Long-Term Effects of Incident Diabetes Mellitus on Cardiovascular Outcomes in People Treated for Hypertension
The ALLHAT Diabetes Extension Study
Background—Thiazide-type diuretics are associated with an increased incidence of diabetes compared with other antihypertensive medications. In this study, we determined the long-term cardiovascular disease (CVD) consequences of incident diuretic-associated diabetes compared with the effects of incident diabetes associated with calcium channel blocker and angiotensin-converting enzyme inhibitor use.
Methods and Results—A total of 22 418 participants from the ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) with baseline diabetes, incident diabetes (7.5% with chlorthalidone, 5.6% with amlodipine, and 4.3% with lisinopril), or no diabetes at 2 years of in-trial follow-up were followed for a mean total of 6.9 years (2.9 years in-trial and 4 additional years posttrial) through the use of national databases. The primary outcome was CVD mortality (death from coronary heart disease [CHD], stroke, heart failure, or other CVD). Among other outcomes were all-cause mortality, non-CVD mortality, and CHD (nonfatal myocardial infarction or fatal CHD). Participants on chlorthalidone with incident diabetes versus no diabetes had consistently lower, nonsignificant risk for CVD mortality (hazard ratio [HR], 1.04; 95% CI, 0.74–1.47), all-cause mortality (HR, 1.04; 95% CI, 0.82–1.30), and non-CVD mortality (HR, 1.05; 95% CI, 0.77–1.42) than participants on amlodipine or lisinopril with incident diabetes (HR range, 1.22–1.53). Participants with incident diabetes had elevated CHD risk compared with those with no diabetes (HR, 1.46; 95% CI, 1.09–1.96), but those on chlorthalidone had significantly lower risk than those on lisinopril (HR, 1.18 versus 2.57; P=0.04 for interaction).
Conclusions—The findings suggest that thiazide-related incident diabetes has less adverse long-term CVD impact than incident diabetes that develops while on other antihypertensive medications.
In placebo- and active-controlled clinical trials with an average follow-up of up to 5 years, diuretic therapy for the treatment of hypertension has been associated with more-favorable clinical cardiovascular outcomes than other hypertension medications.1 On the basis of decades of rigorously conducted clinical trials, diuretic therapy has been endorsed as first-line therapy.2 Despite these benefits, the long-term use of diuretics (>5 years) is still questioned because diuretics are associated with potentially unfavorable metabolic consequences, especially increased risk of incident diabetes mellitus (DM).3 In the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) the risk of incident DM at 4 years follow-up was 15% to 30% higher with the thiazide-like diuretic chlorthalidone (11%) versus the calcium channel blocker amlodipine (9.3%), or the angiotensin-converting enzyme inhibitor lisinopril (7.8%).4 Any deleterious impact of incident DM worsens with time, suggesting that there could be an attenuation of the medium-term salutary effects of diuretic therapy on cardiovascular disease (CVD) over longer periods of follow-up.5
Editorial see p 145
Here, we examine long-term CVD mortality and morbidity, total mortality, and end-stage renal disease (ESRD) in individuals who during ALLHAT were classified as having DM at baseline, incident DM (based on 2-year glucose levels), or no DM at baseline or 2 years. Participants were passively followed for 4 years after trial completion (mean total follow-up, 8.9 years; after the 2-year diabetes determination, 6.9 years). We hypothesized that the effects of incident DM on CVD and renal outcomes is less with chlorthalidone than with amlodipine or lisinopril, as was found in the in-trial period.4
The use of chlorthalidone therapy for the treatment of hypertension has been questioned because of its associated increased risk of elevated glucose levels and diabetes compared with other blood pressure-lowering medications.
In a prior report from ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial), the increased risk of diabetes with chlorthalidone therapy versus angiotensin-converting enzyme inhibitor or calcium channel blocker therapy was modest and did not translate into more cardiovascular disease compared with diabetes during an average of 2.9 years of follow-up for postdevelopment of new-onset diabetes during the first 2 years of ALLHAT.
ALLHAT participant follow-up was extended up to an average of 6.9 years through querying national databases and confirms our prior findings.
Although chlorthalidone therapy is associated with an increased risk of diabetes compared with other blood pressure-lowering medications, diabetes associated with chlorthalidone use has lower long-term cardiovascular disease risk than diabetes associated with angiotensin-converting enzyme inhibitor or calcium channel blocker use.
The risk of diabetes associated with chlorthalidone should not deter clinicians from using it long-term.
Details of the ALLHAT design and results have been previously published.4 The in-trial period lasted from 1994 through 2002. All participants signed an informed consent on study entry. After trial completion, the posttrial follow-up of participants through 2006 was accomplished using national databases (see End Points sections). The Institutional Review Board of The University of Texas Health Science Center approved the long-term follow-up study.
ALLHAT Participants and Laboratory Testing
Eligibility criteria for ALLHAT have been previously published.4 The dose of each step 1 blinded medication (chlorthalidone, amlodipine, and lisinopril) was titrated to achieve a target blood pressure <140/90 mm Hg. If the blood pressure could not be controlled using the maximum dose of step 1 medication, open-label step 2 and step 3 medications (atenolol, reserpine, clonidine, and hydralazine) were added. Other drugs, including low doses of open-label step 1 drug classes, were permitted if clinically indicated or blood pressure was not controlled. Potassium supplementation was mandated when a local recheck confirmed a potassium level of <3.2 mEq/L and was encouraged for levels consistently <3.5 mEq/L. After initial titration visits, participants were seen routinely every 3 months during the first year of follow-up and every 4 months throughout the rest of the active phase of the trial.
Baseline central laboratory test results for glucose, lipid, creatinine, and potassium levels were obtained; a sample obtained after >8 hours without food was considered a fasting sample. At years 2, 4, and 6, glucose levels were evaluated again. Serum potassium and creatinine levels were measured at 1 month and at years 1, 2, 4, and 6.
Cohorts for Analysis
Baseline DM was defined as a physician diagnosis or a baseline fasting glucose (FG) ≥126 mg/dL or non-FG ≥200 mg/dL. Participants with no history of DM with either an FG <126 mg/dL or a non-FG <100 mg/dL were classified as nondiabetic at baseline. Participants with a non-FG of 100 to 199 mg/dL could not be classified and were excluded. Diagnostic evidence confirming diabetic history was not systematically sought. Participants who were nondiabetic at baseline were further classified as having incident DM (follow-up FG ≥126 mg/dL or follow-up non-FG ≥200 mg/dL) or no DM (follow-up FG <126 mg/dL or follow-up non-FG <100 mg/dL) based on glucose testing at year 2. We chose the more conservative criterion of 100 to 199 mg/dL for non-FG levels (and not 126–199 mg/dL) to exclude participants with diabetes with non-FG levels of 100 to 125 mg/dL whose glucose levels were obtained <8 hours after eating and did not reach the >126 mg/dL criterion. The associations of baseline DM and incident DM compared with no DM with the risks of primary and secondary outcomes were evaluated based on DM status at 2 years because (1) this was the first FG available during follow-up, (2) more-complete glucose data were available at 2 years than at 4 years or 6 years, and (3) there was more follow-up time for events. In-trial average follow-up time was 4.9 years, and average follow-up, including the extended follow-up, was 8.9 years (6.9 years after 2-year incident DM determination).
A fourth arm in the ALLHAT study, randomization to doxazosin, was terminated early because of a nearly twofold higher risk of incident heart failure (HF) and a low probability of reaching a statistically significant difference in the primary end point.4,6 Because of differences in follow-up time, comparisons of the impact of incident DM on CVD outcomes between doxazosin and chlorthalidone are not reported.
Extended Follow-Up End Point Definition and Determination
For the posttrial period, data are not available on treatments, blood pressure levels, outpatient morbidity, or laboratory values.
Mortality End Points
Mortality data were available for the entire cohort during both in-trial and posttrial periods, except for Canadian participants (because of a lack of access to databases). During the trial, most causes of death were determined by the investigator. Additional in-trial and posttrial all-cause and cause-specific mortality were ascertained from the National Death Index (NDI), using social security number, name, sex, and date of birth as matching criteria.
CVD mortality (death from coronary heart disease [CHD], stroke, HF, or other CVD) was designated a priori as the primary end point of the extended follow-up. Total mortality and its components, including CHD death, were prespecified and assessed as secondary outcomes.
A death identified through passive surveillance was defined as a possible match through NDI or Social Security Administration that was verified at the coordinating center after receipt of a death certificate from the state. Death certificates were used only for verification of participant identity. Causes of death (ICD-10 [International Classification of Diseases and Related Health Problems, 10th Revision] coding) were obtained from NDI Plus and collapsed into the categories used in these analyses. NDI Plus (fact of death plus cause) data were initially provided under the ICD-9 (International Classification of Diseases, Ninth Revision); for deaths occurring in 1999 forward, NDI Plus provided data under the ICD-10. To continue with the original conversion scheme of ICD-9 to ALLHAT category, the World Health Organization Two-Way Translator for the Ninth and Tenth Revisions was used to convert ICD-10 codes to ICD-9 codes.7
Secondary End Points
Morbidity data for hospitalized events were available for both in-trial and posttrial periods. During the in-trial period, events were ascertained by the investigator and confirmed by the coordinating center end points department based on discharge summaries. Nonfatal events were also ascertained from the Centers for Medicare & Medicaid Services (formerly the Health Care Financing Administration) and the US Renal Data System. During the posttrial period, nonfatal events (except renal events) were ascertained from the Centers for Medicare & Medicaid Services only for participants with valid Medicare or social security numbers who were not enrolled from Veterans Affairs (VA) sites (69% of all non-Canadian participants). Data on renal events were obtained from the US Renal Data System, which includes VA participants. Because of the lack of access to databases, Canadian and VA participants were not included in any combined morbidity/mortality analyses (except ESRD analysis for VA participants). Lack of access to a VA database involved administrative issues related to informed consent for posttrial follow-up specific to VA patients. The following fatal and nonfatal outcomes were prespecified as secondary end points: 1) total CVD (mortality, or hospitalized nonfatal myocardial infarction, or fatal/ nonfatal hospitalized stroke, or fatal/nonfatal hospitalized HF); 2) CHD (mortality, or hospitalized nonfatal myocardial infarction; 3) fatal/nonfatal hospitalized stroke; and 4) ESRD.
Contingency tables and Z-tests were used to compare baseline characteristics of participants assigned to amlodipine or lisinopril versus chlorthalidone within the baseline DM group and to compare glucose values and DM incidence during follow-up. Evaluations of the effect of baseline and incident DM compared with no DM on the risks for the primary and secondary outcomes subsequent to 2 years were performed using Cox regression by treatment groups and for all treatment groups combined, adjusting for baseline age, sex, race, body mass index, cigarette smoking, atherosclerotic CVD, left ventricular hypertrophy, baseline systolic blood pressure, baseline diastolic blood pressure, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol. Comparisons of the hazard ratios (HRs) for baseline DM and incident DM compared with no DM for each treatment group were evaluated using treatment×diabetes status interaction terms in Cox regressions; comparisons were also done for incident DM compared with baseline DM. The Cox proportional hazards regression model assumption was examined by using log-log plots and testing a treatment×time (time-dependent) interaction term.
In addition, among participants with no DM at baseline, the occurrence of outcomes before and after 2 years was examined by treatment group and by DM status at 2 years (no DM, incident DM, unknown status [death before year 2 follow-up or glucose level unavailable after baseline]) using contingency table analysis (χ2 or Fisher exact test) to examine whether there were any treatment differences over the entire follow-up period. These diabetes status subgroups are subject to confounding because they were based on a postrandomization measurement. Given the many multivariate, subgroup, and interaction analyses performed, statistical significance at the 0.05 level should be interpreted with caution.
For analyses of mortality end points, 20 000 of 42 418 randomized participants who were assigned to doxazosin (9061), were Canadian (553), who died before 2 years (585), or whose baseline or 2-year DM status could not be determined (9801) were excluded. Of the 9801 excluded because of unknown diabetes status, 7105 had missing glucose values and 2696 had non-FG values between 100 and 199 mg/dL. The remaining 22 418 participants assigned to chlorthalidone, amlodipine, or lisinopril were classified according to baseline and 2-year DM status (Figure 1). For analyses of fatal and nonfatal total CVD, an additional 8618 participants were excluded because we lacked the data or the participants experienced a CVD event before 2 years (Figure 2). Analyses of other events included varying numbers of participants, depending on how many participants experienced those events before 2 years.
Of 22 418 randomized participants, 46% were women, 81% were aged ≥60 years (mean, 66±7.5 years), 35% were black, 19% were Hispanic, and 55% had a history of type 2 DM. Table 1 shows baseline characteristics for the mortality cohort by treatment group within diabetes strata. Compared to participants with no DM at baseline or at 2 years, participants with DM at baseline were younger, had higher systolic blood pressure and lower diastolic blood pressure, had higher body mass index, and had lower high-density lipoprotein and low-density lipoprotein cholesterol levels; they were more likely to be women or black and were less likely to be current smokers, to have a history of CHD or atherosclerotic CVD, or to have baseline left ventricular hypertrophy. Participants with incident DM at 2 years were younger and had higher systolic blood pressure, higher body mass index, and lower high-density lipoprotein cholesterol than participants with no DM at baseline or at 2 years and were less likely to be women. Similar findings were found in the cohorts used for total CVD morbidity analysis (online-only Data Supplement Table I).
Table 2 depicts incident diabetes in the mortality cohort. During follow-up, mean glucose levels increased from baseline in all treatment groups for those who did not have baseline DM. Of participants assigned to chlorthalidone, 7.5% met the FG or non-FG criteria for incident DM at 2 years compared with 5.6% assigned to amlodipine (P=0.002) and 4.3% assigned to lisinopril (P<0.001). Between years 2 and 6, incident DM developed at similar rates in those treated with amlodipine, lisinopril, and chlorthalidone (1.1%, 1.0%, and 0.9%, respectively).
For all treatment groups combined and within each treatment group, participants with baseline DM had significantly higher risks for all outcomes than those with no DM at baseline or at 2 years (Table 3, online-only Data Supplement Figures I–III). For all treatment groups combined, participants with incident DM at 2 years were also at higher risk than those with no DM for nonfatal myocardial infarction plus CHD death (HR, 1.46; 95% CI, 1.09–1.96) and total CVD (HR, 1.28; 95% CI, 1.03–1.59). For most end points, participants with incident DM had an intermediate risk between participants with no DM and participants with baseline DM.
For the primary outcome of CVD mortality, there were no significant differences in HRs between treatment groups in those who developed incident DM versus those with no DM (P=0.24, P=0.46 for interaction) (online-only Data Supplement Figure III). However, given the number of events observed, there was <20% power to detect an interaction effect (ratio of HRs) on the order of what was actually seen (1.28–1.41).8 There were differences, however, in HRs across treatment groups for several secondary outcomes. For fatal and nonfatal CHD (online-only Data Supplement Figure III), the comparison of incident DM with baseline DM within the lisinopril group (HR, 1.50; 95% CI, 0.85–2.64) was significantly different from the same comparison in the chlorthalidone group (HR, 0.65; 95% CI, 0.42–0.99; P=0.01 for interaction). Participants assigned to lisinopril who developed incident DM had a significantly elevated risk for fatal myocardial infarction and nonfatal CHD relative to those with no DM (HR, 2.57; 95% CI, 1.45–4.54), whereas the HR for chlorthalidone was not significant (1.18; 95% CI, 0.77–1.81; P=0.04 for interaction). Participants treated with amlodipine who developed incident DM had significantly elevated risks for all-cause mortality (HR, 1.40; 95% CI, 1.01–1.95) and stroke (HR, 1.95; 95% CI, 1.04–3.65) relative to those who had no DM, but interaction terms were not significant (versus chlorthalidone and lisinopril). Among the other incident DM and no DM comparisons, HRs were lowest in the chlorthalidone group for all-cause mortality, CVD mortality, non-CVD mortality, and stroke, but the differences were not statistically significant (nonsignificant interaction terms). The proportional hazard assumption was tested for all treatment and diabetes status HRs, and there were no violations.
Mortality and morbidity outcomes among those with no DM at baseline or after 2 years follow-up, those with incident DM at year 2, or those whose status at year 2 was unknown were calculated (online-only Data Supplement Tables II and III). Notwithstanding the limitations of analyses using subgroups based on a postrandomization definition,9 neither amlodipine nor lisinopril was significantly superior to chlorthalidone in preventing the occurrence of outcomes before and after 2 years, regardless of DM status. The one exception was HF among participants with incident DM. However, there were few events (n=4) before 2 years, and after 2 years, there were no significant differences among the treatment groups for this outcome (P=0.17).
Adjusted Kaplan-Meier plots of outcomes by DM status are shown in Figure 3. Participants randomized to chlorthalidone who developed incident DM had outcomes similar to chlorthalidone participants with no DM; amlodipine and lisinopril participants who developed incident DM had outcomes intermediate to those with baseline DM. These patterns were especially noticeable for CVD mortality, non-CVD mortality, and fatal and nonfatal CHD. They were less so for fatal and nonfatal total CVD.
In this extension of ALLHAT, analysis by assigned primary antihypertensive medication showed that for participants who developed incident DM versus those with no DM, chlorthalidone had the lowest HR for CVD mortality. Those treated with chlorthalidone also had the lowest HR for total mortality, non-CV mortality, CHD, and stroke. For no outcome did incident DM have a significant adverse effect on risk in the chlorthalidone group, despite the much larger sample size compared to the amlodipine and lisinopril groups.
The present findings are consistent with those of our previous ALLHAT report10 and 2 long-term post hoc analyses of trials that examined the impact of diuretic-associated DM on CVD mortality. In the 14-year follow-up of the SHEP (Systolic Hypertension in Elderly Program) study, DM that developed during chlorthalidone therapy did not have a statistically significant impact on CVD mortality (risk ratio, 1.04; 95% CI, 0.75–1.46), similar to our own result, or on all-cause mortality (risk ratio, 1.15; 95% CI, 0.92–1.43) in contrast to DM that developed while assigned to placebo.11 In a second study, a 14-year follow-up of 686 middle-aged adults with hypertension treated with diuretics, incident DM did not have a significant effect on CVD mortality, whereas baseline DM did.12
With regard to fatal and nonfatal stroke, HF, and ESRD, randomization to chlorthalidone was associated with a mixed picture. Compared with amlodipine or lisinopril, the HR for stroke was lowest, whereas for ESRD, it was highest. There were fewer ESRD outcomes than stroke outcomes, introducing uncertainty to this comparison and mitigating the absolute impact associated with chlorthalidone for ESRD outcomes. With regard to HF, incident DM with chlorthalidone use was associated with a higher risk compared to amlodipine or lisinopril, but interaction terms were not significant, suggesting that the DM-associated risks of HF in the 3 groups were not statistically different.
Other findings should be noted. First, in almost all instances, participants with baseline DM had a worse outcome than either those with no DM or those with incident DM. Within diabetes mellitus subgroups, there were (in general) no differences in HRs whether the participant was treated with chlorthalidone, amlodipine, or lisinopril.
Second, our starting point for follow-up was based on incident DM detected at 2 years of in-trial treatment. A higher percentage of the incident DM associated with chlorthalidone use was captured during this time period than that associated with amlodipine or lisinopril use, making our estimates of the long-term impact of incident DM associated with amlodipine or lisinopril conservative relative to those reported for chlorthalidone.
Third, among chlorthalidone participants, CVD mortality and fatal and nonfatal CHD associated with incident DM closely resembled those with no DM, whereas among amlodipine or lisinopril participants, outcomes resembled participants with baseline DM. These findings suggest differences in the nature of amlodipine- and lisinopril-associated DM compared to chlorthalidone-associated DM. We previously hypothesized10 that depletion of potassium plays a role in the excess incidence of DM that is associated with chlorthalidone use (above and beyond the DM that is expected with having hypertension). Depletion of potassium inhibits insulin release from pancreatic β cells, and potassium restoration reverses this effect.13–15 In contrast, DM associated with the use of amlodipine or lisinopril is likely due to progression of insulin resistance that is present despite the glucose-neutral or glucose-protective effects of these agents.
To our knowledge, the present study has the largest number of participants with incident DM and is the only one to compare results of randomization to chlorthalidone against other hypertension medications. This point is important because persons with hypertension are prone to develop DM irrespective of treatment type. Assuming that calcium channel blockers are metabolically neutral, comparison of DM incidence rates at 2 years of in-trial follow-up for chlorthalidone (7.5%) versus amlodipine (5.6%) suggests that 74.7% of the new-onset DM in the chlorthalidone group is not caused by the diuretic (ie, only about one fourth of the cases were diuretic induced).
This study has several limitations. First, the randomized treatments were discontinued at the conclusion of the trial in 2002. The administrative data used to document extended follow-up do not provide information about medication use during the period of passive observation. Second, glucose levels fluctuate, and repeated testing is recommended to confirm glycemic status. This was not done in ALLHAT and is a common practice in large trials because of the inconvenience and cost of recalling large numbers of participants. Misclassification of DM status, however, would have occurred randomly across treatment groups and should not have affected the findings. Third, the results present data stratified by postrandomization characteristics (incident DM and no DM), which is the only way of studying the postrandomization effects of randomly assigned drugs, and many participants were excluded. Therefore, the treatment groups may no longer have been balanced on observed and unobserved variables.9 Finally, many participants from the trial were not included in posttrial follow-up because of lack of access to relevant databases.
In conclusion, the findings suggest that thiazide-associated incident DM is associated with lower CVD mortality and morbidity relative to amlodipine- or lisinopril-associated incident DM over an average of 6.9 years. Therefore, concerns regarding potential adverse diabetic effects associated with thiazide-type diuretic therapy should not inhibit its use. In this regard, a recent pooled analysis of 5 statin studies16 showed that incident DM was more common in persons treated with intensive-dose therapy versus moderate-dose therapy. Nonetheless, the benefits of reduced cholesterol were deemed to outweigh any possible deleterious effects of incident diabetes mellitus on CVD outcomes. Similarly, thiazide-like diuretics have been shown to be highly effective for preventing CVD outcomes through decades of rigorously controlled clinical trials.
Sources of Funding
This study was supported by contract N01-HC-35130 from the National Heart, Lung, and Blood Institute. The ALLHAT investigators acknowledge contributions of study medications supplied by Pfizer, Inc (amlodipine), AstraZeneca (atenolol and lisinopril), and Bristol-Myers Squibb (pravastatin) and financial support provided by Pfizer, Inc.
None of the authors reports a conflict of interest with regard to the contents of this article. The authors report the following financial disclosures: Dr Barzilay has held a financial interest in Pfizer and Schering-Plough. Dr Black has consulted for Bayer Corporation, Boehringer Ingelheim, Bristol-Myers Squibb, CVRx, Daiichi Sankyo, Gilead, Merck, Mitsubishi, Novartis, Pfizer, Servier, and Takeda; has received honoraria from Bristol-Myers Squibb; and has held a financial interest in Boehringer Ingelheim. Dr Davis has consulted for Amgen and Takeda. Dr Cushman has consulted for Daiichi Sankyo, Novartis, Noven, Sanofi Aventis, Takeda, and Theravance; has received honoraria from Bristol-Myers Squibb, Daiichi Sankyo, Novartis, and Sanofi Aventis; and has had research grants and contracts with GlaxoSmithKline, Merck, and Novartis. Dr Margolis has received research grants from Bristol-Myers Squibb. Dr Oparil has consulted for Boehringer Ingelheim, Daiichi Sankyo, Eli Lilly, Forest Laboratories, Forest Pharmaceuticals, NicOx, Novartis, Omron Healthcare, Pfizer, and Schering-Plough and has received research grants from Amgen, Daiichi Sankyo, Gilead, Merck, and Takeda. Dr Sweeney has received research grants from GlaxoSmithKline, Merck, and Novartis. Dr Wong has received research grants and contracts from Forest Pharmaceuticals and Novartis. Dr Wright has consulted for CVRx, Daiichi Sankyo, Novartis, and Sanofi Aventis and has received honoraria from Sanofi Aventis. Ms Pressel and Drs Cutler, Einhorn, Ford, Moloo, Piller, Simmons, and Whelton have no financial interests to report.
The online-only Data Supplement is available at http://circoutcomes.ahajournals.org/lookup/suppl/doi:10.1161/CIRCOUTCOMES.111.962522/-/DC1.
- Received June 30, 2011.
- Accepted December 30, 2011.
- © 2012 American Heart Association, Inc.
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