Department of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Rome, Italy.
Daiichi-Sankyo Europe, Munich, Germany.
J Am Coll Cardiol. 2017 Jan 31;69(4):409-419. doi: 10.1016/j.jacc.2016.10.069.
Diabetes is a known risk predictor for thromboembolic events in patients with atrial fibrillation (AF), but no study has explored the prognostic weight of insulin in this setting.
This study evaluated the differential role of insulin versus no insulin therapy on thromboembolic risk in patients with diabetes and AF.
We accessed individual patient data from the prospective, real-world, multicenter, PREFER in AF (European Prevention of thromboembolic events-European Registry in Atrial Fibrillation). We compared the rates of stroke/systemic embolism at 1 year according to diabetes status (no diabetes, diabetes without insulin therapy, diabetes on insulin therapy).
In an overall population of 5,717 patients, 1,288 had diabetes, 22.4% of whom were on insulin. For patients with diabetes who were on insulin, there was a significantly increased risk of stroke/systemic embolism at 1 year versus either no diabetes (5.2% vs. 1.9%; hazard ratio: 2.89; 95% confidence interval: 1.67 to 5.02; p = 0.0002) or diabetes without insulin treatment (5.2% vs. 1.8%; hazard ratio: 2.96; 95% confidence interval: 1.49 to 5.87; p = 0.0019). Notably, rates of stroke/embolism were similar in patients with diabetes not receiving insulin versus patients without diabetes (hazard ratio: 0.97; 95% confidence interval: 0.58 to 1.61; p = 0.90). The selective predictive role of insulin-requiring diabetes was independent of potential confounders, including diabetes duration, and was maintained in various subpopulations, including the subgroup receiving anticoagulant therapy.
In this cohort of anticoagulated patients with AF, the sole presence of diabetes not requiring insulin did not imply an increased thromboembolic risk. Conversely, insulin-requiring diabetes contributed most, if not exclusively, to the overall increase of thromboembolic risk in AF.
糖尿病是房颤（AF）患者发生血栓栓塞事件的已知危险因素，但尚无研究探讨在此情况下胰岛素的预后权重。
本研究评估了胰岛素与无胰岛素治疗对糖尿病合并 AF 患者血栓栓塞风险的差异作用。
我们从前瞻性、真实世界、多中心 PREFER in AF（欧洲房颤血栓预防事件登记研究）中获取了个体患者数据。我们根据糖尿病状态（无糖尿病、无胰岛素治疗的糖尿病、胰岛素治疗的糖尿病）比较了 1 年时卒中/全身性栓塞的发生率。
在 5717 例患者的总体人群中，有 1288 例患有糖尿病，其中 22.4%的患者接受胰岛素治疗。对于接受胰岛素治疗的糖尿病患者，与无糖尿病（5.2%比 1.9%；风险比：2.89；95%置信区间：1.67 至 5.02；p=0.0002）或无胰岛素治疗的糖尿病（5.2%比 1.8%；风险比：2.96；95%置信区间：1.49 至 5.87；p=0.0019）相比，1 年时卒中/全身性栓塞的风险显著增加。值得注意的是，未接受胰岛素治疗的糖尿病患者与无糖尿病患者的卒中/栓塞发生率相似（风险比：0.97；95%置信区间：0.58 至 1.61；p=0.90）。胰岛素依赖型糖尿病的选择性预测作用独立于潜在的混杂因素，包括糖尿病病程，并在各种亚人群中得到维持，包括接受抗凝治疗的亚组。
在本队列接受抗凝治疗的 AF 患者中，单纯存在无需胰岛素的糖尿病并不意味着血栓栓塞风险增加。相反，胰岛素依赖型糖尿病是 AF 中血栓栓塞风险总体增加的主要原因（如果不是唯一原因）。
