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Diabetes requiring insulin increases stroke risk in AF

Diabetes requiring insulin increases stroke risk in AF

Publication date: Sunday, 12 March 2017
Contributor(s): Jeremy Bray

Atrial fibrillation (AF) patients with insulin-requiring diabetes are at greater risk of suffering a stroke or systemic embolism than those with non-insulin requiring diabetes, or no diabetes at all. While diabetes is a known risk factor for thromboembolic events, this finding sheds new light on the role of insulin in the clinical setting.

These results are based on subanalyses of the PREFER in AF registry, a study conducted to provide insights into the management of AF in Europe, following the introduction of non-vitamin K oral anticoagulants (NOACs).

In a group of 1288 diabetic AF patients enrolled in the PREFER in AF registry, those with insulin-requiring diabetes were found to have a greater than 2.5-fold increased risk of stroke or systemic embolism at one year compared to those with non-insulin requiring diabetes (HR 2.96: 1.49 to 5.87; p = 0.0019) and no diabetes (HR: 2.89; 95% CI: 1.67 to 5.02; p = 0.0002) (Table 1).

These findings were found to be the case irrespective of comorbidities and the type of anticoagulant treatment used. Interestingly, rates of stroke or systemic embolism were not observed to be different in patients with diabetes not receiving insulin compared to those without diabetes (HR: 0.97; 0.58 to 1.61; p = 0.90), which suggests that insulin-requiring diabetes may increase the thromboembolic risk in AF patients.
Table 1: Risk of stroke or systemic embolism in patients with AF at 1 year.

Patient group

Cases of stroke/systemic embolism

Diabetes patients requiring insulin

5.2 per 100 patients/year

Diabetes patients not requiring insulin

1.8 per 100 patients/year

Non-diabetic patients

1.9 per 100 patients/year


Although the presence of diabetes (not requiring insulin) did not imply an increased thromboembolic risk in these patients, insulin-requiring diabetes contributes significantly to the overall increase of thromboembolic risk in AF. This could have significant implications for clinical practice to ensure that AF patients with diabetes who are taking insulin receive appropriate anticoagulation treatment to mitigate additional risk. Further studies are required to substantiate the findings.

Patti G, et al. Insulin-Requiring Versus Noninsulin-Requiring Diabetes and Thromboembolic Risk in Patients With Atrial Fibrillation: PREFER in AF. JACC 2017; 69(4):

Kirchhof P, et al. Management of atrial fibrillation in seven European countries after the publication of the 2010 ESC Guidelines on atrial fibrillation: primary results of the PREvention oF thromboembolic events - European Registry in Atrial Fibrillation (PREFER in AF). Europace 2013. doi: 10.1093/europace/eut263.

Topics covered:
Category: Evidence in Practice
Edition: Volume 2 Number 2 PCCJ Online 2017
Contributor(s): Jeremy Bray

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