ReviewMortality in diabetes compared with previous cardiovascular disease: A gender-specific meta-analysisComparaison du risque de mortalité chez les diabétiques et les patients non-diabétiques avec antécédent de malade cardiovasculaire : méta-analyse selon le sexe
Introduction
Over 10 years ago, Haffner and colleagues [1] reported that mortality in diabetes patients was similar to that of patients with previous myocardial infarction (MI). These findings contributed to the concept of diabetes as a cardiovascular disease (CVD) ‘risk equivalent’ [2], [3], [4], [5], [6], [7], and led to more aggressive risk-management strategies in diabetes patients. This was a welcome development, given that diabetes confers a two- to fourfold risk increase for heart disease and stroke [8]. CVD prevention requires careful attention to physical-activity levels, dietary intake and appropriate use of cardioprotective medications [9].
However, diabetes may not only be a CVD risk equivalent in women, but may actually confer greater risk: in an updated analysis of the cohort examined by Haffner and colleagues [10], women with diabetes had higher rates of mortality than women with previous CVD. Although not all other investigators have identified such a gender difference, the updated analysis was consistent with studies suggesting that the relative risk increase for acute MI with diabetes is higher in women than in men [11], [12].
A relatively higher mortality for women with diabetes compared with those with prior CVD would suggest inadequate attention to CVD prevention in women with diabetes. While, a study using Framingham data reported declining mortality rates for both women and men with diabetes [13], an analysis of the US National Health and Nutrition Examination Survey (NHANES) data demonstrated declines in all-cause mortality over time for men with diabetes, but not for women [14]. Thus, the latter has highlighted a need to carefully examine gender differences in the effects of diabetes on mortality towards the goal of establishing appropriate preventative strategies in both women and men.
For this reason and returning specifically to the question of gender-specific differences in the context of diabetes and CVD ‘equivalence’, the present study has examined the totality of evidence through a systematic review and meta-analysis aiming to obtain gender-specific hazard ratios (HRs) by comparing diabetes and CVD patients in terms of all-cause, CVD and coronary heart disease (CHD) mortality.
Section snippets
Study selection
For our review, observational studies were identified that prospectively examined the mortality rates in individuals with diabetes, but without a prior history of CVD, that were compared directly with mortality in individuals with CVD, but without a previous history of diabetes. Our study also required that outcomes (such as all-cause, CVD and/or CHD mortality) be reported separately for women and/or men.
Literature search
Searches were performed (C.L.) with a medical librarian's assistance (A.C.), using three
Trial flow/flow of included studies
Nine studies were examined in detail and included (Fig. 1, Table 1). The PubMed search for previous meta-analyses assessing CVD risk in the context of type 2 diabetes or previous CVD generated 191 titles, among which one was deemed potentially relevant [16]. An updated search (August 1, 2009 to December 13, 2009) did not result in any additional primary research studies for inclusion, but did identify a second potentially relevant meta-analysis [17].
Previous meta-analyses
One previous meta-analysis [16] was published
Discussion
The present findings confirm that, in men, CVD and CHD mortality is lower with diabetes alone compared with previous CVD (CVD mortality HR: 0.82, 95% CrI: 0.69–0.98; CHD mortality HR: 0.73, 95% CrI: 0.65–0.83), while the all-cause mortality was similar with diabetes and previous CVD (HR: 1.02, 95% CrI: 0.93–1.12). In women, the paucity of studies has limited firm conclusions, but there is an indication that CVD, CHD and all-cause mortality may be higher with diabetes alone compared with
Disclosure of interest
The authors declare that they have no conflicts of interest concerning this article.
Acknowledgements
We are grateful to Mr Patrick Belisle, MSc, of the Research Institute of the McGill University Health Centre, for performing the statistical programming for the meta-analyses, and to Ms Amanda Wilkins, BSc, BEd, also of the Research Institute of the McGill University Health Centre, for her administrative support.
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