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Paulo A. Lotufo, MD, DrPH; J. Michael Gaziano, MD, MPH; Claudia U. Chae, MD, MPH; Umed A. Ajani, MBBS, MPH; Gina Moreno-John, MD, MPH; Julie E. Buring, ScD; JoAnn E. Manson, MD, DrPH

Arch Intern Med. 2001;161:242-247.

Background  While diabetes has long been associated with increased risk of coronary heart disease (CHD), the magnitude of risk of diabetes-related CHD is uncertain.

Objective  To evaluate the impact of diabetes and prior CHD on all-cause and CHD mortality.

Methods  In a prospective cohort study of 91 285 US male physicians aged 40 to 84 years, participants were divided into 4 groups: (1) a reference group of 82 247 men free of both diabetes and CHD (previous myocardial infarction and/or angina) at baseline, (2) 2317 men with a history of diabetes but not CHD, (3) 5906 men with a history of CHD but not diabetes, and (4) 815 men with a history of both diabetes and CHD. Rates of all-cause and CHD mortality were compared in these groups.

Results  Over 5 years (49 7952 person-years of follow-up), 3627 deaths from all causes were documented, including 1242 deaths from CHD. Compared with men with no diabetes or CHD, the age-adjusted relative risk of death from any cause was 2.3 (95% confidence interval [CI], 2.0-2.6) among men with diabetes and without CHD, 2.2 (95% CI, 2.0-2.4) among men with CHD and without diabetes, and 4.7 (95% CI, 4.0-5.4) among men with both diabetes and CHD. The relative risk of CHD death was 3.3 (95% CI, 2.6-4.1) among men with diabetes and without CHD, 5.6 (95% CI, 4.9-6.3) among men with CHD and without diabetes, and 12.0 (95% CI, 9.9-14.6) among men with both diabetes and CHD. Multivariate adjustment for body mass index, smoking status, alcohol intake, and physical activity as well as stratification by these variables did not materially alter these associations.

Conclusions  These prospective data indicate that diabetes is associated with a substantial increase in all-cause and CHD mortality. For all-cause mortality, the magnitude of excess risk conferred by diabetes is similar to that conferred by a history of CHD; for mortality from CHD, a history of CHD is a more potent predictor of death. The presence of both diabetes and CHD, however, identifies a particularly high-risk group.

From the Division of Preventive Medicine (Drs Lotufo, Gaziano, Chae, Ajani, Buring, and Manson), Division of Cardiovascular Disease (Dr Gaziano), and Channing Laboratory (Dr Manson), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass; Massachusetts Veterans Epidemiology Research and Information Center, Veterans Affairs Medical Center, Brockton/West Roxbury (Dr Gaziano); Cardiology Division, Massachusetts General Hospital, Boston (Dr Chae); Division of General Internal Medicine, University of California, San Francisco (Dr Moreno-John); and Department of Epidemiology, Harvard School of Public Health, Boston (Drs Buring and Manson).

Corresponding author and reprints: JoAnn E. Manson, MD, DrPH, Division of Preventive Medicine, Brigham and Women's Hospital, 900 Commonwealth Ave E, Boston, MA 02215-1204 (e-mail: jmanson{at}rics.bwh.harvard.edu).

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