pandemic Planning and Research (GDPPR) were identified. Their records of 12 risk factor measurements were extracted between November 2018 and March 2024. Number of measurements per 1,000 individuals were calculated by age group, sex, ethnicity, and area deprivation quintile. The observed number of measurements were compared to a composite expectation band, derived as the union of the 95% confidence intervals of 2 estimates: (1) a projected trend based on data prior to the COVID-19 pandemic; and (2) an assumed stable trend from before pandemic. Point estimates were calculated as the mid-point of the expectation band. A cohort of 49,303,410 individuals aged ≥18 years were included. There was sharp drop in all measurements in March 2020 to February 2022, but overall recovered to the expected levels during March 2022 to February 2023 except for blood pressure, which had prolonged recovery. In March 2023 to March 2024, blood pressure measurements were below expectation by 16% (-19 per 1,000) overall, in people aged 18 to 39 (-23%; -18 per 1,000), 60 to 79 (-17%; -27 per 1,000), and ≥80 (-31%; -57 per 1,000). There was suggestion that recovery in blood pressure measurements was socioeconomically patterned. The second most deprived quintile had the highest deviation (-20%; -23 per 1,000) from expectation compared to least deprived quintile (-13%; -15 per 1,000).

CONCLUSIONS

There was a substantial reduction in routine measurements of cardiometabolic risk factors following the COVID-19 pandemic, with variable recovery. The implications for missed diagnoses, worse prognosis, and health inequality are a concern.

Relationship between four visceral obesity indices and prediabetes and diabetes: a cross-sectional study in Dalian, China

BACKGROUND

In recent times, a number of new indices for measuring visceral obesity have been developed. This research sought to investigate the relationship between four visceral obesity indices and prediabetes and diabetes.

METHODS

Conducted in 2011 as a cross-sectional analysis in Dalian, China, this study utilized logistic regression models to explore the relationships between four visceral obesity indices and prediabetes and diabetes. It also assessed the dose-response relationships using restricted cubic splines (RCS), performed subgroup analyses, and conducted interaction tests. The predictive values of four visceral obesity indices were evaluated using receiver operating characteristic (ROC) curves.

RESULTS

The study enrolled 10,090 participants, with prediabetes and diabetes prevalence at 80.53%. Multifactorial logistic regression revealed positive relationships between the four visceral obesity indices and prediabetes and diabetes. The results of the RCS analysis revealed a linear relationship between the body roundness index (BRI), cardiometabolic index (CMI) and prediabetes and diabetes. Conversely, a non-linear relationship was observed between Chinese visceral adiposity index (CVAI), lipid accumulation product (LAP) and prediabetes and diabetes. Subgroup analyses demonstrated stronger relationships of CMI, CVAI, and LAP with prediabetes and diabetes among females. ROC curves suggested that LAP could be an effective predictor of these conditions.

CONCLUSION

This research confirmed that four visceral obesity indices are linked with a higher risk of prediabetes and diabetes in middle-aged and elderly individuals in Dalian. Importantly, LAP could be an effective predictor of prediabetes and diabetes. Effective weight management significantly reduces the risk of both prediabetes and diabetes.

Establishment and validation of nomogram model for predicting major adverse cardiac events in patients with acute ST-segment elevation myocardial infarction based on glycosylated hemoglobin A1c to apolipoprotein A1 ratio: An observational study

The objective of the current study is to assess the usefulness of HbA1cAp ratio in predicting in-hospital major adverse cardiac events (MACEs) among acute ST-segment elevation myocardial infarction (STEMI) patients that have undergone percutaneous coronary intervention (PCI). Further, the study aims to construct a ratio nomogram for prediction with this ratio. The training cohort comprised of 511 STEMI patients who underwent emergency PCI at the Huaibei Miners' General Hospital between January 2019 and May 2023. Simultaneously, 384 patients treated with the same strategy in First People's Hospital of Hefei formed the validation cohort during the study period. LASSO regression was used to screen predictors of nonzero coefficients, multivariate logistic regression was used to analyze the independent factors of in-hospital MACE in STEMI patients after PCI, and nomogram models and validation were established. The LASSO regression analysis demonstrated that systolic blood pressure, diastolic blood pressure, D-dimer, urea, and glycosylated hemoglobin A1c (HbA1c)/apolipoprotein A1 (ApoA1) were significant predictors with nonzero coefficients. Multivariate logistic regression analysis was further conducted to identify systolic blood pressure, D-dimer, urea, and HbA1c/ApoA1 as independent factors associated with in-hospital MACE after PCI in STEMI patients. Based on these findings, a nomogram model was developed and validated, with the C-index in the training set at 0.77 (95% CI: 0.723-0.817), and the C-index in the validation set at 0.788 (95% CI: 0.734-0.841), indicating excellent discrimination accuracy. The calibration curves and clinical decision curves also demonstrated the good performance of the nomogram models. In patients with STEMI who underwent PCI, it was noted that a higher HbA1c of the ApoA1 ratio is significantly associated with in-hospital MACE. In addition, a nomogram is constructed having considered the above-mentioned risk factors to provide predictive information on in-hospital MACE occurrence in these patients. In particular, this tool is of great value to the clinical practitioners in determination of patients with a high risk.

Reframing prediabetes: A call for better risk stratification and intervention

Prediabetes is an intermediate state of glucose homeostasis whereby plasma glucose concentrations are above normal but below the threshold of diagnosis for diabetes. Over the last several decades, criteria for prediabetes have changed as the cut points for normal glucose concentration and diagnosis of diabetes have shifted. Global consensus does not exist for prediabetes criteria; as a result, the clinical course and risk for type 2 diabetes vary. At present, we can identify individuals with prediabetes based on three glycemic tests (hemoglobin A1c, fasting plasma glucose, and 2-h plasma glucose during an oral glucose tolerance test). The majority of individuals diagnosed with prediabetes meet only one of these criteria. Meeting one, two, or all glycemic criteria changes risk for type 2 diabetes, but this information is not widely known and does not currently guide intervention strategies for individuals with prediabetes. This review summarizes current epidemiology, prognosis, and intervention strategies for individuals diagnosed with prediabetes and suggests a call for more precise risk stratification of individuals with prediabetes as elevated (one prediabetes criterion), high risk (two prediabetes criteria), and very high risk (three prediabetes criteria). In addition, the roles of oral glucose tolerance testing and continuous glucose monitoring in the diagnostic criteria for prediabetes need reassessment. Finally, we must reframe our goals for prediabetes and prioritize intensive interventions for those at high and very high risk for type 2 diabetes.

Differences in the impact of newly diagnosed type 2 diabetes on cardiovascular mortality between normotensive and hypertensive individuals

OBJECTIVE

We investigated the interrelationship between hyperglycemia and hypertension on cardiovascular mortality in the middle-aged and elderly people.

METHODS

In this retrospective cohort study that used data from the Hiroshima Study on Glucose Metabolism and Cardiovascular Diseases, we included 16,564 participants without cardiovascular disease (mean age: 65.8 years; 6179 normoglycemic people, 3017 people with newly diagnosed type 2 diabetes, and 7368 people with prediabetes per the 75-g oral glucose tolerance test). Hypertension was defined as the use of antihypertensive medications and/or having a systolic/diastolic blood pressure of at least 140/90 mm Hg.

RESULTS

During a median follow-up period of 12.4 years, a total of 1513 cardiovascular death occurred. Cardiovascular death rates per 1000 participant-years were 4.01, 4.98, 8.33, 8.22, 8.81, and 11.1 among normotensive participants with normal glycemia, prediabetes, and diabetes and hypertensive participants with normal glycemia, prediabetes, and diabetes, respectively. Prediabetes was significantly associated with a high risk of cardiovascular mortality in normotensive individuals [hazard ratio: 1.24, 95% confidence interval (95% CI): 1.02-1.50] but not in hypertensive individuals. Type 2 diabetes was associated with a high risk of cardiovascular mortality in both normotensive (hazard ratio: 1.94, 95% CI: 1.55-2.43) and hypertensive individuals (hazard ratio: 1.35, 95% CI: 1.13-1.62). Stratified analyses revealed no significant impact of type 2 diabetes on cardiovascular mortality in hypertensive individuals aged at least 65 years.

CONCLUSION

The effect of hyperglycemia on cardiovascular death differed with age and the presence or absence of hypertension, demonstrating the clinical importance of case-specific risk assessments.

Cardiovascular and Kidney Risks in Individuals With Type 2 Diabetes: Contemporary Understanding With Greater Emphasis on Excess Adiposity

In high-income countries, rates of atherosclerotic complications in type 2 diabetes have declined markedly over time due to better management of traditional risk factors including lipids, blood pressure, and glycemia levels. Population-wide reductions in smoking have also helped lower atherosclerotic complications and so reduce premature mortality in type 2 diabetes. However, as excess adiposity is a stronger driver for heart failure (HF), and obesity levels have remained largely unchanged, HF risks have not declined as much and may even be rising in the increasing number of people developing type 2 diabetes at younger ages. Excess weight is also an underrecognized risk factor for chronic kidney disease (CKD). Based on evidence from a range of sources, we explain how excess adiposity must be influencing most risks well before diabetes develops, particularly in younger-onset diabetes, which is linked to greater excess adiposity. We also review potential mechanisms linking excess adiposity to HF and CKD and speculate on how some of the responsible pathways-e.g., hemodynamic, cellular overnutrition, and inflammatory-could be favorably influenced by intentional weight loss (via lifestyle or drugs). On the basis of available evidence, we suggest that the cardiorenal outcome benefits seen with sodium-glucose cotransporter 2 inhibitors may partially derive from their interference of some of these same pathways. We also note that many other complications common in diabetes (e.g., hepatic, joint disease, perhaps mental health) are also variably linked to excess adiposity, the aggregated exposure to which has now increased in type 2 diabetes. All such observations suggest a greater need to tackle excess adiposity earlier in type 2 diabetes.

Metabolic disorders in prediabetes: From mechanisms to therapeutic management

Diabetes, one of the world's top ten diseases, is known for its high mortality and complication rates and low cure rate. Prediabetes precedes the onset of diabetes, during which effective treatment can reduce diabetes risk. Prediabetes risk factors include high-calorie and high-fat diets, sedentary lifestyles, and stress. Consequences may include considerable damage to vital organs, including the retina, liver, and kidneys. Interventions for treating prediabetes include a healthy lifestyle diet and pharmacological treatments. However, while these options are effective in the short term, they may fail due to the difficulty of long-term implementation. Medications may also be used to treat prediabetes. This review examines prediabetic treatments, particularly metformin, glucagon-like peptide-1 receptor agonists, sodium glucose cotransporter 2 inhibitors, vitamin D, and herbal medicines. Given the remarkable impact of prediabetes on the progression of diabetes mellitus, it is crucial to intervene promptly and effectively to regulate prediabetes. However, the current body of research on prediabetes is limited, and there is considerable confusion surrounding clinically relevant medications. This paper aims to provide a comprehensive summary of the pathogenesis of pre-diabetes mellitus and its associated therapeutic drugs. The ultimate goal is to facilitate the clinical utilization of medications and achieve efficient and timely control of diabetes mellitus.

Predictive value of lung function measures for cardiovascular risk: a large prospective cohort study

INTRODUCTION

Although lung function measures are associated with cardiovascular disease (CVD), the added predictive values of these measures remain unclear.

METHODS

From the UK Biobank, 308 415 participants free of CVD with spirometry parameters were included. The CVD outcomes included were defined by QRISK3, the American College of Cardiology/American Heart Association (ACC/AHA) and the European Systematic Coronary Risk Evaluation (SCORE) prediction models, respectively. Cox proportional hazard models were used to estimate the associations of lung function measures with CVD outcomes. The predictive capability was determined by the decision curve analyses.

RESULTS

Over a median follow-up of 12.5 years, 21 885 QRISK3 events, 12 843 ACC/AHA events and 2987 SCORE events were recorded. The associations of spirometry parameters with CVD outcomes were L-shaped. Restrictive and obstructive impairments were associated with adjusted HRs of 1.84 (95% CI: 1.65 to 2.06) and 1.72 (95% CI: 1.55 to 1.90) for SCORE CVD, respectively, compared with normal spirometry. Similar associations were seen for QRISK3 CVD (restrictive vs normal, adjusted HR: 1.30, 95% CI: 1.25 to 1.36; obstructive vs normal, adjusted HR: 1.20, 95% CI: 1.15 to 1.25) and ACC/AHA CVD (restrictive vs normal, adjusted HR: 1.39, 95% CI: 1.31 to 1.47; obstructive vs normal, adjusted HR: 1.26, 95% CI: 1.19 to 1.33). Using models that integrated non-linear forced expiratory volume in 1 s led to additional 10-year net benefits per 100 000 persons of 25, 43 and 5 for QRISK3 CVD at the threshold of 10%, ACC/AHA CVD at 7.5% and SCORE CVD at 5.0%, respectively.

CONCLUSION

Clinicians could consider spirometry indicators in CVD risk assessment. Cost-effectiveness studies and clinical trials are needed to put new CVD risk assessment into practice.

Comprehensive Factors for Predicting the Complications of DiabetesMellitus: A Systematic Review

BACKGROUND

This article focuses on extracting a standard feature set for predicting the complications of diabetes mellitus by systematically reviewing the literature. It is conducted and reported by following the guidelines of PRISMA, a well-known systematic review and meta-analysis method. The research articles included in this study are extracted using the search engine "Web of Science" over eight years. The most common complications of diabetes, diabetic neuropathy, retinopathy, nephropathy, and cardiovascular diseases are considered in the study.

METHOD

The features used to predict the complications are identified and categorised by scrutinising the standards of electronic health records.

RESULT

Overall, 102 research articles have been reviewed, resulting in 59 frequent features being identified. Nineteen attributes are recognised as a standard in all four considered complications, which are age, gender, ethnicity, weight, height, BMI, smoking history, HbA1c, SBP, eGFR, DBP, HDL, LDL, total cholesterol, triglyceride, use of insulin, duration of diabetes, family history of CVD, and diabetes. The existence of a well-accepted and updated feature set for health analytics models to predict the complications of diabetes mellitus is a vital and contemporary requirement. A widely accepted feature set is beneficial for benchmarking the risk factors of complications of diabetes.

CONCLUSION

This study is a thorough literature review to provide a clear state of the art for academicians, clinicians, and other stakeholders regarding the risk factors and their importance.

Risk of first-time major cardiovascular event among individuals with newly diagnosed type 2 diabetes: data from Danish registers

AIMS/HYPOTHESIS

We aimed to examine whether individuals with initial omission of glucose-lowering drug treatment (GLDT), including those achieving initial remission of type 2 diabetes, may experience a higher risk of major adverse cardiovascular events (MACE) compared with well-controlled individuals on GLDT after a new type 2 diabetes diagnosis in real-world clinical practice. Furthermore, we examined whether a higher risk could be related to lower initiation of statins and renin-angiotensin system inhibitors (RASi).

METHODS

In this cohort study, we used Danish registers to identify individuals with a first measured HbA1c between 48 and 57 mmol/mol (6.5-7.4%) from 2014 to 2020. Six months later, we divided participants into four groups according to GLDT and achieved HbA1c (<48 vs ≥48 mmol/mol [6.5%]): well-controlled and poorly controlled on GLDT; remission and persistent type 2 diabetes not on GLDT. We reported how much the standardised 5 year risk of MACE could be reduced for each group if initiation of statins and RASi was the same as in the well-controlled group on GLDT.

RESULTS

We included 14,221 individuals. Compared with well-controlled participants on GLDT, the 5 year standardised risk of MACE was higher in the three other exposure groups: by 3.3% (95% CI 1.6, 5.1) in the persistent type 2 diabetes group not on GLDT; 2.0% (95% CI 0.4, 3.7) in the remission group not on GLDT; and 3.5% (95% CI 1.3, 5.7) in the poorly controlled group on GLDT. Fewer individuals not on GLDT initiated statins and RASi compared with individuals on GLDT. If initiation of statins and RASi had been the same as in the well-controlled group on GLDT, participants not on GLDT could have reduced their risk of MACE by 2.1% (95% CI 1.2, 2.9) in the persistent type 2 diabetes group and by 1.1% (95% CI 0.4, 1.9) in the remission group.

CONCLUSIONS/INTERPRETATION

Compared with well-controlled individuals on GLDT, individuals not on initial GLDT had a higher 5 year risk of MACE, even among those achieving remission of type 2 diabetes. This may be related to lower use of statins and RASi.

Independent external validation of the QRISK3 cardiovascular disease risk prediction model using UK Biobank

OBJECTIVE

To externally evaluate the performance of QRISK3 for predicting 10 year risk of cardiovascular disease (CVD) in the UK Biobank cohort.

METHODS

We used data from the UK Biobank, a large-scale prospective cohort study of 403 370 participants aged 40-69 years recruited between 2006 and 2010 in the UK. We included participants with no previous history of CVD or statin treatment and defined the outcome to be the first occurrence of coronary heart disease, ischaemic stroke or transient ischaemic attack, derived from linked hospital inpatient records and death registrations.

RESULTS

Our study population included 233 233 women and 170 137 men, with 9295 and 13 028 incident CVD events, respectively. Overall, QRISK3 had moderate discrimination for UK Biobank participants (Harrell's C-statistic 0.722 in women and 0.697 in men) and discrimination declined by age (<0.62 in all participants aged 65 years or older). QRISK3 systematically overpredicted CVD risk in UK Biobank, particularly in older participants, by as much as 20%.

CONCLUSIONS

QRISK3 had moderate overall discrimination in UK Biobank, which was best in younger participants. The observed CVD risk for UK Biobank participants was lower than that predicted by QRISK3, particularly for older participants. It may be necessary to recalibrate QRISK3 or use an alternate model in studies that require accurate CVD risk prediction in UK Biobank.

Cardiovascular risk in diabetes mellitus: epidemiology, assessment and prevention

Cardiovascular diseases (CVDs) are the leading causes of morbidity and mortality in individuals with type 2 diabetes mellitus (T2DM). Secular changes in CVD outcomes have occurred over the past few decades, mainly due to a decline in the incidence of ischaemic heart disease. The onset of T2DM at a young age (<40 years), leading to a greater number of life-years lost, has also become increasingly common. Researchers are now looking beyond established risk factors in patients with T2DM towards the role of ectopic fat and, potentially, haemodynamic abnormalities in mediating important outcomes (such as heart failure). T2DM confers a wide spectrum of risk and is not necessarily a CVD risk equivalent, indicating the importance of risk assessment strategies (such as global risk scoring, consideration of risk-enhancing factors and assessment of subclinical atherosclerosis) to inform treatment. Data from epidemiological studies and clinical trials demonstrate that successful control of multiple risk factors can reduce the risk of CVD events by ≥50%; however, only ≤20% of patients achieve targets for risk factor reduction (plasma lipid levels, blood pressure, glycaemic control, body weight and non-smoking status). Improvements in composite risk factor control with lifestyle management (including a greater emphasis on weight loss interventions) and evidence-based generic and novel pharmacological therapies are therefore needed when the risk of CVD is high.

Genetic Evidence Strongly Supports Managing Weight and Blood Pressure in Addition to Glycemic Control in Preventing Vascular Complications in People With Type 2 Diabetes

OBJECTIVE

To investigate the causal association of type 2 diabetes and its components with risk of vascular complications independent of shared risk factors obesity and hypertension and to identify the main driver of this risk.

RESEARCH DESIGN AND METHODS

We conducted Mendelian randomization (MR) using independent genetic variants previously associated with type 2 diabetes, fasting glucose, HbA1c, fasting insulin, BMI, and systolic blood pressure as instrumental variables. We obtained summary-level data for 18 vascular diseases (15 for type 2 diabetes) from FinnGen and publicly available genome-wide association studies as our outcomes. We conducted univariable and multivariable MR, in addition to sensitivity tests to detect and minimize pleiotropic effects.

RESULTS

Univariable MR analysis showed that type 2 diabetes was associated with 9 of 15 outcomes; BMI and systolic blood pressure were associated with 13 and 15 of 18 vascular outcomes, respectively; and fasting insulin was associated with 4 and fasting glucose with 2. No robust association was found for HbA1c instruments. With adjustment for correlated traits in the multivariable test, BMI and systolic blood pressure, consistent causal effects were maintained, while five associations with type 2 diabetes (chronic kidney disease, ischemic heart disease, heart failure, subarachnoid hemorrhage, and intracerebral hemorrhage) were attenuated to null.

CONCLUSIONS

Our findings add strong evidence to support the importance of BMI and systolic blood pressure in the development of vascular complications in people with type 2 diabetes. Such findings strongly support the need for better weight and blood pressure management in type 2 diabetes, independent of glucose lowering, to limit important complications.

Prevalence of atherosclerosis in individuals with prediabetes and diabetes compared to normoglycaemic individuals-a Swedish population-based study

BACKGROUND

Patients with type 2 diabetes have an increased risk of death and cardiovascular events and people with diabetes or prediabetes have been found to have increased atherosclerotic burden in the coronary and carotid arteries. This study will estimate the cross-sectional prevalence of atherosclerosis in the coronary and carotid arteries in individuals with prediabetes and diabetes, compared with normoglycaemic individuals in a large population-based cohort.

METHODS

The 30,154 study participants, 50-64 years, were categorized according to their fasting glycaemic status or self-reported data as normoglycaemic, prediabetes, and previously undetected or known diabetes. Prevalence of affected coronary artery segments, severity of stenosis and coronary artery calcium score (CACS) were determined by coronary computed tomography angiography. Total atherosclerotic burden was assessed in the 11 clinically most relevant segments using the Segment Involvement Score and as the presence of any coronary atherosclerosis. The presence of atherosclerotic plaque in the carotid arteries was determined by ultrasound examination.

RESULTS

Study participants with prediabetes (n = 4804, 16.0%) or diabetes (n = 2282, 7.6%) had greater coronary artery plaque burden, more coronary stenosis and higher CACS than normoglycaemic participants (all, p < 0.01). Among male participants with diabetes 35.3% had CACS ≥ 100 compared to 16.1% among normoglycaemic participants. For women, the corresponding figures were 8.9% vs 6.1%. The prevalence of atherosclerosis in the coronary arteries was higher in participants with previously undetected diabetes than prediabetes, but lower than in patients with known diabetes. The prevalence of any plaque in the carotid arteries was higher in participants with prediabetes or diabetes than in normoglycaemic participants.

CONCLUSIONS

In this large population-based cohort of currently asymptomatic people, the atherosclerotic burden in the coronary and carotid arteries increased with increasing degree of dysglycaemia. The finding that the atherosclerotic burden in the coronary arteries in the undetected diabetes category was midway between the prediabetes category and patients with known diabetes may have implications for screening strategies and tailored prevention interventions for people with dysglycaemia in the future.

Glycemic and metabolic sub-classification of prediabetes and risk factors for cardiovascular disease in the D2d cohort

Objectives

Prediabetes represents a spectrum of metabolic abnormalities, including insulin resistance and secretory impairment, that carries increased cardiovascular disease (CVD) risk. It is unclear whether specific glycemic and metabolic sub-classifications are associated with CVD risk. This cross-sectional analysis of 3946 participants from the Vitamin D and Type 2 Diabetes (D2d) study cohort aimed to determine the associations between various baseline CVD risk factors, glycemic sub-classifications of prediabetes (FPG, 2hPG, and HbA1c), and measures of insulin sensitivity and secretion from an OGTT.

Methods

The metabolic syndrome and atherosclerotic cardiovascular disease (ASCVD) risk scores were determined for tertiles of insulin sensitivity (HOMA2S) and insulinogenic index (IGI). Unadjusted analyses showed elevated CVD risk factors in the lowest tertile for both IGI and HOMA2S.

Results

After adjustment for age, gender, race, obesity, and smoking status, the association remained between HOMA2S and ASCVD score (r = -0.11, p< 0.001) but not for IGI. Those who met at least 2 diagnosic criteria for prediabetes had the largest proportion (> 40%) of participants with high ASCVD risk score >20. A higher percentage of individuals that met all 3 criteria for prediabetes had metabolic syndrome and ASCVD risk score >20 (87.2% and 15.3%, respectively) than those who only met 1 prediabetes criterion (51.6% and 7.1%, respectively).

Conclusions

In conclusion, multiple metabolic (HOMA2S, IGI) and glycemic criteria of prediabetes (FPG, 2hPG, & HbA1c) are needed to fully recognize the elevated CVD risk profile that can manifest in prediabetes.

Sex-specific risks for cardiovascular disease across the glycaemic spectrum: a population-based cohort study using the UK Biobank

Background

We sought to examine sex-specific risks for incident cardiovascular disease (CVD) across the full glycaemic spectrum.

Methods

Using data from UK Biobank, we categorised participants' glycated haemoglobin (HbA1c) at baseline as low-normal (<35 mmol/mol), normal (35-41 mmol/mol), pre-diabetes (42-47 mmol/mol), undiagnosed diabetes (≥48 mmol/mol), or diagnosed diabetes. Our outcomes were coronary artery disease (CAD), atrial fibrillation, deep vein thrombosis (DVT), pulmonary embolism (PE), stroke, heart failure, and a composite outcome of any CVD. Cox regression estimated sex-specific associations between HbA1c and each outcome, sequentially adjusting for socio-demographic, lifestyle, and clinical characteristics.

Findings

Among 427,435 people, CVD rates were 16.9 and 9.1 events/1000 person-years for men and women, respectively. Both men and women with pre-diabetes, undiagnosed diabetes, and, more markedly, diagnosed diabetes were at higher risks of CVD than those with normal HbA1c, with relative increases more pronounced in women than men. Age-adjusted HRs for pre-diabetes and undiagnosed diabetes ranged from 1.30 to 1.47; HRs for diagnosed diabetes were 1.55 (1.49-1.61) in men and 2.00 (1.89-2.12) in women (p-interaction <0.0001). Excess risks attenuated and were more similar between men and women after adjusting for clinical and lifestyle factors particularly obesity and antihypertensive or statin use (fully adjusted HRs for diagnosed diabetes: 1.06 [1.02-1.11] and 1.17 [1.10-1.24], respectively).

Interpretation

Excess risks in men and women were largely explained by modifiable factors, and could be ameliorated by attention to weight reduction strategies and greater use of antihypertensive and statin medications. Addressing these risk factors could reduce sex disparities in risk of CVD among people with and without diabetes.

Funding

Diabetes UK (#15/0005250) and British Heart Foundation (SP/16/6/32726).

Association of Fish Oil Supplementation with Risk of Coronary Heart Disease in Individuals with Diabetes and Prediabetes: A Prospective Study in the UK Biobank

This study aimed to explore the association between habitual intake of fish oil supplementation and the risk of developing CHD in patients with prediabetes and diabetes. Habitual use of fish oil was assessed by repeated questionnaires. Cox proportional hazard models were applied to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). Over a median follow-up of 11.6 years, 4304 and 3294 CHD cases were documented among 47,663 individuals with prediabetes and 22,146 patients with diabetes in the UK Biobank, respectively. After multivariable adjustment, the HRs (95% CI) of CHD were 0.91 (0.85-0.98) and 0.87 (0.80-0.95) for individuals utilizing fish oil supplementation compared with non-users among the participants with prediabetes and diabetes, respectively. Furthermore, we identified an inverse relationship between fish oil use and CHD incidence, which was significantly mediated by serum C-reactive protein (CRP) levels in individuals with prediabetes and by very-low-density lipoprotein cholesterol (VLDL-C) in patients with diabetes at baseline. The inverse associations were consistent in the analyses stratified by potential confounders. In conclusion, the consumption of fish oil supplements was linked to decreased serum CRP and VLDL-C levels and subsequent CHD risk among adults with prediabetes and diabetes. Our findings highlight the important role of the habitual intake of fish oil supplements in preventing CHD in individuals with impaired glucose metabolism.

Effect of lifestyle intervention on HbA1c levels in overweight and obese adults with type 2 diabetes across ethnicities: A systematic review and meta-analysis of randomized controlled trials

AIMS

Weight reduction is fundamental for the management and remission of diabetes. We aimed to assess ethnic differences in the effects of lifestyle weight-loss interventions on HbA1c levels in overweight or obese adults with type 2 diabetes mellitus (T2DM).

METHODS

We systematically searched PubMed/MEDLINE and Web of Science online databases up to 31 Dec 2022. Randomized controlled trials using lifestyle weight-loss interventions in overweight or obese adults with T2DM were selected. We performed subgroup analyses to explore the heterogeneity across different ethnicities (Asians, White/Caucasians, Black/Africans and Hispanics). A random effects model was applied to calculate weighted mean difference (WMD) with 95% confidence interval (CI).

RESULTS

Thirty studies including 7580 subjects from different ethnicities were identified according to the predefined inclusion and exclusion criteria. HbA1c levels were significantly reduced by lifestyle weight-loss intervention. Notably, a significantly beneficial effect on HbA1c was observed in White/Caucasians (WMD = -0.59, 95% CI: -0.90, -0.28, P < 0.001) and Asians (WMD = -0.48, 95% CI: -0.63, -0.33, P < 0.001), but not in the Black/African or Hispanic group (both P > 0.05). The findings remained essentially unchanged in the sensitivity analysis.

CONCLUSIONS

Lifestyle weight-loss interventions had distinct beneficial effects on HbA1c levels in different ethnic groups with T2DM, especially in Caucasians and Asians.

Prediabetes and all-cause mortality in young patients undergoing coronary artery angiography: a multicenter cohort study in China

BACKGROUND

The prevalence of prediabetes is increasing in young adults and patients undergoing coronary angiography. However, whether prediabetes is a considerable risk factor for all-cause mortality remains undetermined in young patients undergoing coronary angiography.

METHODS

In this study, we retrospectively included 8868 young patients (men aged < 45 years, women aged < 55 years) who underwent coronary angiography (CAG). Patients were categorized as normoglycemic, prediabetes and diabetes according to the HbA1c level or documented history of diabetes. The association of all-cause mortality with diabetes and prediabetes was detected by Cox proportional hazards regression analysis.

RESULTS

A total of 3240 (36.5%) among 8868 young patients receiving CAG were prediabetes and 2218 (25.0%) were diabetes. 728 patients died during a median follow-up of 4.92 years. Compared to the normoglycemic group, prediabetes increased the risk of all-cause mortality in young CAG patients by 24%(adjusted HR: 1.24, 95% CI: 1.04-1.49, p = 0.019) and diabetes increased the risk of all-cause mortality by 46%(adjusted HR:1.46, 95% CI:1.2-1.79, p < 0.001). Subgroup analysis showed that diabetes and prediabetes increased the risk of death mainly in patients without comorbidities.

CONCLUSION

Prediabetes accounts for more than one-third of the young adults undergoing CAG and was associated with an increased risk of all-cause mortality, active prevention strategy should be considered for these patients.

Prediabetes as a risk factor for new-onset atrial fibrillation: the propensity-score matching cohort analyzed using the Cox regression model coupled with the random survival forest

BACKGROUND

The glycemic continuum often indicates a gradual decline in insulin sensitivity leading to an increase in glucose levels. Although prediabetes is an established risk factor for both macrovascular and microvascular diseases, whether prediabetes is independently associated with the risk of developing atrial fibrillation (AF), particularly the occurrence time, has not been well studied using a high-quality research design in combination with statistical machine-learning algorithms.

METHODS

Using data available from electronic medical records collected from the National Taiwan University Hospital, a tertiary medical center in Taiwan, we conducted a retrospective cohort study consisting 174,835 adult patients between 2014 and 2019 to investigate the relationship between prediabetes and AF. To render patients with prediabetes as comparable to those with normal glucose test, a propensity-score matching design was used to select the matched pairs of two groups with a 1:1 ratio. The Kaplan-Meier method was used to compare the cumulative risk of AF between prediabetes and normal glucose test using log-rank test. The multivariable Cox regression model was employed to estimate adjusted hazard ratio (HR) for prediabetes versus normal glucose test by stratifying three levels of glycosylated hemoglobin (HbA1c). The machine-learning algorithm using the random survival forest (RSF) method was further used to identify the importance of clinical factors associated with AF in patients with prediabetes.

RESULTS

A sample of 14,309 pairs of patients with prediabetes and normal glucose test result were selected. The incidence of AF was 11.6 cases per 1000 person-years during a median follow-up period of 47.1 months. The Kaplan-Meier analysis revealed that the risk of AF was significantly higher in patients with prediabetes (log-rank p < 0.001). The multivariable Cox regression model indicated that prediabetes was independently associated with a significant increased risk of AF (HR 1.24, 95% confidence interval 1.11-1.39, p < 0.001), particularly for patients with HbA1c above 5.5%. The RSF method identified elevated N-terminal natriuretic peptide and altered left heart structure as the two most important risk factors for AF among patients with prediabetes.

CONCLUSIONS

Our study found that prediabetes is independently associated with a higher risk of AF. Furthermore, alterations in left heart structure make a significant contribution to this elevated risk, and these structural changes may begin during the prediabetes stage.

Associations Between HbA1c Across the Normal Range, Diagnosed, and Undiagnosed Diabetes and Retinal Layer Thickness in UK Biobank Cohort

Purpose

The purpose of this study was to investigate the association between glycated hemoglobin (HbA1c) levels and retinal sub-layer thicknesses in people with and without diabetes.

Methods

We included 41,453 UK Biobank participants aged 40 to 69 years old. Diabetes status was defined by self-report of diagnosis or use of insulin. Participants were categorized into groups: (1) those with HbA1c <48 mmol/mol were subdivided into quintiles according to normal range of HbA1c; (2) those previously diagnosed with diabetes with no evidence of diabetic retinopathy; and (3) undiagnosed diabetes: >48 mmol/mol. Total macular and retinal sub-layer thicknesses were derived from spectral-domain optical coherence tomography (SD-OCT) images. Multivariable linear regression was used to evaluate the associations between diabetes status and retinal layer thickness.

Results

Compared with participants in the second quintile of the normal HbA1c range, those in the fifth quintile had a thinner photoreceptor layer thickness (-0.33 µm, P = 0.006). Participants with diagnosed diabetes had a thinner macular retinal nerve fiber layer (mRNFL; -0.58 µm, P < 0.001), photoreceptor layer thickness (-0.94 µm, P < 0.001), and total macular thickness (-1.61 µm, P < 0.001), whereas undiagnosed diabetes participants had a reduced photoreceptor layer thickness (-1.22 µm, P = 0.009) and total macular thickness (-2.26 µm, P = 0.005). Compared to participants without diabetes, those with diabetes had a thinner mRNFL (-0.50 µm, P < 0.001), photoreceptor layer thickness (-0.77 µm, P < 0.001), and total macular thickness (-1.36 µm, P < 0.001).

Conclusions

Participants with higher HbA1c in the normal range had marginally thinner photoreceptor thickness, whereas those with diabetes (including undiagnosed diabetes) had meaningfully thinner retinal sublayer and total macular thickness.

Translational Relevance

We showed that early retinal neurodegeneration occurs in people whose HbA1c levels are below the current diabetes diagnostic threshold; this might impact the management of pre-diabetes individuals.

Validation of a deep-learning-based retinal biomarker (Reti-CVD) in the prediction of cardiovascular disease: data from UK Biobank

BACKGROUND

Currently in the United Kingdom, cardiovascular disease (CVD) risk assessment is based on the QRISK3 score, in which 10% 10-year CVD risk indicates clinical intervention. However, this benchmark has limited efficacy in clinical practice and the need for a more simple, non-invasive risk stratification tool is necessary. Retinal photography is becoming increasingly acceptable as a non-invasive imaging tool for CVD. Previously, we developed a novel CVD risk stratification system based on retinal photographs predicting future CVD risk. This study aims to further validate our biomarker, Reti-CVD, (1) to detect risk group of ≥ 10% in 10-year CVD risk and (2) enhance risk assessment in individuals with QRISK3 of 7.5-10% (termed as borderline-QRISK3 group) using the UK Biobank.

METHODS

Reti-CVD scores were calculated and stratified into three risk groups based on optimized cut-off values from the UK Biobank. We used Cox proportional-hazards models to evaluate the ability of Reti-CVD to predict CVD events in the general population. C-statistics was used to assess the prognostic value of adding Reti-CVD to QRISK3 in borderline-QRISK3 group and three vulnerable subgroups.

RESULTS

Among 48,260 participants with no history of CVD, 6.3% had CVD events during the 11-year follow-up. Reti-CVD was associated with an increased risk of CVD (adjusted hazard ratio [HR] 1.41; 95% confidence interval [CI], 1.30-1.52) with a 13.1% (95% CI, 11.7-14.6%) 10-year CVD risk in Reti-CVD-high-risk group. The 10-year CVD risk of the borderline-QRISK3 group was greater than 10% in Reti-CVD-high-risk group (11.5% in non-statin cohort [n = 45,473], 11.5% in stage 1 hypertension cohort [n = 11,966], and 14.2% in middle-aged cohort [n = 38,941]). C statistics increased by 0.014 (0.010-0.017) in non-statin cohort, 0.013 (0.007-0.019) in stage 1 hypertension cohort, and 0.023 (0.018-0.029) in middle-aged cohort for CVD event prediction after adding Reti-CVD to QRISK3.

CONCLUSIONS

Reti-CVD has the potential to identify individuals with ≥ 10% 10-year CVD risk who are likely to benefit from earlier preventative CVD interventions. For borderline-QRISK3 individuals with 10-year CVD risk between 7.5 and 10%, Reti-CVD could be used as a risk enhancer tool to help improve discernment accuracy, especially in adult groups that may be pre-disposed to CVD.

The association between stress hyperglycemia and unfavorable outcomes in patients with anterior circulation stroke after mechanical thrombectomy

Background and purpose

Stress hyperglycemia is common in critical and severe diseases. However, few studies have examined the association between stress hyperglycemia and the functional outcomes of patients with anterior circulation stroke, after mechanical thrombectomy (MT), in different diabetes status. This study therefore aimed to determine the relationship between stress hyperglycemia and the risk of adverse neurological functional outcomes in anterior circulation stroke patients with and without diabetes after MT.

Methods

Data of 408 patients with acute anterior circulation stroke treated with MT through the green-channel treatment system for emergency stroke at the First Affiliated Hospital of Jinan University between January 2016 and December 2020 were reviewed retrospectively. The stress hyperglycemia ratio (SHR) was calculated as fasting plasma glucose (mmol/L) divided by glycosylated hemoglobin (%). The patients were stratified into four groups by quartiles of SHR (Q1-Q4). The primary outcome was an excellent (nondisabled) functional outcome at 3 months after admission (modified Rankin Scale score of 0-1). The relationship between stress hyperglycemia and neurological outcome after stroke was assessed using multivariate logistic regression.

Results

After adjusting for potential confounders, compared with patients in Q1, those in Q4 were less likely to have an excellent outcome at 3 months (odds ratio [OR], 0.32, 95% confidence interval [CI], 0.14-0.66, p = 0.003), a good outcome at 3 months (OR, 0.41, 95% CI, 0.20-0.84, p = 0.020), and major neurological improvement (OR, 0.38, 95% CI, 0.19-0.73, p = 0.004). Severe stress hyperglycemia increased risks of 3-months all-cause mortality (OR, 2.82, 95% CI, 1.09-8.29, p = 0.041) and ICH (OR, 2.54, 95% CI, 1.21-5.50, p = 0.015).

Conclusion

Stress hyperglycemia was associated with a reduced rate of excellent neurological outcomes, and increased mortality and ICH risks in patients with anterior circulation stroke after MT regardless of diabetes status.

The Association between Dietary Iron Intake and Incidence of Dementia in Adults Aged 60 Years or over in the UK Biobank

Background Several studies have investigated the association between dietary iron intake and cognitive impairment, but little is known about the relationship between iron intake and dementia incidence. Objectives This study explored the association between dietary iron intake and incident dementia in males and females. Whether this association was modified by factors such as age and medical diseases was also examined. Methods We included 41,213 males and 48,892 females aged 60 years or over, from the UK-Biobank cohort. Dietary iron intake was measured using a web-based 24-h dietary recall questionnaire from between 2009 and 2012. Incident dementia was ascertained using hospital inpatient records and death registers until April 2021. Cox proportional regression models examined the association between iron intake and incident dementia, and hazard ratio curves were constructed with knots from the analysis indicating insufficient or excessive iron intake. Results During a mean follow-up of 11.8 years, 560 males and 492 females developed dementia. A non-linear relationship between iron intake and incident dementia was observed in both males and females. The lowest incidence rates were observed in the higher iron intake quintile (Q4: ≥15.73, <17.57 mg/day) for males, and the intermediate iron intake quintile (Q3: ≥12.4, <13.71 mg/day) for females. Among those aged 60 and above, all-cause dementia in males was associated with deficient iron intake (Q1 versus Q4: Hazard ratio [HR]: 1.37, 95% Confidence interval [95%CI]: 1.01−1.86, p = 0.042) and excessive iron intake (Q5 versus Q4: HR: 1.49, 95%CI: 1.14−1.96, p = 0.003), whilst significant associations between all-cause dementia and deficient iron intake were only observed in females without hypertension. Smoking status was a significant moderator (p-value for trend = 0.017) for dementia in males only. Conclusions Excessive iron intake (≥17.57 mg/day) is associated with a higher incidence of all-cause dementia in males and smoking status modified this association amongst males. Deficient iron intake (<10.93 mg/day) was associated with a higher incidence of all-cause dementia in females without a history of hypertension.

The relationship between glycated hemoglobin level and the stage of periodontitis in individuals without diabetes

Glycemic control appears to have a significant impact on the relationship between periodontitis and diabetes. The current study aimed to investigate the association between the stage of periodontitis and hemoglobin A1c (HbA1c) levels in patients considered to be normoglycemic. A total of 135 patients (100 females and 35 males) with no history of diabetes were included in the study. The mean age of the participants was 38.4 years old. All patients underwent a full-mouth periodontal examination. Periodontal diagnosis was determined according to the 2017 World Workshop on the Classification of Periodontal Disease. The glycemic state of the patients was assessed using a chair-side HbA1c analyzer. Ninety patients were diagnosed with periodontitis. Higher average HbA1c levels were associated with the different stages of periodontitis (p<0.01). Most of the non-periodontitis patients were in the non-diabetes group (67%), while most of the periodontitis patients were in the undiagnosed pre-diabetes group (47% of the stages I and II group, and 44% of the stages III and IV groups) (p<0.001). Periodontitis was found to be significantly associated with elevated glycated hemoglobin levels in patients not previously diagnosed with diabetes, and the elevation in HbA1c levels was more evident in patients with stage III and IV periodontitis.

Addressing the Continuum of Dysglycaemia and Vascular Complications in Prediabetes and Type 2 Diabetes: Need for Early and Intensive Treatment

The onset of type 2 diabetes increases the risk of vascular complications and death. We know now that that this risk begins long before the diabetes diagnosis. Prediabetes and type 2 diabetes are not separate entities in practice and exist within a continuum of dysglycaemia and vascular risk that increases in severity over time. This excess risk requires early intervention with lifestyle therapy supported with pharmacologic antidiabetic therapy, intensified promptly where necessary throughout the duration of the diabetes continuum. Metformin is an evidence-based treatment for preventing prediabetes and improves cardiovascular outcomes in people with type 2 diabetes from diagnosis onwards. Newer agents (SGLT2 inhibitors and GLP-1 agonists) are appropriate for people presenting with type 2 diabetes and significant cardiovascular comorbidity. Additional therapies should be used without delay to achieve patients' individualised HbA1c goals and to minimise cardiovascular risk.

Risk of Carotid Atherosclerosis in Subjects with Prediabetes Overlapping Metabolic Syndrome

Background: While the number of individuals with prediabetes and metabolic syndrome (MetS) is increasing, only a few studies have reported differences in cardiovascular risk according to the presence or absence of MetS in individuals with prediabetes. Here, we examined differences in carotid intima-media thickness (CIMT) and carotid plaques in individuals with prediabetes with or without MetS among subjects who visited a single center in Seoul (Huh Diabetes Center). Methods: A total of 328 participants aged ≥20 years, including the group with normoglycemia, were enrolled in the analysis, of which 273 had prediabetes. Individuals with prediabetes were defined as those who met one or more of the following two criteria: fasting plasma glucose of 100-125 mg/dL and/or HbA1c level of 5.7%-6.4%. Carotid atherosclerosis was determined by mean and maximal CIMT and by the presence of carotid plaques. Results: Eighty-nine subjects (32.6% of prediabetes group) were categorized as having MetS. Those with MetS had significantly higher mean CIMT and maximal CIMT than those without (P < 0.05). Moreover, the group with MetS had a significantly higher prevalence of carotid plaques than the group without MetS [odds ratio (OR): 2.45, 95% confidence interval (CI): 1.43-4.19; P = 0.001]. After adjusting for age, sex, body mass index, and low-density lipoprotein cholesterol, individuals with MetS still had greater mean and maximal CIMT than individuals without MetS (P < 0.05), and the presence of MetS was significantly associated with a higher risk of carotid plaques (OR: 2.55, 95% CI: 1.06-6.15; P = 0.037). Conclusion: These results suggest that MetS is independently associated with increased CIMT and the presence of carotid plaques in prediabetes. Our study indicates that the risk of cardiovascular disease (CVD) is high in prediabetic individuals with MetS, and that more attention is needed on the risk of CVD in these individuals.

Artificial intelligence-enabled retinal vasculometry for prediction of circulatory mortality, myocardial infarction and stroke

AIMS

We examine whether inclusion of artificial intelligence (AI)-enabled retinal vasculometry (RV) improves existing risk algorithms for incident stroke, myocardial infarction (MI) and circulatory mortality.

METHODS

AI-enabled retinal vessel image analysis processed images from 88 052 UK Biobank (UKB) participants (aged 40-69 years at image capture) and 7411 European Prospective Investigation into Cancer (EPIC)-Norfolk participants (aged 48-92). Retinal arteriolar and venular width, tortuosity and area were extracted. Prediction models were developed in UKB using multivariable Cox proportional hazards regression for circulatory mortality, incident stroke and MI, and externally validated in EPIC-Norfolk. Model performance was assessed using optimism adjusted calibration, C-statistics and R² statistics. Performance of Framingham risk scores (FRS) for incident stroke and incident MI, with addition of RV to FRS, were compared with a simpler model based on RV, age, smoking status and medical history (antihypertensive/cholesterol lowering medication, diabetes, prevalent stroke/MI).

RESULTS

UKB prognostic models were developed on 65 144 participants (mean age 56.8; median follow-up 7.7 years) and validated in 5862 EPIC-Norfolk participants (67.6, 9.1 years, respectively). Prediction models for circulatory mortality in men and women had optimism adjusted C-statistics and R² statistics between 0.75-0.77 and 0.33-0.44, respectively. For incident stroke and MI, addition of RV to FRS did not improve model performance in either cohort. However, the simpler RV model performed equally or better than FRS.

CONCLUSION

RV offers an alternative predictive biomarker to traditional risk-scores for vascular health, without the need for blood sampling or blood pressure measurement. Further work is needed to examine RV in population screening to triage individuals at high-risk.

Vascular complications in prediabetes and type 2 diabetes: a continuous process arising from a common pathology

The term, "prediabetes", describes a state of hyperglycaemia that is intermediate between true normoglycaemia and the diagnostic cut-offs for indices of glycaemia that are used to diagnose type 2 diabetes. The presence of prediabetes markedly increases the risk of developing type 2 diabetes. Numerous randomized, controlled evaluations of various agents have demonstrated significant prevention or delay of the onset of type 2 diabetes in subjects with prediabetes. Intensive lifestyle interventions and metformin have been studied most widely, with the lifestyle intervention being more effective in the majority of subjects. The application of therapeutic interventions at the time of prediabetes to preserve long-term outcomes has been controversial, however, due to a lack of evidence relating to the pathogenic effects of prediabetes and the effectiveness of interventions to produce a long-term clinical benefit. Recent studies have confirmed that prediabetes, however defined, is associated with a significantly increased risk of macrovascular and microvascular complications essentially identical to those of diabetes, and also with subclinical derangements of the function of microvasculature and neurons that likely signify increased risk of compilations in future. Normoglycaemia, prediabetes and type 2 diabetes appear to be part of a continuum of increased risk of adverse outcomes. Long-term (25-30 years) post-trial follow up of two major diabetes prevention trials have shown that short-term interventions to prevent diabetes lead to long-term reductions in the risk of complications. These findings support the concept of therapeutic intervention to preserve long-term health in people with prediabetes before type 2 diabetes becomes established.

Does the Effect of a 3-Year Lifestyle Intervention on Body Weight and Cardiometabolic Health Differ by Prediabetes Metabolic Phenotype? A Post Hoc Analysis of the PREVIEW Study

OBJECTIVE

To examine whether the effect of a 3-year lifestyle intervention on body weight and cardiometabolic risk factors differs by prediabetes metabolic phenotype.

RESEARCH DESIGN AND METHODS

This post hoc analysis of the multicenter, randomized trial, PREVention of diabetes through lifestyle interventions and population studies In Europe and around the World (PREVIEW), included 1,510 participants with prediabetes (BMI ≥25 kg ⋅ m-2; defined using oral glucose tolerance tests). Of these, 58% had isolated impaired fasting glucose (iIFG), 6% had isolated impaired glucose tolerance (iIGT), and 36% had IFG+IGT; 73% had normal hemoglobin A1c (HbA1c; <39 mmol ⋅ mol-1) and 25% had intermediate HbA1c (39-47 mmol ⋅ mol-1). Participants underwent an 8-week diet-induced rapid weight loss, followed by a 148-week lifestyle-based weight maintenance intervention. Linear mixed models adjusted for intervention arm and other confounders were used.

RESULTS

In the available-case and complete-case analyses, participants with IFG+IGT had greater sustained weight loss after lifestyle intervention (adjusted mean at 156 weeks -3.5% [95% CI, -4.7%, -2.3%]) than those with iIFG (mean -2.5% [-3.6%, -1.3%]) relative to baseline (P = 0.011). Participants with IFG+IGT and iIFG had similar cardiometabolic benefits from the lifestyle intervention. The differences in cardiometabolic benefits between those with iIGT and IFG+IGT were minor or inconsistent in different analyses. Participants with normal versus intermediate HbA1c had similar weight loss over 3 years and minor differences in cardiometabolic benefits during weight loss, whereas those with normal HbA1c had greater improvements in fasting glucose, 2-h glucose (adjusted between-group difference at 156 weeks -0.54 mmol ⋅ L-1 [95% CI -0.70, -0.39], P < 0.001), and triglycerides (difference -0.07 mmol ⋅ L-1 [-0.11, -0.03], P < 0.001) during the lifestyle intervention.

CONCLUSIONS

Individuals with iIFG and IFG+IGT had similar improvements in cardiometabolic health from a lifestyle intervention. Those with normal HbA1c had greater improvements than those with intermediate HbA1c.

Blood pressure-lowering treatment for prevention of major cardiovascular diseases in people with and without type 2 diabetes: an individual participant-level data meta-analysis

BACKGROUND

Controversy exists as to whether the threshold for blood pressure-lowering treatment should differ between people with and without type 2 diabetes. We aimed to investigate the effects of blood pressure-lowering treatment on the risk of major cardiovascular events by type 2 diabetes status, as well as by baseline levels of systolic blood pressure.

METHODS

We conducted a one-stage individual participant-level data meta-analysis of major randomised controlled trials using the Blood Pressure Lowering Treatment Trialists' Collaboration dataset. Trials with information on type 2 diabetes status at baseline were eligible if they compared blood pressure-lowering medications versus placebo or other classes of blood pressure-lowering medications, or an intensive versus a standard blood pressure-lowering strategy, and reported at least 1000 persons-years of follow-up in each group. Trials exclusively on participants with heart failure or with short-term therapies and acute myocardial infarction or other acute settings were excluded. We expressed treatment effect per 5 mm Hg reduction in systolic blood pressure on the risk of developing a major cardiovascular event as the primary outcome, defined as the first occurrence of fatal or non-fatal stroke or cerebrovascular disease, fatal or non-fatal ischaemic heart disease, or heart failure causing death or requiring hospitalisation. Cox proportional hazard models, stratified by trial, were used to estimate hazard ratios (HRs) separately by type 2 diabetes status at baseline, with further stratification by baseline categories of systolic blood pressure (in 10 mm Hg increments from <120 mm Hg to ≥170 mm Hg). To estimate absolute risk reductions, we used a Poisson regression model over the follow-up duration. The effect of each of the five major blood pressure-lowering drug classes, including angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, β blockers, calcium channel blockers, and thiazide diuretics, was estimated using a network meta-analysis framework. This study is registered with PROSPERO, CRD42018099283.

FINDINGS

We included data from 51 randomised clinical trials published between 1981 and 2014 involving 358 533 participants (58% men), among whom 103 325 (29%) had known type 2 diabetes at baseline. The baseline mean systolic/diastolic blood pressure of those with and without type 2 diabetes was 149/84 mm Hg (SD 19/11) and 153/88 mm Hg (SD 21/12), respectively. Over 4·2 years median follow-up (IQR 3·0-5·0), a 5 mm Hg reduction in systolic blood pressure decreased the risk of major cardiovascular events in both groups, but with a weaker relative treatment effect in participants with type 2 diabetes (HR 0·94 [95% CI 0·91-0·98]) compared with those without type 2 diabetes (0·89 [0·87-0·92]; p_interaction=0·0013). However, absolute risk reductions did not differ substantially between people with and without type 2 diabetes because of the higher absolute cardiovascular risk among participants with type 2 diabetes. We found no reliable evidence for heterogeneity of treatment effects by baseline systolic blood pressure in either group. In keeping with the primary findings, analysis using stratified network meta-analysis showed no evidence that relative treatment effects differed substantially between participants with type 2 diabetes and those without for any of the drug classes investigated.

INTERPRETATION

Although the relative beneficial effects of blood pressure reduction on major cardiovascular events were weaker in participants with type 2 diabetes than in those without, absolute effects were similar. The difference in relative risk reduction was not related to the baseline blood pressure or allocation to different drug classes. Therefore, the adoption of differential blood pressure thresholds, intensities of blood pressure lowering, or drug classes used in people with and without type 2 diabetes is not warranted.

FUNDING

British Heart Foundation, UK National Institute for Health Research, and Oxford Martin School.

Age- and sex-specific effects of a long-term lifestyle intervention on body weight and cardiometabolic health markers in adults with prediabetes: results from the diabetes prevention study PREVIEW

AIMS/HYPOTHESIS

Lifestyle interventions are the first-line treatment option for body weight and cardiometabolic health management. However, whether age groups or women and men respond differently to lifestyle interventions is under debate. We aimed to examine age- and sex-specific effects of a low-energy diet (LED) followed by a long-term lifestyle intervention on body weight, body composition and cardiometabolic health markers in adults with prediabetes (i.e. impaired fasting glucose and/or impaired glucose tolerance).

METHODS

This observational study used longitudinal data from 2223 overweight participants with prediabetes in the multicentre diabetes prevention study PREVIEW. The participants underwent a LED-induced rapid weight loss (WL) period followed by a 3 year lifestyle-based weight maintenance (WM) intervention. Changes in outcomes of interest in prespecified age (younger: 25-45 years; middle-aged: 46-54 years; older: 55-70 years) or sex (women and men) groups were compared.

RESULTS

In total, 783 younger, 319 middle-aged and 1121 older adults and 1503 women and 720 men were included in the analysis. In the available case and complete case analyses, multivariable-adjusted linear mixed models showed that younger and older adults had similar weight loss after the LED, whereas older adults had greater sustained weight loss after the WM intervention (adjusted difference for older vs younger adults -1.25% [95% CI -1.92, -0.58], p<0.001). After the WM intervention, older adults lost more fat-free mass and bone mass and had smaller improvements in 2 h plasma glucose (adjusted difference for older vs younger adults 0.65 mmol/l [95% CI 0.50, 0.80], p<0.001) and systolic blood pressure (adjusted difference for older vs younger adults 2.57 mmHg [95% CI 1.37, 3.77], p<0.001) than younger adults. Older adults had smaller decreases in fasting and 2 h glucose, HbA1c and systolic blood pressure after the WM intervention than middle-aged adults. In the complete case analysis, the above-mentioned differences between middle-aged and older adults disappeared, but the direction of the effect size did not change. After the WL period, compared with men, women had less weight loss (adjusted difference for women vs men 1.78% [95% CI 1.12, 2.43], p<0.001) with greater fat-free mass and bone mass loss and smaller improvements in HbA1c, LDL-cholesterol and diastolic blood pressure. After the WM intervention, women had greater fat-free mass and bone mass loss and smaller improvements in HbA1c and LDL-cholesterol, while they had greater improvements in fasting glucose, triacylglycerol (adjusted difference for women vs men -0.08 mmol/l [-0.11, -0.04], p<0.001) and HDL-cholesterol.

CONCLUSIONS/INTERPRETATION

Older adults benefited less from a lifestyle intervention in relation to body composition and cardiometabolic health markers than younger adults, despite greater sustained weight loss. Women benefited less from a LED followed by a lifestyle intervention in relation to body weight and body composition than men. Future interventions targeting older adults or women should take prevention of fat-free mass and bone mass loss into consideration.

CLINICAL TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT01777893.

Stress hyperglycemia is predictive of clinical outcomes in patients with spontaneous intracerebral hemorrhage

Background

Stress hyperglycemia is a common condition in patients suffering from critical illness such as spontaneous intracerebral hemorrhage (ICH). Our study aimed to use glucose-to-glycated hemoglobin (HbA1c) ratio to investigate the impact of stress hyperglycemia on clinical outcomes in patients with ICH.

Methods

A sample of eligible 586 patients with spontaneous intracerebral hemorrhage from a multicenter, hospital-based cohort between 2014 and 2016 were recruited in our study. Stress hyperglycemia was evaluated by the index of the glucose-to-HbA1c ratio that was calculated by fasting blood glucose (mmol/L) divided by HbA1c (%). Patients were divided into two groups based on the median of the glucose-to-HbA1c ratio. The main outcomes were poor functional outcomes (modified Rankin Scale score of 3–6) at discharge and 90 days. Multivariable logistic regression and stratified analyses were performed to explore the association of stress hyperglycemia with poor prognosis of ICH.

Results

On multivariable analysis, higher glucose-to-HbA1c ratio (≥1.02) was independently correlated with poor functional outcomes at discharge (adjusted OR = 3.52, 95%CI: 1.98–6.23) and 90 days (adjusted OR = 2.27, 95%CI: 1.38–3.73) after adjusting for potential confounding factors. The correlation between glucose-to-HbA1c ratio and worse functional outcomes still retained in patients with or without diabetes mellitus.

Conclusions

Stress hyperglycemia, calculated by glucose-to-HbA1c ratio, was independently correlated with worse functional outcomes at discharge and 90 days in patients with ICH. Moreover, glucose-to-HbA1c ratio, might not only be used as a simple and readily available index to predict clinical outcomes of ICH but also provide meaningful insight into future analysis to investigate the optimal range of glucose levels among ICH patients and develop tailored glucose-lowering strategies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02760-9.

Ethnic differences in cardiovascular risk: examining differential exposure and susceptibility to risk factors

BACKGROUND

Ethnic differences in cardiovascular disease (CVD) risk have been known for decades, but a systematic exploration of how exposure and susceptibility to risk factors may contribute is lacking. This study aimed to investigate the potential impact of differential exposure and susceptibility between South Asian, Black, and White individuals.

METHODS

This is a population-based prospective cohort study of UK Biobank participants with a median follow-up of 11.3 years. The association between ethnic group and CVD risk was studied. Additional risk factors were then adjusted to examine mediations. Moderation analysis was conducted to identify whether risk factors had a stronger association in the ethnic minority groups. Population attributable fractions were also calculated to quantify the relative contributions of risk factors for each ethnic group.

RESULTS

When adjusted for only age and sex, there was a higher risk of CVD among South Asian (n=8815; HR [95% CI] 1.69 [1.59-1.79]) and Black (n=7526; HR [95% CI] 1.12 [1.03-1.22]) compared with White participants (n=434,809). The excess risk of Black participants was completely attenuated following adjustment for deprivation. Compared with White participants, the associations of BMI, triglycerides, and HbA1c with CVD were stronger in South Asians. Adiposity was attributable to the highest proportion of CVD regardless of ethnicity. Smoking had the second largest contribution to CVD among White and Black participants, and HbA1c among South Asian participants.

CONCLUSIONS

Adiposity is an important risk factor for CVD regardless of ethnicity. Ethnic inequalities in CVD incidence may be best tackled by targeting interventions according to ethnic differences in risk profiles.

Impact of preprocedural biological markers on 10-year mortality in the SYNTAXES trial

BACKGROUND

Creatinine clearance (CrCl) is an independent determinant of mortality in predictive models of revascularisation outcomes for complex coronary artery disease.

AIMS

This study aimed to investigate the impact of preprocedural biological markers on 10-year mortality following coronary revascularisation.

METHODS

The SYNTAX Extended Survival (SYNTAXES) study evaluated the 10-year vital status follow-up of 1,800 patients with de novo three-vessel (3VD) and/or left main coronary artery disease (LMCAD) randomised to include percutaneous or surgical coronary revascularisation. The associations between mortality and preprocedural C-reactive protein (CRP), haemoglobin, HbA1c, CrCl, fasting triglycerides, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol were analysed.

RESULTS

Out of 1,800 patients, 460 patients died before the 10-year follow-up. CRP, HbA1c and CrCl with threshold values of ≥2 mg/L, ≥6% (42 mmol/mol) and <60 ml/min, respectively, were associated with 10-year all-cause death (adjusted hazard ratio [95% confidence interval]: 1.35 [1.01-1.82], 1.51 [1.16-1.95], and 1.46 [1.07-2.00], respectively). There was no significant interaction between the biological markers on all-cause mortality and the type of revascularisation. Preprocedural lipid markers were not significantly associated with 10-year all-cause death, but the non-use of statins was a determinant factor of worse prognosis (adjusted hazard ratio [95% confidence interval]: 1.68 [1.26-2.25]).

CONCLUSIONS

Preprocedural biomarkers, such as CRP and HbA1c, are associated with long-term mortality post revascularisation, regardless of the revascularisation technique. Conventional lipidic biomarkers associated with high-risk of cardiovascular events seem to be effectively mitigated by the long-term use of statins, whereas the non-use of statins was a factor of a worse prognosis, emphasising the importance of pharmacological treatment.

TRIAL REGISTRATION

SYNTAXES ClinicalTrials.gov: NCT03417050. SYNTAX ClinicalTrials.gov: NCT00114972.

Causal Association of Type 2 Diabetes Mellitus and Glycemic Traits With Cardiovascular Diseases and Lipid Traits: A Mendelian Randomization Study

Objective

We aimed to evaluate the causal effect of type 2 diabetes mellitus (T2DM) and glycemic traits on the risk of a wide range of cardiovascular diseases (CVDs) and lipid traits using Mendelian randomization (MR).

Methods

Genetic variants associated with T2DM, fasting glucose, fasting insulin, and hemoglobin A1c were selected as instrumental variables to perform both univariable and multivariable MR analyses.

Results

In univariable MR, genetically predicted T2DM was associated with higher odds of peripheral artery disease (pooled odds ratio (OR) =1.207, 95% CI: 1.162-1.254), myocardial infarction (OR =1.132, 95% CI: 1.104-1.160), ischemic heart disease (OR =1.129, 95% CI: 1.105-1.154), heart failure (OR =1.050, 95% CI: 1.029-1.072), stroke (OR =1.087, 95% CI: 1.068-1.107), ischemic stroke (OR =1.080, 95% CI: 1.059-1.102), essential hypertension (OR =1.013, 95% CI: 1.010-1.015), coronary atherosclerosis (OR =1.005, 95% CI: 1.004-1.007), and major coronary heart disease event (OR =1.003, 95% CI: 1.002-1.004). Additionally, T2DM was causally related to lower levels of high-density lipoprotein cholesterol (OR =0.965, 95% CI: 0.958-0.973) and apolipoprotein A (OR =0.982, 95% CI: 0.977-0.987) but a higher level of triglycerides (OR =1.060, 95% CI: 1.036-1.084). Moreover, causal effect of glycemic traits on CVDs and lipid traits were also observed. Finally, most results of univariable MR were supported by multivariable MR.

Conclusion

We provided evidence for the causal effects of T2DM and glycemic traits on the risk of CVDs and dyslipidemia. Further investigations to elucidate the underlying mechanisms are warranted.

Glycated Hemoglobin as an Integrator of Cardiovascular Risk in Individuals Without Diabetes: Lessons from Recent Epidemiologic Studies

PURPOSE OF REVIEW

Prediabetes, or dysglycemia in the absence of diabetes, is a prevalent condition typically defined by a glycated hemoglobin (HgbA1c) of 5.7- < 6.5%. This article reviews current contemporary data examining the association between prediabetes and cardiovascular disease (CVD) as well as HgbA1c as a continuous measure of cardiovascular risk across the glycemic spectrum.

RECENT FINDINGS

Dysglycemia in the prediabetic range is associated with an increased risk of both subclinical and clinical CVD, including atherosclerotic CVD, chronic kidney disease, and heart failure. Several recent large, prospective studies demonstrate roughly linear risk with increasing HgbA1c, even below the threshold for prediabetes. "High-risk" patients with prediabetes have similar CVD risk as those with diabetes. HgbA1c below the threshold for diabetes stratifies CVD risk. Use of HgbA1c as a continuous measure, rather than simply dichotomized, may inform current and future prevention strategies. Given the high population attributable risk associated with prediabetes, targeted prevention strategies in this population warrant dedicated study.

Historical review of the diagnosis of prediabetes/intermediate hyperglycemia: Case for the international criteria

In 1997, the ADA recommended an IFG criterion for diagnosing prediabetes/intermediate hyperglycemia of FPG concentrations of 6.1-6.9 mmol/L (110-125 mg/dL). In 2003, they lowered it to 5.6-6.9 mmol/L (100-125 mg/dL) to equalize developing diabetes between IGT and IFG. International organizations accepted the first IFG criterion but not the second. The ADA subsequently recommended HbA1c levels for diagnosing prediabetes/intermediate hyperglycemia of 39-47 mmol/mol (5.7-6.4%) based on a model that utilized the composite risk of developing diabetes and CVD. However, the evidence that the intermediate hyperglycemia that defines prediabetes is independently associated with CVD is weak. Rather, the other risk factors for CVD in the metabolic syndrome are responsible. The WHO opined that prediabetes/intermediate hyperglycemia could not be diagnosed by HbA1c levels but the Canadians and Europeans recommended its diagnosis by values of 42-47 mmol/mol (6.0-6.4%). With the ADA criteria, approximately one-half of people are normal on re-testing, one-third spontaneously revert to normal over time and two-thirds never develop diabetes in their lifetimes. The international criteria for prediabetes/intermediate hyperglycemia increase the risk of developing diabetes and might motivate these individuals to more seriously undertake lifestyle interventions as a preventive measure.

Preconception hemoglobin A1c in healthy women is not associated with fecundability or pregnancy loss

Objective

To examine the relationship of preconception hemoglobin A1c, a marker of cumulative exposure to glucose over the preceding 2–3 months, with time to pregnancy, pregnancy loss, and live birth among fecund women without diagnosed diabetes or other medical diseases.

Design

A secondary analysis of a prospective cohort of women participating in the Effects of Aspirin in Gestation and Reproduction (EAGeR) trial.

Setting

Four US academic medical centers.

Patient(s)

A total of 1,194 healthy women aged 18–40 years with a history of one or two pregnancy losses attempting spontaneous conception were observed for up to six cycles while attempting pregnancy and throughout pregnancy if they conceived.

Intervention(s)

Not applicable.

Main Outcome Measure(s)

Time to pregnancy, human chorionic gonadotropin pregnancy, clinical pregnancy, pregnancy loss, and live birth.

Result(s)

Although increasing preconception A1c level was associated with reduced fecundability (fecundability odds ratio [FOR] per unit increase in A1c 0.74; 95% confidence interval [CI] 0.57, 0.96) in unadjusted models and models adjusted for age, race, smoking and treatment arm (FOR 0.79; 95% CI 0.60, 1.04), results were attenuated after further adjustment for body mass index (FOR 0.91; 95% CI 0.68, 1.21). Preconception A1c levels among women without diagnosed diabetes were not associated with live birth or pregnancy loss.

Conclusions(s)

Among healthy women without diagnosed diabetes, we observed no association of A1c with live birth or pregnancy loss. The association between A1c and fecundability was influenced by body mass index, a strong risk factor for both diabetes and infertility. These data support current recommendations that preconception A1c screening should be reserved for patients with risk factors for diabetes.

Clinical Trial Registration Number

ClinicalTrials.gov: NCT00467363.

Effects of aerobic training and resistance training in reducing cardiovascular disease risk for patients with prediabetes: A multi-center randomized controlled trial

AIMS

Aerobic training (AT) and resistance training (RT) can reduce blood glucose and type 2 diabetes risk, and increase muscle mass for prediabetes patients. However, the impact of long-term AT and RT on cardiovascular disease (CVD) risk remains unclear. The purpose of this study was to investigate the impact of AT and RT on CVD risk reduction in prediabetes patients.

MATERIALS AND METHODS

248 prediabetes patients were enrolled in this multi-center randomized controlled trial (RCT). Patients were randomly divided into 3 groups: RT (n = 82), aerobic training (AT (n = 83)), and control group (n = 83). Participants in RT and AT groups had moderate RT or AT 3 times a week (150 min/week) under supervision in 3 research centers for 24 months. Primary outcome was CVD risk measured by Framingham Risk Score (FRS) and The Chinese 10-year ischemic cardiovascular disease (ICVD) risk assessment tool. Secondary outcomes included in HOMA2-IR, HbA1c, blood pressure and serum lipid profile.

RESULTS

Both RT and AT groups experienced a significant reduction in HOMA2-IR, HbA1c, LDL-C, TC, SBP, and DBP at the end of 12 and 24 months. Compared to the control group, Both RT and AT groups had significant reduction of the Chinese 10-year ICVD risk (P < 0.05), but FRS CVD risk declined significantly only in the AT group (all P < 0.05). Although FRS CVD risk decreased more in the RT group than in the control group, the difference was not statistically significant. After adjusting for age, gender, statin use, BMI, and WHR, in COX's proportional hazard model, RT (HR = 0.419, P = 0.037) and AT (HR = 0.310, P = 0.026) were protective factors for CVD risk in prediabetes patients. 24-month RT and AT decreased respectively 58.1% and 69.0% of CVD risk (10-year ICVD risk assessment) in prediabetes patients.

CONCLUSIONS

This study demonstrated that 24-month moderate AT reduces the Chinese 10-year ICVD risk and FRS CVD risk in prediabetes patients. RT groups had significant reduction of CVD risk (10-year ICVD risk assessment) in prediabetes patients.

TRIAL REGISTRATION

Clinical trial registration number: NCT02561377.

DATE OF REGISTRATION

24/09/2015.

Prediabetes Defined by First Measured HbA1c Predicts Higher Cardiovascular Risk Compared With HbA1c in the Diabetes Range: A Cohort Study of Nationwide Registries

OBJECTIVE

To assess the risk of major adverse cardiovascular events (MACE), all-cause mortality, and initiation of medical treatment in subjects with prediabetes according to first-time measured HbA_1c.

RESEARCH DESIGN AND METHODS

Through registry databases, we identified 326,305 Danish patients with a first HbA_1c between 40 and 51 mmol/mol (5.8-6.8%) from 2011 to 2017. After exclusion of patients with prior disease, 84,678 patients were followed 12 months after first HbA_1c measurement. Cox regression models were used to estimate hazard ratios (HRs) of MACE and standardized absolute risks. Cumulative incidences were used to analyze initiation of glucose-lowering, antihypertensive, cholesterol-lowering, and antithrombotic medication.

RESULTS

The 12-month risk of MACE and all-cause mortality increased gradually with increasing HbA_1c until 47 mmol/mol (6.5%). In comparisons of subjects with HbA_1c 40-41 mmol/mol (5.8-5.9%), subjects with HbA_1c 46-47 mmol/mol (6.4-6.5%) had a 0.79% (95% CI 0.33-1.24) higher standardized absolute risk and an HR of 2.21 (95% CI 1.67-2.92) of MACE. Patients with HbA_1c 48-49 mmol/mol (6.5-6.6%) had a 0.09% (95% CI -0.35 to 0.52) lower absolute risk and an HR of 1.33 (95% CI 0.87-2.05) of MACE. Initiation of medication was significantly lower among patients with HbA_1c of 46-47 mmol/mol (6.4-6.5%) than among patients with HbA_1c of 48-49 mmol/mol (6.5-6.6%).

CONCLUSIONS

In the Danish population screened for diabetes with HbA_1c, the highest risk of MACE and all-cause mortality was found in subjects with HbA_1c just below the diagnostic threshold for diabetes. Our results highlight the need for increased focus on the treatment of cardiovascular risk factors for subjects with prediabetes.