EHJ: AF signals higher mortality risk for diabetics; aggressive control needed
There is a strong link between diabetics who have atrial fibrillation (AF) and an increased risk of other heart-related problems and death, according to the ADVANCE trial in the March 12 issue of the European Heart Journal.

The ADVANCE [Action in Diabetes and Vascular Disease: preterAx and diamicroN-MR Controlled Evaluation] researchers examined 11,140 patients with type 2 diabetes. They found that patients who had AF at the start of the trial had a 61 percent increased risk of dying from any cause, a 77 percent increased risk of dying from cardiovascular causes such as a heart attack or stroke and a 68 percent increased risk of developing heart failure or other cerebrovascular problems such as stroke, when compared with diabetic patients who did not have AF.

However, the study also found that if clinicians gave more aggressive treatments to the diabetic AF patients, such as a combination blood pressure lowering drugs, (perindopril and indapamide), the risk of dying or developing any complications was reduced. It was also reduced in diabetic patients without AF who were given the same treatment.

"Active treatment produced similar relative benefits to patients with and without AF. However, because of their higher risk at the start of the study, the absolute benefit associated with active treatment was greater in patients with AF than without," said the study's lead author Anushka Patel, MD, director of the cardiovascular division at the George Institute for International Health at the University of Sydney in Australia. "We estimate that five years of active treatment would prevent one death among every 42 patients with AF and one death among every 120 patients without AF."

The findings have important implications for the management of diabetics and for policy in this area, according to the authors. "The number of diabetic patients is projected to increase to 380 million at 2025. We might expect that about 40 million of these will also have AF," Patel said.

"The prevalence of AF varies greatly according to the population's age and other health problems. It ranges between 4 percent in primary care settings to 15 percent in hospitalized patients. In our study, 7.6 percent of the 11,140 patients had AF at baseline and a further 352 patients developed AF over an average follow-up of 4.3 years. The overall prevalence in this population was about 11 percent. There are data to suggest that the prevalence of AF in people with diabetes is about twice that among people without diabetes." Patel said.

"This study informs clinicians that AF is a marker of greater risk of cardiovascular events and mortality among diabetics, both men and women. Such patients should have their cardiovascular risk factors, such as blood pressure and cholesterol, controlled more aggressively...These issues are important, but we believe our data suggest that heightened awareness and management of overall cardiovascular risk is also important," he noted.

"An example of this comes from the results of the blood pressure intervention in ADVANCE. Routine administration of a fixed combination of perindopril and indapamide to patients with type 2 diabetes resulted in 18 percent reduction of cardiovascular death and 14 percent reduction of death from any cause in both patients with and without AF," Patel said. "However, because of their higher baseline risks, patients with AF benefited more, in absolute terms."

The study also found that there was a significantly stronger association between AF and deaths from cardiovascular disease in women compared with men-women with AF were twice as likely to die than women without AF, whereas men with AF were 50 percent more likely to die then men without AF.