THE BIG IDEA: UNCOVERED

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The Impact of Site and Extent of Vascular
Disease on New Vascular Events in Type 2
Diabetes PatientsP.M. Gorter, F. L. J.
Visseren, A. Algra, Y. van der Graaf
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Type 2 Diabetes and Risk of Vascular Events

• Elevated risk
• Type 2 diabetes (DM2) patients
• 2- to 3-fold increased cardiovascular risk
• High risk
• DM2 a CHD risk equivalent?
• Very high risk
• DM2 and vascular disease

Haffner, N Engl J Med. 1998
Grundy, Circulation 2004
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Risk Gradation in DM2 Patients
N4,549
10-yr cumulative incidence
Howard, et al. Diabetes Care 2006
Howard, et al. Diabetes Care 2006
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DM2 Patients and Risk of Vascular Events

• DM2 patients with prior MI
• Excess cardiovascular risk
• DM2 patients with other vascular diseases
• Comparable risk?
• Not clear whether the extent of prior vascular
  disease
• contribute to a risk gradation

Lotufo, Arch Intern Med. 2001
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Research Questions

• 1. To quantify and compare the effect of the site
  of
• clinically evident vascular disease on
  the risk of
• new vascular events in patients with
  type 2 diabetes
• 2. To determine the impact of the number of sites
  clinically affected by vascular disease and the
  influence of the extent of atherosclerotic burden
  on the risk of new events in patients with type 2
  diabetes

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Methods

• SMART Study
• Referred for DM2, Hyperlipidemia,
  Hypertension,
• Manifest Vascular Disease
• Prospective cohort study
• Type 2 diabetes patients (DM2) (n776)
• Type 2 diabetes was ascertained by inclusion
  diagnosis
• or medical history (use of glucose-lowering
  medications)

Coronary heart disease Cerebrovascular
disease Peripheral arterial disease Abdominal
aortic aneurysm
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Study Population
Included with risk factor vascular history
before entering the study (n97)
Included with CVD (n106)
Included with CHD (n138)
Included with PAD (n117)
Clinically evident vascular disease (n458)
Vascular disease at 1 site (n351)
DM2 n776
Vascular disease at 2 sites (n107)
No clinically evident vascular disease (n318)
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Methods
PAD
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Methods

• Kaplan-Meier Survival Analysis
• Cox Proportional Hazard Models
• Outcome
• First fatal or nonfatal vascular event
• Ischemic stroke
• Myocardial infarction
• Cardiovascular death
• Carotid intima-media thickness and
• albuminuria were used as markers
• for atherosclerotic burden

CVD
CHD
PAD
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Methods
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DM2 patients, according to Site of previous
vascular disease
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DM2 patients, according to Extent of previous
vascular disease
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Results

• Median follow-up 2.9 years 2631 person- years
• First cardiovascular events 87
• 37 cardiovascular death
• 19 ischemic stroke
• 31 MI
• 
  

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Site and Extent of previous vascular disease and
new vascular events
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Extent of previous vascular disease and new
vascular events in DM2 patients
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Extensive previous vascular disease is
associated with increased cardiovascular risk
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Conclusions

• 1. Patients with type 2 diabetes and CVD, CHD
  or PAD
• had a similar 3 to 4-fold higher risk of
  new vascular events compared with patients with
  diabetes without vascular disease
• 2. Patients with diabetes and clinically
  evident vascular disease at two or more sites had
  a 6-fold higher risk of new events than those
  without vascular disease
• 3. This risk was not influenced by the extent of
  atherosclerotic burden

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Potential Clinical Implications

• Data may contribute to the identification of DM2
  patients at the highest risk of developing new
  cardiovascular events
• Benefit the most from aggressive preventive risk
  factor management?

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