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Diabetes and number of years of life lost with and without cardiovascular disease: a multi-state homogeneous semi-Markov model

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Abstract

Aims

We quantified the impact of type 2 diabetes on incidence of non-fatal cardiovascular disease (CVD) and mortality, considering CVD as a continuum from occurrence of diabetes to the end point, and estimated the 15-year life expectancy with and without CVD.

Methods

A total of 7239 Iranian adults (3246 men), aged ≥ 30 years, were followed from 1999 to 2014. We applied a multi-state semi-Markov model with three transitions including CVD-free to non-fatal CVD, CVD-free to death and non-fatal CVD to death, and studied the influence of diabetes on each transition rate, stratifying by sex and adjusting for confounders.

Results

Diabetes was significantly associated with increased risk of non-fatal CVD in men [hazard ratio, 1.70 (1.36–3.53)] and women [2.19 (1.74–2.77)], and of all-cause death [2.72 (2.03–3.63) and 1.92 (1.37–2.67) in men and women, respectively]. An increased risk of mortality was found only among diabetic men, when non-fatal CVD was occurred [2.19 (1.36–3.53)]. Men with diabetes experienced first non-fatal CVD and death without CVD 1.7 and 1.4 years, respectively, earlier than those without diabetes; the corresponding values were 1.4 and 0.7 years for women. Moreover, diabetic men lived 1.3 years less than non-diabetic counterparts when non-fatal CVD was occurred.

Conclusions

Diabetes increased the risk of non-fatal CVD events and all-cause mortality and consequently decreased the number of years lived without CVD. A decrease in LE was found only among diabetic men compared to non-diabetics after non-fatal CVD occurred.

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References

  1. Marzona I, Avanzini F, Lucisano G et al (2017) Are all people with diabetes and cardiovascular risk factors or microvascular complications at very high risk? Findings from the Risk and Prevention Study. Acta Diabetol 54(2):123–131

    Article  PubMed  Google Scholar 

  2. Guariguata L, Whiting D, Hambleton I, Beagley J, Linnenkamp U, Shaw J (2014) Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract 103(2):137–149

    Article  CAS  PubMed  Google Scholar 

  3. Derakhshan A, Sardarinia M, Khalili D, Momenan AA, Azizi F, Hadaegh F (2014) Sex specific incidence rates of type 2 diabetes and its risk factors over 9 years of follow-up: Tehran Lipid and Glucose Study. PLoS ONE 9(7):e102563

    Article  PubMed  PubMed Central  Google Scholar 

  4. Barutta F, Bruno G, Matullo G et al (2017) MicroRNA-126 and micro-/macrovascular complications of type 1 diabetes in the EURODIAB Prospective Complications Study. Acta Diabetol 54(2):133–139

    Article  CAS  PubMed  Google Scholar 

  5. Anjana RM, Shanthirani CS, Unnikrishnan R et al (2015) Regularity of follow-up, glycemic burden, and risk of microvascular complications in patients with type 2 diabetes: a 9-year follow-up study. Acta Diabetol 52(3):601–609

    Article  CAS  PubMed  Google Scholar 

  6. Tadic M, Cuspidi C, Vukomanovic V et al (2016) The influence of type 2 diabetes and arterial hypertension on right ventricular layer-specific mechanics. Acta Diabetol 53(5):791–797

    Article  CAS  PubMed  Google Scholar 

  7. Mozaffarian (2016) Heart Disease and Stroke Statistics-2016 Update: a Report From the American Heart Association (vol 133, pg e38, 2016). Circulation 133(15):E599–E599

    Article  Google Scholar 

  8. Hudzik B, Szkodziński J, Hawranek M, Lekston A, Poloński L, Gąsior M (2016) CHA2DS2-VASc score is useful in predicting poor 12-month outcomes following myocardial infarction in diabetic patients without atrial fibrillation. Acta Diabetol 53(5):807–815

    Article  PubMed  PubMed Central  Google Scholar 

  9. Patel PA, Cubbon RM, Sapsford RJ et al (2016) An evaluation of 20 year survival in patients with diabetes mellitus and acute myocardial infarction. Int J Cardiol 203:141–144

    Article  PubMed  Google Scholar 

  10. Rousan TA, Pappy RM, Chen AY, Roe MT, Saucedo JF (2014) Impact of diabetes mellitus on clinical characteristics, management, and in-hospital outcomes in patients with acute myocardial infarction (from the NCDR). Am J Cardiol 114(8):1136–1144

    Article  PubMed  Google Scholar 

  11. Tasci I, Basgoz BB, Saglam K (2016) Glycemic control and the risk of microvascular complications in people with diabetes mellitus. Acta Diabetol 53(1):129–130

    Article  PubMed  Google Scholar 

  12. Tancredi M, Rosengren A, Svensson A-M et al (2015) Excess mortality among persons with type 2 diabetes. N Engl J Med 373(18):1720–1732

    Article  CAS  PubMed  Google Scholar 

  13. Sardarinia M, Akbarpour S, Lotfaliany M et al (2016) Risk factors for incidence of cardiovascular diseases and all-cause mortality in a Middle Eastern Population over a decade follow-up: Tehran lipid and glucose study. PLoS ONE 11(12):e0167623

    Article  PubMed  PubMed Central  Google Scholar 

  14. Andersen PK, Keiding N (2002) Multi-state models for event history analysis. Stat Methods Med Res 11(2):91–115

    Article  PubMed  Google Scholar 

  15. Putter H, Fiocco M, Geskus R (2007) Tutorial in biostatistics: competing risks and multi-state models. Stat Med 26(11):2389–2430

    Article  CAS  PubMed  Google Scholar 

  16. Meier-Hirmer C, Schumacher M (2013) Multi-state model for studying an intermediate event using time-dependent covariates: application to breast cancer. BMC Med Res Methodol 13(1):80

    Article  PubMed  PubMed Central  Google Scholar 

  17. Gillam MH, Ryan P, Salter A, Graves SE (2012) Multi-state models and arthroplasty histories after unilateral total hip arthroplasties: introducing the Summary Notation for Arthroplasty Histories. Acta Orthop 83(3):220–226

    Article  PubMed  PubMed Central  Google Scholar 

  18. Eulenburg C, Mahner S, Woelber L, Wegscheider K (2015) A systematic model specification procedure for an illness-death model without recovery. PLoS ONE 10(4):e0123489

    Article  PubMed  PubMed Central  Google Scholar 

  19. Azizi F, Ghanbarian A, Momenan AA et al (2009) Prevention of non-communicable disease in a population in nutrition transition: Tehran lipid and glucose study phase II. Trials 10(1):5

    Article  PubMed  PubMed Central  Google Scholar 

  20. Delshad M, Sarbazi N, Rezaei_Ghaleh N, Ghanbarian A, Azizi F (2012) Reliability and validity of the Modifiable Activity Questionnaire (MAQ) in an Iranian urban adult population. Arch Iran Med 15(5):279

    PubMed  Google Scholar 

  21. Afsharian S, Akbarpour S, Abdi H et al (2016) Risk factors for cardiovascular disease and mortality events in adults with type 2 diabetes-a 10-year follow-up: Tehran Lipid and Glucose Study. Diabetes Metab Res Rev 32(6):596–606

    Article  CAS  PubMed  Google Scholar 

  22. Franco OH, Steyerberg EW, Hu FB, Mackenbach J, Nusselder W (2007) Associations of diabetes mellitus with total life expectancy and life expectancy with and without cardiovascular disease. Arch Intern Med 167(11):1145–1151

    Article  PubMed  Google Scholar 

  23. Committee IR (2005) Guidelines for data processing and analysis of the International Physical Activity Questionnaire (IPAQ)–short and long forms. Retrieved September 17:2008

  24. Royston P, Parmar MK (2011) The use of restricted mean survival time to estimate the treatment effect in randomized clinical trials when the proportional hazards assumption is in doubt. Stat Med 30(19):2409–2421

    Article  PubMed  Google Scholar 

  25. Royston P, Parmar MK (2013) Restricted mean survival time: an alternative to the hazard ratio for the design and analysis of randomized trials with a time-to-event outcome. BMC Med Res Methodol 13(1):152

    Article  PubMed  PubMed Central  Google Scholar 

  26. Uno H, Claggett B, Tian L et al (2014) Moving beyond the hazard ratio in quantifying the between-group difference in survival analysis. J Clin Oncol 32(22):2380–2385

    Article  PubMed  PubMed Central  Google Scholar 

  27. Klein JP, Gerster M, Andersen PK, Tarima S, Perme MP (2008) SAS and R functions to compute pseudo-values for censored data regression. Comput Methods Programs Biomed 89(3):289–300

    Article  PubMed  PubMed Central  Google Scholar 

  28. De Wreede LC, Fiocco M, Putter H (2010) The mstate package for estimation and prediction in non-and semi-parametric multi-state and competing risks models. Comput Methods Progr Biomed 99(3):261–274

    Article  Google Scholar 

  29. Spencer EA, Pirie KL, Stevens RJ et al (2008) Diabetes and modifiable risk factors for cardiovascular disease: the prospective Million Women Study. Eur J Epidemiol 23(12):793

    Article  PubMed  Google Scholar 

  30. Schramm TK, Gislason GH, Køber L et al (2008) Diabetes patients requiring glucose-lowering therapy and nondiabetics with a prior myocardial infarction carry the same cardiovascular risk. Circulation 117(15):1945–1954

    Article  CAS  PubMed  Google Scholar 

  31. Janghorbani M, Hu FB, Willett WC et al (2007) Prospective study of type 1 and type 2 diabetes and risk of stroke subtypes. Diabetes Care 30(7):1730–1735

    Article  PubMed  Google Scholar 

  32. Collaboration ERF (2010) Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet 375(9733):2215–2222

    Article  Google Scholar 

  33. Helfand M, Buckley DI, Freeman M et al (2009) Emerging risk factors for coronary heart disease: a summary of systematic reviews conducted for the US Preventive Services Task Force. Ann Intern Med 151(7):496–507

    Article  PubMed  Google Scholar 

  34. Control CfD, Prevention (2011) National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention 201 (1)

  35. Collaboration ERF (2011) Diabetes mellitus, fasting glucose, and risk of cause-specific death. N Engl J Med 2011(364):829–841

    Article  Google Scholar 

  36. Osterberg L, Blaschke T (2005) Adherence to medication. N Engl J Med 353(5):487–497

    Article  CAS  PubMed  Google Scholar 

  37. Naderi SH, Bestwick JP, Wald DS (2012) Adherence to drugs that prevent cardiovascular disease: meta-analysis on 376,162 patients. Am J Med 125(9):882–887

    Article  PubMed  Google Scholar 

  38. Poulsen MK, Henriksen JE, Dahl J et al (2009) Myocardial ischemia, carotid, and peripheral arterial disease and their interrelationship in type 2 diabetes patients. J Nucl Cardiol 16(6):878–887

    Article  PubMed  Google Scholar 

  39. Farhan S, Baber U, Vogel B et al (2017) Impact of diabetes mellitus on ischemic events in men and women after percutaneous coronary intervention. Am J Cardiol 119(8):1166–1172

    Article  PubMed  Google Scholar 

  40. Kim BJ, Lee S-H, Kim CK et al (2011) Advanced coronary artery calcification and cerebral small vessel diseases in the healthy elderly. Circ J 75(2):451–456

    Article  PubMed  Google Scholar 

  41. Gu K, Cowie CC, Harris MI (1998) Mortality in adults with and without diabetes in a national cohort of the US population, 1971–1993. Diabetes Care 21(7):1138–1145

    Article  CAS  PubMed  Google Scholar 

  42. Narayan KV, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF (2003) Lifetime risk for diabetes mellitus in the United States. JAMA 290(14):1884–1890

    Article  CAS  PubMed  Google Scholar 

  43. Salomon JA, Wang H, Freeman MK et al (2013) Healthy life expectancy for 187 countries, 1990–2010: a systematic analysis for the Global Burden Disease Study 2010. Lancet 380(9859):2144–2162

    Article  Google Scholar 

  44. Leening MJ, Ferket BS, Steyerberg EW et al (2014) Sex differences in lifetime risk and first manifestation of cardiovascular disease: prospective population based cohort study. BMJ 349:g5992

    Article  PubMed  PubMed Central  Google Scholar 

  45. Tang W, Tu XM (2013) Modern clinical trial analysis. Springer, Berlin

    Book  Google Scholar 

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Acknowledgements

The authors wish to acknowledge Ms Niloofar Shiva for critical editing of English grammar and syntax of the manuscript. The authors also wish to thank Dr Hajime Uno from Harvard Medical School, who introduced the correct methods for estimating the restricted mean survival time.

Funding

This study was supported by Grant No. 121 from the National Research Council of the Islamic Republic of Iran.

Author information

Authors and Affiliations

  1. Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Floor 3th, Number 24, Yemen Street, Shahid Chamran Highway, P.O. Box: 19395-4763, Tehran, Iran

    Azra Ramezankhani, Farzad Hadaegh & Amir Abbas Momenan

  2. Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran

    Fereidoun Azizi

Authors
  1. Azra Ramezankhani
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  2. Fereidoun Azizi
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  3. Farzad Hadaegh
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  4. Amir Abbas Momenan
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Corresponding author

Correspondence to Farzad Hadaegh.

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Conflicts of interest

None.

Ethical approval

This study was approved by the ethics committee of the Research Institute for Endocrine Sciences of the Shahid Beheshti University of Medical Sciences according to the principles of the Declaration of Helsinki.

Informed consent

All participants were informed of the study protocol, and their written informed consents were obtained before inclusion.

Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Additional information

Managed by Antonio Secchi.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Online Resource 1 Study participants selection, Tehran lipid and glucose study (1999-2014) (PDF 57 kb)

Online Resource 2 Detail of measurement and statistical methods (PDF 92 kb)

592_2017_1083_MOESM3_ESM.pdf

Online Resource 3 Stacked probability transition curves for participants with diabetes (A) and without diabetes (B); the distance between two curves represent the probabilities of the different events (PDF 65 kb)

592_2017_1083_MOESM4_ESM.pdf

Online resource 4 Adjusted restricted mean survival time (RMST) of total population; Tehran Lipid and Glucose Study (1999-2014) (PDF 20 kb)

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Ramezankhani, A., Azizi, F., Hadaegh, F. et al. Diabetes and number of years of life lost with and without cardiovascular disease: a multi-state homogeneous semi-Markov model. Acta Diabetol 55, 253–262 (2018). https://doi.org/10.1007/s00592-017-1083-x

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  • DOI: https://doi.org/10.1007/s00592-017-1083-x

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