PORTLAND, OR — Hypoglycemia is an underutilized, independent risk marker for cardiovascular disease and death in patients with diabetes, researchers report[1].

Over 15 years of follow-up, among Atherosclerosis Risk in Communities (ARIC) study participants (aged >65 years) who had diabetes but were free of cardiovascular disease, those who had severe hypoglycemia resulting in a hospital visit were more likely to develop CVD or die from all causes than other participants, after adjustment for multiple confounders.

Alexandra K Lee (Johns Hopkins Bloomberg School of Public Health, Baltimore, MD) presented the findings at a "hot topics in diabetes epidemiology" session at the EPI|LIFESTYLE 2017 Scientific Sessions .

Based on this study, "We can certainly say severe hypoglycemia is a strong indicator of poor prognosis," she said. "However, it remains unclear whether avoiding hypoglycemia would reduce the risk of cardiovascular disease or mortality."

Clinically, practitioners are shying away from intensive glucose lowering, after the findings of the ACCORD trial in high-risk patients, so it would be interesting to see whether there is a subgroup of patients who are at lower risk of hypoglycemia and to determine whether multiple hypoglycemic events confer an even higher risk of CVD or death, session moderator Dr Ryan Demmer (Columbia University, New York, NY) commented to heart wire from Medscape.

The study shows that hypoglycemia predicts incident CVD and mortality and thus supports the American Diabetes Association practice guidelines that recommend that clinicians consider the risk of hypoglycemia when determining appropriate treatments and glycemic targets for individual patients, especially older adults, Lee told heartwire .

Hypoglycemia in a Community Cohort of Diabetic Patients

Lee and colleagues identified 1134 participants in ARIC at the fourth visit (1996–1998) who had diabetes (almost all type 2 diabetes), of whom 178 participants had at least one episode of severe hypoglycemia during follow-up.

Compared with other patients at baseline, those with hypoglycemia were slightly older (mean age 65 vs 63) and more likely to be female (57% vs 53%) and black (44% vs 29%). They were also more likely to be receiving insulin (48% vs 24%) and to have an eGFR <60 mL/min/1.73 m2 (19% vs 11%), higher mean LDL cholesterol (120 vs 117 mg/dL), higher systolic blood pressure (136 vs 131 mm Hg), and CVD (24% vs 19%).

The 228 patients with CVD (coronary heart disease or stroke) at baseline were excluded from the analysis of incident CVD but included in the all-cause mortality analysis.

The 3-year cumulative mortality was 30% higher among patients who had severe hypoglycemia.

After adjustment for multiple confounders, patients with hypoglycemia had a significantly higher risk of CVD and all-cause mortality during the 15-year follow-up.

CVD or Mortality Risk in Patients With Hypoglycemia

Outcome Events HR (95% CI )*
CVD 216/905 1.64 (1.03–2.58)
All-cause mortality 535/1134 1.70 (1.34–2.16)
*Adjusted for age, sex, race, center, diabetes medication, diabetes duration, fructosamine, low eGFR, albuminuria, income, digit symbol substitution test, race-specific Z score, difficulty with activities of daily living, systolic BP, antihypertensive medication, LDL and HDL cholesterol, cholesterol-lowering medications, and smoking

Hypoglycemia increased the risk of coronary heart disease, but not for stroke; however, there were few strokes, Lee noted.

The risks for all-cause mortality during follow-up were similar for both genders, blacks and whites, participants younger and older than 65, those with diabetes of a long (>8 years) or short duration, and those with or without CVD at baseline.

"Our results support continued concern about hypoglycemia risk in adults with type 2 diabetes and the evaluation of the risks and benefits of glucose-lowering treatment," Lee and colleagues conclude.

The authors have no relevant financial relationships.

For more from theheart.org, follow us on Twitter and Facebook.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.