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. 2025 May 16;20(5):e0322502.
doi: 10.1371/journal.pone.0322502. eCollection 2025.

Incidence and predictors of cardiovascular disease mortality and all-cause mortality in patients with type II diabetes with peripheral arterial disease

Amaraporn Rerkasem  1   2 , Ampica Mangklabruks  3 , Supawan Buranapin  3 , Kiran Sony  4 , Nimit Inpankaew  5 , Rath Rerkasem  6 , Sasinat Pongtam  1 , Kochaphan Phirom  1 , Kittipan Rerkasem  1   7
Affiliations

Incidence and predictors of cardiovascular disease mortality and all-cause mortality in patients with type II diabetes with peripheral arterial disease

Amaraporn Rerkasem et al. PLoS One. .

Abstract

Objective: This cohort study estimated the incidence and predictors of cardiovascular disease (CVD) and all-cause mortality among patients with type 2 diabetes mellitus (T2DM) and various stages of peripheral arterial disease (PAD) at the largest tertiary referral hospitals in upper-northern Thailand.

Methods: This study recruited 278 T2DM and PAD patients for a 7-year cohort study. These patients completed health questionnaires and underwent physical examinations including ankle-brachial index measurements and clinical assessment to determine PAD severity. Mortality endpoints were determined using hospital death registers and national death records. The Cox proportional hazards and subdistribution hazard models were used to estimate PAD's effect on mortality, quantifying the association with hazard ratios (HR) and subdistribution hazard ratios (SHR).

Results: PAD patients were categorized into three subgroups. Over seven years, the cumulative all-cause mortality rate was 36%, or 6.4 deaths per 100 person-years. Multivariable analysis revealed critical limb ischemia (CLI) patients had significantly higher risks of all-cause (HR 5.26, 95%CI 3.10-8.94) and CVD mortality (SHR 6.20, 95%CI 3.20-12.03) compared to their asymptomatic peers. No statistically significant differences in non-CVD mortality were noted across PAD subgroups.

Conclusion: CLI, chronic kidney disease, and underweight (body mass index < 18.5 kg/m2) emerged as independent mortality predictors. Conversely, asymptomatic PAD patients had a similar overall mortality risk as those with intermittent claudication. These findings highlight the need for risk stratification and patient empowerment to optimize management of these complex conditions.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. CVD and non-CVD mortality by year of follow-up.
Numbers in bars indicate the number of deaths.
Fig 2
Fig 2. Kaplan-Meier failure curve shows the cumulative probability for all-cause mortality for participants with T2DM and PAD, stratified by PAD severity at baseline.
Patients with CLI had higher mortality rate than the asymptomatic group (p < .001) but marginally higher for patients with IC (p = .069). A slightly higher rate of dying during follow-up for those patients with IC compared to those with asymptomatic PAD was observed (p = .052).
Fig 3
Fig 3. Competing risk curves depict the cumulative probability of time to death for participants with T2DM and PAD stratified by PAD severity.
(A) The left panel shows the probabilities of CVD mortality. Patients with CLI had the highest event rates compared to the other groups (p < .05). However, the rate of CVD mortality did not significantly differ between those with IC and asymptomatic PAD (p = .37). (B) The right panel shows the competing risk event, i.e., other causes of death occurring before the CVD mortality. There was no significant difference in the non-CVD mortality rates among the three groups of participants.
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