Sex-specific risks for cardiovascular disease across the glycaemic spectrum: a population-based cohort study using the UK Biobank
Authors: Rentsch Christopher T , Garfield Victoria , Mathur Rohini , Eastwood Sophie V , Smeeth Liam , Chaturvedi Nish , Bhaskaran Krishnan 
Published: March 2023

Background

We sought to examine sex-specific risks for incident cardiovascular disease (CVD) across the full glycaemic spectrum.

Methods

Using data from UK Biobank, we categorised participants’ glycosylated haemoglobin (HbA1c) at baseline as low-normal (<35 mmol/mol), normal (35-41 mmol/mol), pre-diabetes (42-47 mmol/mol), undiagnosed diabetes (≥48 mmol/mol), or diagnosed diabetes. Our outcomes were coronary artery disease (CAD), atrial fibrillation, deep vein thrombosis (DVT), pulmonary embolism (PE), stroke, heart failure, and a composite outcome of any CVD. Cox regression estimated sex-specific associations between HbA1c and each outcome, sequentially adjusting for socio-demographic, lifestyle, and clinical characteristics.

Findings

Among 427,435 people, CVD rates were 16.9 and 9.1 events/1000 person-years for men and women, respectively. Both men and women with pre-diabetes, undiagnosed diabetes, and, more markedly, diagnosed diabetes were at higher risks of CVD than those with normal HbA1c, with relative increases more pronounced in women than men. Age-adjusted HRs for pre-diabetes and undiagnosed diabetes ranged from 1.30 to 1.47; HRs for diagnosed diabetes were 1.55 (1.49-1.61) in men and 2.00 (1.89-2.12) in women (p-interaction<0.0001). Excess risks attenuated and were more similar between men and women after adjusting for clinical and lifestyle factors particularly obesity and antihypertensive or statin use (fully adjusted HRs for diabetes: 1.06 [1.02-1.11] and 1.17 [1.10-1.24], respectively).

Interpretation

Excess risks in men and women were largely explained by modifiable factors, and could be ameliorated by attention to weight reduction strategies and greater use of antihypertensive and statin medications. Addressing these risk factors could reduce sex disparities in glycaemia-related risks of CVD.

Funding

Diabetes UK (#15/0005250) and British Heart Foundation (SP/16/6/32726)

Research in context

Evidence before this study

It has long been asserted that men and women with diabetes have differential risks of cardiovascular disease (CVD), but it is unclear which risk factors drive these sex differences, and whether men or women with moderately elevated glycosylated haemoglobin (HbA1c) below the threshold for diabetes are also at increased risk of CVD. We searched MEDLINE and PubMed on 15 March 2023 for studies evaluating sex differences in the risk of CVD across the glycaemic spectrum. The keywords “ (sex difference* OR sex disparit* OR sex-strat* OR sex-specific) AND (glycaemia OR glycemia OR glycosylated OR hemoglobin OR haemoglobin) AND (non-diabetes OR non-diabetic) AND (cardiovascular) AND (rate OR hazard OR odds OR risk)” were used and results were filtered to articles with an abstract available in English. 33 papers were identified and all 33 were eligible for screening; none reported sex-stratified associations of CVD risk across the full glycaemic spectrum. Previous studies have suggested a J-shaped curve in the relationship between HbA1c and outcomes including CVD and all-cause mortality, with individuals with low-normal HbA1c at excess risk compared to normal HbA1c. However, these studies were limited in sample size, combined people with controlled diabetes with those without diabetes, and did not analyse individual CVD outcomes. The present study leveraged UK Biobank data, which measured HbA1c on ∼500,000 men and women, regardless of diabetes status, presenting a unique opportunity to study sex disparities in the risk of CVD across the glycaemic spectrum.

Added value of this study

We uncovered novel insights around sex disparities in CVD risk across the glycaemic spectrum. Absolute CVD rates were higher in men than women at all levels of HbA1c. Both men and women with pre-diabetes, undiagnosed diabetes, and, more markedly, diagnosed diabetes were at higher risks of CVD than those with normal HbA1c, with relative increases in risk more pronounced in women than men. Both men and women with low-normal HbA1c had lower absolute rates of CVD than those with normal HbA1c. We extended previous evidence by showing most excess risk, and thereby differential relative risks between men and women, disappeared after accounting for lifestyle and clinical characteristics, namely measures of obesity and use of antihypertensive or lipid-lowering medications.

Implications of all the available evidence

This is the largest study to date to investigate sex differences in the risk of CVD across the glycaemic spectrum. While those with diagnosed diabetes carried the highest risk compared to those with normal HbA1c, men and women with pre-diabetes and undiagnosed diabetes were also at higher risk and those with low-normal HbA1c were at lower risk of CVD outcomes, highlighting the need for strategies to reduce risk of CVD across the glycaemic spectrum. Our findings suggest that excess risks in both men and women were largely explained by modifiable factors and could be ameliorated by attention to weight reduction strategies and greater use of antihypertensive and statin medications. Addressing these risk factors could reduce sex disparities in glycaemia-related risks of CVD.