The Hemoglobin A1c Level as a Progressive Risk Factor for Cardiovascular Death, Hospitalization for Heart Failure, or Death in Patients With Chronic Heart Failure

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Abstract
Diabetes is a metabolic disorder characterized by hyperglycemia and is well established as a strong independent risk factor for cardiovascular (CV) events1; indeed, diabetes confers a CV risk that is comparable to an age increase of 15 years.2 The exact reasons for this relationship remain unknown; however, they include the strong association between diabetes and other established CV risk factors, such as hypertension, dyslipidemia, and renal insufficiency. Moreover, a growing body of epidemiologic evidence now implicates elevated glucose levels themselves as important determinants of CV disease,3-6 and biologic evidence suggests that this relationship may be mediated by (1) a direct effect of the elevated glucose levels7; (2) insufficient insulin effect due to the relative or absolute lack of insulin that permits the glucose levels to rise; (3) insulin resistance; (4) an antecedent problem that increases both the risk of diabetes and the risk of CV events; or (5) some combination of these factors.8