Atherosclerotic Cardiovascular Disease or Heart Failure: First Cardiovascular Event in Adults with Prediabetes and Diabetes

Published:November 04, 2022DOI:



      Individuals with prediabetes and diabetes are at increased risk of atherosclerotic cardiovascular disease (ASCVD) and heart failure (HF). Whether ASCVD or HF is more likely to occur first in these populations within different race-sex groups is unknown.


      Determine the competing risk for the first cardiovascular event by subtype in Black and White men and women with prediabetes and diabetes.


      Individual-level data from adults without ASCVD or HF were pooled from 6 population-based cohorts. We estimated the competing cumulative incidences of ASCVD, HF, and non-cardiovascular death as the first event in middle-aged (40-59 years) and older (60-79 years) adults, stratified by race and sex, with normal fasting plasma glucose (FPG <100 mg/dL), prediabetes (FPG 100-125 mg/dL) and diabetes (FPG ≥126 mg/dL or on antihyperglycemic agents) at baseline. Within each race-sex group, we estimated risk (aHR) of ASCVD, HF, and non-cardiovascular death in adults with prediabetes and diabetes relative to adults with normoglycemia after adjusting for cardiovascular risk factors.


      In 40,117 participants with 638,910 person-years of follow-up, 5,781 cases of incident ASCVD and 3,179 cases of incident HF occurred. In middle-aged adults with diabetes, competing cumulative incidence of ASCVD as first event was higher than HF in White men (35.4% vs. 11.6%), Black men (31.6% vs. 15.1%), and White women (24.3% vs 17.2%), but not in Black women (26.4% vs 28.4%). Within each group, aHR of ASCVD and HF was significantly higher in adults with diabetes compared with adults with normal FPG. Findings were largely similar in middle-aged adults with prediabetes and older adults with prediabetes or diabetes.


      Black women with diabetes are more likely to develop HF as their first CVD event, while individuals with diabetes from other race-sex groups are more likely to present first with ASCVD. These results can inform tailoring primary prevention therapies for either HF- or ASCVD-specific pathways based on individual-level risk.

      Graphical Abstract


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