title: Diabetes mellitus and risk of ischemic stroke in patients with heart failure and no atrial fibrillation.
abstract: OBJECTIVE
  The risk of ischemic stroke, systemic thromboembolism, and all-cause death among heart failure patients previously diagnosed with diabetes mellitus is poorly described. We evaluated the risk of these endpoints among heart failure patients without diagnosed atrial fibrillation according to the presence of diabetes mellitus.
  
  
  METHODS
  Population-based nationwide cohort study of non-anticoagulated patients diagnosed with incident heart failure during 2000-2012, identified by record linkage between nationwide registries in Denmark. We calculated relative risks after 1year to evaluate the association between diabetes and risk of events in 39,357 heart failure patients, among whom 18.1% had diabetes. Analysis took into account competing risks of death.
  
  
  RESULTS
  Absolute risks of all endpoints were higher in patients with diabetes compared to patients without diabetes after 1-year follow-up (ischemic stroke: 4.1% vs. 2.8%; systemic thromboembolism: 11.9% vs. 8.6%; all-cause death: 22.1% vs. 21.4%). Diabetes was significantly associated with an increased risk of ischemic stroke (adjusted relative risk [RR]: 1.27, 95% confidence interval [CI]: 1.07-1.51); systemic thromboembolism (RR: 1.20, 95% CI: 1.11-1.30); and all-cause death (RR: 1.17, 95% CI: 1.11-1.23). Additionally, time since diabetes diagnosis was associated with higher adjusted cumulative incidences of ischemic stroke, systemic thromboembolism, and all-cause death (p for trend, p<0.001).
  
  
  CONCLUSIONS
  Among heart failure patients without atrial fibrillation, diabetes was associated with a significantly increased risk of ischemic stroke, systemic thromboembolism, and all-cause death compared to those without diabetes, even after adjustment for concomitant cardiovascular risk factors. Increased focus on secondary prevention in heart failure patients with diabetes may be warranted.
authors.affiliation: Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark. Electronic address: line.melgaard@rn.dk.
authors.forename: Line
authors.initials: L
authors.lastname: Melgaard
authors.affiliation: Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; Unit of Clinical Biostatistics, Aalborg University Hospital, Aalborg, Denmark. Electronic address: agorstras@gmail.com.
authors.forename: Anders
authors.initials: A
authors.lastname: Gorst-Rasmussen
authors.affiliation: Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark. Electronic address: p.soegaard@rn.dk.
authors.forename: Peter
authors.initials: P
authors.lastname: Søgaard
authors.affiliation: Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark. Electronic address: lhr@adm.aau.dk.
authors.forename: Lars Hvilsted
authors.initials: LH
authors.lastname: Rasmussen
authors.affiliation: Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; University of Birmingham Centre for Cardiovascular Sciences City Hospital, Birmingham, United Kingdom. Electronic address: g.y.h.lip@bham.ac.uk.
authors.forename: Gregory Y H
authors.initials: GY
authors.lastname: Lip
authors.affiliation: Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark. Electronic address: tobl@rn.dk.
authors.forename: Torben Bjerregaard
authors.initials: TB
authors.lastname: Larsen
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001281:Atrial Fibrillation; D002545:Brain Ischemia / Q000175:diagnosis / Q000453:epidemiology*; D015331:Cohort Studies; D003718:Denmark / Q000453:epidemiology; D003920:Diabetes Mellitus / Q000175:diagnosis / Q000453:epidemiology*; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000175:diagnosis / Q000453:epidemiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011159:Population Surveillance; D012042:Registries; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis / Q000453:epidemiology*
keywords: Death; Diabetes; Heart failure; Risk stratification; Stroke; Systemic thromboembolism