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European Heart Journal (2005) 26, 2142–2147

doi:10.1093/eurheartj/ehi376
Clinical research

Diabetes, glucose level, and risk of sudden cardiac death


Xavier Jouven1,2*, Rozenn N. Lemaı̂tre3, Thomas D. Rea3, Nona Sotoodehnia3,
Jean-Philippe Empana2, and David S. Siscovick3
1
Service de Cardiologie, Université Paris-5, Faculté René Descartes, Hôpital Européen Georges Pompidou, 20 rue Leblanc,
75015 Paris, France; 2 Equipe AVENIR et Unité INSERM 258, Hôpital Paul Brousse, Villejuif, France; and 3 University of
Washington, Cardiovascular Research Unit, Metropolitan Park, East Tower, Seattle, WA 98101, USA
Received 25 August 2004; revised 20 April 2005; accepted 19 May 2005; online publish-ahead-of-print 24 June 2005

KEYWORDS Aims The prevalence of diabetes mellitus in industrialized countries is rapidly increasing, and diabetes
Sudden death; is suspected to carry a particular high risk for sudden cardiac death (SCD).
Cardiac arrest; Methods and results We conducted a population-based case–control study at Group Health Coopera-
Diabetes; tive. Cases (n ¼ 2040) experienced out-of-hospital cardiac arrest due to heart disease between 1980
Glycaemia and 1994. Controls (n ¼ 3800) were a stratified random sample of enrollees. Diabetes status was classi-
fied into four exclusive groups: (i) no diabetes, (ii) borderline, (iii) diabetes without microvascular
disease (retinopathy or proteinuria), and (iv) diabetes with microvascular disease. When compared
with no diabetes, we observed progressively higher risk of SCD associated with borderline diabetes
[Odds ratio (OR) ¼ 1.24 (0.98–1.57)], diabetes without microvascular disease [OR ¼ 1.73
(1.28–2.34)], and diabetes with microvascular disease [OR ¼ 2.66 (1.84–3.85)], after adjustment for
potential confounders (P-value for trend ,0.001). Higher glucose levels were also associated with
the risk of SCD both in the absence and in the presence of microvascular disease. However, subjects
with microvascular complications but with glucose level ,7.7 mmol/L were not at significant increased
risk of SCD.
Conclusion These results emphasize the role of diabetes as a strong risk factor for SCD and outline the
importance of glucose level at every stage of diabetes severity.

Introduction SCD.7 Although cholesterol-lowering treatment and anti-


hypertensive therapy reduced the risk of macrovascular
Sudden cardiac death (SCD), also known as primary cardiac disease among diabetics, the effects of glucose level
arrest, is a major problem in industrially developed control on the risk of macrovascular disease remain dis-
countries.1–3 Despite a decline in heart disease mortality, cussed.8 We examined whether glucose level and diabetes
hundreds of thousands of persons die each year from SCD. were associated with an elevated risk of SCD in a large
Furthermore, although ‘the chain of survival’ outlines population-based case–control study.
opportunities to improve treatment, successful resuscita-
tion remains ,5% in most communities.4,5 The ideal solution
would be to prevent the disease processes that cause SCD Methods
and, strategies aimed at identifying persons or clinical Design and study subjects
groups at particularly high risk of SCD may represent a
We conducted a population-based case–control study at Group
major challenge.
Health Cooperative (GHC) of Puget Sound, a large health mainte-
Glucose intolerance and diabetes have been associated nance organization with over 400 000 enrollees based in Western
with an increased risk of coronary heart disease outcomes, Washington State.
and a particular high risk for SCD is suspected. 6 However, Cases were GHC enrollees aged 40–79 who experienced incident,
the (physiological) processes such as microvascular out-of-hospital SCD between 1 January 1980 and 31 December 1994.
disease, glycaemia, or coronary ischaemia through which We defined SCD as a sudden pulseless condition in the absence of
diabetes may confer elevated risk of SCD have not been evidence of a non-cardiac condition as the cause of cardiac
fully evaluated. For example, in the United Kingdom arrest.9 All potentially eligible cases of SCD among GHC enrollees
Prospective Diabetes Study, glycaemic control significantly were initially identified from both computerized emergency
reduced the incidence of microvascular disease, but had medical services databases from Seattle and King County
Washington and from GHC death records. All cases were confirmed
more limited effects on cardiovascular events including
by a review of the ambulatory medical record to ensure that the
SCD was of cardiac origin and to confirm the absence of a life-
* Corresponding author. Fax: þ33 1 56 09 22 64. threatening non-cardiac condition prior to the occurrence of
E-mail address: xavier.jouven@egp.ap-hop-paris.fr cardiac arrest.

& The European Society of Cardiology 2005. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

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Diabetes, glucose level, and risk of SCD 2143

Controls were a stratified random sample of GHC enrollees, where were observed with and without Bonferroni corrections for multiple
the strata were defined in cases by age (decade), gender, calendar testing, so that the statistics of descriptive analysis were reported
year, and treatment with digoxin or nitroglycerin. Stratification on without such a correction. We used conditional logistic regression
the use of digoxin or nitroglycerin served as a proxy for heart to obtain estimates of the odds ratio (OR) for SCD. The conditional
disease in the sampling of controls, as this information was available logistic regression analyses accounted for the sampling variables
through automated pharmacy records on all enrollees. However, as (age decade, gender, calendar year, and use of digoxin or nitrogly-
stated subsequently, we used ambulatory medical record data for cerin). To estimate the OR of SCD associated with progressively
the final classification of each case and control with regard to the more severe diabetes, we included three indicator variables for
presence or the absence of prior physician-diagnosed heart disease. diabetes (borderline diabetes, diabetes without microvascular com-
In each stratum, the ratio of controls to cases was 2:1. plications, and diabetes with microvascular complications) using the
As the focus of this investigation was SCD due to heart disease, we non-diabetes category as reference. We also combined glucose cat-
excluded cases and controls with life-threatening non-cardiac con- egories (,7.7, 7.7–11.1,and .11.1 mmol/L) with the presence or
ditions including metastatic cancer, brain tumour, end-stage liver absence of microvascular complications, so that we estimated the
disease, or respiratory failure. We also excluded subjects who had associated OR of SCD for each category using non-diabetics subjects
been enrolled in the Health Maintenance Organization for ,1 year with glucose level ,7.7 mmol/L as the reference category. Logistic
or had less than four ambulatory care visits prior to the index/ regression was systematically adjusted for major risk factors for
event date. For these analyses, we excluded patients with type I sudden coronary death including current smoking status, systolic
diabetes (22 cases and 7 controls) and subjects who did not have blood pressure, anti-diabetic treatment, and history of myocardial
a plasma glucose measurement (167 cases and 366 controls). The infarction and congestive heart failure. Other known potential risk
study population for this report thus included 2040 cases and 3800 factors such as body mass index, serum cholesterol and creatinine
controls. levels, and heart rate were subsequently added to multivariate
models after imputing missing data by the mean of each correspond-
Data collection ing variable (taken from controls). Analyses were also stratified on
clinically recognized heart disease and gender, and interaction
Each study subject was assigned an index date. The index date was terms between diabetes categories and clinically recognized heart
the date of SCD for cases. Controls, within the same strata as cases, disease and gender respectively were included in the models.
were randomly assigned an index date from the same calendar year. All continuous variables included in regression analysis verified
We reviewed the ambulatory medical record of GHC to obtain the linearity assumption (assessed by plotting the proportion of
information about various clinical characteristics before the index cases by deciles of continuous variables).
date. The record includes not only notes from the ambulatory
care visits, but also results (and dates) of diagnostic and laboratory
tests, discharge summaries of hospitalizations, consultant reports,
responses to annual GHC questionnaires, and updated problem Results
lists. We collected the plasma glucose level measured most recently Characteristics of cases and controls are compared in
before the index date from the ambulatory care medical record.
Table 1, stratified on the presence (n ¼ 3493) or the
Information on whether the glucose measurement was obtained
absence (n ¼ 2347) of clinical heart disease. Among both
during fasting or non-fasting state was not consistently available.
We used the GHC pharmacy database to assess medications. The study subjects with or without clinically recognized heart
pharmacy database includes all prescriptions filled for enrollees disease, a greater proportion of cases were current
since 1976. Previous surveys suggest that 98% of all prescriptions smokers and heavy alcohol drinkers, cases had on average
for enrollees were filled at pharmacies included in the database. a higher basal heart rate and higher levels of cholesterol,
creatinine, and blood glucose than controls, and a greater
Definitions proportion of cases had pharmacologically treated diabetes.
Body mass index and systolic blood pressure were higher in
We defined four mutually exclusive categories of diabetes status:
(i) no diabetes defined as plasma glucose ,7.7 mmol/L without
cases than controls among study subjects without heart
physician diagnosis of diabetes; (ii) borderline diabetes defined as disease but lower in cases than controls among study sub-
plasma glucose between 7.7 and 11.1 mmol/L without physician jects with heart disease. The proportion of borderline
diagnosis of diabetes; (iii) diabetes without microvascular disease diabetic subjects was similar among cases and controls,
defined as physician diagnosis of diabetes or blood glucose although the proportion of diabetic subjects with microvas-
.11.1 mmol/L but no evidence of microvascular disease; and cular complications (including retinopathy and urine
(iv) diabetes with microvascular disease. Diabetes-related protein) was greater among cases than among controls
microvascular disease was defined as physician diagnosis of dia- (Table 1 ).
betes-associated retinopathy (non-proliferative retinopathy or The ORs (95% CI) for SCD of 1 SD increase of glucose level
proliferative retinopathy or macular oedema) or a urine analysis
(2.7 mmol/L in controls) and for the presence of microvas-
with at least 1 þ proteinuria.
Clinically recognized heart disease was defined as physician-
cular complications were 1.20 (1.12–1.28) and 1.64
diagnosed myocardial infarction, angina pectoris (stable and (1.22–2.22), respectively, after adjustment for current
unstable), coronary revascularization (coronary artery bypass smoking status, systolic blood pressure, anti-diabetic treat-
surgery and graft and percutaneous transluminal angioplasty), ment, and history of myocardial infarction and congestive
atrial or ventricular arrhythmia, congenital or valvular heart heart failure. When compared with no diabetes, we
disease, cardiomyopathy, or congestive heart failure. observed progressively higher risk of SCD associated with
borderline diabetes [OR ¼ 1.24 (0.98–1.57)], diabetes
Statistical analyses without microvascular disease [OR ¼ 1.73 (1.28–2.34)],
Statistical analyses were made on Stata 7.0 software (Stata and diabetes with microvascular disease [OR ¼ 2.66
Corporation, College Station, TX, USA) and all tests were two- (1.84–3.85)], after adjustment for current smoking status,
sided. In descriptive analyses, we compared the prevalence of risk systolic blood pressure, anti-diabetic treatment, and
factors between cases and controls using x2 tests for categorical history of myocardial infarction and congestive heart
variables and t-tests for continuous variables. Consistent results failure (P-value for trend ,0.001; Table 2 ). The ORs

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2144 X. Jouven et al.

Table 1 Main characteristics of cases and controls in the overall sample and by heart disease status

Variables Overall n ¼ 5840 No heart disease n ¼ 2347 Heart disease n ¼ 3493

Cases Controls Cases Controls Cases Controls


(n ¼ 2040) (n ¼ 3800) (n ¼ 697) (n ¼ 1650) (n ¼ 1343) (n ¼ 2150)

Age (years) 67.0 (9.5) 66.9 (9.3) 64.5 (10.7) 65.0 (10.2) 68.4 (8.5) 68.4 (8.3)
Male 70.7 69.2 66.9 64.6 72.8 72.7
Current smoker 29.4 16.3 36.6 17.6 25.7 15.4
Congestive heart failure 31.1 9.8 — — 47.2 17.3
Myocardial infarction 32.8 17.4 — — 49.7 30.7
BMIa (kg/m2) 26.8 (5.3) 26.7 (4.5) 27.2 (5.5) 26.4 (4.4) 26.5 (5.2) 26.9 (4.6)
Pulse at resta (b.p.m.) 77.6 (14.1) 74.4 (12.6) 78.6 (13.7) 75.6 (11.6) 77.2 (14.2) 73.7 (13.2)
Systolic BP (mmHg) 135.9 (22.6) 136.9 (19.9) 140.9 (20.5) 135.9 (19.6) 133.3 (23.2) 137.7 (20.2)
Total cholesterola (mg/dl) 238.2 (49.4) 228.8 (42.1) 242.6 (49.8) 226.8 (40.6) 236.2 (49.1) 230.1 (43.1)
Creatinina (g/L) 1.3 (0.6) 1.2 (0.5) 1.2 (0.5) 1.1 (0.5) 1.4 (0.6) 1.2 (0.5)
Non-fasting glycaemia 7.3 (3.9) 6.2 (2.7) 6.7 (3.3) 5.8 (2.2) 7.6 (4.2) 6.5 (3.0)
(mmol/L)
Diabetes pharmacological 17.7 8.0 11.1 4.2 21.2 10.9
treatment
Diabetes status
No diabetes 69.9 82.8 79.3 90.0 65.1 77.2
Borderline diabetes 7.3 6.2 5.5 4.1 8.2 7.9
Diabetes without 12.8 7.7 9.3 4.2 14.7 10.3
microvascular disease
Diabetes with microvascular 9.9 3.3 5.9 1.6 12.1 4.6
disease

Values are mean (SD) and per cent for continuous and categorical variables, respectively. BMI, body mass index.
a
Missing data: BMI for 102 cases and 126 controls; pulse for 202 cases and 394 controls; total cholesterol for 435 cases and 665 controls; creatinine for 49
cases and 152 controls.

Table 2 Association of diabetes status with out-of-hospital cardiac arrest

Diabetes status Overall No heart disease Heart disease

Case/control ORa 95% CI Case/control ORa 95% CI Case/control ORa 95% CI

No diabetes 1427/3145 1 553/1485 1 874/1860 1


Borderline diabetes 148/237 1.24 0.98–1.57 38/68 1.53 0.99–2.34 110/169 1.09 0.82–1.45
Diabetes without 262/292 1.73 1.28–2.34 65/70 2.25 1.27–3.98 197/222 1.45 1.01–2.07
microvscular disease
Diabetes with 203/126 2.66 1.84–3.85 41/27 3.35 1.66–6.74 162/99 2.32 1.50–3.61
microvascular disease

Stratification on clinically diagnosed heart disease.


a
Conditional logistic regression adjusted for age, current smoking status, systolic blood pressure, and antidiabetic treatment and for those with heart
disease and for myocardial infarction and congestive heart failure.

associated with diabetes were higher among subjects overlapping (P-value for interaction with heart disease in
without clinically recognized heart disease than among sub- men is 0.19 and in women is 0.06; data not shown).
jects with heart disease (P-value for interaction ¼ 0.005). We observed higher risk of SCD associated with higher
However, the ORs increased in a stepwise fashion across levels of glucose both in the presence and in the absence
diabetes status categories both among persons without of microvascular disease after adjustment for current
heart disease (P-value for trend ,0.001) and among smoking status, systolic blood pressure, anti-diabetic
persons with heart disease, (P-value for trend ¼ 0.001, treatment, and history of myocardial infarction and conges-
Table 2 ). Similarly, the ORs associated with diabetes were tive heart failure (Table 4 ). When compared with study sub-
higher among women than among men (P-value for inter- jects without microvascular disease and with glucose
action ,0.001); however, the stepwise increase in OR was ,7.7 mmol/L, the ORs increased progressively and signifi-
observed both among women (P-value for trend ,0.001) cantly in subjects with glucose level between 7.7 and
and among men, (P-value for trend ¼ 0.001, Table 3 ). We 11.1 mmol/L and in subjects with glucose .11.1 mmol/L,
generally observed higher ORs among men without heart in the absence and in the presence of microvascular
disease than among men with heart disease and among disease. However, subjects with microvascular compli-
women without heart disease than among women with cations but with glucose level ,7.7 mmol/L were not at sig-
heart disease, although the 95% CI were large and nificant increased risk of SCD (Table 4 ).

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Diabetes, glucose level, and risk of SCD 2145

Table 3 Association of diabetes status with out-of-hospital cardiac arrest among men and women

Diabetes status Men Women

Case/control ORa 95% CI Case/control ORa 95% CI

No diabetes 1032/2135 1 395/1010 1


Borderline diabetes 112/184 1.25 0.97–1.61 36/53 1.64 1.0–2.67
Diabetes without microvascular disease 177/211 1.63 1.18–2.27 85/81 2.47 1.33–4.60
Diabetes with microvascular disease 122/100 2.42 1.63–3.60 81/26 5.79 2.61–12.8
a
Conditional logistic regression adjusted for age, current smoking status, systolic blood pressure, and antidiabetic treatment and for those with heart
disease and for myocardial infarction and congestive heart failure.

Table 4 Association of out-of-hospital cardiac with non-fasting glycaemia level and microvascular disease

Non-fasting glycaemia (mmol/L) Overall No heart disease Heart disease

Case/control ORa 95% CI Case/control ORa 95% CI Case/control ORa 95% CI

No microvascular disease
,7.7 1516/3290 1 575/1526 1 941/1764 1
7.7–11.1 170/249 1.26 0.99–1.58 42/73 1.44 0.94–2.22 128/176 1.12 0.85–1.49
.11.1 151/135 2.08 1.52–2.85 39/24 3.32 1.77–6.23 112/111 1.68 1.16–2.43
Microvascular disease
,7.7 42/41 1.48 0.89–2.46 9/8 2.46 0.88–6.86 33/33 1.24 0.69–2.25
7.7–11.1 61/38 2.62 1.60–4.28 12/8 2.68 0.98–7.34 49/30 2.46 1.39–4.36
.11.1 100/47 3.23 2.06–5.06 20/11 3.40 1.42–8.10 80/36 3.03 1.79–5.15

Stratification on clinically diagnosed heart disease.


a
Conditional logistic regression adjusted for age, current smoking status, systolic blood pressure and antidiabetic treatment and for those with heart
disease and for myocardial infarction and congestive heart failure.

As in the previous analyses, ORs were higher among study compared with non-diabetic subjects. In the Paris
subjects without heart disease (P-value for interaction with Prospective Study I, a study of middle-aged men free of
heart disease is 0.01) and among women (P-value for inter- clinical heart disease working for the city of Paris, the risk
action with sex ,0.001); however, similar patterns of of SCD, but not of fatal myocardial infarction, was increased
increasing ORs across categories of glucose levels were in diabetes when compared with normal subjects.11,12 In the
generally observed among subjects without and with heart Framingham study, diabetes was strongly associated with
disease (Table 4 ) and among men and women (Table 5 ). the incidence of SCD and the association was stronger in
Further adjustments for body mass index, serum choles- women than in men.13 In a case–control study by Escobedo
terol and creatinine levels, and heart rate did not change et al. 14 diabetes was related to sudden coronary death
the results. Similar results were obtained in subjects only in subjects with prior coronary heart disease.14
younger or older than 65 years. However, in this latter study, diabetes (and other risk
factors) was self-reported and sudden death cases were
identified through death certificates and interview of infor-
Discussion mants. Likewise, in another Australian case–control study,
In this population-based case–control study, diabetes and diabetes was strongly associated with SCD.15
diabetes-related microvascular complications as well as However, in two other prospective studies of middle-aged
high level of hyperglycaemia were associated with an ele- men from Finland and England, diabetes and glucose level
vated risk of SCD. Given the increasing prevalence of dia- were not associated with SCD.16,17 Several reasons may
betes and the considerable health burden of SCD, these explain these apparent discrepancies. For instance, in the
results have potentially important public health impli- Finnish study, the prevalence of diabetes was low, only
cations.6 Subjects with diabetes-related microvascular com- 1.5% (53/3589) of study participants.16 The definition of
plications but glycaemia ,7.7 mmol/L did not have a diabetes and cut-off used to define hyperglycaemia may
significant increased risk of SCD, underscoring the prognos- have been different between studies. For instance, in the
tic importance of keeping glycaemia within the normal British Heart Regional Study, diabetes was self-reported
range at all stages of diabetes. and non-fasting glycaemia .6.1 mmol/L was used to
The few previous studies that have assessed the risk of define hyperglycaemia when compared with 7.7 mmol/L in
SCD associated with diabetes mellitus have provided mixed the present study.17 Therefore, in the British Heart
results. Interestingly, positive association was found in Regional Study, non-diabetics may have been included in
studies with long-term follow-up (typically .20 years). For the group of diabetic subjects resulting in the underestima-
instance, Curb et al. 10 found an increased relative risk of tion of the true association between diabetes and SCD.
SCD in diabetic middle-aged Japanese American men when Finally, these two studies had relative short duration of

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Table 5 Association of out-of-hospital cardiac with non-fasting glycaemia level and microvascular disease among men and women

Non-fasting glycaemia (mmol/L) Men Women

Case/control ORa 95% CI Case/control ORa 95% CI

No microvascular disease
,7.7 1099/2237 1 417/1053 1
7.7–11.1 127/193 1.19 0.91–1.55 43/56 1.53 0.95–2.47
.11.1 95/100 1.56 1.08–2.27 56/35 4.28 2.29–8.01
Microvascular disease
,7.7 24/35 1.05 0.57–1.92 18/6 3.9 1.32–11.50
7.7–11.1 45/30 2.23 1.27–3.91 16/8 5.35 1.89–15.12
.11.1 53/35 2.37 1.38–4.08 47/12 6.84 2.91–16.13
a
Conditional logistic regression adjusted for age, current smoking status, systolic blood pressure, and antidiabetic treatment and for those with heart
disease and for myocardial infarction and congestive heart failure.

follow-up, 8 and 11 years, respectively, when compared supports the role of microvascular processes: risk increased
with 20 years of follow-up in previous prospective studies stepwise for those with diabetes with clinical microvascular
cited earlier. disease when compared with those with diabetes without
Moreover, most previous studies were restricted to men microvascular disease. This elevated risk of SCD among
and were conducted in middle-aged subjects without preva- persons with diabetes and microvascular disease was
lent coronary heart disease. In addition, these studies were evident among persons with and without clinical heart
not able to investigate the role of microvascular disease disease and did not appear to be due to confounding
complications. factors. Alternatively, the presence of microvascular
The results of the current investigation support an associ- disease might have been a marker for duration of diabetes,
ation between diabetes and an elevated risk of SCD overall a factor that might increase macrovascular disease. The
as well as among demographic (age/gender) and clinical design (stratified on clinical heart disease) of the current
subgroups (with and without heart disease). The estimated study limits the ability to evaluate the macrovascular contri-
OR between diabetes and SCD was particularly large bution to SCD among persons with diabetes; though prior
among women and persons without clinically recognized investigations have established that coronary heart disease
heart disease. This is consistent with the Framingham is more prevalent in persons with diabetes and that coronary
study in which the association between diabetes and SCD lesions are present in .80% of SCD victims.22 Some data also
was stronger in women independent of age.13 Moreover, in suggest an accelerated coronary atherosclerosis.23–26
the British Heart Regional Study, other risk factors, such as Moreover, a prothrombotic state has been reported as a
heavy alcohol consumption and heart rate, were particularly mechanism linking diabetes and SCD.27
associated with SCD in men without pre-existing ischaemic
heart disease.17 However, in the current study, the larger Blood glucose level
relative risks in these subgroups (gender and pre-existing
ischaemic heart disease) should be considered with In the current study, an increasing level of blood glucose was
respect to the lower incidence and lower absolute risk of associated with an elevated risk of SCD, a relationship that
SCD for women compared with men and for persons was present among those with and without clinical evidence
without heart disease compared with persons with heart of microvascular disease. Several factors may explain the
disease. Furthermore, direct comparison of the OR for SCD relationship of hyperglycaemia and SCD. Hyperglycaemia
between gender and subjects with and without heart may promote microvascular disease that was not clinically
disease is difficult, because the reference category (first apparent (or documented) and that in turn may contribute
level of diabetes category of each subgroup) may not carry to SCD risk. Hyperglycaemia may be a surrogate for other
the same absolute risk of SCD. In addition, the presence of health markers such as poor health behaviours or medical
heart disease is a strong risk factor of SCD by itself, which care that may be associated with the risk of SCD. Finally,
may attenuate the effect of other risk factor including hyperglycaemia may confer risk through some other yet
diabetes. unknown mechanisms. Moreover, in the present study, sub-
jects with microvascular complications but with glucose
Suspected mechanisms level ,7.7 mmol/L were not at statistically significant
increased risk of SCD after multivariate adjustment. This
The association between SCD and diabetes may be due to argues in favour of a tight control of blood glucose level
either microvascular processes including cardiac autonomic even in more severe diabetes.
dysfunction, macrovascular disease such as coronary athero-
sclerosis or some combination of macro- and microvascular
Limitations
processes. Microvascular disease may produce autonomic
neuropathy that manifests as a prolonged QT interval, In this study, it was not possible to determine whether the
increased QT dispersion, or decreased heart rate variability, measure of blood glucose in the medical record was
which in turn may contribute to the occurrence of ventricu- performed in the fasting state, a characteristic that may
lar arrhythmias.18–21 In the current study, some evidence have produced some misclassification, if some

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Diabetes, glucose level, and risk of SCD 2147

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