Excess risk of fatal coronary heart disease associated with diabetes in men and women: meta-analysis of 37 prospective cohort studies

Abstract Objective To estimate the relative risk for fatal coronary heart disease associated with diabetes in men and women. Design Meta-analysis of prospective cohort studies. Data sources Studies published between 1966 and March 2005, identified through Embase and Medline, using a combined text word and MESH heading search strategy, in addition to studies from the Asia Pacific Cohort Studies Collaboration. Review methods Studies were eligible if they had reported estimates of the relative risk for fatal coronary heart disease comparing men and women with and without diabetes. Studies were excluded if the estimates were not adjusted at least for age. Results 37 studies of type 2 diabetes and fatal coronary heart disease among a total of 447 064 patients were identified. The rate of fatal coronary heart disease was higher in patients with diabetes than in those without (5.4 v 1.6%). The overall summary relative risk for fatal coronary heart disease in patients with diabetes compared with no diabetes was significantly greater among women than it was among men: 3.50, 95% confidence interval 2.70 to 4.53 v 2.06, 1.81 to 2.34. After exclusion of the eight studies that had adjusted only for age, the difference in risk between the sexes was substantially reduced but still highly significant. The pooled ratio of the relative risks (women: men) from the 29 studies with multiple adjusted estimates was 1.46 (1.14 to 1.88). Conclusions The relative risk for fatal coronary heart disease associated with diabetes is 50% higher in women than it is in men. This greater excess coronary risk may be explained by more adverse cardiovascular risk profiles among women with diabetes, combined with possible disparities in treatment that favour men.

[1]  M. Laakso,et al.  NIDDM and Its Metabolic Control Predict Coronary Heart Disease in Elderly Subjects , 1994, Diabetes.

[2]  B. Zinman,et al.  Impact of diabetes on coronary artery disease in women and men: a meta-analysis of prospective studies. , 2000, Diabetes care.

[3]  T. Orchard.  The impact of gender and general risk factors on the occurrence of atherosclerotic vascular disease in non-insulin-dependent diabetes mellitus. , 1996, Annals of medicine.

[4]  S. Lipsitz,et al.  Sex differences in the effect of diabetes duration on coronary heart disease mortality. , 2005, Archives of internal medicine.

[5]  M. Woodward,et al.  Comparison of the prediction by 27 different factors of coronary heart disease and death in men and women of the Scottish heart health study: cohort study , 1997, BMJ.

[6]  I. Olkin,et al.  Meta-analysis of observational studies in epidemiology - A proposal for reporting , 2000 .

[7]  R J Jarrett,et al.  Mortality from coronary heart disease and stroke in relation to degree of glycaemia: the Whitehall study. , 1983, British medical journal.

[8]  J. Madans,et al.  Mortality among diabetics in a national sample. , 1988, American journal of epidemiology.

[9]  M. Laakso,et al.  Does NIDDM increase the risk for coronary heart disease similarly in both low- and high-risk populations? , 1995, Diabetologia.

[10]  J. Meigs,et al.  Sex disparities in treatment of cardiac risk factors in patients with type 2 diabetes. , 2005, Diabetes care.

[11]  T. Vetter,et al.  Epidemiology: Study Design and Data Analysis , 2000 .

[12]  P. Bennett,et al.  Impact of NIDDM on Mortality and Causes of Death in Pima Indians , 1992, Diabetes Care.

[13]  P. Zimmet,et al.  Non‐insulin‐dependent Diabetes and 11‐Year Mortality in Asian Indian and Melanesian Fijians , 1996, Diabetic medicine : a journal of the British Diabetic Association.

[14]  A. Dyer,et al.  Relationship of clinical diabetes and asymptomatic hyperglycemia to risk of coronary heart disease mortality in men and women. , 1986, American journal of epidemiology.

[15]  S. Yusuf,et al.  Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study , 2004, The Lancet.

[16]  A. Folsom,et al.  A Prospective Study of Coronary Heart Disease in Relation to Fasting Insulin, Glucose, and Diabetes: The Atherosclerosis Risk in Communities (ARIC) Study , 1997, Diabetes Care.

[17]  S. Johansson,et al.  Multivariate analyses of mortality from coronary heart disease due to biological and behavioural factors , 1996, Scandinavian journal of social medicine.

[18]  M. Woodward,et al.  The effects of diabetes on the risks of major cardiovascular diseases and death in the Asia-Pacific region. , 2003, Diabetes care.

[19]  M. Woodward,et al.  The Asia Pacific Cohort Studies Collaboration , 2003 .

[20]  Mark Woodward,et al.  Epidemiology: Study Design and Data Analysis , 1999 .

[21]  Y. Friedlander,et al.  Diabetes, mortality and coronary heart disease in the prospective Dubbo study of Australian elderly. , 1996, Australian and New Zealand journal of medicine.

[22]  E. Vartiainen,et al.  Sex, age, cardiovascular risk factors, and coronary heart disease: a prospective follow-up study of 14 786 middle-aged men and women in Finland. , 1999, Circulation.

[23]  R. Holman,et al.  Changing aspirin use in patients with Type 2 diabetes in the UKPDS , 2004, Diabetic medicine : a journal of the British Diabetic Association.

[24]  E. Barrett-Connor,et al.  Explaining the sex difference in coronary heart disease mortality among patients with type 2 diabetes mellitus: a meta-analysis. , 2002, Archives of internal medicine.

[25]  P. Wilson,et al.  Risk factors that attenuate the female coronary disease advantage. , 1995, Archives of internal medicine.

[26]  W. L. Beeson,et al.  Effects of Traditional Coronary Risk Factors on Rates of Incident Coronary Events in a Low‐Risk Population: The Adventist Health Study , 1992, Circulation.

[27]  L. Berkman,et al.  Risk factors for coronary heart disease among older men and women: a prospective study of community-dwelling elderly. , 1993, American journal of epidemiology.

[28]  E. Barrett-Connor,et al.  Why is diabetes mellitus a stronger risk factor for fatal ischemic heart disease in women than in men? The Rancho Bernardo Study. , 1991, JAMA.

[29]  D T Lackland,et al.  Mortality rates and risk factors for coronary disease in black as compared with white men and women. , 1993, The New England journal of medicine.

[30]  W. Kannel,et al.  Diabetes and cardiovascular disease. The Framingham study. , 1979, JAMA.

[31]  S. Tonstad,et al.  Undertreatment and overtreatment with statins: the Oslo Health Study 2000–2001 , 2004, Journal of internal medicine.

[32]  M. Toyofuku,et al.  Influence of type 2 diabetes mellitus on cardiovascular disease mortality: findings from the Hawaii-Los Angeles-Hiroshima study. , 2002, Diabetes research and clinical practice.

[33]  S Greenland,et al.  Invited commentary: a critical look at some popular meta-analytic methods. , 1994, American journal of epidemiology.

[34]  P. Wahl,et al.  Sex differences in the effect of diabetes mellitus on lipoprotein triglyceride and cholesterol concentrations. , 1984, The New England journal of medicine.

[35]  H. Keen,et al.  Haemostatic variables associated with diabetes and its complications. , 1979, British medical journal.

[36]  M. Egger,et al.  The hazards of scoring the quality of clinical trials for meta-analysis. , 1999, JAMA.

[37]  D. E. Lamphiear,et al.  Mortality from coronary heart disease in the Tecumseh study. Long-term effect of diabetes mellitus, glucose tolerance and other risk factors. , 1985, American journal of epidemiology.

[38]  G. Sigurdsson,et al.  Coronary heart disease mortality amongst non‐insulin‐dependent diabetic subjects in Iceland: the independent effect of diabetes. The Reykjavik Study 17‐year follow up , 1998, Journal of internal medicine.

[39]  G. Heiss,et al.  Sex differences in coronary mortality among diabetics in Evans County, Georgia. , 1980, Journal of chronic diseases.

[40]  E. Barrett-Connor,et al.  Is Insulin Really a Heart Disease Risk Factor? , 1995, Diabetes Care.

[41]  Stephen D. Persell,et al.  Aspirin use among adults with diabetes: recent trends and emerging sex disparities. , 2004, Archives of internal medicine.

[42]  W. Castelli,et al.  Cardiovascular disease in women. , 1988, American journal of obstetrics and gynecology.

[43]  Seppo Lehto,et al.  Gender difference in the impact of type 2 diabetes on coronary heart disease risk. , 2004, Diabetes care.