The impact of diabetes, education and income on mortality and cardiovascular events in hypertensive patients: A cohort study from the Swedish Primary Care Cardiovascular Database (SPCCD).

Tobias Andersson,Karin Manhem,Per Hjerpe,Thomas Kahan,Per Wändell,Linus Schiöler,Jan Hasselström,Kristina Bengtsson Boström,Axel C Carlsson,Miriam Pikkemaat,Carmine Pizzi

doi:10.1371/journal.pone.0237107

Abstract

ObjectiveIn this study we aimed to estimate the effect of diabetes, educational level and income on the risk of mortality and cardiovascular events in primary care patients with hypertension.MethodsWe followed 62,557 individuals with hypertension diagnosed 2001–2008, in the Swedish Primary Care Cardiovascular Database. Study outcomes were death, myocardial infarction, and ischemic stroke, assessed using national registers until 2012. Cox regression models were used to estimate adjusted hazard ratios of outcomes according to diabetes status, educational level, and income.ResultsDuring follow-up, 13,231 individuals died, 9981 were diagnosed with diabetes, 4431 with myocardial infarction, and 4433 with ischemic stroke. Hazard ratios (95% confidence intervals) for diabetes versus no diabetes: mortality 1.57 (1.50–1.65), myocardial infarction 1.24 (1.14–1.34), and ischemic stroke 1.17 (1.07–1.27). Hazard ratios for diabetes and ≤9 years of school versus no diabetes and >12 years of school: mortality 1.56 (1.41–1.73), myocardial infarction 1.36 (1.17–1.59), and ischemic stroke 1.27 (1.08–1.50). Hazard ratios for diabetes and income in the lowest fifth group versus no diabetes and income in the highest fifth group: mortality 3.82 (3.36–4.34), myocardial infarction 2.00 (1.66–2.42), and ischemic stroke 1.91 (1.58–2.31).ConclusionsDiabetes combined with low income was associated with substantial excess risk of mortality, myocardial infarction and ischemic stroke among primary care patients with hypertension.

Highlights

Hypertension and diabetes are common conditions and are important risk factors both separately and in combination for later development of cardiovascular disease and premature death [1, 2]
Diabetes combined with low income was associated with substantial excess risk of mortality, myocardial infarction and ischemic stroke among primary care patients with hypertension
Increased risk of cardiovascular disease has been shown among patients with prediabetes, where adverse outcomes have been associated with endothelial dysfunction and increased inflammatory tone [9, 10]

Summary

Introduction

Hypertension and diabetes are common conditions and are important risk factors both separately and in combination for later development of cardiovascular disease and premature death [1, 2]. In 2017, almost half a billion were estimated to be living with diabetes globally [5], and from an international viewpoint the Swedish prevalence of 5% is relatively low [6]. The connection between type 2 diabetes and heart failure [7], and increased risk of cardiovascular disease [8] is well established. Regarding the risk of stroke, type 2 diabetes has been observed to confer an increased risk of subclinical episodes of atrial fibrillation and stroke among young patients with low thrombo-embolic risk [11]

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Results

Conclusion