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Determinants of new onset diabetes among hypertensive patients randomised in the ASCOT-BPLA Trial

Determinants of new onset diabetes among hypertensive patients randomised in the ASCOT-BPLA Trial. Dr Ajay K Gupta International Centre for Circulatory Health NHLI, Imperial College London. Presented on behalf of the ASCOT Investigators. Background.

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Determinants of new onset diabetes among hypertensive patients randomised in the ASCOT-BPLA Trial

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  1. Determinants of new onset diabetes among hypertensive patients randomised in the ASCOT-BPLA Trial Dr Ajay K Gupta International Centre for Circulatory Health NHLI, Imperial College London Presented on behalf of the ASCOT Investigators

  2. Background • Hypertension and diabetes are common co-morbid conditions, and their relationship is complex • Hypertension is an independent risk factor for diabetes development, and increases risk by 2-3 times • Recent studies have shown that antihypertensive drugs -particularly beta-blockers and diuretics - variably potentiate this enhanced risk • Controversy still persists because of methodological criticisms of these studies, and lack of robust evidence for reduction in cardiovascular benefits as a result of new onset diabetes development

  3. 10,305 patients TC ≤ 6.5 mmol/L (250 mg/dL) ASCOT-LLA atorvastatin10 mg placebo Double-blind ASCOT-BPLA 19,342 hypertensive patients ASCOT-BPLA PROBE design atenolol ± bendroflumethiazide amlodipine ± perindopril www. ascotstudy.org

  4. New onset diabetes* in ASCOT-BPLA % 10.0 Atenolol  thiazide (No. of events = 799) 8.0 31% 6.0 Cumulative Events Amlodipine  perindopril (No. of events = 567) 4.0 2.0 0.0 Years 0.0 3.0 4.0 5.0 1.0 2.0 * New onset diabetes was a pre-specified outcome in ASCOT

  5. Objectives • To determine the predictors of new onset diabetes (NOD) among hypertensive patients in ASCOT-BPLA • To develop a risk score to identify those at high risk

  6. Outcome definitions • Baseline diabetes : Presence of any 1 of 3 criteria • FPG ≥ 7 mmol/l and/or random glucose ≥11.1mmol/l • Self reported diabetes and receiving dietary or drug therapy • Presence of both IFG (≥ 6mmol/l) and glucosuria in absence of above two criteria (endpoint committee exclusion definition) • New onset diabetes : according to WHO 1999 definition

  7. Methods • A multivariable Cox proportional hazard regression model was developed using forward stepwise selection (p<0.05) with age, sex and blood pressure treatment group as covariates. The model was assessed for internal validity and discriminative ability • Based on the Cox model, risk scores for individuals were estimated by summing of the product of the coefficient and the variable value • Risk scores were divided into quartiles and model calibration was evaluated by comparing the observed outcomes with the predicted outcomes

  8. ASCOT-BPLA: Trial Profile 19342 randomised 85 excluded because of blood pressure measurement irregularities 19257 evaluable 5137 with “diabetes” at baseline* 14120 patient at risk of NOD 7046 in atenolol-based treatment group 7074 in amlodipine-based treatment group 799 (11.4%) developed new onset diabetes 567 (8%) developed new onset diabetes

  9. Baseline characteristics

  10. Baseline characteristics

  11. Multivariable Cox proportional hazard model ( Primary Cox model n=12692; cases=1212) * All those having FBS≤5 mmol/l were given baseline risk ** All those with BMI >35 kg/m2 were given similar risk, hazard ratio for every 5 unit rise from baseline

  12. New onset diabetes according to risk score quartiles 0.30 4 0.20 Probability of new onset diabetes 0.10 3 2 1 0.00 0 1 2 3 4 5 Follow-up time (years)

  13. Probability of development of diabetes stratified by quartile of risk score and the treatment drug* 0.30 Atenolol-based treatment 4 0.20 Probability of new onset diabetes Amlodipine-based treatment 0.10 3 2 1 0.00 0 1 2 3 4 5 Follow-up time (years) Atenolol ± thiazide =solid; Amlodipine± perindopril=dash *treatment adjusted for but excluded in risk score calculation

  14. Observed and expected probabilities of the development of diabetes by quartile of risk score in ASCOT Number of observed events 105 44 206 765

  15. Summary & conclusions • FPG, BMI, antihypertensive therapy, HDL-c and triglyceride level are important baseline predictors for development of diabetes • Compared with use of atenolol ± thiazide, the use of amlodipine± perindopril is associated with 34% reduction in risk of NOD, and this decrease is irrespective of the baseline risk category • Risk model developed is robust, has an excellent discriminative ability, and potentially could play an important role in clinical practice

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