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Ken Gu, PhD; Catherine C. Cowie, PhD, MPH; Maureen I. Harris, PhD, MPH

JAMA. 1999;281:1291-1297.

ABSTRACT
Context  Mortality from coronary heart disease has declined substantially in the United States during the past 30 years. However, it is unknown whether patients with diabetes have also experienced a decline in heart disease mortality.

Objective  To compare adults with diabetes with those without diabetes for time trends in mortality from all causes, heart disease, and ischemic heart disease.

Design, Setting, and Participants  Representative cohorts of subjects with and without diabetes were derived from the First National Health and Nutrition Examination Survey (NHANES I) conducted between 1971 and 1975 (n=9639) and the NHANES I Epidemiologic Follow-up Survey conducted between 1982 and 1984 (n=8463). The cohorts were followed up prospectively for mortality for an average of 8 to 9 years.

Main Outcome Measure  Changes in mortality rates per 1000 person-years for all causes, heart disease, and ischemic heart disease for the 1982-1984 cohort compared with the 1971-1975 cohort.

Results  For the 2 periods, nondiabetic men experienced a 36.4% decline in age-adjusted heart disease mortality compared with a 13.1% decline for diabetic men. Age-adjusted heart disease mortality declined 27% in nondiabetic women but increased 23% in diabetic women. These patterns were also found for all-cause mortality and ischemic heart disease mortality.

Conclusions  The decline in heart disease mortality in the general US population has been attributed to reduction in cardiovascular risk factors and improvement in treatment of heart disease. The smaller declines in mortality for diabetic subjects in the present study indicate that these changes may have been less effective for people with diabetes, particularly women.

INTRODUCTION

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Mortality from heart disease has declined substantially in the United States during the past 30 years.^1-4 Because heart disease is the major cause of death associated with diabetes,^5-6 it would be expected that the mortality decline in the United States as a whole also would have been experienced by those with diabetes. However, no study has examined whether people with diabetes in the United States have benefited from this general phenomenon and, if so, whether the extent of their mortality rate decline is similar to that of people without diabetes.

To examine these issues, we analyzed mortality in 2 representative national cohorts derived from subjects in the First National Health and Nutrition Examination Survey (NHANES I) of 1971 through 1975 and the NHANES I Epidemiologic Follow-up Survey (NHEFS) of 1982 through 1984. Both cohorts were followed up prospectively for mortality for an average of 8 to 9 years.

METHODS

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NHANES I included a national probability sample of 14,376 persons aged 25 to 74 years who were interviewed for sociodemographic information and history of diabetes. The NHANES I subjects were followed up in 1982-1984, 1986, 1987, and 1992-1993 in the NHEFS. In each follow-up, the subjects (or their proxies) were interviewed again to determine vital status (alive or dead), whether diabetes had been diagnosed, and other information. Follow-up was completed for 96% of subjects.⁵ Two nationally representative cross-sectional samples of adults aged 35 to 74 years were created from these data. Cohort 1 was derived from 10,649 people in NHANES I who were aged 35 to 74 years at the time of their 1971-1975 interview. Cohort 2 was derived from 9233 subjects in NHEFS who were aged 35 to 74 years on the date of the self or proxy interview in 1982-1984.

Cohort 1

Of the 10,649 subjects aged 35 to 74 years in NHANES I, 670 subjects (285 men and 385 women) reported a physician diagnosis of diabetes and were defined as having diabetes. It has previously been demonstrated that a self-report of physician-diagnosed diabetes is accurate and valid.^7-9 Of the 9979 subjects without a history of diabetes, 1110 individuals were excluded from analysis, including 1070 subjects for whom any follow-up interview data indicated that they had been diagnosed as having diabetes and 40 subjects who had diabetes listed on their death certificate. The remaining 8869 subjects (3826 men and 5043 women) were defined as not having diabetes. The follow-up period for cohort 1 was from the date of the 1971-1975 interview to the date of the self or proxy interview in 1982-1984. The mean follow-up was 9.1 years, during which time there were 264 deaths among subjects with diabetes and 1625 deaths among subjects without diabetes.

Cohort 2

Of the 9233 subjects in NHEFS who were aged 35 to 74 years on the date of the self or proxy interview in 1982-1984, there were 637 subjects (233 men and 404 women) with diabetes. This included 271 who had diabetes in the 1971-1975 survey and 366 who did not have diabetes in 1971-1975 but stated in the 1982-1984 interview that they had been diagnosed as having diabetes. Of the remaining 8596 subjects, 770 were excluded from analysis, including 435 subjects who had a diagnosis of diabetes made after the 1982-1984 interview, 10 subjects without diabetes in 1982-1984 who died and had diabetes listed as a cause of death on their death certificate, and 325 subjects with unknown diabetes status. The remaining 7826 subjects (2841 men and 4985 women) were defined as not having diabetes. The follow-up period for cohort 2 was from the date of the 1982-1984 interview to the date of death or the date of the last follow-up interview. The mean follow-up was 8.7 years, during which time there were 184 deaths among subjects with diabetes and 747 deaths among those without diabetes.

Although all cohort 1 and cohort 2 members were part of the NHANES I survey, there was only a 3% to 8% overlap in the 10-year age and diabetes groups used in analysis. The lack of overlap occurred because the beginnings of the cohort observation periods were an average of 9.7 years apart and, thus, most subjects aged 65 to 74 years in cohort 1 were not in cohort 2, most subjects aged 35 to 44 years in cohort 2 were not in cohort 1, and most subjects aged 35 to 64 years in cohort 1 were in an older 10-year age group in cohort 2. In addition, 366 subjects had diabetes in cohort 2 but not in cohort 1.

The type of diabetes in this study could not be determined, but the adult age of the cohorts and the high proportion of type 2 diabetes in the US population with diabetes^10-11 indicate that the cohorts contained type 2 diabetes almost exclusively. Death due to any heart disease or ischemic heart disease was based on the underlying cause of death on the death certificates, which were coded using the International Classification of Diseases, Ninth Revision. Codes used for heart disease were 390-398, 402, 404, 410-417, and 420-429, and for ischemic heart disease, 410-414. Death certificates were obtained for 97.3% of decedents who had had diabetes and 96.5% of decedents who had not had diabetes.

Statistical Analyses

Age-specific mortality rates per 1000 person-years were calculated using the number of deaths as the numerator and total years of follow-up as the denominator for 3 age groups (35-54, 55-64, and 65-74 years) stratified by cohort, diabetes status, and sex. The variance of the person-year rate was estimated by the Chiang method.^12-13 Age-adjusted mortality rates for each cohort stratified by diabetes status and sex were calculated by the direct method, using four 10-year age groups (35-44, 45-54, 55-64, and 65-74 years) and the 1980 US population as the standard. The variance of the age-adjusted rate was calculated by summing the variance of each age-specific rate multiplied by the square of its US population proportion. The percentage difference between cohort 1 and cohort 2 was calculated as the mortality rate in cohort 2 minus the rate in cohort 1, divided by the rate in cohort 1, and multiplied by 100. The variance of the percentage difference was estimated by a Taylor series approximation for estimation of the variance of a ratio from a sample.¹⁴ Variance of the relative risk was computed by the same method.

Covariance due to the small overlap between cohort 1 and cohort 2 was not considered in computing variance estimates because the overlap was only 3% to 8% in the 10-year age and diabetes groups used in analysis, as explained herein. The cohorts were divided into deciles of age for examination of mean age; there were no significant differences in mean age by sex and diabetes status in any of the age groups. The race distribution differed nonsignificantly between the 2 cohorts; nonwhites constituted 19.1% of cohort 1 and 18.9% of cohort 2.

RESULTS

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Figure 1 shows mortality from all causes, heart disease, and ischemic heart disease for men and women with and without diabetes in cohort 1 and cohort 2, according to age at baseline. Details about sample sizes; person-years of follow-up; number of deaths by age, sex, and diabetes status; and statistical significance are provided in Table 1 and Table 2. For all groups, mortality rates increased with age, were higher in men than women, and were higher in subjects with diabetes than their counterparts without diabetes. Among men and women without diabetes, mortality rates were higher in cohort 1 than cohort 2 for almost all age groups and causes of death. The differences between cohort 1 and cohort 2 were statistically significant for men without diabetes in all age groups for all 3 causes of death (P<.01). For women without diabetes, differences were statistically significant only at ages 65 to 74 years for all-cause and heart disease mortality (P<.05). Among men with diabetes, mortality rates in cohort 1 were generally higher than in cohort 2 at ages 35 to 54 and 55 to 64 years and were slightly lower at ages 65 to 74 years. Among women with diabetes, mortality rates in specific age groups tended to be lower in cohort 1 than in cohort 2. However, 95% confidence limits around the rates of diabetes for both men and women were large, and no differences between cohort 1 and cohort 2 were statistically significant for any cause of death (Table 1 and Table 2).

View larger version (30K): [in this window] [in a new window] Figure 1. Age-Specific Mortality Rates for Death Due to All Causes, Heart Disease, and Ischemic Heart Disease for Men and Women With and Without Diabetes in Cohorts 1 and 2, According to Age at Baseline Mortality rates are shown per 1000 person-years with 95% confidence intervals. Cohort 1 was defined in 1971-1975 and was followed up for mortality through 1982-1984. Cohort 2 was defined in 1982-1984 and was followed up for mortality through 1992-1993. Details about sample sizes, number of deaths, point estimates, and statistical significance are shown in Table 1 and Table 2.

View this table: [in this window] [in a new window] Table 1. All-Cause Mortality Rates for Adults in Cohorts 1 and 2, by Diabetes Status, Sex, and Age*

View this table: [in this window] [in a new window] Table 2. Mortality Rates for Heart Disease and Ischemic Heart Disease as the Underlying Cause of Death for Adults in Cohorts 1 and 2, by Diabetes Status, Sex, and Age*

Figure 2 shows age-adjusted mortality rates from all causes, heart disease, and ischemic heart disease for men and women with and without diabetes in cohort 1 and cohort 2. For men with and without diabetes, the rate was higher in cohort 1 than in cohort 2 for each cause of death. The differences between cohort 1 and cohort 2 were statistically significant for men without diabetes (P<.001) but not for men with diabetes. Among women without diabetes, age-adjusted rates were higher in cohort 1 than in cohort 2, and the difference was statistically significant for all causes (P=.04) and heart disease (P=.009). For women with diabetes, the rate was lower in cohort 1 than in cohort 2 for each cause of death, but none of the differences were statistically significant.

View larger version (18K): [in this window] [in a new window] Figure 2. Age-Adjusted Mortality Rates for Death Due to All Causes, Heart Disease, and Ischemic Heart Disease for Men and Women With and Without Diabetes in Cohorts 1 and 2, According to Age at Baseline Mortality rates are shown per 1000 person-years with 95% confidence intervals. Cohort 1 was defined in 1971-1975 and was followed up for mortality through 1982-1984. Cohort 2 was defined in 1982-1984 and was followed up for mortality through 1992-1993. Details about sample sizes, number of deaths, point estimates, and statistical significance are shown in Table 1 and Table 2.

Figure 3 summarizes the percentage change in age-adjusted mortality rates from cohort 1 to cohort 2. For men without diabetes, there were substantial decreases in the mortality rates for each cause of death, ranging from a 19.7% decline in the all-cause rate to a 43.8% decline in the rate for ischemic heart disease. For men with diabetes, the decreases were smaller and ranged from a 1.1% decline for all causes of death to a 16.6% decline for ischemic heart disease. Women without diabetes also experienced declines in age-adjusted mortality, including a 12.9% decrease in the all-cause rate, a 27.1% decrease in the heart disease rate, and a 20.4% decrease in the ischemic heart disease rate. In contrast, women with diabetes had increases in their mortality rates that ranged from a 10.7% increase for ischemic heart disease to a 22.9% increase for heart disease. The percentage changes for subjects without diabetes were statistically significant. However, because the 95% confidence intervals for diabetic subjects were wide, the mortality changes for men and women with diabetes did not achieve statistical significance.

View larger version (17K): [in this window] [in a new window] Figure 3. Percentage Change from Cohort 1 to Cohort 2 in Mortality From All Causes, Heart Disease, and Ischemic Heart Disease for Men and Women With and Without Diabetes Data are shown as percentage change in the age-adjusted mortality rates, with 95% confidence intervals. Percentage change was calculated as the mortality rate in cohort 2 minus the rate in cohort 1, divided by the rate in cohort 1, and multiplied by 100. Details about sample sizes, number of deaths, point estimates, and statistical significance are shown in Table 1 and Table 2.

The mortality data were recomputed using any listing of heart disease or ischemic heart disease on the death certificate. As expected, these multiple-cause mortality rates were higher than those based on heart disease or ischemic heart disease coded only as the underlying cause of death. However, the direction and magnitude of the percentage change from cohort 1 to cohort 2 were similar to those found using the underlying cause alone. The data were also analyzed by retaining, in the components of cohort 1 and cohort 2 without diabetes, those individuals who developed diabetes after the beginning of the mortality observation periods. There was only an approximately 3% increase in the age-adjusted mortality rates for subjects without diabetes. This change thus had virtually no effect on the results.

Figure 4 shows the age-adjusted relative risk for mortality (subjects with compared with subjects without diabetes) in cohort 1 and cohort 2. The relative risk was lower in cohort 1 than in cohort 2 for each of the causes of death in both men and women. The smaller declines in mortality for men with diabetes compared with men without it and the increases in mortality for women with diabetes compared with women without it resulted in increased relative risks for mortality associated with diabetes in cohort 2.

View larger version (26K): [in this window] [in a new window] Figure 4. Increases From Cohort 1 to Cohort 2 in the Relative Risk of Death Due to All Causes, Heart Disease, and Ischemic Heart Disease Data are shown as the age-adjusted mortality rate for subjects with diabetes divided by the age-adjusted rate for subjects without diabetes, with 95% confidence intervals. Details about sample sizes, number of deaths, point estimates, and statistical significance are shown in Table 1 and Table 2.

COMMENT

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These data, based on nationally representative samples of adults with and without diabetes, indicate that mortality from all causes, heart disease, and ischemic heart disease appears to have decreased slightly for men with diabetes during the period 1971-1993 and may have increased for women with diabetes. The data also indicate that adults with diabetes experienced less decline in their mortality rates compared with the decline experienced by adults without diabetes during this period. The lower declines for subjects with diabetes occurred for all causes of death, heart disease, and ischemic heart disease. However, confidence limits around the mortality rate changes for subjects with diabetes were large and the magnitude of the changes could not be determined precisely. In contrast, there were large and statistically significant declines in mortality for adults without diabetes, which mirror the changes in the general US population found in other studies.^1-4

The decline in coronary heart disease mortality in the US population has been attributed to improvement in risk factors for heart disease and improvement in medical treatment of patients with heart disease.^15-17 These changes have resulted in decreased incidence of heart disease and increased survival of patients. Based on these studies, there are several possible reasons that smaller mortality declines among adults with diabetes compared with adults without diabetes may have occurred. First, risk factors for mortality, particularly heart disease risk factors, may have decreased less over time in those with diabetes. Second, the incidence of coronary heart disease, including the incidence of recurrent myocardial infarction, may have decreased less in adults with diabetes. Third, patients with diabetes may have benefited less from improved medical treatment of heart disease, and case-fatality rates may have declined less than in patients without diabetes. Although NHANES I and NHEFS do not have data to assess these factors, there are extant cohort studies that include subjects with diabetes that could be investigated.

Two other recent studies examined time trends in mortality for people with diabetes. In Rochester, Minn, 10-year survival of patients with type 2 diabetes in 1970 and 1980 relative to survival of the Minnesota white population was studied.¹⁸ For men with diabetes, survival relative to men without diabetes was similar for the 1970 and 1980 cohorts, and the authors concluded that the improved survival experienced by the general Minnesota male population was also experienced by men with diabetes. These results differ from our findings that men with diabetes in a representative sample of the US population experienced less reduction in all-cause mortality than men without diabetes. For women with diabetes in Rochester, relative survival was lower for the 1980 cohort than the 1970 cohort, implying that mortality rates for women with diabetes in Rochester decreased less than the rates for women without diabetes. Our data indicate the same trend.

The other study of time trends in diabetes mortality compared age-adjusted mortality rates in the Pima Indians of Arizona in 1975-1982 with rates in 1982-1989.¹⁹ For men, subjects both with and without diabetes experienced small, nonsignificant declines in all-cause mortality; for women, subjects both with and without diabetes experienced small, nonsignificant increases in all-cause mortality.

In our study, there may have been differences between the 1971-1975 cohort and the 1982-1984 cohort that we could not measure that may have accounted for the lower declines in mortality for subjects with diabetes compared with subjects without diabetes. In addition, the completeness and accuracy of listing of heart disease and ischemic heart disease on the death certificate may have changed during the 2 cohort periods. However, the fact that the percentage changes from cohort 1 to cohort 2 were similar when multiple causes of death were analyzed indicates that this may not be a major reason for the lower declines in mortality for those with diabetes. Coding of the underlying cause of death was not a factor because the same procedure to select the underlying cause of death was used for all deaths in the study.

Our study could not precisely differentiate the types of diabetes, but the adult age of the NHANES I cohort and the high proportion of type 2 diabetes in the US population with diabetes indicate that the results reflect mortality in type 2 patients. Our data also do not permit identification of people with undiagnosed diabetes because neither fasting nor postchallenge glucose samples were obtained. Other studies have shown that mortality rates for individuals with undiagnosed diabetes are approximately equal to the rates for patients with diagnosed diabetes.^20-21

In summary, this study indicates that mortality rates for all causes, heart disease, and ischemic heart disease in men and women with diabetes have not decreased to the extent that they have for adults without diabetes. Many changes have caused the declines in death rates in the general US population. These changes appear to have been less favorable or less effective for people with diabetes, particularly for women. With the increasing prevalence of diabetes in the United States²² and the smaller decline in mortality for these individuals, we anticipate that diabetes may become an increasingly important factor for heart disease mortality in the United States.

AUTHOR INFORMATION

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Corresponding Author and Reprints: Maureen I. Harris, PhD, MPH, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Natcher Bldg, Room 5AN24, 45 Center Dr, MSC 6600, Bethesda, MD 20892 (e-mail: harrism{at}ep.niddk.nih.gov).

Author Affiliations: National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md.

REFERENCES

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1. Havlik RJ, Feinleib M. Proceedings of the Conference on the Decline in Coronary Heart Disease Mortality. Washington, DC: US Government Printing Office; 1978. DHEW publication 79-1610. 2. Stamler J. The marked decline in coronary heart disease mortality rates in the United States, 1968-91. Cardiology. 1985;72:11-22. ISI | PUBMED 3. Gillum RF. Trends in acute myocardial infarction and coronary heart disease death in the United States. J Am Coll Cardiol. 1994;23:1273-1277. ABSTRACT 4. Rosamond WD, Chambless LE, Folsom AR, et al. Trends in the incidence of myocardial infarction and in mortality due to coronary heart disease, 1987 to 1994. N Engl J Med. 1998;13:861-867. 5. Gu K, Cowie CC, Harris MI. Mortality in adults with and without diabetes in a national cohort of the US population, 1971-1993. Diabetes Care. 1998;21:1138-1145. ABSTRACT 6. Moss SE, Klein R, Klein BEK. Cause-specific mortality in a population-based study of diabetes. Am J Public Health. 1991;81:1158-1162. FREE FULL TEXT 7. Bush TL, Miller SR, Golden AL, Hale WE. Self-report and medical record report agreement of selected medical conditions in the elderly. Am J Public Health. 1989;79:1554-1556. FREE FULL TEXT 8. Harlow SD, Linet MS. Agreement between questionnaire data and medical records. Am J Epidemiol. 1989;129:233-248. FREE FULL TEXT 9. Kehoe R, Wu SY, Leske MC, Chylack LT. Comparing self-reported and physician-reported medical history. Am J Epidemiol. 1994;139:813-818. FREE FULL TEXT 10. Harris MI, Robbins DC. Prevalence of adult-onset IDDM in the US population. Diabetes Care. 1994;17:1337-1340. ABSTRACT 11. Melton LJ, Ochi JW, Palumbo PJ, Chu CP. Sources of disparity in the spectrum of diabetes mellitus at incidence and prevalence. Diabetes Care. 1983;6:427-431. ABSTRACT 12. Chiang CL. Vital Statistics: Special Report 47. Washington, DC: US Government Printing Office; 1961. Report No 9. 13. Kahn HA, Sempos CT. Statistical Methods in Epidemiology. New York, NY: Oxford University Press; 1989:217. 14. Cochran WG. Sampling Techniques. 3rd ed. New York, NY: John Wiley & Sons Inc; 1977:155. 15. Sytkowski PA, Kannel WB, D'Agostino RB. Changes in risk factors and the decline in mortality from cardiovascular disease: the Framingham Heart Study. N Engl J Med. 1990;322:1635-1641. ABSTRACT 16. McGovern PG, Pankow JS, Shahar E, et al. Recent trends in acute coronary heart disease. N Engl J Med. 1996;334:884-890. FREE FULL TEXT 17. Hunink MG, Goldman L, Tosteson AN, et al. The recent decline in mortality from coronary heart disease, 1980-1990: the effect of secular trends in risk factors and treatment. JAMA. 1997;277:535-542. FREE FULL TEXT 18. Leibson CL, O'Brien PC, Atkinson E, Palumbo PJ, Melton III LJ. Relative contributions of incidence and survival to increasing prevalence of adult-onset diabetes mellitus. Am J Epidemiol. 1997;146:12-22. FREE FULL TEXT 19. Sievers ML, Nelson RG, Bennett PH. Sequential trends in overall and cause-specific mortality in diabetic and nondiabetic Pima Indians. Diabetes Care. 1996;19:107-111. ABSTRACT 20. Jarrett RJ, Shipley MJ. Type 2 (non-insulin-dependent) diabetes mellitus and cardiovascular disease: putative association via common antecedents. Diabetologia. 1988;31:737-740. FULL TEXT | ISI | PUBMED 21. Eschwege E, Richard JL, Thibult N, et al. Coronary heart disease mortality in relation with diabetes, blood glucose, and plasma insulin levels. Horm Metab Res. 1985;15(suppl):41-46. 22. Harris MI, Flegal KM, Cowie CC, et al. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in US adults. Diabetes Care. 1998;21:518-524. ABSTRACT

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Symptom Interpretation in Women With Diabetes and Myocardial Infarction: A Qualitative Study
Mayer and Rosenfeld
The Diabetes Educator 2006;32:918-924.
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Retinal vascular calibre and the risk of coronary heart disease-related death
Wang et al.
Heart 2006;92:1583-1587.
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The Chronic Kidney Disease Epidemic: Stepping Back and Looking Forward
Kiberd
J. Am. Soc. Nephrol. 2006;17:2967-2973.
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Simvastatin Improves Diabetes-Induced Coronary Endothelial Dysfunction
Tawfik et al.
J. Pharmacol. Exp. Ther. 2006;319:386-395.
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Gestational diabetes mellitus increases the risk of cardiovascular disease in women with a family history of type 2 diabetes.
Carr et al.
Diabetes Care 2006;29:2078-2083.
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Implications of the global diabetes epidemic
Steiner
Diabetes and Vascular Disease Research 2006;3:S2-S5.
ABSTRACT  

Temporal Trends in Prevalence of Diabetes Mellitus in a Population-Based Cohort of Incident Myocardial Infarction and Impact of Diabetes on Survival
Gandhi et al.
Mayo Clin Proc. 2006;81:1034-1040.
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Type 2 diabetes does not increase risk of depression.
Brown et al.
CMAJ 2006;175:42-46.
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Hyperglycemia Stimulates Coagulation, Whereas Hyperinsulinemia Impairs Fibrinolysis in Healthy Humans
Stegenga et al.
Diabetes 2006;55:1807-1812.
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Success rates of percutaneous coronary intervention of chronic total occlusions and long-term survival in patients with diabetes mellitus
Safley et al.
Diabetes and Vascular Disease Research 2006;3:45-51.
ABSTRACT  

Intestinal Insulin Resistance and Aberrant Production of Apolipoprotein B48 Lipoproteins in an Animal Model of Insulin Resistance and Metabolic Dyslipidemia: Evidence for Activation of Protein Tyrosine Phosphatase-1B, Extracellular Signal-Related Kinase, and Sterol Regulatory Element-Binding Protein-1c in the Fructose-Fed Hamster Intestine.
Federico et al.
Diabetes 2006;55:1316-1326.
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Role of drug eluting stents in diabetic patients
Boccara et al.
Heart 2006;92:579-581.
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The role of non-invasive imaging in the risk stratification of asymptomatic diabetic subjects
Anand et al.
Eur Heart J 2006;27:905-912.
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Coronary Heart Disease Risk Equivalence in Diabetes Depends on Concomitant Risk Factors
Howard et al.
Diabetes Care 2006;29:391-397.
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Leading Causes of Death in the United States
Tierney et al.
JAMA 2006;295:383-383.
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Recent Trends in Cardiovascular Complications Among Men and Women With and Without Diabetes
Booth et al.
Diabetes Care 2006;29:32-37.
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Evolving treatment paradigms for vascular risk reduction in type 2 diabetes: Report of an international symposium held in Barcelona, Spain, January 27-29, 2006
British Journal of Diabetes & Vascular Disease 2006;6:S1-S12.
 

Type 2 Diabetes as a "Coronary Heart Disease Equivalent": An 18-year prospective population-based study in Finnish subjects
Juutilainen et al.
Diabetes Care 2005;28:2901-2907.
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Ischemia Imaging and Plaque Imaging in Diabetes: Complementary tools to improve cardiovascular risk management
Raggi et al.
Diabetes Care 2005;28:2787-2794.
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Diabetes and percutaneous coronary intervention in the setting of an acute coronary syndrome
Safley and Marso
Diabetes and Vascular Disease Research 2005;2:128-135.
ABSTRACT  

Depression and All-Cause and Coronary Heart Disease Mortality Among Adults With and Without Diabetes
Egede et al.
Diabetes Care 2005;28:1339-1345.
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A prospective study to investigate the incidence of atherosclerotic vascular disease in patients with newly diagnosed type 2 diabetes mellitus
Doyle et al.
British Journal of Diabetes & Vascular Disease 2005;5:155-158.
ABSTRACT  

Trends in Cardiovascular Complications of Diabetes
Leibson and Narayan
JAMA 2005;293:1723-1723.
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Sex Disparities in Treatment of Cardiac Risk Factors in Patients With Type 2 Diabetes
Wexler et al.
Diabetes Care 2005;28:514-520.
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Sex Differences in the Effect of Diabetes Duration on Coronary Heart Disease Mortality
Natarajan et al.
Arch Intern Med 2005;165:430-435.
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Diabetes mellitus and vascular risk: continuing the quest for the elusive keystone
Diabetes and Vascular Disease Research 2005;2:7-8.
 

Modern intervention strategies for managing dyslipidaemia: the case for combination therapy
Drexel
British Journal of Diabetes & Vascular Disease 2005;5:S17-S23.
ABSTRACT  

Aspirin Use Among Adults With Diabetes: Recent Trends and Emerging Sex Disparities
Persell and Baker
Arch Intern Med 2004;164:2492-2499.
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Sex Differences in Quality of Health Care Related to Ischemic Heart Disease Prevention in Patients With Diabetes: The Translating Research Into Action for Diabetes (TRIAD) study, 2000-2001
Ferrara et al.
Diabetes Care 2004;27:2974-2976.
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Interplay of diabetes and coronary heart disease on cardiovascular mortality
Boccara and Cohen
Heart 2004;90:1371-1373.
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Trends in Cardiovascular Complications of Diabetes
Fox et al.
JAMA 2004;292:2495-2499.
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Resistin Promotes Smooth Muscle Cell Proliferation Through Activation of Extracellular Signal-Regulated Kinase 1/2 and Phosphatidylinositol 3-Kinase Pathways
Calabro et al.
Circulation 2004;110:3335-3340.
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Declining Mortality Rate Among People With Diabetes in North Dakota, 1997-2002
Tierney et al.
Diabetes Care 2004;27:2723-2725.
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Decreasing Restenosis Following Angioplasty: The potential of peroxisome proliferator-activated receptor {gamma} agonists
Fonseca et al.
Diabetes Care 2004;27:2764-2766.
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An Epidemiological Perspective on Type 2 Diabetes Among Adult Men
Hardy and Bell
Diabetes Spectr. 2004;17:208-214.
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Thirty-year Trends in Cardiovascular Risk Factor Levels among US Adults with Diabetes: National Health and Nutrition Examination Surveys, 1971-2000
Imperatore et al.
Am J Epidemiol 2004;160:531-539.
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Cardiovascular Disease Risk Factors Predict the Development of Type 2 Diabetes: The Insulin Resistance Atherosclerosis Study
D'Agostino et al.
Diabetes Care 2004;27:2234-2240.
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Commentary: Socioeconomic status and diabetes outcomes; what might we expect and why don't we find it?
Chaturvedi
Int J Epidemiol 2004;33:871-873.
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Treating dyslipidaemia in the patient with type 2 diabetes
Betteridge
Eur Heart J Suppl 2004;6:C28-C33.
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The Evolving Diabetes Burden in the United States
Engelgau et al.
ANN INTERN MED 2004;140:945-950.
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An Explanation for the Increase in Heart Disease Mortality Rates in Diabetic Pima Indians: Effect of renal replacement therapy
Pavkov et al.
Diabetes Care 2004;27:1132-1136.
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Barriers to physical activity in patients with diabetes
Thomas et al.
Postgrad. Med. J. 2004;80:287-291.
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Behavioral and Clinical Factors Associated With Depression Among Individuals With Diabetes
Katon et al.
Diabetes Care 2004;27:914-920.
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Intense Management of Diabetes Mellitus: Role of Glucose Control and Antiplatelet Agents
Mudaliar
J Clin Pharmacol 2004;44:414-422.
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Nontraditional Risk Factors for Cardiovascular Disease in Diabetes
Fonseca et al.
Endocr. Rev. 2004;25:153-175.
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Carbohydrate and Fiber Recommendations for Individuals with Diabetes: A Quantitative Assessment and Meta-Analysis of the Evidence
Anderson et al.
J. Am. Coll. Nutr. 2004;23:5-17.
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Increased Incidence of Coronary Atherosclerosis in Type 2 Diabetes Mellitus: Mechanisms and Management
Hurst and Lee
ANN INTERN MED 2003;139:824-834.
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Intramural Plasminogen Activator Inhibitor Type-1 and Coronary Atherosclerosis
Sobel et al.
Arterioscler. Thromb. Vasc. Bio. 2003;23:1979-1989.
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Importance of Weight Management in Type 2 Diabetes: Review with Meta-analysis of Clinical Studies
Anderson et al.
J. Am. Coll. Nutr. 2003;22:331-339.
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Review: The management of acute myocardial infarction in patients with diabetes mellitus
Williams et al.
British Journal of Diabetes & Vascular Disease 2003;3:319-324.
ABSTRACT  

Diabetes-Induced Oxidative Stress and Low-Grade Inflammation in Porcine Coronary Arteries
Zhang et al.
Circulation 2003;108:472-478.
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Sex Differences in Risk for Coronary Heart Disease Mortality Associated With Diabetes and Established Coronary Heart Disease
Natarajan et al.
Arch Intern Med 2003;163:1735-1740.
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The Rationale and Management of Hyperglycemia for In-Patients with Cardiovascular Disease: Time for Change
Trence et al.
J. Clin. Endocrinol. Metab. 2003;88:2430-2437.
ABSTRACT | FULL TEXT  

Inflammation and Insulin Resistance
Bloomgarden
Diabetes Care 2003;26:1922-1926.
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Under utilisation of evidence-based treatment partial explanation for the unfavourable prognosis in diabetic patients with acute myocardial infarction
Norhammar et al.
Eur Heart J 2003;24:838-844.
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Dyslipidaemia in type 2 diabetes: epidemiology and biochemistry
Valabhji and Elkeles
British Journal of Diabetes & Vascular Disease 2003;3:184-189.
ABSTRACT  

Depression and Coronary Heart Disease in Women With Diabetes
Clouse et al.
Psychosom. Med. 2003;65:376-383.
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Role of chronic hyperglycemia in the pathogenesis of coronary microvascular dysfunction in diabetes
Di Carli et al.
J Am Coll Cardiol 2003;41:1387-1393.
ABSTRACT | FULL TEXT  

Lipid Management in Patients With Diabetes: Translating guidelines into action
Inzucchi and Amatruda
Diabetes Care 2003;26:1309-1311.
FULL TEXT  

Trends in the Mortality Burden Associated With Diabetes Mellitus: A Population-Based Study in Rochester, Minn, 1970-1994
Thomas et al.
Arch Intern Med 2003;163:445-451.
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Relation between hormone replacement therapy and ischaemic heart disease in women: prospective observational study
Lokkegaard et al.
BMJ 2003;326:426-426.
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Burgeoning Dilemmas in the Management of Diabetes and Cardiovascular Disease: Rationale for the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) Trial
Sobel et al.
Circulation 2003;107:636-642.
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Multifactorial Intervention and Cardiovascular Disease in Patients with Type 2 Diabetes
Gaede et al.
NEJM 2003;348:383-393.
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