Type 2 diabetes and incidence of cardiovascular diseases: a cohort study in 1·9 million people

Abstract

Background: The contemporary associations of type 2 diabetes with a wide range of incident cardiovascular diseases have not been compared. We aimed to study associations between type 2 diabetes and 12 initial manifestations of cardiovascular disease.

Methods: We used linked primary care, hospital admission, disease registry, and death certificate records from the CALIBER programme, which links data for people in England recorded in four electronic health data sources. We included people who were (or turned) 30 years or older between Jan 1, 1998, to March 25, 2010, who were free from cardiovascular disease at baseline. The primary endpoint was the first record of one of 12 cardiovascular presentations in any of the data sources. We compared cumulative incidence curves for the initial presentation of cardiovascular disease and used Cox models to estimate cause-specific hazard ratios (HRs). This study is registered at ClinicalTrials.gov (NCT01804439).

Findings: Our cohort consisted of 1 921 260 individuals, of whom 1 887 062 (98·2%) did not have diabetes and 34 198 (1·8%) had type 2 diabetes. We observed 113 638 first presentations of cardiovascular disease during a median follow-up of 5·5 years (IQR 2·1-10·1). Of people with type 2 diabetes, 6137 (17·9%) had a first cardiovascular presentation, the most common of which were peripheral arterial disease (reported in 992 [16·2%] of 6137 patients) and heart failure (866 [14·1%] of 6137 patients). Type 2 diabetes was positively associated with peripheral arterial disease (adjusted HR 2·98 [95% CI 2·76-3·22]), ischaemic stroke (1·72 [1·52-1·95]), stable angina (1·62 [1·49-1·77]), heart failure (1·56 [1·45-1·69]), and non-fatal myocardial infarction (1·54 [1·42-1·67]), but was inversely associated with abdominal aortic aneurysm (0·46 [0·35-0·59]) and subarachnoid haemorrhage (0·48 [0·26-0.89]), and not associated with arrhythmia or sudden cardiac death (0·95 [0·76-1·19]).

Interpretation: Heart failure and peripheral arterial disease are the most common initial manifestations of cardiovascular disease in type 2 diabetes. The differences between relative risks of different cardiovascular diseases in patients with type 2 diabetes have implications for clinical risk assessment and trial design.

Funding: Wellcome Trust, National Institute for Health Research, and Medical Research Council.

Figure 1

Distribution of initial presentations of cardiovascular diseases Distribution of initial presentations of cardiovascular disease in participants with and without type 2 diabetes and no history of cardiovascular disease.

Figure 2

Cumulative incidence curves for the incidence of first presentation of 12 cardiovascular diseases in patients aged ≥40 years, by diabetes status The curves begin at age 40 years rather than 30 years because 40 years is a typical age for a patient to develop type 2 diabetes.

Figure 3

Association of type 2 diabetes with 12 cardiovascular diseases in patients aged ≥30 years Adjusted hazard ratios (HRs) for different initial presentations of cardiovascular diseases associated with type 2 diabetes, adjusted for age, sex, BMI, deprivation, HDL cholesterol, total cholesterol, systolic blood pressure, smoking status, and statin and antihypertensive drug prescriptions. Two non-specific components of the primary endpoint are not shown in the figure for simplicity (they are inprecisely recorded versions of one of the 12 initial presentations): coronary disease not further specified, HR 1·58 (95% CI 1·45–1·73), p<0·0001; stroke not further specified 1·64 (1·48–1·81), p<0·0001.

Figure 4

Hazard ratios for association of type 2 diabetes with 12 cardiovascular diseases by sex and age Hazard ratios by sex and age group for the association of different initial presentations of cardiovascular disease with type 2 diabetes, adjusted for age, BMI, deprivation, HDL cholesterol, total cholesterol, systolic blood pressure, smoking status, and statin and antihypertensive drug prescriptions. NA=not applicable.