Kalyani Rita Rastogi, Lazo Mariana, Ouyang Pamela, Turkbey Evrim, Chevalier Karinne, Brancati Frederick, Becker Diane, Vaidya Dhananjay
Corresponding author: Rita Rastogi Kalyani,
Diabetes Care. 2014;37(3):830-8. doi: 10.2337/dc13-1755. Epub 2013 Oct 31.
Controversy exists about the coronary artery disease (CAD) risk conveyed by diabetes in young and middle-aged women. We investigated sex differences in CAD by diabetes status among healthy individuals with different underlying risks of heart disease.
We examined subjects aged <60 years without CAD at enrollment in the high-risk GeneSTAR Study (n = 1,448; follow-up ∼12 years), Multi-Ethnic Study of Atherosclerosis (MESA; n = 3,072; follow-up ∼7 years), and National Health and Nutrition Examination Survey III (NHANES III) Mortality Follow-up Study (n = 6,997; follow-up ∼15 years). Diabetes was defined by report, hypoglycemic use, and/or fasting glucose ≥126 mg/dL. The outcome was any CAD event during follow-up (fatal CAD in NHANES).
In the absence of diabetes, CAD rates were lower among women in GeneSTAR, MESA, and NHANES (4.27, 1.66, and 0.40/1,000 person-years, respectively) versus men (11.22, 5.64, and 0.88/1,000 person-years); log-rank P < 0.001 (GeneSTAR/MESA) and P = 0.07 (NHANES). In the presence of diabetes, CAD event rates were similar among women (17.65, 7.34, and 2.37/1,000 person-years) versus men (12.86, 9.71, and 1.83/1,000 person-years); all log-rank P values > 0.05. Adjusting for demographics, diabetes was associated with a significant four- to fivefold higher CAD rate among women in each cohort, without differences in men. In meta-analyses of three cohorts, additionally adjusted for BMI, smoking, hypertension, HDL, and non-HDL cholesterol, antihypertensive and cholesterol-lowering medication use, the hazard ratio of CAD in men versus women among nondiabetes was 2.43 (1.76-3.35) and diabetes was 0.89 (0.43-1.83); P = 0.013 interaction by diabetes status.
Though young and middle-aged women are less likely to develop CAD in the absence of diabetes, the presence of diabetes equalizes the risk by sex. Our findings support aggressive CAD prevention strategies in women with diabetes and at similar levels to those that exist in men.
关于糖尿病对中青年女性冠状动脉疾病（CAD）风险的影响存在争议。我们在具有不同潜在心脏病风险的健康个体中，研究了糖尿病状态下CAD的性别差异。
我们对高危基因STAR研究（n = 1448；随访约12年）、多族裔动脉粥样硬化研究（MESA；n = 3072；随访约7年）以及国家健康与营养检查调查III（NHANES III）死亡率随访研究（n = 6997；随访约15年）中入组时年龄<60岁且无CAD的受试者进行了检查。糖尿病通过报告、降糖药物使用和/或空腹血糖≥126 mg/dL来定义。结局为随访期间的任何CAD事件（NHANES中的致命CAD）。
在无糖尿病的情况下，基因STAR研究、MESA研究和NHANES研究中女性的CAD发生率低于男性（分别为4.27、1.66和0.40/1000人年），分别为11.22、5.64和0.88/1000人年；对数秩检验P<0.001（基因STAR研究/MESA研究），P = 0.07（NHANES研究）。在患有糖尿病的情况下，女性的CAD事件发生率与男性相似（分别为17.65、7.34和2.37/1000人年），分别为12.86、9.71和1.83/1000人年；所有对数秩检验P值>0.05。在对人口统计学进行调整后，糖尿病与每个队列中女性CAD发生率显著高出四至五倍相关，男性则无差异。在对三个队列进行的荟萃分析中，进一步调整了体重指数、吸烟、高血压、高密度脂蛋白和非高密度脂蛋白胆固醇、抗高血压和降胆固醇药物使用情况，非糖尿病男性与女性发生CAD的风险比为2.43（1.76 - 3.35），糖尿病患者为0.89（0.43 - 1.83）；糖尿病状态的交互作用P = 0.013。
尽管中青年女性在无糖尿病时患CAD的可能性较小，但糖尿病的存在使性别风险趋于平等。我们的研究结果支持对糖尿病女性采取积极的CAD预防策略，其水平应与男性相似。
