Residual risk for acute stroke in patients with type 2 diabetes and hypertension in primary care: Skaraborg Hypertension and Diabetes Project.

AIM: The aim of this study was to investigate the risk of acute stroke in subgroups of patients treated for hypertension and type 2 diabetes in primary care. METHODS: Patients with hypertension only (n = 695), type 2 diabetes only (n = 181) or both (n = 240), who consecutively attended an annual control in primary care in Skara, Sweden during 1992-1993, were evaluated for cardiovascular disease risk factors and enrolled in this study. Subjects with neither hypertension nor type 2 diabetes (n = 824) who participated in a population survey in the same community served as controls. Possible events of acute stroke through 2002 were validated using hospital records and death certificates. RESULTS: During a mean follow-up time of 8.4 years, 190 first events of acute stroke, fatal or non-fatal, were ascertained. Risk factor levels were generally higher in all patient categories than in controls. Stroke risk was significantly increased in all male patients: hazard ratio 4.2 (95% CI 2.1-8.4) in patients with both conditions, 3.3 (1.5-7.0) in those with type 2 diabetes alone and 2.8 (1.5-5.3) in those with hypertension alone (adjusted for age, total cholesterol, current smoking, BMI and physical activity). Corresponding findings in women were 2.9 (1.5-5.8) in patients with type 2 diabetes only and 2.4 (1.2-4.7) in those with both conditions. However, in women with hypertension only, a significant risk was seen first when subjects were truncated at 85 years of age. There were too few fatal stroke events for conclusive results on stroke mortality. CONCLUSIONS: A considerable risk of acute stroke remains in patients with type 2 diabetes and hypertension. Strategies for stricter multiple risk factor interventions should be implemented in primary care.

Low serum concentration of sulfatide and presence of sulfated lactosylceramid are associated with Type 2 diabetes. The Skaraborg Project.

AIMS: The glycosphingolipid sulfatide (sulfated galactosyl-ceramide) increases exocytosis of beta-cell secretory granules, activates K(ATP)-channels and is thereby able to influence insulin secretion through its presence in the islets. A closely related compound, sulfated lactosylceramide (sulf-lac-cer), is present in the islets during fetal and neonatal life when, as in Type 2 diabetes, insulin is secreted autonomically without the usual first phase response to glucose. The aim was to examine whether serum concentrations of these glycolipids are associated with Type 2 diabetes. METHODS: A case-control study, comprising 286 women and 283 men, was designed using a population-based sample of patients with Type 2 diabetes and a population survey. RESULTS: Low serum concentrations of sulfatide were associated with Type 2 diabetes, independent of traditional risk factors for diabetes in a sex-specific analysis: odds ratio (OR) 2.1 (95% confidence interval 1.1, 3.9) in men, and 2.3 (1.2, 4.3) in women, comparing the lowest and the highest tertiles. Type 2 diabetes was also associated with detectable amounts of sulf-lac-cer in serum: OR 1.7 (0.9, 3.4) in men, and 7.6 (3.8, 15.2) in women. After adjustment for confounding from other diabetes risk factors, these associations remained basically unchanged. The connections between sulfatide and Type 2 diabetes, and sulf-lac-cer and Type 2 diabetes were independent of each other. Insulin resistance (HOMA-IR) was negatively correlated with sulfatide concentration and positively correlated with sulf-lac-cer (both P < 0.0001, independently). CONCLUSIONS: We report a new, robust and highly significant independent association between Type 2 diabetes and serum concentrations of sulfatide in both sexes, and sulf-lac-cer in females. The associations were also independent of other known diabetes risk factors.

Metabolic disorders associated with uncontrolled hypertension.

AIM: To examine the prevalence and characteristics of uncontrolled hypertension (HT). METHODS: A cross-sectional community-based study (1992-93) was carried out in Skara, Sweden, including 894 patients who consecutively underwent an annual follow-up at the hypertension outpatient clinic in primary care. Controlled HT was defined as diastolic blood pressure (DBP) < or =90 mmHg and systolic blood pressure (SBP) < or =160 mmHg and was used as reference. Uncontrolled DBP was defined as DBP >90 mmHg regardless of SBP level, and isolated uncontrolled SBP was defined as SBP >160 mmHg and DBP < or =90 mmHg. Proportions were age-standardized using the Skara population as reference. RESULTS: The prevalence of uncontrolled HT was 43% (isolated uncontrolled SBP 18% and uncontrolled DBP 25%). Both men and women with isolated uncontrolled SBP were older (73 years, CI: 70-75; and 73 years; CI: 72-75) than patients with controlled HT (64 years, CI: 63-66; and 65 years, CI: 64-66). Men and women with known cardiovascular disease (CVD) less often had isolated uncontrolled SBP (OR: 0.4, CI: 0.2-0.9; and OR: 0.5, CI: 0.3-0.9), whereas men and women with known diabetes more often had uncontrolled DBP (OR: 2.3, CI: 1.3-4.1; and OR: 3.3, CI: 1.9-5.7). Men with known CVD less often had uncontrolled DBP (OR: 0.5, CI: 0.3-1.0, p = 0.04), and men with fasting blood glucose >5.5 mmol/l more often had isolated uncontrolled SBP (OR: 1.9, CI: 1.0-3.5, p = 0.04). In women, the following high risk factor levels were associated with uncontrolled DBP: fasting blood glucose >5.5 mmol/l (OR: 1.4, CI: 1.1-1.8), fasting triglycerides > or =1.7 mmol/l (OR: 1.4, CI: 1.1-1.8), body mass index (BMI) >30 kg/m2 (OR: 1.5, CI: 1.1-1.9), waist/hip ratio (WHR) >0.85 cm/cm (OR: 1.7, CI: 1.3-2.2), insulin resistance (homeostasis model assessment (HOMA) >third quartile) (OR: 1.4, CI: 1.1-1.9) and microalbuminuria (OR: 3.2, CI: 1.7-6.2). CONCLUSION: Uncontrolled DBP is in both sexes related to type 2 diabetes, whereas isolated uncontrolled SBP is related to older age. In women, uncontrolled DBP, furthermore, is related to several other CVD risk factors of the metabolic syndrome. Patients with uncontrolled DBP should be carefully evaluated for metabolic disorders.

Impaired glucose metabolism and obesity in Swedish patients with borderline isolated systolic hypertension: Skaraborg Hypertension and Diabetes Project.

AIM: To assess the prevalence of borderline isolated systolic hypertension (borderline ISH), and to examine its association with other cardiovascular risk factors. METHODS: A cross-sectional community-based study was carried out in 1993-1994 in Skara, Sweden, including 1109 randomly chosen subjects > or = 40 years old. Normotension (NT) was defined as systolic blood pressure (SBP) < 140 and diastolic blood pressure (DBP) < 90 mmHg, borderline ISH as SBP 140-159 and DBP < 90 mmHg and hypertension (HT) as SBP > or = 160 or DBP > or = 90 mmHg or ongoing treatment. RESULTS: The prevalence of borderline ISH (n = 203) by age was 4% in ages 40-49 years, 15% in ages 50-59 years, 28% in ages 60-69 years and 25% in ages 70-79 years. With borderline ISH as reference, normotensive subjects less often had fasting blood glucose > 5.5 mmol/l (odds ratio (OR): 0.4, 95% CI: 0.26-0.75), BMI > 27 kg/m2 (OR: 0.6, 95% confidence intervals (CI): 0.42-0.85) and known diabetes (OR: 0.4, 95% CI: 0.16-0.95). Hypertensive subjects more often had high density lipoprotein (HDL) cholesterol < 1.0 mmol/l (OR: 2.0, 95% CI: 1.35-2.99), a history of previous cardiovascular disease (CVD) (OR: 1.7, 95% CI: 1.01-2.72), known diabetes (OR: 2.4, 95% CI: 1.29-4.58) and microalbuminuria (men) (OR: 1.9, 95% CI: 1.15-3.11). CONCLUSION: Borderline ISH is a common condition. It is associated with a more unfavourable risk factor profile than that of normotensive subjects concerning primarily glucose metabolism and obesity. The prevalence of known diabetes increased with the degree of hypertension.

Polymorphism in the angiotensin converting enzyme but not in the angiotensinogen gene is associated with hypertension and type 2 diabetes: the Skaraborg Hypertension and diabetes project.

OBJECTIVE: To study the association between polymorphisms in the angiotensin converting enzyme (ACE) gene and angiotensinogen (AGT) gene and hypertension and/or type 2 diabetes in a community population. PATIENTS AND METHODS: The insertion (I)/deletion (D) polymorphism of the ACE gene and the M235T polymorphism of the AGT gene were genotyped in 773 nondiabetic individuals with hypertension, 193 normotensive patients with type 2 diabetes, 243 patients with type 2 diabetes and hypertension, and in 820 normotensive control individuals identified in a community-based study. RESULTS: The DD genotype was associated with hypertension in individuals less than 70 years [odds ratio (OR) = 1.54, confidence interval (CI) = 1.09-2.18] and remained so when patients with type 2 diabetes were excluded from the analysis (OR = 1.45, CI = 1.01-2.09). The strongest association was with the combination of type 2 diabetes and hypertension (OR = 2.19, CI = 1.09-4.38). There was no association with type 2 diabetes without hypertension. No association was observed between the M235T variant or the 3'-microsatellite polymorphism of the AGT gene and hypertension. CONCLUSION: The D-allele of the ACE gene ID polymorphism increases susceptibility to hypertension, particularly when associated with type 2 diabetes. No association was observed between the M235T variant or 3'-microsatellite polymorphism of the AGT gene and hypertension.

Differences in treatment and metabolic abnormalities between normo- and hypertensive patients with type 2 diabetes: the Skaraborg Hypertension and Diabetes Project.

AIM: To examine treatment and glucose control in type 2 diabetes patients with and without hypertension, and to explore differences in markers for insulin resistance and beta cell function. METHODS: A community-based, cross-sectional observational study was carried out at the hypertension and diabetes outpatient clinic in primary health care, Skara, Sweden. The subjects were all the 400 patients with type 2 diabetes (202 men, 198 women) who underwent annual follow-up from May 1992 through September 1993; 204 of these also had hypertension. RESULTS: The patients with both type 2 diabetes and hypertension had a higher b.m.i. (mean; 28.9 kg m(-2) (s.d.; 4.4) vs. 27.4 kg m(-2)(4.6)), higher triglycerides (2.0 mmol l(-1)(1.1) vs. 1.7 mmol l(-1)(1.1)), higher LDL/HDL cholesterol ratio (4.3(1.4) vs. 4.1(1.2)) and higher fasting insulin (8.5 mU l(-1)(1.1) vs. 6.6 mU l(-1)(1.1)). Conversely, glucose levels were lower; HbA1c (6.4%(1.4) vs. 6.8%(1.6)) and fasting blood glucose (8.1 mmol l(-1)(2.3) vs. 8.9 mmol l(-1)(2.7)) than in patients with type 2 diabetes alone. By the homeostasis model assessment (HOMA), patients with type 2 diabetes alone had more impaired beta cell function. They also had a higher frequency of insulin treatment (20% vs. 12%) and were less often treated non-pharmacologically (33% vs. 50%). CONCLUSIONS: Patients with type 2 diabetes and hypertension constitute a high risk category with a more atherogenic risk factor profile related to the insulin resistance syndrome. Patients with type 2 diabetes without hypertension seem to constitute a subgroup of type 2 diabetes with predominately impaired beta cell function.

Risk factor clustering in patients with hypertension and non-insulin-dependent diabetes mellitus. The Skaraborg Hypertension Project.

OBJECTIVES: To assess the coexistence of hypertension and diabetes, associations with cardiovascular risk factors and the achievement of current treatment goals. DESIGN: A community-based, cross-sectional, observational study. SETTING: Hypertension and diabetes outpatient clinics in primary health care, Skara, Sweden. SUBJECTS: All patients (n = 1116; 488 men, 628 women) who performed an annual follow-up from May 1992 to September 1993. MAIN OUTCOME MEASURES: Hypertension, non-insulin-dependent diabetes mellitus (NIDDM), blood pressure, fasting B-glucose, lipids, HbAlc, body mass index (BMI), waist hip ratio (WHR). RESULTS: Hypertension alone was found in 286 men and 430 women, hypertension and NIDDM combined in 102 men and 102 women, and NIDDM alone in 100 men and 96 women. Taking new cases into account, the proportion of hypertension among NIDDM patients was 57%, and the proportion of NIDDM among hypertensives was 26%. Men and women with both hypertension and NIDDM had a higher systolic blood pressure and women also had a higher diastolic blood pressure (men 168/88 mmHg, women 165/86 mmHg) than those with hypertension alone (men 152/87 mmHg, women 156/82 mmHg) (P < or = 0.001). Cardiovascular risk factors accumulated in patients with both hypertension and NIDDM (triglycerides, BMI and WHR). A diastolic blood pressure < or = 90 mmHg was achieved by 71% men and 84% women with hypertension. HbAlc < 7.5% was attained by 71% men and 70% women with NIDDM. CONCLUSIONS: A considerable coexistence of hypertension and NIDDM was demonstrated. Cardiovascular risk factors clustered in patients with both diseases and their blood pressure was less controlled. These patients thus comprised a clinically defined group at high risk. By current guidelines, control of hypertension and NIDDM seemed appropriate.