Prediction by Low Plasma HbA1c of Mortality,Cardiac and Noncardiac Disease Risk: Modulation by Diabetic Status and Sex

Abstract

Aim

The aim of the study was to evaluate the predictive value of HbA_1c for risk of overall mortality or a composite endpoint of death and nonfatal events.

Methods

Logistic regression retrospectively assessed the longitudinal association of measured HbA_1c with outcome in 746 middle-aged adults, recruited from a tertiary health center and stratified to absence or presence of type 2 diabetes, using the recent American Diabetes Association criteria.

Results

A total of 70 deaths and additional incident nonfatal events in 82 cases were recorded at a median of 3.1-year follow-up. Multivariable linear regression revealed among nondiabetic individuals HbA_1c to be significantly associated—independent of fasted glucose—inversely with triglycerides and high-density lipoprotein cholesterol, distinct from the diabetic sample. Sex and diabetes status differed in baseline HbA_1c values with respect to the development of outcome. Nondiabetic men who subsequently died exhibited significantly lower HbA_1c, as did men and women with incident coronary heart disease. Similar difference was observed for incident hypothyroidism and nondiabetic subjects developing malignancy. In logistic regression analysis, adjusted for sex, age, and fasting glucose, each 0.7% (SD, 1) decrement of baseline HbA_1c predicted the composite endpoint in the nondiabetic sample (risk estimates, 1.49%; 95% confidence interval, 1.07–2.04), but not in the diabetic sample, whereas overall mortality in the whole sample was increased (risk estimates, 1.51%; 95% confidence interval, 1.05–2.17).

Conclusions

Inverse association of HbA_1c with adverse outcomes in men and nondiabetic people indicates the involvement of HbA_1c levels in autoimmune activation. The weaker inverse association with prevalent diabetes and in women is consistent with the operation of more pronounced confounding autoimmune processes.