Risks and Population Burden of Cardiovascular Diseases Associated with Diabetes in China: A Prospective Study of 0.5 Million Adults

BackgroundIn China, diabetes prevalence is rising rapidly, but little is known about the associated risks and population burden of cardiovascular diseases. We assess associations of diabetes with major cardiovascular diseases and the relevance of diabetes duration and other modifiable risk factors to these associations.Methods and FindingsA nationwide prospective study recruited 512,891 men and women aged 30–79 y between 25 June 2004 and 15 July 2008 from ten diverse localities across China. During ~7 y of follow-up, 7,353 cardiovascular deaths and 25,451 non-fatal major cardiovascular events were recorded among 488,760 participants without prior cardiovascular disease at baseline. Cox regression yielded adjusted hazard ratios (HRs) comparing disease risks in individuals with diabetes to those without. Overall, 5.4% (n = 26,335) of participants had self-reported (2.7%) or screen-detected (2.7%) diabetes. Individuals with self-reported diabetes had an adjusted HR of 2.07 (95% CI 1.90–2.26) for cardiovascular mortality. There were significant excess risks of major coronary event (2.44, 95% CI 2.18–2.73), ischaemic stroke (1.68, 95% CI 1.60–1.77), and intracerebral haemorrhage (1.24, 95% CI 1.07–1.44). Screen-detected diabetes was also associated with significant, though more modest, excess cardiovascular risks, with corresponding HRs of 1.66 (95% CI 1.51–1.83), 1.62 (95% CI 1.40–1.86), 1.48 (95% CI 1.40–1.57), and 1.17 (95% CI 1.01–1.36), respectively. Misclassification of screen-detected diabetes may have caused these risk estimates to be underestimated, whilst lack of data on lipids may have resulted in residual confounding of diabetes-associated cardiovascular disease risks. Among individuals with diabetes, cardiovascular risk increased progressively with duration of diabetes and number of other presenting modifiable cardiovascular risk factors. Assuming a causal association, diabetes now accounts for ~0.5 million (489,676, 95% CI 335,777–681,202) cardiovascular deaths annually in China.ConclusionsAmong Chinese adults, diabetes is associated with significantly increased risks of major cardiovascular diseases. The increasing prevalence and younger age of onset of diabetes foreshadow greater diabetes-attributable disease burden in China.研究背景：在中国，糖尿病患病率正快速攀升，但目前对其相关的心血管疾病风险及人群疾病负担仍知之甚少。本研究旨在评估糖尿病与主要心血管疾病的关联，以及糖尿病病程与其他可修正风险因素在该关联中的作用。 研究方法与结果：本研究为一项全国性前瞻性队列研究，于2004年6月25日至2008年7月15日，从全国10个不同地区招募了512891名年龄在30~79岁之间的男性和女性。基线时无心血管疾病的488760名参与者经约7年的随访后，共记录到7353例心血管死亡事件与25451例非致命性主要心血管事件。采用Cox回归分析，计算糖尿病患者相较于非糖尿病患者的校正后风险比（hazard ratio, HR）。总体而言，5.4%（n=26335）的参与者存在自我报告（2.7%）或筛查检出（2.7%）的糖尿病。自我报告糖尿病的参与者心血管死亡的校正后HR为2.07（95%置信区间CI：1.90~2.26）；主要冠脉事件（HR=2.44，95%CI：2.18~2.73）、缺血性脑卒中（HR=1.68，95%CI：1.60~1.77）及脑出血（HR=1.24，95%CI：1.07~1.44）的发病风险均显著升高。筛查检出的糖尿病同样与心血管风险显著升高相关，尽管关联强度稍弱，对应的HR分别为1.66（95%CI：1.51~1.83）、1.62（95%CI：1.40~1.86）、1.48（95%CI：1.40~1.57）及1.17（95%CI：1.01~1.36）。筛查检出糖尿病的分类错误可能导致上述风险估计值被低估，而缺乏血脂数据则可能造成糖尿病相关心血管疾病风险的残余混杂。在糖尿病患者中，心血管风险随糖尿病病程及其他可修正心血管风险因素的数量增加而逐渐升高。若假设二者存在因果关联，目前中国每年约有50万（489676，95%CI：335777~681202）例心血管死亡可归因于糖尿病。 研究结论：在中国成人中，糖尿病与主要心血管疾病风险的显著升高密切相关。糖尿病患病率的持续上升以及发病年龄年轻化的趋势，预示着未来中国糖尿病相关疾病负担将进一步加重。