Early Glycemic Control and Magnitude of HbA1c Reduction Predict Cardiovascular Events and Mortality: Population-Based Cohort Study of 24,752 Metformin Initiators

OBJECTIVE We investigated the association of early achieved HbA 1c level and magnitude of HbA 1c reduction with subsequent risk of cardiovascular events or death in patients with type 2 diabetes who initiate metformin. RESEARCH DESIGN AND METHODS This was a population-based cohort study including all metformin initiators with HbA 1c tests in Northern Denmark, 2000–2012. Six months after metformin initiation, we classified patients by HbA 1c achieved ( 1c change from the pretreatment baseline. We used Cox regression to examine subsequent rates of acute myocardial infarction, stroke, or death, controlling for baseline HbA 1c and other confounding factors. RESULTS We included 24,752 metformin initiators (median age 62.5 years, 55% males) with a median follow-up of 2.6 years. The risk of a combined outcome event gradually increased with rising levels of HbA 1c achieved compared with a target HbA 1c of 1c reduction from baseline also predicted outcome: adjusted HR 0.80 (0.65–0.97) for Δ = −4, HR 0.98 (0.80–1.20) for Δ = −3, HR 0.92 (0.78–1.08) for Δ = −2, and HR 0.99 (0.89–1.10) for Δ = −1 compared with no HbA 1c change (Δ = 0). CONCLUSIONS A large initial HbA 1c reduction and achievement of low HbA 1c levels within 6 months after metformin initiation are associated with a lower risk of cardiovascular events and death in patients with type 2 diabetes.