Variability in Glycated Hemoglobin and Risk of Poor Outcomes Among People With Type 2 Diabetes in a Large Primary Care Cohort Study
Variability in Glycated Hemoglobin and Risk of Poor Outcomes Among People With Type 2 Diabetes in a Large Primary Care Cohort Study
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DOI：
10.2337/dc19-0848
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发表时间：
2019-12-01
期刊：
影响因子：
16.2
通讯作者：
Cook, Derek G.
中科院分区：
文献类型：
--
作者：
Critchley, Julia A.;Carey, Iain M.;Cook, Derek G.
目的糖尿病指南关注目标糖化血红蛋白（HbA(1c)）水平。HbA（1c）的长期变异性可能预测住院或死亡率，但其在不同平均水平或轨迹下的重要性尚不清楚。研究设计和方法使用英国初级保健数据，估计2006-2009年期间58,832例2型糖尿病患者的HbA（1c）平均值（年平均值）、变异系数（变异系数）和轨迹（年回归斜率）。使用Cox回归估计2010-2015年期间死亡率和急诊住院的风险比（HRs），并对年龄、性别、吸烟、BMI、糖尿病持续时间和剥夺进行调整。同时影响的HbA（1c）平均值，变异性和轨迹使用百分位数估计。结果：在相互调整的模型中，HbA（1c）变异性与全因死亡率显示一致的剂量-反应关系，而平均水平仅在分布中最高或最低10%的个体中重要，轨迹无独立影响。最不稳定的HbA(1c)（前10%）患者的死亡率（HR 1.93 [95% CI 1.72-2.16]）几乎是最稳定的（后10%）患者的两倍——这种关联减弱了，但不能用低血糖来解释。对于紧急住院治疗，除了冠状动脉疾病（CAD）和缺血性中风（IS）之外，也出现了类似的趋势，在这两种情况下，平均增加而不是变异性是可预测的。结论：HbA（1c）变异性与总死亡率和急诊住院密切相关，不能用平均HbA（1c）或低血糖发作来解释。只有CAD和IS住院没有发现关联，平均HbA（1c）具有很强的预测性。目标应同时关注HbA（1c）的稳定性和绝对水平。
OBJECTIVE Diabetes guidelines focus on target glycated hemoglobin (HbA(1c)) levels. Long-term variability in HbA(1c) may be predictive of hospitalization or mortality, but its importance at different average levels or trajectories is unclear. RESEARCH DESIGN AND METHODS Using English primary care data, 58,832 patients with type 2 diabetes had HbA(1c) average (mean of annual means), variability (coefficient of variation), and trajectory (annual regression slope) estimated during 2006-2009. Hazard ratios (HRs) for mortality and emergency hospitalization during 2010-2015, with adjustment for age, sex, smoking, BMI, duration of diabetes, and deprivation, were estimated using Cox regression. The simultaneous impact of HbA(1c) average, variability, and trajectory was estimated using percentiles. RESULTS In mutually adjusted models, HbA(1c) variability showed a consistent dose-response relationship with all-cause mortality, while average level was only important among individuals in the highest or lowest 10% of the distribution, and trajectory had no independent effect. Individuals with the most unstable HbA(1c) (top 10%) were almost twice as likely to die (HR 1.93 [95% CI 1.72-2.16]) than were those with the most stable (bottom 10%)-an association attenuated but not explained by hypoglycemia. For emergency hospitalizations, similar trends were seen except for coronary artery disease (CAD) and ischemic stroke (IS), where increasing average rather than variability was predictive. CONCLUSIONS HbA(1c) variability was strongly associated with overall mortality and emergency hospitalization and not explained by average HbA(1c) or hypoglycemic episodes. Only for CAD and IS hospitalizations was no association found, with average HbA(1c) strongly predictive. Targets should focus on both stability and absolute level of HbA(1c).