Doug Brunk

PALM DESERT, CALIF. – Nitric oxide use in neonates with diaphragmatic hernia remains widespread even though its efficacy remains to be proven, results from a large national analysis demonstrated.

"Nitric oxide has been studied extensively in newborns with hypoxemic respiratory failure," Dr. Brendan T. Campbell said at the annual meeting of the American Pediatric Surgical Association. "There have been 14 randomized, controlled trials done in term newborns with respiratory failure, and two of these studies enrolled significant numbers of patients with congenital diaphragmatic hernia. Both studies demonstrated conclusively that treatment with nitric oxide does not improve outcomes in newborns with congenital diaphragmatic hernia."

The first of these studies, he said, found that patients treated with nitric oxide were actually 30% more likely to require extracorporeal membrane oxygenation than were those who did not receive nitric oxide (Pediatrics 1997;99:838-45).

In an effort to describe national trends, interhospital variability in use, and costs associated with nitric oxide use in neonates with congenital diaphragmatic hernia (CDH), a health services research team led by Dr. Campbell analyzed records in the Pediatric Health Information System (PHIS) database. For the years 2003-2010, they identified all patients with a diagnostic code of CDH and a procedural code for CDH repair at 40 children’s hospitals that contribute data to the PHIS. Patients with congenital cardiac anomalies and inaccurate nitric oxide discharge data were excluded from analysis, said Dr. Campbell, a pediatric surgeon at Connecticut Children’s Medical Center, Hartford, who is also with the departments of surgery and pediatrics at the University of Connecticut, Storrs.

A total of 3,651 infants with CDH were identified in the analysis, and 514 with cardiac anomalies and missing or inaccurate data were excluded. The overall mortality rate was 15%, but the mortality rate for the 761 patients treated with nitric oxide was 47%, compared with roughly 5% for the 2,376 patients who were not treated with nitric oxide.

Patients treated with nitric oxide had a significantly longer median length of stay, compared with their counterparts (a median of 31 days vs. 6 days, respectively), and significantly higher median total charges billed (a median of $456,473 vs. $36,270).

Dr. Campbell estimated that the 761 patients treated with nitric oxide generated nearly $34 million in unnecessary hospital charges. "Reducing nitric oxide use in these patients would significantly lower costs without adversely affecting outcomes," he said.

Wide variation in the use of nitric oxide in neonates with CDH existed among the 40 PHIS hospitals. At one hospital, for example, more than 50% were treated with nitric oxide, while the rate was 10% or less at two other PHIS hospitals.

Limitations of the study included its retrospective design and the potential for coding errors and missing data.

Dr. Campbell said that he had no relevant financial conflicts to disclose.

The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Nitric oxide use in neonates with diaphragmatic hernia remains widespread even though its efficacy remains to be proven, results from a large national analysis demonstrated.

"Nitric oxide has been studied extensively in newborns with hypoxemic respiratory failure," Dr. Brendan T. Campbell said at the annual meeting of the American Pediatric Surgical Association. "There have been 14 randomized, controlled trials done in term newborns with respiratory failure, and two of these studies enrolled significant numbers of patients with congenital diaphragmatic hernia. Both studies demonstrated conclusively that treatment with nitric oxide does not improve outcomes in newborns with congenital diaphragmatic hernia."

The first of these studies, he said, found that patients treated with nitric oxide were actually 30% more likely to require extracorporeal membrane oxygenation than were those who did not receive nitric oxide (Pediatrics 1997;99:838-45).

In an effort to describe national trends, interhospital variability in use, and costs associated with nitric oxide use in neonates with congenital diaphragmatic hernia (CDH), a health services research team led by Dr. Campbell analyzed records in the Pediatric Health Information System (PHIS) database. For the years 2003-2010, they identified all patients with a diagnostic code of CDH and a procedural code for CDH repair at 40 children’s hospitals that contribute data to the PHIS. Patients with congenital cardiac anomalies and inaccurate nitric oxide discharge data were excluded from analysis, said Dr. Campbell, a pediatric surgeon at Connecticut Children’s Medical Center, Hartford, who is also with the departments of surgery and pediatrics at the University of Connecticut, Storrs.

A total of 3,651 infants with CDH were identified in the analysis, and 514 with cardiac anomalies and missing or inaccurate data were excluded. The overall mortality rate was 15%, but the mortality rate for the 761 patients treated with nitric oxide was 47%, compared with roughly 5% for the 2,376 patients who were not treated with nitric oxide.

Patients treated with nitric oxide had a significantly longer median length of stay, compared with their counterparts (a median of 31 days vs. 6 days, respectively), and significantly higher median total charges billed (a median of $456,473 vs. $36,270).

Dr. Campbell estimated that the 761 patients treated with nitric oxide generated nearly $34 million in unnecessary hospital charges. "Reducing nitric oxide use in these patients would significantly lower costs without adversely affecting outcomes," he said.

Wide variation in the use of nitric oxide in neonates with CDH existed among the 40 PHIS hospitals. At one hospital, for example, more than 50% were treated with nitric oxide, while the rate was 10% or less at two other PHIS hospitals.

Limitations of the study included its retrospective design and the potential for coding errors and missing data.

Dr. Campbell said that he had no relevant financial conflicts to disclose.

The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Nitric oxide use in neonates with diaphragmatic hernia remains widespread even though its efficacy remains to be proven, results from a large national analysis demonstrated.

"Nitric oxide has been studied extensively in newborns with hypoxemic respiratory failure," Dr. Brendan T. Campbell said at the annual meeting of the American Pediatric Surgical Association. "There have been 14 randomized, controlled trials done in term newborns with respiratory failure, and two of these studies enrolled significant numbers of patients with congenital diaphragmatic hernia. Both studies demonstrated conclusively that treatment with nitric oxide does not improve outcomes in newborns with congenital diaphragmatic hernia."

The first of these studies, he said, found that patients treated with nitric oxide were actually 30% more likely to require extracorporeal membrane oxygenation than were those who did not receive nitric oxide (Pediatrics 1997;99:838-45).

In an effort to describe national trends, interhospital variability in use, and costs associated with nitric oxide use in neonates with congenital diaphragmatic hernia (CDH), a health services research team led by Dr. Campbell analyzed records in the Pediatric Health Information System (PHIS) database. For the years 2003-2010, they identified all patients with a diagnostic code of CDH and a procedural code for CDH repair at 40 children’s hospitals that contribute data to the PHIS. Patients with congenital cardiac anomalies and inaccurate nitric oxide discharge data were excluded from analysis, said Dr. Campbell, a pediatric surgeon at Connecticut Children’s Medical Center, Hartford, who is also with the departments of surgery and pediatrics at the University of Connecticut, Storrs.

A total of 3,651 infants with CDH were identified in the analysis, and 514 with cardiac anomalies and missing or inaccurate data were excluded. The overall mortality rate was 15%, but the mortality rate for the 761 patients treated with nitric oxide was 47%, compared with roughly 5% for the 2,376 patients who were not treated with nitric oxide.

Patients treated with nitric oxide had a significantly longer median length of stay, compared with their counterparts (a median of 31 days vs. 6 days, respectively), and significantly higher median total charges billed (a median of $456,473 vs. $36,270).

Dr. Campbell estimated that the 761 patients treated with nitric oxide generated nearly $34 million in unnecessary hospital charges. "Reducing nitric oxide use in these patients would significantly lower costs without adversely affecting outcomes," he said.

Wide variation in the use of nitric oxide in neonates with CDH existed among the 40 PHIS hospitals. At one hospital, for example, more than 50% were treated with nitric oxide, while the rate was 10% or less at two other PHIS hospitals.

Limitations of the study included its retrospective design and the potential for coding errors and missing data.

Dr. Campbell said that he had no relevant financial conflicts to disclose.

The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Nitric oxide use in neonates with diaphragmatic hernia remains widespread even though its efficacy remains to be proven, results from a large national analysis demonstrated.

"Nitric oxide has been studied extensively in newborns with hypoxemic respiratory failure," Dr. Brendan T. Campbell said at the annual meeting of the American Pediatric Surgical Association. "There have been 14 randomized, controlled trials done in term newborns with respiratory failure, and two of these studies enrolled significant numbers of patients with congenital diaphragmatic hernia. Both studies demonstrated conclusively that treatment with nitric oxide does not improve outcomes in newborns with congenital diaphragmatic hernia."

The first of these studies, he said, found that patients treated with nitric oxide were actually 30% more likely to require extracorporeal membrane oxygenation than were those who did not receive nitric oxide (Pediatrics 1997;99:838-45).

In an effort to describe national trends, interhospital variability in use, and costs associated with nitric oxide use in neonates with congenital diaphragmatic hernia (CDH), a health services research team led by Dr. Campbell analyzed records in the Pediatric Health Information System (PHIS) database. For the years 2003-2010, they identified all patients with a diagnostic code of CDH and a procedural code for CDH repair at 40 children’s hospitals that contribute data to the PHIS. Patients with congenital cardiac anomalies and inaccurate nitric oxide discharge data were excluded from analysis, said Dr. Campbell, a pediatric surgeon at Connecticut Children’s Medical Center, Hartford, who is also with the departments of surgery and pediatrics at the University of Connecticut, Storrs.

A total of 3,651 infants with CDH were identified in the analysis, and 514 with cardiac anomalies and missing or inaccurate data were excluded. The overall mortality rate was 15%, but the mortality rate for the 761 patients treated with nitric oxide was 47%, compared with roughly 5% for the 2,376 patients who were not treated with nitric oxide.

Patients treated with nitric oxide had a significantly longer median length of stay, compared with their counterparts (a median of 31 days vs. 6 days, respectively), and significantly higher median total charges billed (a median of $456,473 vs. $36,270).

Dr. Campbell estimated that the 761 patients treated with nitric oxide generated nearly $34 million in unnecessary hospital charges. "Reducing nitric oxide use in these patients would significantly lower costs without adversely affecting outcomes," he said.

Wide variation in the use of nitric oxide in neonates with CDH existed among the 40 PHIS hospitals. At one hospital, for example, more than 50% were treated with nitric oxide, while the rate was 10% or less at two other PHIS hospitals.

Limitations of the study included its retrospective design and the potential for coding errors and missing data.

Dr. Campbell said that he had no relevant financial conflicts to disclose.

The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Nitric oxide use in neonates with diaphragmatic hernia remains widespread even though its efficacy remains to be proven, results from a large national analysis demonstrated.

"Nitric oxide has been studied extensively in newborns with hypoxemic respiratory failure," Dr. Brendan T. Campbell said at the annual meeting of the American Pediatric Surgical Association. "There have been 14 randomized, controlled trials done in term newborns with respiratory failure, and two of these studies enrolled significant numbers of patients with congenital diaphragmatic hernia. Both studies demonstrated conclusively that treatment with nitric oxide does not improve outcomes in newborns with congenital diaphragmatic hernia."

The first of these studies, he said, found that patients treated with nitric oxide were actually 30% more likely to require extracorporeal membrane oxygenation than were those who did not receive nitric oxide (Pediatrics 1997;99:838-45).

In an effort to describe national trends, interhospital variability in use, and costs associated with nitric oxide use in neonates with congenital diaphragmatic hernia (CDH), a health services research team led by Dr. Campbell analyzed records in the Pediatric Health Information System (PHIS) database. For the years 2003-2010, they identified all patients with a diagnostic code of CDH and a procedural code for CDH repair at 40 children’s hospitals that contribute data to the PHIS. Patients with congenital cardiac anomalies and inaccurate nitric oxide discharge data were excluded from analysis, said Dr. Campbell, a pediatric surgeon at Connecticut Children’s Medical Center, Hartford, who is also with the departments of surgery and pediatrics at the University of Connecticut, Storrs.

A total of 3,651 infants with CDH were identified in the analysis, and 514 with cardiac anomalies and missing or inaccurate data were excluded. The overall mortality rate was 15%, but the mortality rate for the 761 patients treated with nitric oxide was 47%, compared with roughly 5% for the 2,376 patients who were not treated with nitric oxide.

Patients treated with nitric oxide had a significantly longer median length of stay, compared with their counterparts (a median of 31 days vs. 6 days, respectively), and significantly higher median total charges billed (a median of $456,473 vs. $36,270).

Dr. Campbell estimated that the 761 patients treated with nitric oxide generated nearly $34 million in unnecessary hospital charges. "Reducing nitric oxide use in these patients would significantly lower costs without adversely affecting outcomes," he said.

Wide variation in the use of nitric oxide in neonates with CDH existed among the 40 PHIS hospitals. At one hospital, for example, more than 50% were treated with nitric oxide, while the rate was 10% or less at two other PHIS hospitals.

Limitations of the study included its retrospective design and the potential for coding errors and missing data.

Dr. Campbell said that he had no relevant financial conflicts to disclose.

The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Nitric oxide use in neonates with diaphragmatic hernia remains widespread even though its efficacy remains to be proven, results from a large national analysis demonstrated.

"Nitric oxide has been studied extensively in newborns with hypoxemic respiratory failure," Dr. Brendan T. Campbell said at the annual meeting of the American Pediatric Surgical Association. "There have been 14 randomized, controlled trials done in term newborns with respiratory failure, and two of these studies enrolled significant numbers of patients with congenital diaphragmatic hernia. Both studies demonstrated conclusively that treatment with nitric oxide does not improve outcomes in newborns with congenital diaphragmatic hernia."

The first of these studies, he said, found that patients treated with nitric oxide were actually 30% more likely to require extracorporeal membrane oxygenation than were those who did not receive nitric oxide (Pediatrics 1997;99:838-45).

In an effort to describe national trends, interhospital variability in use, and costs associated with nitric oxide use in neonates with congenital diaphragmatic hernia (CDH), a health services research team led by Dr. Campbell analyzed records in the Pediatric Health Information System (PHIS) database. For the years 2003-2010, they identified all patients with a diagnostic code of CDH and a procedural code for CDH repair at 40 children’s hospitals that contribute data to the PHIS. Patients with congenital cardiac anomalies and inaccurate nitric oxide discharge data were excluded from analysis, said Dr. Campbell, a pediatric surgeon at Connecticut Children’s Medical Center, Hartford, who is also with the departments of surgery and pediatrics at the University of Connecticut, Storrs.

A total of 3,651 infants with CDH were identified in the analysis, and 514 with cardiac anomalies and missing or inaccurate data were excluded. The overall mortality rate was 15%, but the mortality rate for the 761 patients treated with nitric oxide was 47%, compared with roughly 5% for the 2,376 patients who were not treated with nitric oxide.

Patients treated with nitric oxide had a significantly longer median length of stay, compared with their counterparts (a median of 31 days vs. 6 days, respectively), and significantly higher median total charges billed (a median of $456,473 vs. $36,270).

Dr. Campbell estimated that the 761 patients treated with nitric oxide generated nearly $34 million in unnecessary hospital charges. "Reducing nitric oxide use in these patients would significantly lower costs without adversely affecting outcomes," he said.

Wide variation in the use of nitric oxide in neonates with CDH existed among the 40 PHIS hospitals. At one hospital, for example, more than 50% were treated with nitric oxide, while the rate was 10% or less at two other PHIS hospitals.

Limitations of the study included its retrospective design and the potential for coding errors and missing data.

Dr. Campbell said that he had no relevant financial conflicts to disclose.

The meeting was supported by a grant from Elsevier, which owns this news organization.

Major Finding: The incidence of heart failure among patients with type 1 diabetes increased in a stepwise fashion as HbA_1c levels increased, from 1.42 per 1,000 patient-years in patients with HbA_1c below 6.5% to 5.20 per 1,000 patient-years in those in with HbA_1c of at least 10.5%.

Data Source: An analysis of 20,985 patients from the Swedish national diabetes registry who were aged 18 years or older, had type 1 disease, no known heart failure, and were registered during 1998-2003 and followed through 2009.

Disclosures: The study was supported by an unrestricted grant from AstraZeneca, Novo Nordisk Scandinavia, the Swedish Heart and Lung Foundation, and the Swedish Research Council. Dr. Lind disclosed that he has received honoraria or served as consultant for Bayer, Eli Lilly, Novartis, Novo Nordisk Scandinavia, Medtronic Pfizer, and Sanofi-Aventis; and has been a member of an advisory board for Novo Nordisk Scandinavia.

SAN DIEGO – Tight control of hemoglobin A_1c levels significantly reduces the risk of heart failure in patients with type 1 diabetes, according to the results from a large, long-term study.

In fact, patients who had very poor glycemic control were four times as likely to experience heart failure, compared with their counterparts who had optimal glycemic control, the researchers said.

“Because treatment for heart failure improves survival and quality of life, clinicians should be observant of signs of heart failure in management of patients with type 1 diabetes, starting at an early stage,” lead author Dr. Marcus Lind wrote in the study, which was presented at the meeting and simultaneously published online.

“Echocardiography might be warranted, especially in the presence of poor glycemic control, long duration of diabetes, or an adverse risk factor profile,” he noted.

Dr. Lind of the department of medicine at Uddevalla (Sweden) Hospital and his associates used the Swedish national diabetes registry to identify 20,985 patients aged 18 years or older with type 1 disease who had no known heart failure and who were registered between January 1998 and December 2003.

The researchers followed the cohort until hospital admission for heart failure, death, or end of follow-up on Dec. 31, 2009 (Lancet 2011 June 25 [doi: 10.1016/S0140-6736(11)60471-6]).

The incidence of heart failure was determined by dividing the number of patient-years of follow-up in a particular HbA_1c category, reported as events per 1,000 years of follow-up. The six HbA_1c categories were less than 6.5%, from 6.5% to less than 7.5%, from 7.5% to less than 8.5%, from 8.5% to less than 9.5%, from 9.5% to less than 10.5%, and 10.5% or greater. Cox regression analysis was used to study possible associations between heart failure and patients' characteristics.

The mean age of patients was 39 years, and 45% were female; they had had diabetes for a mean of 14 years, and their mean body mass index was 25 kg/m

After adjustment for age, sex, duration of diabetes, cardiovascular disease risk factors, acute myocardial infarction, and other comorbidities, a Cox regression analysis revealed that patients with an HbA_1c level of 10.5% or higher were four times more likely to develop heart failure than were those who had an HbA_1c level of less than 6.5%.

Other independent predictors of heart failure included age (hazard ratio, 1.64 per 10-year increase); duration of diabetes (HR, 1.34 per 10-year increase); BMI (HR, 1.05 per 1 kg/m

“For many years there have observations that poor glycemic control is linked to heart attack and cardiovascular mortality,” Dr. Sue Kirkman, senior vice president of medical affairs and community information for the American Diabetes Association, said in an interview at the meeting.

“This may be the first time that it's been shown to be linked to heart failure in a type 1 population,” Dr. Kirkman added.

She called the study “hypothesis-generating,” and noted that a long-term randomized trial will be needed to confirm the findings.

“It is interesting, because it seems that in type 1 diabetes there may be a stronger link between glucose lowering and cardiac outcomes than in type 2 diabetes,” she said.

Dr. Lind and his coinvestigators acknowledged certain limitations of the study, including its observational design and the fact that only data on hospital admission for heart failure were available from the Swedish national diabetes registry, “so the true incidence of heart failure could be underestimated.”

They added: “Patients with early signs of heart failure, or asymptomatic heart failure detectable by echocardiography, will not have been captured.”

Major Finding: The incidence of heart failure among patients with type 1 diabetes increased in a stepwise fashion as HbA_1c levels increased, from 1.42 per 1,000 patient-years in patients with HbA_1c below 6.5% to 5.20 per 1,000 patient-years in those in with HbA_1c of at least 10.5%.

Data Source: An analysis of 20,985 patients from the Swedish national diabetes registry who were aged 18 years or older, had type 1 disease, no known heart failure, and were registered during 1998-2003 and followed through 2009.

Disclosures: The study was supported by an unrestricted grant from AstraZeneca, Novo Nordisk Scandinavia, the Swedish Heart and Lung Foundation, and the Swedish Research Council. Dr. Lind disclosed that he has received honoraria or served as consultant for Bayer, Eli Lilly, Novartis, Novo Nordisk Scandinavia, Medtronic Pfizer, and Sanofi-Aventis; and has been a member of an advisory board for Novo Nordisk Scandinavia.

SAN DIEGO – Tight control of hemoglobin A_1c levels significantly reduces the risk of heart failure in patients with type 1 diabetes, according to the results from a large, long-term study.

In fact, patients who had very poor glycemic control were four times as likely to experience heart failure, compared with their counterparts who had optimal glycemic control, the researchers said.

“Because treatment for heart failure improves survival and quality of life, clinicians should be observant of signs of heart failure in management of patients with type 1 diabetes, starting at an early stage,” lead author Dr. Marcus Lind wrote in the study, which was presented at the meeting and simultaneously published online.

“Echocardiography might be warranted, especially in the presence of poor glycemic control, long duration of diabetes, or an adverse risk factor profile,” he noted.

Dr. Lind of the department of medicine at Uddevalla (Sweden) Hospital and his associates used the Swedish national diabetes registry to identify 20,985 patients aged 18 years or older with type 1 disease who had no known heart failure and who were registered between January 1998 and December 2003.

The researchers followed the cohort until hospital admission for heart failure, death, or end of follow-up on Dec. 31, 2009 (Lancet 2011 June 25 [doi: 10.1016/S0140-6736(11)60471-6]).

The incidence of heart failure was determined by dividing the number of patient-years of follow-up in a particular HbA_1c category, reported as events per 1,000 years of follow-up. The six HbA_1c categories were less than 6.5%, from 6.5% to less than 7.5%, from 7.5% to less than 8.5%, from 8.5% to less than 9.5%, from 9.5% to less than 10.5%, and 10.5% or greater. Cox regression analysis was used to study possible associations between heart failure and patients' characteristics.

The mean age of patients was 39 years, and 45% were female; they had had diabetes for a mean of 14 years, and their mean body mass index was 25 kg/m

After adjustment for age, sex, duration of diabetes, cardiovascular disease risk factors, acute myocardial infarction, and other comorbidities, a Cox regression analysis revealed that patients with an HbA_1c level of 10.5% or higher were four times more likely to develop heart failure than were those who had an HbA_1c level of less than 6.5%.

Other independent predictors of heart failure included age (hazard ratio, 1.64 per 10-year increase); duration of diabetes (HR, 1.34 per 10-year increase); BMI (HR, 1.05 per 1 kg/m

“For many years there have observations that poor glycemic control is linked to heart attack and cardiovascular mortality,” Dr. Sue Kirkman, senior vice president of medical affairs and community information for the American Diabetes Association, said in an interview at the meeting.

“This may be the first time that it's been shown to be linked to heart failure in a type 1 population,” Dr. Kirkman added.

She called the study “hypothesis-generating,” and noted that a long-term randomized trial will be needed to confirm the findings.

“It is interesting, because it seems that in type 1 diabetes there may be a stronger link between glucose lowering and cardiac outcomes than in type 2 diabetes,” she said.

Dr. Lind and his coinvestigators acknowledged certain limitations of the study, including its observational design and the fact that only data on hospital admission for heart failure were available from the Swedish national diabetes registry, “so the true incidence of heart failure could be underestimated.”

They added: “Patients with early signs of heart failure, or asymptomatic heart failure detectable by echocardiography, will not have been captured.”

Major Finding: The incidence of heart failure among patients with type 1 diabetes increased in a stepwise fashion as HbA_1c levels increased, from 1.42 per 1,000 patient-years in patients with HbA_1c below 6.5% to 5.20 per 1,000 patient-years in those in with HbA_1c of at least 10.5%.

Data Source: An analysis of 20,985 patients from the Swedish national diabetes registry who were aged 18 years or older, had type 1 disease, no known heart failure, and were registered during 1998-2003 and followed through 2009.

Disclosures: The study was supported by an unrestricted grant from AstraZeneca, Novo Nordisk Scandinavia, the Swedish Heart and Lung Foundation, and the Swedish Research Council. Dr. Lind disclosed that he has received honoraria or served as consultant for Bayer, Eli Lilly, Novartis, Novo Nordisk Scandinavia, Medtronic Pfizer, and Sanofi-Aventis; and has been a member of an advisory board for Novo Nordisk Scandinavia.

SAN DIEGO – Tight control of hemoglobin A_1c levels significantly reduces the risk of heart failure in patients with type 1 diabetes, according to the results from a large, long-term study.

In fact, patients who had very poor glycemic control were four times as likely to experience heart failure, compared with their counterparts who had optimal glycemic control, the researchers said.

“Because treatment for heart failure improves survival and quality of life, clinicians should be observant of signs of heart failure in management of patients with type 1 diabetes, starting at an early stage,” lead author Dr. Marcus Lind wrote in the study, which was presented at the meeting and simultaneously published online.

“Echocardiography might be warranted, especially in the presence of poor glycemic control, long duration of diabetes, or an adverse risk factor profile,” he noted.

Dr. Lind of the department of medicine at Uddevalla (Sweden) Hospital and his associates used the Swedish national diabetes registry to identify 20,985 patients aged 18 years or older with type 1 disease who had no known heart failure and who were registered between January 1998 and December 2003.

The researchers followed the cohort until hospital admission for heart failure, death, or end of follow-up on Dec. 31, 2009 (Lancet 2011 June 25 [doi: 10.1016/S0140-6736(11)60471-6]).

The incidence of heart failure was determined by dividing the number of patient-years of follow-up in a particular HbA_1c category, reported as events per 1,000 years of follow-up. The six HbA_1c categories were less than 6.5%, from 6.5% to less than 7.5%, from 7.5% to less than 8.5%, from 8.5% to less than 9.5%, from 9.5% to less than 10.5%, and 10.5% or greater. Cox regression analysis was used to study possible associations between heart failure and patients' characteristics.

The mean age of patients was 39 years, and 45% were female; they had had diabetes for a mean of 14 years, and their mean body mass index was 25 kg/m

After adjustment for age, sex, duration of diabetes, cardiovascular disease risk factors, acute myocardial infarction, and other comorbidities, a Cox regression analysis revealed that patients with an HbA_1c level of 10.5% or higher were four times more likely to develop heart failure than were those who had an HbA_1c level of less than 6.5%.

Other independent predictors of heart failure included age (hazard ratio, 1.64 per 10-year increase); duration of diabetes (HR, 1.34 per 10-year increase); BMI (HR, 1.05 per 1 kg/m

“For many years there have observations that poor glycemic control is linked to heart attack and cardiovascular mortality,” Dr. Sue Kirkman, senior vice president of medical affairs and community information for the American Diabetes Association, said in an interview at the meeting.

“This may be the first time that it's been shown to be linked to heart failure in a type 1 population,” Dr. Kirkman added.

She called the study “hypothesis-generating,” and noted that a long-term randomized trial will be needed to confirm the findings.

“It is interesting, because it seems that in type 1 diabetes there may be a stronger link between glucose lowering and cardiac outcomes than in type 2 diabetes,” she said.

Dr. Lind and his coinvestigators acknowledged certain limitations of the study, including its observational design and the fact that only data on hospital admission for heart failure were available from the Swedish national diabetes registry, “so the true incidence of heart failure could be underestimated.”

They added: “Patients with early signs of heart failure, or asymptomatic heart failure detectable by echocardiography, will not have been captured.”

SAN DIEGO – Girls with type 1 diabetes had significantly increased mean hemoglobin A_1c levels, body mass index, LDL cholesterol, and C-reactive protein, compared with boys who have the disease, results from a single-center study demonstrated.

The finding suggests that adolescence "may be a critical period for CVD prevention in girls with type 1 diabetes," Talia L. Brown said at the annual scientific sessions of the American Diabetes Association. "Future studies should investigate factors contributing to these gender differences."

Adults with type 1 diabetes are known to have a higher risk of cardiovascular disease compared with nondiabetic adults, said Ms. Brown, a graduate student who is a research assistant at the Barbara Davis Center for Childhood Diabetes, Aurora, Colo.

"There is a greater relative increase in women, where women with type 1 diabetes have four times the CVD risk as nondiabetic women," Ms. Brown said. "Meanwhile, men with type 1 diabetes have two times greater CVD risk than nondiabetic men. It is uncertain when these gender differences begin."

To find out, she and her associates compared the CVD risk profile of 302 adolescents with type 1 diabetes with 100 nondiabetic adolescents and evaluated gender differences between the groups. The adolescents’ mean age was 15 years. Tanner stage was assessed by a physician or self report at the visit. Measures included fasting lipids, assays for HbA_1c and C-reactive protein, diastolic and systolic blood pressure, and body mass index z score. The researchers used questionnaires to assess physical activity and average insulin dose, and multivariate linear regression to examine each CVD risk factor.

Ms. Brown reported that physical activity was equivalent among the study participants (a mean of about 2 hours per day), and insulin dose was similar between boys and girls (a mean of 1.1 vs. 1.2 units/kg, respectively).

Compared with boys with type 1 diabetes, girls with the disease had significantly increased mean hemoglobin A_1c (9.1% vs. 8.7%, respectively), BMI z score (0.72 vs. 0.49), LDL cholesterol (95 mg/dL vs. 82 mg/dL), and CRP (0.86 mg/dL vs. 0.15 mg/dL). Boys with type 1 had higher levels of systolic blood pressure, compared with girls with the disease – 115 mm Hg vs. 111 mm Hg, respectively. But girls with type 1 had higher levels of systolic blood pressure, compared with nondiabetic girls (111 mm Hg vs. 106 mm Hg, respectively).

"Girls with diabetes had higher LDL levels than both boys with type 1 diabetes and girls without diabetes," Ms. Brown added. "CRP was ninefold higher in girls with type 1 diabetes than in both girls without diabetes and boys with type 1 diabetes."

After adjustment for HbA_1c and BMI z score, a significant increase in CRP and LDL in girls with type 1 diabetes remained. The researchers also found a significant interaction between gender and diabetes, "causing type 1 diabetes to have a more detrimental effect in girls than in boys with regard to LDL cholesterol and systolic blood pressure," Ms. Brown said.

Increased HbA_1c and body mass index "are likely to contribute to the increased blood pressure, inflammation, and cholesterol that we observed in girls with type 1 diabetes," she said. "These findings are somewhat unexpected, because generally there can be an inverse relationship between glycemic control and weight. Increased HbA_1c and obesity are likely to translate into worse CVD outcomes for females, and raises concern for the long-term effects in CVD health."

When asked to speculate why HbA_1c and body mass index were increased in girls with type 1, Ms. Brown said that girls generally "have a hard time controlling both [factors], so it’s hard to know what’s contributing to this."

Prevention efforts such as maintaining a healthy diet, getting adequate physical exercise, and controlling blood pressure and cholesterol levels "may improve this problem," she said.

The study was funded by the Juvenile Diabetes Research Foundation, the National Institute of Diabetes and Digestive and Kidney Diseases, and Children’s Hospital Colorado Clinical Translational Research Center.

Ms. Brown said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Girls with type 1 diabetes had significantly increased mean hemoglobin A_1c levels, body mass index, LDL cholesterol, and C-reactive protein, compared with boys who have the disease, results from a single-center study demonstrated.

The finding suggests that adolescence "may be a critical period for CVD prevention in girls with type 1 diabetes," Talia L. Brown said at the annual scientific sessions of the American Diabetes Association. "Future studies should investigate factors contributing to these gender differences."

Adults with type 1 diabetes are known to have a higher risk of cardiovascular disease compared with nondiabetic adults, said Ms. Brown, a graduate student who is a research assistant at the Barbara Davis Center for Childhood Diabetes, Aurora, Colo.

"There is a greater relative increase in women, where women with type 1 diabetes have four times the CVD risk as nondiabetic women," Ms. Brown said. "Meanwhile, men with type 1 diabetes have two times greater CVD risk than nondiabetic men. It is uncertain when these gender differences begin."

To find out, she and her associates compared the CVD risk profile of 302 adolescents with type 1 diabetes with 100 nondiabetic adolescents and evaluated gender differences between the groups. The adolescents’ mean age was 15 years. Tanner stage was assessed by a physician or self report at the visit. Measures included fasting lipids, assays for HbA_1c and C-reactive protein, diastolic and systolic blood pressure, and body mass index z score. The researchers used questionnaires to assess physical activity and average insulin dose, and multivariate linear regression to examine each CVD risk factor.

Ms. Brown reported that physical activity was equivalent among the study participants (a mean of about 2 hours per day), and insulin dose was similar between boys and girls (a mean of 1.1 vs. 1.2 units/kg, respectively).

Compared with boys with type 1 diabetes, girls with the disease had significantly increased mean hemoglobin A_1c (9.1% vs. 8.7%, respectively), BMI z score (0.72 vs. 0.49), LDL cholesterol (95 mg/dL vs. 82 mg/dL), and CRP (0.86 mg/dL vs. 0.15 mg/dL). Boys with type 1 had higher levels of systolic blood pressure, compared with girls with the disease – 115 mm Hg vs. 111 mm Hg, respectively. But girls with type 1 had higher levels of systolic blood pressure, compared with nondiabetic girls (111 mm Hg vs. 106 mm Hg, respectively).

"Girls with diabetes had higher LDL levels than both boys with type 1 diabetes and girls without diabetes," Ms. Brown added. "CRP was ninefold higher in girls with type 1 diabetes than in both girls without diabetes and boys with type 1 diabetes."

After adjustment for HbA_1c and BMI z score, a significant increase in CRP and LDL in girls with type 1 diabetes remained. The researchers also found a significant interaction between gender and diabetes, "causing type 1 diabetes to have a more detrimental effect in girls than in boys with regard to LDL cholesterol and systolic blood pressure," Ms. Brown said.

Increased HbA_1c and body mass index "are likely to contribute to the increased blood pressure, inflammation, and cholesterol that we observed in girls with type 1 diabetes," she said. "These findings are somewhat unexpected, because generally there can be an inverse relationship between glycemic control and weight. Increased HbA_1c and obesity are likely to translate into worse CVD outcomes for females, and raises concern for the long-term effects in CVD health."

When asked to speculate why HbA_1c and body mass index were increased in girls with type 1, Ms. Brown said that girls generally "have a hard time controlling both [factors], so it’s hard to know what’s contributing to this."

Prevention efforts such as maintaining a healthy diet, getting adequate physical exercise, and controlling blood pressure and cholesterol levels "may improve this problem," she said.

The study was funded by the Juvenile Diabetes Research Foundation, the National Institute of Diabetes and Digestive and Kidney Diseases, and Children’s Hospital Colorado Clinical Translational Research Center.

Ms. Brown said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Girls with type 1 diabetes had significantly increased mean hemoglobin A_1c levels, body mass index, LDL cholesterol, and C-reactive protein, compared with boys who have the disease, results from a single-center study demonstrated.

The finding suggests that adolescence "may be a critical period for CVD prevention in girls with type 1 diabetes," Talia L. Brown said at the annual scientific sessions of the American Diabetes Association. "Future studies should investigate factors contributing to these gender differences."

Adults with type 1 diabetes are known to have a higher risk of cardiovascular disease compared with nondiabetic adults, said Ms. Brown, a graduate student who is a research assistant at the Barbara Davis Center for Childhood Diabetes, Aurora, Colo.

"There is a greater relative increase in women, where women with type 1 diabetes have four times the CVD risk as nondiabetic women," Ms. Brown said. "Meanwhile, men with type 1 diabetes have two times greater CVD risk than nondiabetic men. It is uncertain when these gender differences begin."

To find out, she and her associates compared the CVD risk profile of 302 adolescents with type 1 diabetes with 100 nondiabetic adolescents and evaluated gender differences between the groups. The adolescents’ mean age was 15 years. Tanner stage was assessed by a physician or self report at the visit. Measures included fasting lipids, assays for HbA_1c and C-reactive protein, diastolic and systolic blood pressure, and body mass index z score. The researchers used questionnaires to assess physical activity and average insulin dose, and multivariate linear regression to examine each CVD risk factor.

Ms. Brown reported that physical activity was equivalent among the study participants (a mean of about 2 hours per day), and insulin dose was similar between boys and girls (a mean of 1.1 vs. 1.2 units/kg, respectively).

Compared with boys with type 1 diabetes, girls with the disease had significantly increased mean hemoglobin A_1c (9.1% vs. 8.7%, respectively), BMI z score (0.72 vs. 0.49), LDL cholesterol (95 mg/dL vs. 82 mg/dL), and CRP (0.86 mg/dL vs. 0.15 mg/dL). Boys with type 1 had higher levels of systolic blood pressure, compared with girls with the disease – 115 mm Hg vs. 111 mm Hg, respectively. But girls with type 1 had higher levels of systolic blood pressure, compared with nondiabetic girls (111 mm Hg vs. 106 mm Hg, respectively).

"Girls with diabetes had higher LDL levels than both boys with type 1 diabetes and girls without diabetes," Ms. Brown added. "CRP was ninefold higher in girls with type 1 diabetes than in both girls without diabetes and boys with type 1 diabetes."

After adjustment for HbA_1c and BMI z score, a significant increase in CRP and LDL in girls with type 1 diabetes remained. The researchers also found a significant interaction between gender and diabetes, "causing type 1 diabetes to have a more detrimental effect in girls than in boys with regard to LDL cholesterol and systolic blood pressure," Ms. Brown said.

Increased HbA_1c and body mass index "are likely to contribute to the increased blood pressure, inflammation, and cholesterol that we observed in girls with type 1 diabetes," she said. "These findings are somewhat unexpected, because generally there can be an inverse relationship between glycemic control and weight. Increased HbA_1c and obesity are likely to translate into worse CVD outcomes for females, and raises concern for the long-term effects in CVD health."

When asked to speculate why HbA_1c and body mass index were increased in girls with type 1, Ms. Brown said that girls generally "have a hard time controlling both [factors], so it’s hard to know what’s contributing to this."

Prevention efforts such as maintaining a healthy diet, getting adequate physical exercise, and controlling blood pressure and cholesterol levels "may improve this problem," she said.

The study was funded by the Juvenile Diabetes Research Foundation, the National Institute of Diabetes and Digestive and Kidney Diseases, and Children’s Hospital Colorado Clinical Translational Research Center.

Ms. Brown said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Girls with type 1 diabetes had significantly increased mean hemoglobin A_1c levels, body mass index, LDL cholesterol, and C-reactive protein, compared with boys who have the disease, results from a single-center study demonstrated.

The finding suggests that adolescence "may be a critical period for CVD prevention in girls with type 1 diabetes," Talia L. Brown said at the annual scientific sessions of the American Diabetes Association. "Future studies should investigate factors contributing to these gender differences."

Adults with type 1 diabetes are known to have a higher risk of cardiovascular disease compared with nondiabetic adults, said Ms. Brown, a graduate student who is a research assistant at the Barbara Davis Center for Childhood Diabetes, Aurora, Colo.

"There is a greater relative increase in women, where women with type 1 diabetes have four times the CVD risk as nondiabetic women," Ms. Brown said. "Meanwhile, men with type 1 diabetes have two times greater CVD risk than nondiabetic men. It is uncertain when these gender differences begin."

To find out, she and her associates compared the CVD risk profile of 302 adolescents with type 1 diabetes with 100 nondiabetic adolescents and evaluated gender differences between the groups. The adolescents’ mean age was 15 years. Tanner stage was assessed by a physician or self report at the visit. Measures included fasting lipids, assays for HbA_1c and C-reactive protein, diastolic and systolic blood pressure, and body mass index z score. The researchers used questionnaires to assess physical activity and average insulin dose, and multivariate linear regression to examine each CVD risk factor.

Ms. Brown reported that physical activity was equivalent among the study participants (a mean of about 2 hours per day), and insulin dose was similar between boys and girls (a mean of 1.1 vs. 1.2 units/kg, respectively).

Compared with boys with type 1 diabetes, girls with the disease had significantly increased mean hemoglobin A_1c (9.1% vs. 8.7%, respectively), BMI z score (0.72 vs. 0.49), LDL cholesterol (95 mg/dL vs. 82 mg/dL), and CRP (0.86 mg/dL vs. 0.15 mg/dL). Boys with type 1 had higher levels of systolic blood pressure, compared with girls with the disease – 115 mm Hg vs. 111 mm Hg, respectively. But girls with type 1 had higher levels of systolic blood pressure, compared with nondiabetic girls (111 mm Hg vs. 106 mm Hg, respectively).

"Girls with diabetes had higher LDL levels than both boys with type 1 diabetes and girls without diabetes," Ms. Brown added. "CRP was ninefold higher in girls with type 1 diabetes than in both girls without diabetes and boys with type 1 diabetes."

After adjustment for HbA_1c and BMI z score, a significant increase in CRP and LDL in girls with type 1 diabetes remained. The researchers also found a significant interaction between gender and diabetes, "causing type 1 diabetes to have a more detrimental effect in girls than in boys with regard to LDL cholesterol and systolic blood pressure," Ms. Brown said.

Increased HbA_1c and body mass index "are likely to contribute to the increased blood pressure, inflammation, and cholesterol that we observed in girls with type 1 diabetes," she said. "These findings are somewhat unexpected, because generally there can be an inverse relationship between glycemic control and weight. Increased HbA_1c and obesity are likely to translate into worse CVD outcomes for females, and raises concern for the long-term effects in CVD health."

When asked to speculate why HbA_1c and body mass index were increased in girls with type 1, Ms. Brown said that girls generally "have a hard time controlling both [factors], so it’s hard to know what’s contributing to this."

Prevention efforts such as maintaining a healthy diet, getting adequate physical exercise, and controlling blood pressure and cholesterol levels "may improve this problem," she said.

The study was funded by the Juvenile Diabetes Research Foundation, the National Institute of Diabetes and Digestive and Kidney Diseases, and Children’s Hospital Colorado Clinical Translational Research Center.

Ms. Brown said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Girls with type 1 diabetes had significantly increased mean hemoglobin A_1c levels, body mass index, LDL cholesterol, and C-reactive protein, compared with boys who have the disease, results from a single-center study demonstrated.

The finding suggests that adolescence "may be a critical period for CVD prevention in girls with type 1 diabetes," Talia L. Brown said at the annual scientific sessions of the American Diabetes Association. "Future studies should investigate factors contributing to these gender differences."

Adults with type 1 diabetes are known to have a higher risk of cardiovascular disease compared with nondiabetic adults, said Ms. Brown, a graduate student who is a research assistant at the Barbara Davis Center for Childhood Diabetes, Aurora, Colo.

"There is a greater relative increase in women, where women with type 1 diabetes have four times the CVD risk as nondiabetic women," Ms. Brown said. "Meanwhile, men with type 1 diabetes have two times greater CVD risk than nondiabetic men. It is uncertain when these gender differences begin."

To find out, she and her associates compared the CVD risk profile of 302 adolescents with type 1 diabetes with 100 nondiabetic adolescents and evaluated gender differences between the groups. The adolescents’ mean age was 15 years. Tanner stage was assessed by a physician or self report at the visit. Measures included fasting lipids, assays for HbA_1c and C-reactive protein, diastolic and systolic blood pressure, and body mass index z score. The researchers used questionnaires to assess physical activity and average insulin dose, and multivariate linear regression to examine each CVD risk factor.

Ms. Brown reported that physical activity was equivalent among the study participants (a mean of about 2 hours per day), and insulin dose was similar between boys and girls (a mean of 1.1 vs. 1.2 units/kg, respectively).

Compared with boys with type 1 diabetes, girls with the disease had significantly increased mean hemoglobin A_1c (9.1% vs. 8.7%, respectively), BMI z score (0.72 vs. 0.49), LDL cholesterol (95 mg/dL vs. 82 mg/dL), and CRP (0.86 mg/dL vs. 0.15 mg/dL). Boys with type 1 had higher levels of systolic blood pressure, compared with girls with the disease – 115 mm Hg vs. 111 mm Hg, respectively. But girls with type 1 had higher levels of systolic blood pressure, compared with nondiabetic girls (111 mm Hg vs. 106 mm Hg, respectively).

"Girls with diabetes had higher LDL levels than both boys with type 1 diabetes and girls without diabetes," Ms. Brown added. "CRP was ninefold higher in girls with type 1 diabetes than in both girls without diabetes and boys with type 1 diabetes."

After adjustment for HbA_1c and BMI z score, a significant increase in CRP and LDL in girls with type 1 diabetes remained. The researchers also found a significant interaction between gender and diabetes, "causing type 1 diabetes to have a more detrimental effect in girls than in boys with regard to LDL cholesterol and systolic blood pressure," Ms. Brown said.

Increased HbA_1c and body mass index "are likely to contribute to the increased blood pressure, inflammation, and cholesterol that we observed in girls with type 1 diabetes," she said. "These findings are somewhat unexpected, because generally there can be an inverse relationship between glycemic control and weight. Increased HbA_1c and obesity are likely to translate into worse CVD outcomes for females, and raises concern for the long-term effects in CVD health."

When asked to speculate why HbA_1c and body mass index were increased in girls with type 1, Ms. Brown said that girls generally "have a hard time controlling both [factors], so it’s hard to know what’s contributing to this."

Prevention efforts such as maintaining a healthy diet, getting adequate physical exercise, and controlling blood pressure and cholesterol levels "may improve this problem," she said.

The study was funded by the Juvenile Diabetes Research Foundation, the National Institute of Diabetes and Digestive and Kidney Diseases, and Children’s Hospital Colorado Clinical Translational Research Center.

Ms. Brown said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Girls with type 1 diabetes had significantly increased mean hemoglobin A_1c levels, body mass index, LDL cholesterol, and C-reactive protein, compared with boys who have the disease, results from a single-center study demonstrated.

The finding suggests that adolescence "may be a critical period for CVD prevention in girls with type 1 diabetes," Talia L. Brown said at the annual scientific sessions of the American Diabetes Association. "Future studies should investigate factors contributing to these gender differences."

Adults with type 1 diabetes are known to have a higher risk of cardiovascular disease compared with nondiabetic adults, said Ms. Brown, a graduate student who is a research assistant at the Barbara Davis Center for Childhood Diabetes, Aurora, Colo.

"There is a greater relative increase in women, where women with type 1 diabetes have four times the CVD risk as nondiabetic women," Ms. Brown said. "Meanwhile, men with type 1 diabetes have two times greater CVD risk than nondiabetic men. It is uncertain when these gender differences begin."

To find out, she and her associates compared the CVD risk profile of 302 adolescents with type 1 diabetes with 100 nondiabetic adolescents and evaluated gender differences between the groups. The adolescents’ mean age was 15 years. Tanner stage was assessed by a physician or self report at the visit. Measures included fasting lipids, assays for HbA_1c and C-reactive protein, diastolic and systolic blood pressure, and body mass index z score. The researchers used questionnaires to assess physical activity and average insulin dose, and multivariate linear regression to examine each CVD risk factor.

Ms. Brown reported that physical activity was equivalent among the study participants (a mean of about 2 hours per day), and insulin dose was similar between boys and girls (a mean of 1.1 vs. 1.2 units/kg, respectively).

Compared with boys with type 1 diabetes, girls with the disease had significantly increased mean hemoglobin A_1c (9.1% vs. 8.7%, respectively), BMI z score (0.72 vs. 0.49), LDL cholesterol (95 mg/dL vs. 82 mg/dL), and CRP (0.86 mg/dL vs. 0.15 mg/dL). Boys with type 1 had higher levels of systolic blood pressure, compared with girls with the disease – 115 mm Hg vs. 111 mm Hg, respectively. But girls with type 1 had higher levels of systolic blood pressure, compared with nondiabetic girls (111 mm Hg vs. 106 mm Hg, respectively).

"Girls with diabetes had higher LDL levels than both boys with type 1 diabetes and girls without diabetes," Ms. Brown added. "CRP was ninefold higher in girls with type 1 diabetes than in both girls without diabetes and boys with type 1 diabetes."

After adjustment for HbA_1c and BMI z score, a significant increase in CRP and LDL in girls with type 1 diabetes remained. The researchers also found a significant interaction between gender and diabetes, "causing type 1 diabetes to have a more detrimental effect in girls than in boys with regard to LDL cholesterol and systolic blood pressure," Ms. Brown said.

Increased HbA_1c and body mass index "are likely to contribute to the increased blood pressure, inflammation, and cholesterol that we observed in girls with type 1 diabetes," she said. "These findings are somewhat unexpected, because generally there can be an inverse relationship between glycemic control and weight. Increased HbA_1c and obesity are likely to translate into worse CVD outcomes for females, and raises concern for the long-term effects in CVD health."

When asked to speculate why HbA_1c and body mass index were increased in girls with type 1, Ms. Brown said that girls generally "have a hard time controlling both [factors], so it’s hard to know what’s contributing to this."

Prevention efforts such as maintaining a healthy diet, getting adequate physical exercise, and controlling blood pressure and cholesterol levels "may improve this problem," she said.

The study was funded by the Juvenile Diabetes Research Foundation, the National Institute of Diabetes and Digestive and Kidney Diseases, and Children’s Hospital Colorado Clinical Translational Research Center.

Ms. Brown said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Since the mid-2000s clinicians dramatically shifted away from prescribing rosiglitazone and pioglitazone in favor of other novel type 2 diabetes medications, results from a large, single-center suggest.

At the annual scientific sessions of the American Diabetes Association, Dr. Sanjeev N. Mehta presented findings from a study of electronic medical records at Joslin Diabetes Center, Boston, that evaluated 10-year prescribing patterns for rosiglitazone and pioglitazone, as well as uptake of novel drug classes (categorized as "other") approved between 2001 and 2010. The "other" group consisted of amylin analogs, GLP-1 analogs, DPP-IV inhibitors, and bile acid sequestrants. Insulin use was not studied, nor were medications introduced prior to 2001.

The analysis aimed to measure provider response to the 2007 FDA black box warning for rosiglitazone, which was implemented due to the drug’s association with adverse cardiovascular outcomes.

"Given the availability of these new drugs, there’s a need to better understand provider patterns reading the use of new and established medications, [including] responsiveness to FDA indications and safety warnings," said Dr. Mehta, a staff physician at Joslin Diabetes Center.

Electronic health records with integrated prescribing functionality "may best describe provider behaviors, as their content is not limited top patient claims," he added. "Further, the detailed clinical information may provide the information necessary to validate both patient conditions and health outcomes."

Eligible patients had a diagnosis of type 2 diabetes based on an algorithm that used ICD-9 codes and a field that specified diabetes type. If a medication was used and later resumed, he and his associates used the earliest start date. For validation they conducted a manual review of 60 random electronic medical records.

Over the 10-year study period, 7,846 patients with type 2 diabetes had 9,178 new prescriptions for rosiglitazone, pioglitazone, and other agents. After 2007, the number of new prescriptions for rosiglitazone and pioglitazone declined dramatically.

By 2010, new prescriptions for rosiglitazone and pioglitazone were at 7% and 47%, respectively, of peak levels. The relative proportion of prescriptions for rosiglitazone, pioglitazone, and other medications was 44%, 50%, and 6% in 2005 and 2%, 18%, and 80% in 2010.

"Prescribing patterns may be described using EHR-based clinical data," Dr. Mehta concluded. "The data suggest provider responsiveness to an FDA warning for an established medication, as well as rapid adoption of new drugs and drug classes during this period. However, the explanation for provider behaviors cannot be fully determined in the present analysis, but merit further investigation."

Dr. Mehta said that he had no relevant financial conflicts to disclose.

SAN DIEGO – Since the mid-2000s clinicians dramatically shifted away from prescribing rosiglitazone and pioglitazone in favor of other novel type 2 diabetes medications, results from a large, single-center suggest.

At the annual scientific sessions of the American Diabetes Association, Dr. Sanjeev N. Mehta presented findings from a study of electronic medical records at Joslin Diabetes Center, Boston, that evaluated 10-year prescribing patterns for rosiglitazone and pioglitazone, as well as uptake of novel drug classes (categorized as "other") approved between 2001 and 2010. The "other" group consisted of amylin analogs, GLP-1 analogs, DPP-IV inhibitors, and bile acid sequestrants. Insulin use was not studied, nor were medications introduced prior to 2001.

The analysis aimed to measure provider response to the 2007 FDA black box warning for rosiglitazone, which was implemented due to the drug’s association with adverse cardiovascular outcomes.

"Given the availability of these new drugs, there’s a need to better understand provider patterns reading the use of new and established medications, [including] responsiveness to FDA indications and safety warnings," said Dr. Mehta, a staff physician at Joslin Diabetes Center.

Electronic health records with integrated prescribing functionality "may best describe provider behaviors, as their content is not limited top patient claims," he added. "Further, the detailed clinical information may provide the information necessary to validate both patient conditions and health outcomes."

Eligible patients had a diagnosis of type 2 diabetes based on an algorithm that used ICD-9 codes and a field that specified diabetes type. If a medication was used and later resumed, he and his associates used the earliest start date. For validation they conducted a manual review of 60 random electronic medical records.

Over the 10-year study period, 7,846 patients with type 2 diabetes had 9,178 new prescriptions for rosiglitazone, pioglitazone, and other agents. After 2007, the number of new prescriptions for rosiglitazone and pioglitazone declined dramatically.

By 2010, new prescriptions for rosiglitazone and pioglitazone were at 7% and 47%, respectively, of peak levels. The relative proportion of prescriptions for rosiglitazone, pioglitazone, and other medications was 44%, 50%, and 6% in 2005 and 2%, 18%, and 80% in 2010.

"Prescribing patterns may be described using EHR-based clinical data," Dr. Mehta concluded. "The data suggest provider responsiveness to an FDA warning for an established medication, as well as rapid adoption of new drugs and drug classes during this period. However, the explanation for provider behaviors cannot be fully determined in the present analysis, but merit further investigation."

Dr. Mehta said that he had no relevant financial conflicts to disclose.

SAN DIEGO – Since the mid-2000s clinicians dramatically shifted away from prescribing rosiglitazone and pioglitazone in favor of other novel type 2 diabetes medications, results from a large, single-center suggest.

At the annual scientific sessions of the American Diabetes Association, Dr. Sanjeev N. Mehta presented findings from a study of electronic medical records at Joslin Diabetes Center, Boston, that evaluated 10-year prescribing patterns for rosiglitazone and pioglitazone, as well as uptake of novel drug classes (categorized as "other") approved between 2001 and 2010. The "other" group consisted of amylin analogs, GLP-1 analogs, DPP-IV inhibitors, and bile acid sequestrants. Insulin use was not studied, nor were medications introduced prior to 2001.

The analysis aimed to measure provider response to the 2007 FDA black box warning for rosiglitazone, which was implemented due to the drug’s association with adverse cardiovascular outcomes.

"Given the availability of these new drugs, there’s a need to better understand provider patterns reading the use of new and established medications, [including] responsiveness to FDA indications and safety warnings," said Dr. Mehta, a staff physician at Joslin Diabetes Center.

Electronic health records with integrated prescribing functionality "may best describe provider behaviors, as their content is not limited top patient claims," he added. "Further, the detailed clinical information may provide the information necessary to validate both patient conditions and health outcomes."

Eligible patients had a diagnosis of type 2 diabetes based on an algorithm that used ICD-9 codes and a field that specified diabetes type. If a medication was used and later resumed, he and his associates used the earliest start date. For validation they conducted a manual review of 60 random electronic medical records.

Over the 10-year study period, 7,846 patients with type 2 diabetes had 9,178 new prescriptions for rosiglitazone, pioglitazone, and other agents. After 2007, the number of new prescriptions for rosiglitazone and pioglitazone declined dramatically.

By 2010, new prescriptions for rosiglitazone and pioglitazone were at 7% and 47%, respectively, of peak levels. The relative proportion of prescriptions for rosiglitazone, pioglitazone, and other medications was 44%, 50%, and 6% in 2005 and 2%, 18%, and 80% in 2010.

"Prescribing patterns may be described using EHR-based clinical data," Dr. Mehta concluded. "The data suggest provider responsiveness to an FDA warning for an established medication, as well as rapid adoption of new drugs and drug classes during this period. However, the explanation for provider behaviors cannot be fully determined in the present analysis, but merit further investigation."

Dr. Mehta said that he had no relevant financial conflicts to disclose.

SAN DIEGO – Since the mid-2000s clinicians dramatically shifted away from prescribing rosiglitazone and pioglitazone in favor of other novel type 2 diabetes medications, results from a large, single-center suggest.

At the annual scientific sessions of the American Diabetes Association, Dr. Sanjeev N. Mehta presented findings from a study of electronic medical records at Joslin Diabetes Center, Boston, that evaluated 10-year prescribing patterns for rosiglitazone and pioglitazone, as well as uptake of novel drug classes (categorized as "other") approved between 2001 and 2010. The "other" group consisted of amylin analogs, GLP-1 analogs, DPP-IV inhibitors, and bile acid sequestrants. Insulin use was not studied, nor were medications introduced prior to 2001.

The analysis aimed to measure provider response to the 2007 FDA black box warning for rosiglitazone, which was implemented due to the drug’s association with adverse cardiovascular outcomes.

"Given the availability of these new drugs, there’s a need to better understand provider patterns reading the use of new and established medications, [including] responsiveness to FDA indications and safety warnings," said Dr. Mehta, a staff physician at Joslin Diabetes Center.

Electronic health records with integrated prescribing functionality "may best describe provider behaviors, as their content is not limited top patient claims," he added. "Further, the detailed clinical information may provide the information necessary to validate both patient conditions and health outcomes."

Eligible patients had a diagnosis of type 2 diabetes based on an algorithm that used ICD-9 codes and a field that specified diabetes type. If a medication was used and later resumed, he and his associates used the earliest start date. For validation they conducted a manual review of 60 random electronic medical records.

Over the 10-year study period, 7,846 patients with type 2 diabetes had 9,178 new prescriptions for rosiglitazone, pioglitazone, and other agents. After 2007, the number of new prescriptions for rosiglitazone and pioglitazone declined dramatically.

By 2010, new prescriptions for rosiglitazone and pioglitazone were at 7% and 47%, respectively, of peak levels. The relative proportion of prescriptions for rosiglitazone, pioglitazone, and other medications was 44%, 50%, and 6% in 2005 and 2%, 18%, and 80% in 2010.

"Prescribing patterns may be described using EHR-based clinical data," Dr. Mehta concluded. "The data suggest provider responsiveness to an FDA warning for an established medication, as well as rapid adoption of new drugs and drug classes during this period. However, the explanation for provider behaviors cannot be fully determined in the present analysis, but merit further investigation."

Dr. Mehta said that he had no relevant financial conflicts to disclose.

SAN DIEGO – Since the mid-2000s clinicians dramatically shifted away from prescribing rosiglitazone and pioglitazone in favor of other novel type 2 diabetes medications, results from a large, single-center suggest.

At the annual scientific sessions of the American Diabetes Association, Dr. Sanjeev N. Mehta presented findings from a study of electronic medical records at Joslin Diabetes Center, Boston, that evaluated 10-year prescribing patterns for rosiglitazone and pioglitazone, as well as uptake of novel drug classes (categorized as "other") approved between 2001 and 2010. The "other" group consisted of amylin analogs, GLP-1 analogs, DPP-IV inhibitors, and bile acid sequestrants. Insulin use was not studied, nor were medications introduced prior to 2001.

The analysis aimed to measure provider response to the 2007 FDA black box warning for rosiglitazone, which was implemented due to the drug’s association with adverse cardiovascular outcomes.

"Given the availability of these new drugs, there’s a need to better understand provider patterns reading the use of new and established medications, [including] responsiveness to FDA indications and safety warnings," said Dr. Mehta, a staff physician at Joslin Diabetes Center.

Electronic health records with integrated prescribing functionality "may best describe provider behaviors, as their content is not limited top patient claims," he added. "Further, the detailed clinical information may provide the information necessary to validate both patient conditions and health outcomes."

Eligible patients had a diagnosis of type 2 diabetes based on an algorithm that used ICD-9 codes and a field that specified diabetes type. If a medication was used and later resumed, he and his associates used the earliest start date. For validation they conducted a manual review of 60 random electronic medical records.

Over the 10-year study period, 7,846 patients with type 2 diabetes had 9,178 new prescriptions for rosiglitazone, pioglitazone, and other agents. After 2007, the number of new prescriptions for rosiglitazone and pioglitazone declined dramatically.

By 2010, new prescriptions for rosiglitazone and pioglitazone were at 7% and 47%, respectively, of peak levels. The relative proportion of prescriptions for rosiglitazone, pioglitazone, and other medications was 44%, 50%, and 6% in 2005 and 2%, 18%, and 80% in 2010.

"Prescribing patterns may be described using EHR-based clinical data," Dr. Mehta concluded. "The data suggest provider responsiveness to an FDA warning for an established medication, as well as rapid adoption of new drugs and drug classes during this period. However, the explanation for provider behaviors cannot be fully determined in the present analysis, but merit further investigation."

Dr. Mehta said that he had no relevant financial conflicts to disclose.

SAN DIEGO – Since the mid-2000s clinicians dramatically shifted away from prescribing rosiglitazone and pioglitazone in favor of other novel type 2 diabetes medications, results from a large, single-center suggest.

At the annual scientific sessions of the American Diabetes Association, Dr. Sanjeev N. Mehta presented findings from a study of electronic medical records at Joslin Diabetes Center, Boston, that evaluated 10-year prescribing patterns for rosiglitazone and pioglitazone, as well as uptake of novel drug classes (categorized as "other") approved between 2001 and 2010. The "other" group consisted of amylin analogs, GLP-1 analogs, DPP-IV inhibitors, and bile acid sequestrants. Insulin use was not studied, nor were medications introduced prior to 2001.

The analysis aimed to measure provider response to the 2007 FDA black box warning for rosiglitazone, which was implemented due to the drug’s association with adverse cardiovascular outcomes.

"Given the availability of these new drugs, there’s a need to better understand provider patterns reading the use of new and established medications, [including] responsiveness to FDA indications and safety warnings," said Dr. Mehta, a staff physician at Joslin Diabetes Center.

Electronic health records with integrated prescribing functionality "may best describe provider behaviors, as their content is not limited top patient claims," he added. "Further, the detailed clinical information may provide the information necessary to validate both patient conditions and health outcomes."

Eligible patients had a diagnosis of type 2 diabetes based on an algorithm that used ICD-9 codes and a field that specified diabetes type. If a medication was used and later resumed, he and his associates used the earliest start date. For validation they conducted a manual review of 60 random electronic medical records.

Over the 10-year study period, 7,846 patients with type 2 diabetes had 9,178 new prescriptions for rosiglitazone, pioglitazone, and other agents. After 2007, the number of new prescriptions for rosiglitazone and pioglitazone declined dramatically.

By 2010, new prescriptions for rosiglitazone and pioglitazone were at 7% and 47%, respectively, of peak levels. The relative proportion of prescriptions for rosiglitazone, pioglitazone, and other medications was 44%, 50%, and 6% in 2005 and 2%, 18%, and 80% in 2010.

"Prescribing patterns may be described using EHR-based clinical data," Dr. Mehta concluded. "The data suggest provider responsiveness to an FDA warning for an established medication, as well as rapid adoption of new drugs and drug classes during this period. However, the explanation for provider behaviors cannot be fully determined in the present analysis, but merit further investigation."

Dr. Mehta said that he had no relevant financial conflicts to disclose.

SAN DIEGO – Tight control of hemoglobin A_1c levels significantly reduces the risk of heart failure in patients with type 1 diabetes, results from a large, long-term study show.

In fact, patients with very poor glycemic control were four times as likely to experience heart failure, compared with their counterparts with optimal glycemic control.

"Because treatment for heart failure improves survival and quality of life, clinicians should be observant of signs of heart failure in management of patients with type 1 diabetes, starting at an early stage," lead author Dr. Marcus Lind wrote in the study, which was presented at the annual scientific sessions of the American Diabetes Association and simultaneously published online in the Lancet on June 25. "Echocardiography might be warranted, especially in the presence of poor glycemic control, long duration of diabetes, or an adverse risk factor profile."

Dr. Lind of the department of medicine at Uddevalla (Sweden) Hospital and his associates used the Swedish national diabetes registry to identify 20,985 patients aged 18 years or older with type 1 disease who had no known heart failure and who were registered between January 1998 and December 2003. They followed the cohort until hospital admission for heart failure, death, or end of follow-up on Dec. 31, 2009 (Lancet 2011 June 25 [doi: 10.1016/S0140-6736(11)60471-6]).

The incidence of heart failure was determined by dividing the number of patient-years of follow-up in a particular HbA_1c category, reported as events per 1,000 years of follow-up. The six HbA_1c categories were less than 6.5%, from 6.5% to less than 7.5%, from 7.5% to less than 8.5%, from 8.5% to less than 9.5%, from 9.5% to less than 10.5%, and 10.5% or greater. Cox regression analysis was used to study possible associations between heart failure and patients’ characteristics.

The mean age of patients was 39 years, and 45% were female; they had had diabetes for a mean of 14 years, and their mean body mass index was 25 kg/m². During a median follow-up of 9 years, 635 patients (3%) were admitted with a primary or secondary diagnosis of heart failure, for an incidence of 3.38 per 1,000 patient-years. The incidence of heart failure increased in a stepwise fashion as HbA_1c levels increased, from an incidence of 1.42 per 1,000 patient-years among patients in the below-6.5% category of HbA_1c to an incidence of 5.20 per 1,000 patient-years among those in the 10.5% or higher category of HbA_1c.

After adjustment for age, sex, duration of diabetes, cardiovascular disease risk factors, acute myocardial infarction, and other comorbidities, a Cox regression analysis revealed that patients with an HbA_1c level of 10.5% or higher were four times more likely to develop heart failure than were those who had an HbA_1c level of less than 6.5%.

Other independent predictors of heart failure included age (hazard ratio, 1.64 per 10-year increase); duration of diabetes (HR, 1.34 per 10-year increase); BMI (HR, 1.05 per 1 kg/m² increase); systolic blood pressure (HR, 1.15 per 10 mm Hg increase); smoking (HR, 1.11-1.90, according to reported frequency); valve surgery (HR, 2.32); atrial fibrillation (HR 1.89); myocardial infarction (HR, 6.42), and ischemic heart disease (HR, 2.9).

"For many years there have observations that poor glycemic control is linked to heart attack and cardiovascular mortality," Dr. Sue Kirkman, senior vice president of medical affairs and community information for the American Diabetes Association, said in an interview at the meeting. "This may be the first time that it’s been shown to be linked to heart failure in a type 1 population."

She called the study "hypothesis-generating," and noted that a long-term randomized trial will be needed to confirm the findings. "It is interesting, because it seems that in type 1 diabetes there may be a stronger link between glucose lowering and cardiac outcomes than in type 2 diabetes," she said.

The researchers acknowledged certain limitations of the study, including its observational design and the fact that only data on hospital admission for heart failure were available from the Swedish national diabetes registry, "so the true incidence of heart failure could be underestimated," they wrote. "Patients with early signs of heart failure, or asymptomatic heart failure detectable by echocardiography, will not have been captured."

The study was supported by an unrestricted grant from AstraZeneca, Novo Nordisk Scandinavia, the Swedish Heart and Lung Foundation, and the Swedish Research Council. Dr. Lind disclosed that he has received honoraria or served as consultant for Bayer, Eli Lilly, Novartis, Novo Nordisk Scandinavia, Medtronic Pfizer, and Sanofi-Aventis; and has been a member of an advisory board for Novo Nordisk Scandinavia.

SAN DIEGO – Tight control of hemoglobin A_1c levels significantly reduces the risk of heart failure in patients with type 1 diabetes, results from a large, long-term study show.

In fact, patients with very poor glycemic control were four times as likely to experience heart failure, compared with their counterparts with optimal glycemic control.

"Because treatment for heart failure improves survival and quality of life, clinicians should be observant of signs of heart failure in management of patients with type 1 diabetes, starting at an early stage," lead author Dr. Marcus Lind wrote in the study, which was presented at the annual scientific sessions of the American Diabetes Association and simultaneously published online in the Lancet on June 25. "Echocardiography might be warranted, especially in the presence of poor glycemic control, long duration of diabetes, or an adverse risk factor profile."

Dr. Lind of the department of medicine at Uddevalla (Sweden) Hospital and his associates used the Swedish national diabetes registry to identify 20,985 patients aged 18 years or older with type 1 disease who had no known heart failure and who were registered between January 1998 and December 2003. They followed the cohort until hospital admission for heart failure, death, or end of follow-up on Dec. 31, 2009 (Lancet 2011 June 25 [doi: 10.1016/S0140-6736(11)60471-6]).

The incidence of heart failure was determined by dividing the number of patient-years of follow-up in a particular HbA_1c category, reported as events per 1,000 years of follow-up. The six HbA_1c categories were less than 6.5%, from 6.5% to less than 7.5%, from 7.5% to less than 8.5%, from 8.5% to less than 9.5%, from 9.5% to less than 10.5%, and 10.5% or greater. Cox regression analysis was used to study possible associations between heart failure and patients’ characteristics.

The mean age of patients was 39 years, and 45% were female; they had had diabetes for a mean of 14 years, and their mean body mass index was 25 kg/m². During a median follow-up of 9 years, 635 patients (3%) were admitted with a primary or secondary diagnosis of heart failure, for an incidence of 3.38 per 1,000 patient-years. The incidence of heart failure increased in a stepwise fashion as HbA_1c levels increased, from an incidence of 1.42 per 1,000 patient-years among patients in the below-6.5% category of HbA_1c to an incidence of 5.20 per 1,000 patient-years among those in the 10.5% or higher category of HbA_1c.

After adjustment for age, sex, duration of diabetes, cardiovascular disease risk factors, acute myocardial infarction, and other comorbidities, a Cox regression analysis revealed that patients with an HbA_1c level of 10.5% or higher were four times more likely to develop heart failure than were those who had an HbA_1c level of less than 6.5%.

Other independent predictors of heart failure included age (hazard ratio, 1.64 per 10-year increase); duration of diabetes (HR, 1.34 per 10-year increase); BMI (HR, 1.05 per 1 kg/m² increase); systolic blood pressure (HR, 1.15 per 10 mm Hg increase); smoking (HR, 1.11-1.90, according to reported frequency); valve surgery (HR, 2.32); atrial fibrillation (HR 1.89); myocardial infarction (HR, 6.42), and ischemic heart disease (HR, 2.9).

"For many years there have observations that poor glycemic control is linked to heart attack and cardiovascular mortality," Dr. Sue Kirkman, senior vice president of medical affairs and community information for the American Diabetes Association, said in an interview at the meeting. "This may be the first time that it’s been shown to be linked to heart failure in a type 1 population."

She called the study "hypothesis-generating," and noted that a long-term randomized trial will be needed to confirm the findings. "It is interesting, because it seems that in type 1 diabetes there may be a stronger link between glucose lowering and cardiac outcomes than in type 2 diabetes," she said.

The researchers acknowledged certain limitations of the study, including its observational design and the fact that only data on hospital admission for heart failure were available from the Swedish national diabetes registry, "so the true incidence of heart failure could be underestimated," they wrote. "Patients with early signs of heart failure, or asymptomatic heart failure detectable by echocardiography, will not have been captured."

The study was supported by an unrestricted grant from AstraZeneca, Novo Nordisk Scandinavia, the Swedish Heart and Lung Foundation, and the Swedish Research Council. Dr. Lind disclosed that he has received honoraria or served as consultant for Bayer, Eli Lilly, Novartis, Novo Nordisk Scandinavia, Medtronic Pfizer, and Sanofi-Aventis; and has been a member of an advisory board for Novo Nordisk Scandinavia.

SAN DIEGO – Tight control of hemoglobin A_1c levels significantly reduces the risk of heart failure in patients with type 1 diabetes, results from a large, long-term study show.

In fact, patients with very poor glycemic control were four times as likely to experience heart failure, compared with their counterparts with optimal glycemic control.

"Because treatment for heart failure improves survival and quality of life, clinicians should be observant of signs of heart failure in management of patients with type 1 diabetes, starting at an early stage," lead author Dr. Marcus Lind wrote in the study, which was presented at the annual scientific sessions of the American Diabetes Association and simultaneously published online in the Lancet on June 25. "Echocardiography might be warranted, especially in the presence of poor glycemic control, long duration of diabetes, or an adverse risk factor profile."

Dr. Lind of the department of medicine at Uddevalla (Sweden) Hospital and his associates used the Swedish national diabetes registry to identify 20,985 patients aged 18 years or older with type 1 disease who had no known heart failure and who were registered between January 1998 and December 2003. They followed the cohort until hospital admission for heart failure, death, or end of follow-up on Dec. 31, 2009 (Lancet 2011 June 25 [doi: 10.1016/S0140-6736(11)60471-6]).

The incidence of heart failure was determined by dividing the number of patient-years of follow-up in a particular HbA_1c category, reported as events per 1,000 years of follow-up. The six HbA_1c categories were less than 6.5%, from 6.5% to less than 7.5%, from 7.5% to less than 8.5%, from 8.5% to less than 9.5%, from 9.5% to less than 10.5%, and 10.5% or greater. Cox regression analysis was used to study possible associations between heart failure and patients’ characteristics.

The mean age of patients was 39 years, and 45% were female; they had had diabetes for a mean of 14 years, and their mean body mass index was 25 kg/m². During a median follow-up of 9 years, 635 patients (3%) were admitted with a primary or secondary diagnosis of heart failure, for an incidence of 3.38 per 1,000 patient-years. The incidence of heart failure increased in a stepwise fashion as HbA_1c levels increased, from an incidence of 1.42 per 1,000 patient-years among patients in the below-6.5% category of HbA_1c to an incidence of 5.20 per 1,000 patient-years among those in the 10.5% or higher category of HbA_1c.

After adjustment for age, sex, duration of diabetes, cardiovascular disease risk factors, acute myocardial infarction, and other comorbidities, a Cox regression analysis revealed that patients with an HbA_1c level of 10.5% or higher were four times more likely to develop heart failure than were those who had an HbA_1c level of less than 6.5%.

Other independent predictors of heart failure included age (hazard ratio, 1.64 per 10-year increase); duration of diabetes (HR, 1.34 per 10-year increase); BMI (HR, 1.05 per 1 kg/m² increase); systolic blood pressure (HR, 1.15 per 10 mm Hg increase); smoking (HR, 1.11-1.90, according to reported frequency); valve surgery (HR, 2.32); atrial fibrillation (HR 1.89); myocardial infarction (HR, 6.42), and ischemic heart disease (HR, 2.9).

"For many years there have observations that poor glycemic control is linked to heart attack and cardiovascular mortality," Dr. Sue Kirkman, senior vice president of medical affairs and community information for the American Diabetes Association, said in an interview at the meeting. "This may be the first time that it’s been shown to be linked to heart failure in a type 1 population."

She called the study "hypothesis-generating," and noted that a long-term randomized trial will be needed to confirm the findings. "It is interesting, because it seems that in type 1 diabetes there may be a stronger link between glucose lowering and cardiac outcomes than in type 2 diabetes," she said.

The researchers acknowledged certain limitations of the study, including its observational design and the fact that only data on hospital admission for heart failure were available from the Swedish national diabetes registry, "so the true incidence of heart failure could be underestimated," they wrote. "Patients with early signs of heart failure, or asymptomatic heart failure detectable by echocardiography, will not have been captured."

The study was supported by an unrestricted grant from AstraZeneca, Novo Nordisk Scandinavia, the Swedish Heart and Lung Foundation, and the Swedish Research Council. Dr. Lind disclosed that he has received honoraria or served as consultant for Bayer, Eli Lilly, Novartis, Novo Nordisk Scandinavia, Medtronic Pfizer, and Sanofi-Aventis; and has been a member of an advisory board for Novo Nordisk Scandinavia.

SAN DIEGO – Tight control of hemoglobin A_1c levels significantly reduces the risk of heart failure in patients with type 1 diabetes, results from a large, long-term study show.

In fact, patients with very poor glycemic control were four times as likely to experience heart failure, compared with their counterparts with optimal glycemic control.

"Because treatment for heart failure improves survival and quality of life, clinicians should be observant of signs of heart failure in management of patients with type 1 diabetes, starting at an early stage," lead author Dr. Marcus Lind wrote in the study, which was presented at the annual scientific sessions of the American Diabetes Association and simultaneously published online in the Lancet on June 25. "Echocardiography might be warranted, especially in the presence of poor glycemic control, long duration of diabetes, or an adverse risk factor profile."

Dr. Lind of the department of medicine at Uddevalla (Sweden) Hospital and his associates used the Swedish national diabetes registry to identify 20,985 patients aged 18 years or older with type 1 disease who had no known heart failure and who were registered between January 1998 and December 2003. They followed the cohort until hospital admission for heart failure, death, or end of follow-up on Dec. 31, 2009 (Lancet 2011 June 25 [doi: 10.1016/S0140-6736(11)60471-6]).

The incidence of heart failure was determined by dividing the number of patient-years of follow-up in a particular HbA_1c category, reported as events per 1,000 years of follow-up. The six HbA_1c categories were less than 6.5%, from 6.5% to less than 7.5%, from 7.5% to less than 8.5%, from 8.5% to less than 9.5%, from 9.5% to less than 10.5%, and 10.5% or greater. Cox regression analysis was used to study possible associations between heart failure and patients’ characteristics.

The mean age of patients was 39 years, and 45% were female; they had had diabetes for a mean of 14 years, and their mean body mass index was 25 kg/m². During a median follow-up of 9 years, 635 patients (3%) were admitted with a primary or secondary diagnosis of heart failure, for an incidence of 3.38 per 1,000 patient-years. The incidence of heart failure increased in a stepwise fashion as HbA_1c levels increased, from an incidence of 1.42 per 1,000 patient-years among patients in the below-6.5% category of HbA_1c to an incidence of 5.20 per 1,000 patient-years among those in the 10.5% or higher category of HbA_1c.

After adjustment for age, sex, duration of diabetes, cardiovascular disease risk factors, acute myocardial infarction, and other comorbidities, a Cox regression analysis revealed that patients with an HbA_1c level of 10.5% or higher were four times more likely to develop heart failure than were those who had an HbA_1c level of less than 6.5%.

Other independent predictors of heart failure included age (hazard ratio, 1.64 per 10-year increase); duration of diabetes (HR, 1.34 per 10-year increase); BMI (HR, 1.05 per 1 kg/m² increase); systolic blood pressure (HR, 1.15 per 10 mm Hg increase); smoking (HR, 1.11-1.90, according to reported frequency); valve surgery (HR, 2.32); atrial fibrillation (HR 1.89); myocardial infarction (HR, 6.42), and ischemic heart disease (HR, 2.9).

"For many years there have observations that poor glycemic control is linked to heart attack and cardiovascular mortality," Dr. Sue Kirkman, senior vice president of medical affairs and community information for the American Diabetes Association, said in an interview at the meeting. "This may be the first time that it’s been shown to be linked to heart failure in a type 1 population."

She called the study "hypothesis-generating," and noted that a long-term randomized trial will be needed to confirm the findings. "It is interesting, because it seems that in type 1 diabetes there may be a stronger link between glucose lowering and cardiac outcomes than in type 2 diabetes," she said.

The researchers acknowledged certain limitations of the study, including its observational design and the fact that only data on hospital admission for heart failure were available from the Swedish national diabetes registry, "so the true incidence of heart failure could be underestimated," they wrote. "Patients with early signs of heart failure, or asymptomatic heart failure detectable by echocardiography, will not have been captured."

The study was supported by an unrestricted grant from AstraZeneca, Novo Nordisk Scandinavia, the Swedish Heart and Lung Foundation, and the Swedish Research Council. Dr. Lind disclosed that he has received honoraria or served as consultant for Bayer, Eli Lilly, Novartis, Novo Nordisk Scandinavia, Medtronic Pfizer, and Sanofi-Aventis; and has been a member of an advisory board for Novo Nordisk Scandinavia.

SAN DIEGO – Tight control of hemoglobin A_1c levels significantly reduces the risk of heart failure in patients with type 1 diabetes, results from a large, long-term study show.

In fact, patients with very poor glycemic control were four times as likely to experience heart failure, compared with their counterparts with optimal glycemic control.

"Because treatment for heart failure improves survival and quality of life, clinicians should be observant of signs of heart failure in management of patients with type 1 diabetes, starting at an early stage," lead author Dr. Marcus Lind wrote in the study, which was presented at the annual scientific sessions of the American Diabetes Association and simultaneously published online in the Lancet on June 25. "Echocardiography might be warranted, especially in the presence of poor glycemic control, long duration of diabetes, or an adverse risk factor profile."

Dr. Lind of the department of medicine at Uddevalla (Sweden) Hospital and his associates used the Swedish national diabetes registry to identify 20,985 patients aged 18 years or older with type 1 disease who had no known heart failure and who were registered between January 1998 and December 2003. They followed the cohort until hospital admission for heart failure, death, or end of follow-up on Dec. 31, 2009 (Lancet 2011 June 25 [doi: 10.1016/S0140-6736(11)60471-6]).

The incidence of heart failure was determined by dividing the number of patient-years of follow-up in a particular HbA_1c category, reported as events per 1,000 years of follow-up. The six HbA_1c categories were less than 6.5%, from 6.5% to less than 7.5%, from 7.5% to less than 8.5%, from 8.5% to less than 9.5%, from 9.5% to less than 10.5%, and 10.5% or greater. Cox regression analysis was used to study possible associations between heart failure and patients’ characteristics.

The mean age of patients was 39 years, and 45% were female; they had had diabetes for a mean of 14 years, and their mean body mass index was 25 kg/m². During a median follow-up of 9 years, 635 patients (3%) were admitted with a primary or secondary diagnosis of heart failure, for an incidence of 3.38 per 1,000 patient-years. The incidence of heart failure increased in a stepwise fashion as HbA_1c levels increased, from an incidence of 1.42 per 1,000 patient-years among patients in the below-6.5% category of HbA_1c to an incidence of 5.20 per 1,000 patient-years among those in the 10.5% or higher category of HbA_1c.

After adjustment for age, sex, duration of diabetes, cardiovascular disease risk factors, acute myocardial infarction, and other comorbidities, a Cox regression analysis revealed that patients with an HbA_1c level of 10.5% or higher were four times more likely to develop heart failure than were those who had an HbA_1c level of less than 6.5%.

Other independent predictors of heart failure included age (hazard ratio, 1.64 per 10-year increase); duration of diabetes (HR, 1.34 per 10-year increase); BMI (HR, 1.05 per 1 kg/m² increase); systolic blood pressure (HR, 1.15 per 10 mm Hg increase); smoking (HR, 1.11-1.90, according to reported frequency); valve surgery (HR, 2.32); atrial fibrillation (HR 1.89); myocardial infarction (HR, 6.42), and ischemic heart disease (HR, 2.9).

"For many years there have observations that poor glycemic control is linked to heart attack and cardiovascular mortality," Dr. Sue Kirkman, senior vice president of medical affairs and community information for the American Diabetes Association, said in an interview at the meeting. "This may be the first time that it’s been shown to be linked to heart failure in a type 1 population."

She called the study "hypothesis-generating," and noted that a long-term randomized trial will be needed to confirm the findings. "It is interesting, because it seems that in type 1 diabetes there may be a stronger link between glucose lowering and cardiac outcomes than in type 2 diabetes," she said.

The researchers acknowledged certain limitations of the study, including its observational design and the fact that only data on hospital admission for heart failure were available from the Swedish national diabetes registry, "so the true incidence of heart failure could be underestimated," they wrote. "Patients with early signs of heart failure, or asymptomatic heart failure detectable by echocardiography, will not have been captured."

The study was supported by an unrestricted grant from AstraZeneca, Novo Nordisk Scandinavia, the Swedish Heart and Lung Foundation, and the Swedish Research Council. Dr. Lind disclosed that he has received honoraria or served as consultant for Bayer, Eli Lilly, Novartis, Novo Nordisk Scandinavia, Medtronic Pfizer, and Sanofi-Aventis; and has been a member of an advisory board for Novo Nordisk Scandinavia.

SAN DIEGO – Tight control of hemoglobin A_1c levels significantly reduces the risk of heart failure in patients with type 1 diabetes, results from a large, long-term study show.

In fact, patients with very poor glycemic control were four times as likely to experience heart failure, compared with their counterparts with optimal glycemic control.

"Because treatment for heart failure improves survival and quality of life, clinicians should be observant of signs of heart failure in management of patients with type 1 diabetes, starting at an early stage," lead author Dr. Marcus Lind wrote in the study, which was presented at the annual scientific sessions of the American Diabetes Association and simultaneously published online in the Lancet on June 25. "Echocardiography might be warranted, especially in the presence of poor glycemic control, long duration of diabetes, or an adverse risk factor profile."

Dr. Lind of the department of medicine at Uddevalla (Sweden) Hospital and his associates used the Swedish national diabetes registry to identify 20,985 patients aged 18 years or older with type 1 disease who had no known heart failure and who were registered between January 1998 and December 2003. They followed the cohort until hospital admission for heart failure, death, or end of follow-up on Dec. 31, 2009 (Lancet 2011 June 25 [doi: 10.1016/S0140-6736(11)60471-6]).

The incidence of heart failure was determined by dividing the number of patient-years of follow-up in a particular HbA_1c category, reported as events per 1,000 years of follow-up. The six HbA_1c categories were less than 6.5%, from 6.5% to less than 7.5%, from 7.5% to less than 8.5%, from 8.5% to less than 9.5%, from 9.5% to less than 10.5%, and 10.5% or greater. Cox regression analysis was used to study possible associations between heart failure and patients’ characteristics.

The mean age of patients was 39 years, and 45% were female; they had had diabetes for a mean of 14 years, and their mean body mass index was 25 kg/m². During a median follow-up of 9 years, 635 patients (3%) were admitted with a primary or secondary diagnosis of heart failure, for an incidence of 3.38 per 1,000 patient-years. The incidence of heart failure increased in a stepwise fashion as HbA_1c levels increased, from an incidence of 1.42 per 1,000 patient-years among patients in the below-6.5% category of HbA_1c to an incidence of 5.20 per 1,000 patient-years among those in the 10.5% or higher category of HbA_1c.

After adjustment for age, sex, duration of diabetes, cardiovascular disease risk factors, acute myocardial infarction, and other comorbidities, a Cox regression analysis revealed that patients with an HbA_1c level of 10.5% or higher were four times more likely to develop heart failure than were those who had an HbA_1c level of less than 6.5%.

Other independent predictors of heart failure included age (hazard ratio, 1.64 per 10-year increase); duration of diabetes (HR, 1.34 per 10-year increase); BMI (HR, 1.05 per 1 kg/m² increase); systolic blood pressure (HR, 1.15 per 10 mm Hg increase); smoking (HR, 1.11-1.90, according to reported frequency); valve surgery (HR, 2.32); atrial fibrillation (HR 1.89); myocardial infarction (HR, 6.42), and ischemic heart disease (HR, 2.9).

"For many years there have observations that poor glycemic control is linked to heart attack and cardiovascular mortality," Dr. Sue Kirkman, senior vice president of medical affairs and community information for the American Diabetes Association, said in an interview at the meeting. "This may be the first time that it’s been shown to be linked to heart failure in a type 1 population."

She called the study "hypothesis-generating," and noted that a long-term randomized trial will be needed to confirm the findings. "It is interesting, because it seems that in type 1 diabetes there may be a stronger link between glucose lowering and cardiac outcomes than in type 2 diabetes," she said.

The researchers acknowledged certain limitations of the study, including its observational design and the fact that only data on hospital admission for heart failure were available from the Swedish national diabetes registry, "so the true incidence of heart failure could be underestimated," they wrote. "Patients with early signs of heart failure, or asymptomatic heart failure detectable by echocardiography, will not have been captured."

The study was supported by an unrestricted grant from AstraZeneca, Novo Nordisk Scandinavia, the Swedish Heart and Lung Foundation, and the Swedish Research Council. Dr. Lind disclosed that he has received honoraria or served as consultant for Bayer, Eli Lilly, Novartis, Novo Nordisk Scandinavia, Medtronic Pfizer, and Sanofi-Aventis; and has been a member of an advisory board for Novo Nordisk Scandinavia.

PALM DESERT, CALIF. – Compared with portosystemic shunting in the management of extrahepatic portal vein obstruction, mesenterico-left portal vein bypass restores portal circulation and achieves superior relief of thrombocytopenia and certain metabolic symptoms, results from a single-center study showed.

"For surgeons who still perform portosystemic shunts as a first-line operation for extrahepatic portal vein obstruction, we hope that this evidence provides further proof of the advantages of doing the mesenterico-left portal vein bypass," Dr. Timothy B. Lautz said at the annual meeting of the American Pediatric Surgical Association.

Modern surgical options for extrahepatic portal vein obstruction include the distal splenorenal shunt and the mesenterico-left portal vein bypass (meso-Rex). "The distal splenorenal shunt preserves the spleen but diverts the splenic portion of portal flow into the systemic circulation," said Dr. Lautz of the department of surgery at Children’s Memorial Hospital, the primary pediatric teaching hospital of Northwestern University, Chicago.

"The meso-Rex bypass, on the other hand, is a totally restorative procedure that diverts all portal flow around the area of obstruction and into the intrahepatic left portal vein," he said.

In an effort to compare the two procedures, Dr. Lautz and senior author Dr. Riccardo A. Superina evaluated 91 consecutive patients who underwent an operation for extrahepatic portal vein obstruction at the hospital between 1998 and 2009. Their mean age was 7 years, and 58% were male. Meso-Rex bypass was the treatment of choice in all cases, but portosytemic shunts were reserved for those with anatomic or technical constraints that prevented meso-Rex. Analysis was limited to patients with at least 1 year of postoperative follow-up.

Dr. Lautz reported that 72 patients underwent the meso-Rex procedure (group 1) and 19 underwent portosystemic shunts (group 2). Prior to surgery, patients in both groups experienced growth retardation, thrombocytopenia, hyperammonemia, and impaired synthetic function.

Following surgery, variceal bleeding resolved in 59 of the group-1 patients and in 13 group-2 patients who manifested this symptom preoperatively. In addition, group-1 patients had significantly better improvements compared with group-2 patients in weight for age z-score (+0.76 vs. +0.13, respectively; P = .048), platelet count (+77,700 vs. +29,000 per mL; P = 0.006), international normalized ratio (-0.23 vs. +0.22; P = .002), and serum ammonia (-25.5 vs. +18 micromol/L; P = .002).

"The meso-Rex bypass and portosystemic shunts are both effective at relieving portal hypertensive bleeding," Dr. Lautz concluded. "By restoring normal physiologic portal venous circulation, the meso-Rex bypass better relieves hypersplenism, liver dysfunction, and growth impairment."

Dr. Lautz said he had no relevant financial disclosures to make.

The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Compared with portosystemic shunting in the management of extrahepatic portal vein obstruction, mesenterico-left portal vein bypass restores portal circulation and achieves superior relief of thrombocytopenia and certain metabolic symptoms, results from a single-center study showed.

"For surgeons who still perform portosystemic shunts as a first-line operation for extrahepatic portal vein obstruction, we hope that this evidence provides further proof of the advantages of doing the mesenterico-left portal vein bypass," Dr. Timothy B. Lautz said at the annual meeting of the American Pediatric Surgical Association.

Modern surgical options for extrahepatic portal vein obstruction include the distal splenorenal shunt and the mesenterico-left portal vein bypass (meso-Rex). "The distal splenorenal shunt preserves the spleen but diverts the splenic portion of portal flow into the systemic circulation," said Dr. Lautz of the department of surgery at Children’s Memorial Hospital, the primary pediatric teaching hospital of Northwestern University, Chicago.

"The meso-Rex bypass, on the other hand, is a totally restorative procedure that diverts all portal flow around the area of obstruction and into the intrahepatic left portal vein," he said.

In an effort to compare the two procedures, Dr. Lautz and senior author Dr. Riccardo A. Superina evaluated 91 consecutive patients who underwent an operation for extrahepatic portal vein obstruction at the hospital between 1998 and 2009. Their mean age was 7 years, and 58% were male. Meso-Rex bypass was the treatment of choice in all cases, but portosytemic shunts were reserved for those with anatomic or technical constraints that prevented meso-Rex. Analysis was limited to patients with at least 1 year of postoperative follow-up.

Dr. Lautz reported that 72 patients underwent the meso-Rex procedure (group 1) and 19 underwent portosystemic shunts (group 2). Prior to surgery, patients in both groups experienced growth retardation, thrombocytopenia, hyperammonemia, and impaired synthetic function.

Following surgery, variceal bleeding resolved in 59 of the group-1 patients and in 13 group-2 patients who manifested this symptom preoperatively. In addition, group-1 patients had significantly better improvements compared with group-2 patients in weight for age z-score (+0.76 vs. +0.13, respectively; P = .048), platelet count (+77,700 vs. +29,000 per mL; P = 0.006), international normalized ratio (-0.23 vs. +0.22; P = .002), and serum ammonia (-25.5 vs. +18 micromol/L; P = .002).

"The meso-Rex bypass and portosystemic shunts are both effective at relieving portal hypertensive bleeding," Dr. Lautz concluded. "By restoring normal physiologic portal venous circulation, the meso-Rex bypass better relieves hypersplenism, liver dysfunction, and growth impairment."

Dr. Lautz said he had no relevant financial disclosures to make.

The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Compared with portosystemic shunting in the management of extrahepatic portal vein obstruction, mesenterico-left portal vein bypass restores portal circulation and achieves superior relief of thrombocytopenia and certain metabolic symptoms, results from a single-center study showed.

"For surgeons who still perform portosystemic shunts as a first-line operation for extrahepatic portal vein obstruction, we hope that this evidence provides further proof of the advantages of doing the mesenterico-left portal vein bypass," Dr. Timothy B. Lautz said at the annual meeting of the American Pediatric Surgical Association.

Modern surgical options for extrahepatic portal vein obstruction include the distal splenorenal shunt and the mesenterico-left portal vein bypass (meso-Rex). "The distal splenorenal shunt preserves the spleen but diverts the splenic portion of portal flow into the systemic circulation," said Dr. Lautz of the department of surgery at Children’s Memorial Hospital, the primary pediatric teaching hospital of Northwestern University, Chicago.

"The meso-Rex bypass, on the other hand, is a totally restorative procedure that diverts all portal flow around the area of obstruction and into the intrahepatic left portal vein," he said.

In an effort to compare the two procedures, Dr. Lautz and senior author Dr. Riccardo A. Superina evaluated 91 consecutive patients who underwent an operation for extrahepatic portal vein obstruction at the hospital between 1998 and 2009. Their mean age was 7 years, and 58% were male. Meso-Rex bypass was the treatment of choice in all cases, but portosytemic shunts were reserved for those with anatomic or technical constraints that prevented meso-Rex. Analysis was limited to patients with at least 1 year of postoperative follow-up.

Dr. Lautz reported that 72 patients underwent the meso-Rex procedure (group 1) and 19 underwent portosystemic shunts (group 2). Prior to surgery, patients in both groups experienced growth retardation, thrombocytopenia, hyperammonemia, and impaired synthetic function.

Following surgery, variceal bleeding resolved in 59 of the group-1 patients and in 13 group-2 patients who manifested this symptom preoperatively. In addition, group-1 patients had significantly better improvements compared with group-2 patients in weight for age z-score (+0.76 vs. +0.13, respectively; P = .048), platelet count (+77,700 vs. +29,000 per mL; P = 0.006), international normalized ratio (-0.23 vs. +0.22; P = .002), and serum ammonia (-25.5 vs. +18 micromol/L; P = .002).

"The meso-Rex bypass and portosystemic shunts are both effective at relieving portal hypertensive bleeding," Dr. Lautz concluded. "By restoring normal physiologic portal venous circulation, the meso-Rex bypass better relieves hypersplenism, liver dysfunction, and growth impairment."

Dr. Lautz said he had no relevant financial disclosures to make.

The meeting was supported by a grant from Elsevier, which owns this news organization.