Associations of HbA(1c) and educational level with risk of cardiovascular events in 32 871 drug-treated patients with Type 2 diabetes: a cohort study in primary care

AIMS: To explore the association of HbA(1c) and educational level with risk of cardiovascular events and mortality in patients with Type 2 diabetes. METHODS: A cohort of 32 871 patients with Type 2 diabetes aged 35 years and older identified by extracting data from electronic patient records for all patients who had a diagnosis of Type 2 diabetes and had glucose-lowering agents prescribed between 1999 and 2009 at 84 primary care centres in Sweden. Associations of mean HbA(1c) levels and educational level with risks of cardiovascular events and all-cause mortality were analysed. RESULTS: The associations of HbA(1c) with risk of all-cause and cardiovascular mortality were J-shaped, with the lowest risk observed for cardiovascular mortality at an HbA(1c) level of 51 mmol/mol (6.8%) for subjects on oral agents and 56 mmol/mol (7.3%) in insulin-treated patients. The lowest risk observed for all-cause mortality was at an HbA(1c) level of 51 mmol/mol (6.8%) for subjects on oral agents and 56 mmol/mol (7.3%) in insulin-treated patients. There was an increased risk for cardiovascular death [hazard ratio 1.6 (1.2–2.1), P = 0.0008] at the lowest HbA(1c) decile for subjects in the low education category. For subjects with higher education there was no evident J curve for cardiovascular death [hazard ratio 1.2 (0.8–1.6), P = 0.3873]. CONCLUSIONS: Our results lend support to the recent American Diabetes Association/ European Association for the Study of Diabetes position statement that emphasizes the importance of additional factors, including the propensity for hypoglycaemia, which should influence HbA(1c) targets and treatment choices for individual patients. (Clinical Trials Registry No; NCT 01121315)