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Insulin Resistance as Estimated by Homeostasis Model Assessment Predicts Incident Symptomatic Cardiovascular Disease in Caucasian Subjects From the General Population

The Bruneck Study

¹ Division of Endocrinology and Metabolic Diseases, University of Verona Medical School, Verona, Italy
² Department of Neurology, University of Innsbruck Medical School, Innsbruck, Austria
³ Division of Internal Medicine, Hospital of Bruneck, Bruneck, Italy
⁴ Harvard Medical School and General Medicine Unit, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts

Address correspondence and reprint requests to Prof. Enzo Bonora, Endocrinologia e Malattie del Metabolismo, Ospedale Maggiore, Piazzale Stefani, 1, 37126 Verona, Italy. E-mail: enzobonora{at}virgilio.it

OBJECTIVE—The purpose of this study was to evaluate whether insulin resistance is associated to cardiovascular disease (CVD) and to understand whether this association can be explained by traditional and novel CVD risk factors associated with this metabolic disorder.

RESEARCH DESIGN AND METHODS—We examined a sample representative of the population of Bruneck, Italy (n = 919; aged 40–79 years). Insulin-resistant subjects were those with a score in the top quartile of the homeostasis model assessment (HOMA) for insulin resistance (HOMA-IR). Risk factors correlated with insulin resistance included BMI, A1C, HDL cholesterol, triglycerides, blood pressure, high-sensitivity C-reactive protein (hsCRP), fibrinogen, oxidized LDL, vascular cell adhesion molecule-1 (VCAM-1), and adiponectin. Subjects without CVD at baseline were followed up for 15 years for incident CVD, a composite end point including fatal and nonfatal myocardial infarction and stroke, transient ischemic attack, and any revascularization procedure.

RESULTS—During follow-up, 118 subjects experienced a first symptomatic CVD event. Levels of HOMA-IR were higher at baseline among subjects who developed CVD (2.8) compared with those remaining free of CVD (2.5) (P < 0.05). Levels of HOMA-IR also were significantly correlated (P < 0.05) with most CVD risk factors we evaluated. In Cox proportional hazard models, insulin-resistant subjects had an age-, sex-, and smoking-adjusted 2.1-fold increased risk (95% CI 1.3–3.1) of incident symptomatic CVD relative to non–insulin-resistant subjects. After sequential adjustment for physical activity and classic risk factors (A1C, LDL cholesterol, and hypertension) as well as BMI, HDL cholesterol, triglycerides, and novel risk factors, including fibrinogen, oxidized LDL, hsCRP, VCAM-1, and adiponectin, the association between HOMA-IR and incident CVD remained significant and virtually unchanged (hazard ratio 2.2 [95% CI 1.4–3.6], P < 0.001).

CONCLUSIONS—HOMA-estimated insulin resistance is associated with subsequent symptomatic CVD in the general population independently of all classic and several nontraditional risk factors. These data suggest that insulin resistance may be an important target to reduce CVD risk.

Abbreviations: CVD, cardiovascular disease • hsCRP, high-sensitivity C-reactive protein • HOMA, homeostasis model assessment • HOMA-IR, HOMA of insulin resistance • IFG, impaired fasting glucose • IGT, impaired glucose tolerance • TIA, transient ischemic attack • VCAM-1, vascular adhesion molecule-1

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