title: Hypoglycemia in Diabetes Mellitus as a Coronary Artery Disease Risk Factor in Patients at Elevated Vascular Risk.
abstract: BACKGROUND
  Although clinical trials have shown that hypoglycemia is associated with coronary artery disease (CAD), little is known whether hypoglycemia is a CAD risk factor in primary care.
  
  
  OBJECTIVE
  We sought to determine whether previous hypoglycemia was associated with incident CAD, and whether this association differed in patients of different underlying vascular risk.
  
  
  METHODS
  This is a longitudinal cohort study of diabetes patients without CAD before January 1, 2006 (n = 9173) followed at an academic network of 13 primary care practices from January 1, 2006 to June 30, 2012. Hypoglycemic events before January 1, 2006 were identified via International Classification of Diseases Ninth Revision codes from emergency department, inpatient and outpatient visits.
  
  
  METHODS
  Patients were followed until incident CAD or June 30, 2012. Cox regression with time interaction was used to determine the association between hypoglycemia and CAD (significance set at P ≤ .05). We then tested the association among high vascular risk patients (age ≥ 55 y, hemoglobin A1c ≥ 7.5%, ≥2 risk factors [dyslipidemia, hypertension or obesity]), a subset of high vascular risk patients aged 65 years or older, and the remaining patients with lower vascular risk.
  
  
  RESULTS
  Three percent of patients (n = 285) had previous hypoglycemia. Hypoglycemia was associated with a 2-fold CAD risk (hazard ratio [HR] 2.15; 95% confidence interval [95%CI] 1.24-3.74), adjusting for time interaction and vascular risk factors. Among high vascular risk patients, the risk was 3-fold (HR 3.01 [95%CI 1.15-7.91], n = 1823 [20% of cohort]), and over 4-fold (HR 4.62 [95%CI 1.65-12.9], n = 996) in the subset aged more than or equal to 65 years. No association was found in the remaining 80% of the cohort with lower vascular risk.
  
  
  CONCLUSIONS
  Previous hypoglycemia was associated with CAD among high vascular risk patients. Hypoglycemia may not be a CAD risk factor for the majority of primary care patients with lower underlying vascular risk.
authors.affiliation: Division of General Internal Medicine (A.L., S.A.B., V.A.T., B.P., W.H., S.J.A., D.J.W., J.B.M.), Massachusetts General Hospital, Boston, Massachusetts 02114-2698; Harvard Medical School (A.L., S.A.B., V.A.T., S.J.A., J.B.M.), Boston, Massachusetts 02115; and Diabetes Center (S.A.B., D.J.W.), Massachusetts General Hospital, Boston, Massachusetts 02114.
authors.forename: Aaron
authors.initials: A
authors.lastname: Leong
authors.affiliation: Division of General Internal Medicine (A.L., S.A.B., V.A.T., B.P., W.H., S.J.A., D.J.W., J.B.M.), Massachusetts General Hospital, Boston, Massachusetts 02114-2698; Harvard Medical School (A.L., S.A.B., V.A.T., S.J.A., J.B.M.), Boston, Massachusetts 02115; and Diabetes Center (S.A.B., D.J.W.), Massachusetts General Hospital, Boston, Massachusetts 02114.
authors.forename: Seth A
authors.initials: SA
authors.lastname: Berkowitz
authors.affiliation: Division of General Internal Medicine (A.L., S.A.B., V.A.T., B.P., W.H., S.J.A., D.J.W., J.B.M.), Massachusetts General Hospital, Boston, Massachusetts 02114-2698; Harvard Medical School (A.L., S.A.B., V.A.T., S.J.A., J.B.M.), Boston, Massachusetts 02115; and Diabetes Center (S.A.B., D.J.W.), Massachusetts General Hospital, Boston, Massachusetts 02114.
authors.forename: Virginia A
authors.initials: VA
authors.lastname: Triant
authors.affiliation: Division of General Internal Medicine (A.L., S.A.B., V.A.T., B.P., W.H., S.J.A., D.J.W., J.B.M.), Massachusetts General Hospital, Boston, Massachusetts 02114-2698; Harvard Medical School (A.L., S.A.B., V.A.T., S.J.A., J.B.M.), Boston, Massachusetts 02115; and Diabetes Center (S.A.B., D.J.W.), Massachusetts General Hospital, Boston, Massachusetts 02114.
authors.forename: Bianca
authors.initials: B
authors.lastname: Porneala
authors.affiliation: Division of General Internal Medicine (A.L., S.A.B., V.A.T., B.P., W.H., S.J.A., D.J.W., J.B.M.), Massachusetts General Hospital, Boston, Massachusetts 02114-2698; Harvard Medical School (A.L., S.A.B., V.A.T., S.J.A., J.B.M.), Boston, Massachusetts 02115; and Diabetes Center (S.A.B., D.J.W.), Massachusetts General Hospital, Boston, Massachusetts 02114.
authors.forename: Wei
authors.initials: W
authors.lastname: He
authors.affiliation: Division of General Internal Medicine (A.L., S.A.B., V.A.T., B.P., W.H., S.J.A., D.J.W., J.B.M.), Massachusetts General Hospital, Boston, Massachusetts 02114-2698; Harvard Medical School (A.L., S.A.B., V.A.T., S.J.A., J.B.M.), Boston, Massachusetts 02115; and Diabetes Center (S.A.B., D.J.W.), Massachusetts General Hospital, Boston, Massachusetts 02114.
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Atlas
authors.affiliation: Division of General Internal Medicine (A.L., S.A.B., V.A.T., B.P., W.H., S.J.A., D.J.W., J.B.M.), Massachusetts General Hospital, Boston, Massachusetts 02114-2698; Harvard Medical School (A.L., S.A.B., V.A.T., S.J.A., J.B.M.), Boston, Massachusetts 02115; and Diabetes Center (S.A.B., D.J.W.), Massachusetts General Hospital, Boston, Massachusetts 02114.
authors.forename: Deborah J
authors.initials: DJ
authors.lastname: Wexler
authors.affiliation: Division of General Internal Medicine (A.L., S.A.B., V.A.T., B.P., W.H., S.J.A., D.J.W., J.B.M.), Massachusetts General Hospital, Boston, Massachusetts 02114-2698; Harvard Medical School (A.L., S.A.B., V.A.T., S.J.A., J.B.M.), Boston, Massachusetts 02115; and Diabetes Center (S.A.B., D.J.W.), Massachusetts General Hospital, Boston, Massachusetts 02114.
authors.forename: James B
authors.initials: JB
authors.lastname: Meigs
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D003324:Coronary Artery Disease / Q000453:epidemiology* / Q000209:etiology*; D003920:Diabetes Mellitus / Q000097:blood* / Q000453:epidemiology*; D003925:Diabetic Angiopathies / Q000453:epidemiology*; D050171:Dyslipidemias / Q000097:blood / Q000453:epidemiology; D005260:Female; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D006973:Hypertension / Q000097:blood / Q000453:epidemiology; D007003:Hypoglycemia / Q000453:epidemiology* / Q000209:etiology*; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000097:blood / Q000453:epidemiology; D011320:Primary Health Care; D012307:Risk Factors; D012959:Socioeconomic Factors
chemical_list: D006442:Glycated Hemoglobin