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Diabetes, lipids and metabolism
A propensity-matched study of the effect of diabetes on the natural history of heart failure: variations by sex and age
  1. Ali Ahmed1,
  2. Inmaculada B Aban2,
  3. Viola Vaccarino3,
  4. Donald M Lloyd-Jones4,
  5. David C Goff Jr5,
  6. Jiannan Zhao2,
  7. Thomas E Love6,
  8. Christine Ritchie1,
  9. Fernando Ovalle1,
  10. Giovanni Gambassi7,
  11. Louis J Dell’Italia1
  1. 1
    University of Alabama at Birmingham and VA Medical Center, Birmingham, AL, USA
  2. 2
    University of Alabama at Birmingham, Birmingham, AL, USA
  3. 3
    Emory University, Atlanta, GA, USA
  4. 4
    Northwestern University, Chicago, IL, USA
  5. 5
    Wake Forest University, Winston-Salem, NC, USA
  6. 6
    Case Western Reserve University, Cleveland OH, USA
  7. 7
    Universitè Cattolica del Sacro Cuore, Rome, Italy
  1. Ali Ahmed, MD, MPH, University of Alabama at Birmingham, 1530 3rd Ave South, CH-19, Ste-219, Birmingham, AL 35294-2041, USA; aahmed{at}


Background: Poor prognosis in heart failure (HF) patients with diabetes is often attributed to increased co-morbidity and advanced disease. Further, this effect may be worse in women.

Objective: To determine whether the effect of diabetes on outcomes and the sex-related variation persisted in a propensity score-matched HF population, and whether the sex-related variation was a function of age.

Methods: Of the 7788 HF patients in the Digitalis Investigation Group trial, 2218 had a history of diabetes. Propensity score for diabetes was calculated for each patient using a non-parsimonious logistic regression model incorporating all measured baseline covariates, and was used to match 2056 (93%) diabetic patients with 2056 non-diabetic patients.

Results: All-cause mortality occurred in 135 (25%) and 216 (39%) women without and with diabetes (adjusted HR = 1.67; 95% CI = 1.34 to 2.08; p<0.001). Among men, 535 (36%) and 609 (41%) patients without and with diabetes died from all causes (adjusted HR = 1.21; 95% CI = 1.07 to 1.36; p = 0.002). Sex–diabetes interaction (overall adjusted p<0.001) was only significant in patients ⩾65 years (15% absolute risk increase in women; multivariable p for interaction = 0.005), but not in younger patients (2% increase in women; p for interaction = 0.173). Risk-adjusted HR (95% CI) for all-cause hospitalisation for women and men were 1.49 (1.28 to 1.72) and 1.21 (1.11 to 1.32), respectively, also with significant sex–diabetes interaction (p = 0.011).

Conclusions: Diabetes-associated increases in morbidity and mortality in chronic HF were more pronounced in women, and theses sex-related differences in outcomes were primarily observed in elderly patients.

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  • AA conceived the study hypothesis and design, and wrote the first and subsequent drafts of the paper. AA conducted statistical analyses in consultation with IBA, TEL, VV and JZ. All authors interpreted the data, participated in critical revision of the paper for important intellectual content, and approved the final version of the article. IBA and AA had full access to the data.

  • Competing interests: None declared.

  • Funding: AA is supported by the National Institutes of Health through grants from the National Institute on Aging (1-K23-AG19211-04) and the National Heart, Lung, and Blood Institute (1-R01-HL085561-01 and P50-HL077100). LJD is supported by a Specialized Center for Clinically Oriented Research (SCCOR) in Cardiac Dysfunction grant P50HL077100 from the National Institutes of Health, National Heart, Lung and Blood Institute and the Office of Research and Development, Medical Service, Department of Veteran Affairs.

  • Abbreviations:
    heart failure
    hazard ratio
    New York Heart Association