Individuals with type 2 diabetes who have 5 risk-factor variables within the target ranges had little to no excess risk for death, myocardial infarction, or stroke when compared with the population at large, according to findings published in The New England Journal of Medicine.

Patients with type 2 diabetes have a risk for death and cardiovascular events that is approximately 2 to 4 times greater than that of the general population. In this cohort study, the researchers investigated whether the excess risk for death and cardiovascular events seen in type 2 diabetes could be reduced or eliminated. The final analysis included 271,174 patients with type 2 diabetes and 1,355,870 matched controls. Patients were assessed according to age and the presence of 5 risk factors: elevated glycated hemoglobin level, elevated low-density lipoprotein cholesterol level, albuminuria, smoking, and elevated blood pressure.

At a median follow up of 5.7 years, there were 175,345 deaths, and among patients with diabetes, the excess risk for outcomes declined stepwise for each risk-factor variable within the target range. For those with all 5 variables within target ranges, the hazard ratio for death from any cause vs controls was 1.06 (95% CI, 1.00-1.12), and for acute myocardial infarction it was 0.84 (95% CI, 0.75-0.93), and 0.95 (95% CI, 0.84-1.07) for stroke.  

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Patients with type 2 diabetes with all 5 risk-factor variables outside of the target ranges who were younger than 55 years had the highest excess risk for hospitalization for heart failure (11.35; 95% CI, 7.16-18.01). Hospitalization for heart failure in patients with no variables outside of the target ranges was 1.45 (95% CI, 1.34-1.57).

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The strongest predictors for cardiovascular outcomes and death were low physical activity, smoking, glycated hemoglobin level, systolic blood pressure, and low-density lipoprotein cholesterol level outside of target range. A glycated hemoglobin level outside the target range was the strongest predictor of stroke and acute myocardial infarction for patients with diabetes, and smoking was the strongest predictor of death. Atrial fibrillation and a body mass index outside of target range were predictors for hospitalization for heart failure.

“The study indicates that having all 5 risk-factor variables within the target ranges could theoretically eliminate the excess risk of acute myocardial infarction,” wrote the authors, although they point out that, “there was a substantial excess risk of hospitalization for heart failure among patients who had all the variables within target ranges.”


Rawshani A, Rawshani A, Franzén S, et al. Risk factors, mortality, and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med. 2018;379(7):633-644.