Obesity, Diabetes, and Acute Coronary Syndrome: Differences Between Asians and Whites

To access, purchase, authenticate, or subscribe to the full-text of this article, please visit this link: http://dx.doi.org/10.1016/j.amjmed.2017.03.030 Byline: Masaya Koshizaka, MD, PhD [overslope@chiba-u.jp] (a,b,*), Renato D. Lopes, MD, PhD, MHS (a), L. Kristin Newby, MD, MHS (a), Robert M. Clare, MS (a), Phillip J. Schulte, PhD (a), Pierluigi Tricoci, MD, MHS (a), Kenneth W. Mahaffey, MD (c), Hisao Ogawa, MD, PhD (d), David J. Moliterno, MD (e), Robert P. Giugliano, MD, SM (f), Kurt Huber, MD (g), Stefan James, MD, PhD (h), Robert A. Harrington, MD (c), John H. Alexander, MD, MHS (a) Keywords Acute coronary syndrome; Diabetes; Ischemic outcomes; Obesity; Race Abstract Background Most diabetes and cardiovascular studies have been conducted in white patients, with data being extrapolated to other population groups. Methods For this analysis, patient-level data were extracted from 5 randomized clinical trials in patients with acute coronary syndrome; we compared obesity levels between Asian and white populations, stratified by diabetes status. By using an adjusted Cox proportional hazards model, hazard ratios (HRs) for cardiovascular outcomes after an acute coronary syndrome were determined. Results We identified 49,224 patient records from the 5 trials, with 3176 Asians and 46,048 whites. Whites with diabetes had higher body mass index values than those without diabetes (median 29.3 vs 27.2 kg/m.sup.2; P < .0001), whereas Asians with diabetes and without diabetes had similar body mass index (24.7 vs 24.2 kg/m.sup.2). Asians with diabetes (HR, 1.63; 95% confidence interval [CI], 1.32-2.02), whites with diabetes (HR, 1.15; 95% CI, 1.06-1.25), and Asians without diabetes (HR, 1.36; 95% CI, 1.14-1.64) had higher rates of the composite of death, myocardial infarction, or stroke at 30 days than whites without diabetes. Asians with diabetes (HR, 1.84; 95% CI, 1.47-2.31), whites with diabetes (HR, 1.47; 95% CI, 1.33-1.62), and Asians without diabetes (HR, 1.38; 95% CI, 1.11-1.73) had higher rates of death at 1 year compared with whites without diabetes. There were no significant interactions between race and diabetes for ischemic outcomes. Conclusions Although Asians with diabetes and acute coronary syndrome are less likely to be obese than their white counterparts, their risk for death or recurrent ischemic events was not lower. Author Affiliation: (a) Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (b) Division of Diabetes, Metabolism and Endocrinology, Clinical Research Center, Chiba University Hospital, Japan (c) Department of Medicine, Stanford University, Calif (d) National Cerebral and Cardiovascular Center, Osaka, Japan (e) Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington (f) Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital, Boston, Mass (g) 3rd Medical Department, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, and Sigmund Freud Private University, Medical School, Vienna, Austria (h) Department of Medical Sciences, Cardiology, Uppsala University and Uppsala Clinical Research Center, Sweden * Requests for reprints should be addressed to Masaya Koshizaka, MD, PhD, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba City, Chiba 260-8670, Japan. (footnote) Funding: The following sponsors funded the individual trials: Platelet IIb/IIIa Antagonist for the Reduction of Acute Coronary Syndrome Events in a Global Organization Network (PARAGON B): F. Hoffmann-La Roche Ltd (Basel, Switzerland); Early Glycoprotein IIb/IIIa Inhibition in Patients With Non--ST-Segment Elevation Acute Coronary Syndrome (EARLY ACS): Schering-Plough (Kenilworth, NJ); Apixaban for Prevention of Acute Ischemic Events 2 (APPRAISE-2): Bristol-Myers Squibb (Princeton, NJ) and Pfizer (New York, NY); Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRACER): Merck (Whitehouse Station, NJ); Study of Platelet Inhibition and Patient Outcomes (PLATO): AstraZeneca (London, UK). The companies listed funded the original studies, but they had no input or involvement in the statistical analyses performed for this study, which was funded by the Duke Clinical Research Institute. (footnote) Conflict of Interest: MK received research funds from Astellas and lecture fees from Kowa Pharmaceutical and Kyowa Hakko Kirin. RDL received consulting fees from Bayer Corporation US (Bayer AG/Bayer in Japan--subsidiaries), Boehringer Ingelheim, Merck, Pfizer, and Portola; research funds and consulting fees from Bristol-Myers Squibb and GlaxoSmithKline; and research funds from Guidant Corporation. LKN received consulting fees from the American College of Cardiology, American Heart Association, American College of Physicians, AstraZeneca, BioKier, CardioDx, Inc, Cubist Pharmaceuticals, Daiichi Sankyo, DSI-Lilly, Eli Lilly & Company, Genentech, INC Research, JAHA, Janssen Pharmaceutical Products, Medscape/TheHeart.org, MetroHearth System, National Institutes of Health, Navigant, Novartis, Philips, Roche Diagnostic Corp, Society of CV Patient Care, and VoxMedia; research funds from Amylin, Inc, Bristol-Myers Squibb, GlaxoSmithKline, Google Life Sciences, MURDOCK Study, National Heart, Lung, and Blood Institute, and PCORI; and research funds and consulting fees from Merck & Co. PT received research funds and consulting fees from CSL Behring and Merck & Co; and research funds from Regeneron and Sanofi-Aventis. KWM's financial disclosures can be viewed at http://med.stanford.edu/profiles/kenneth-mahaffey(http://med.stanford.edu/profiles/kenneth-mahaffey) and research grant or contract from Afferent, Amgen, AstraZeneca, Daiichi, Ferring, Google (Verily), Johnson & Johnsohn, Medtronic, Merck, Novartis, St. Jude and received consulting fees or other services (including CME) from Ablynx, AstraZeneca, BAROnova, Bio2Medical, Boehringer Ingelheim, Bristol Myers Squibb, Cardiometabolic health Congress, Cubist, Eli Lilly, Elsevier, Epson, GlaxoSmithKline, Johnson & Johnson, Merck, Mt Sinai, Myokardia, Novartis, Oculeve, Portola, Radiomeer, Springer Publishing, The Medicines Company, Theravance, Vindico, WebMD. KWM has equity in BioPrint Fitness. HO has none to report. RPG received research support from Schering-Plough, Amgen, Daiichi-Sankyo, and Merck; honoraria from Amgen, Daiichi-Sankyo, and Merck; and consulting fees from Amarin, American College of Cardiology, Amgen, Angel Med, Beckman-Coulter, CVS Caremark, Daiichi-Sankyo, Janssen, Lexicon, Merck, Portola, Pfizer, Regeneron, Sanofi-Aventis, St Jude, and Stealth Peptides. KH received lecture fees from AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Eli Lilly, Sanofi-Aventis, and The Medicines Company. SJ received institutional research grant from AstraZeneca, Eli Lilly, Bristol-Myers Squibb, Terumo Inc, Medtronic, and Vascular Solutions; honoraria from The Medicines Company, AstraZeneca, Eli Lilly, Bristol-Myers Squibb, and IROKO; and consultant/advisory board fees from AstraZeneca, Eli Lilly, Merck, Medtronic, and Sanofi. RAH received research grants from AstraZeneca, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, GlaxoSmithKline, Johnson & Johnson, Merck, Portola Pharmaceuticals, Regado, Sanofi, and The Medicines Company; and consulting fees from Bristol-Myers Squibb, CSL, Daiichi-Sankyo, Gilead, Johnson & Johnson, Merck, and MyoKardia. JHA received research grants from Bristol-Myers Squibb, Boehringer Ingelheim, CSL Behring, Sanofi, and Tenax Therapeutics and received consulting fees/honoraria from Cempra, CryoLife, CSL Behring, Pfizer, Portola Pharmaceuticals, VasoPrep Surgical. (footnote) Authorship: All authors had access to the data and played a role in writing this manuscript.