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Prediction by Low Plasma HbA1c of Mortality, Cardiac and Noncardiac Disease Risk
  1. Servet Altay, MD*,
  2. Altan Onat, MD,
  3. Yusuf Karadeniz, MD§,
  4. Fatma Özpamuk-Karadeniz, MD,
  5. Günay Can, MD
  1. From the *Department of Cardiology, Edirne State Hospital, Edirne; Departments of †Cardiology and ‡Public Health, Cerrahpaşa Medical Faculty, Istanbul University; §Department of Internal Medicine, Haseki Training and Research Hospital; and ∥Cardiology Section, Siyami Ersek Center for Cardiovascular Surgery, Istanbul, Turkey.
  1. Received December 25, 2014, and in revised form March 11, 2015.
  2. Accepted for publication May 14, 2015.
  3. Reprints: Servet Altay, MD, Şükrüpaşa mah, Namık Kemal sok, 4b Blok, No. 17, Edirne, Turkey. E-mail: svtaltay{at}
  4. Servet Altay, Altan Onat, Yusuf Karadeniz, Fatma Ozpamuk Karadeniz and Gunay Can declare that they have no conflict of interest.
  5. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (

Modulation by Diabetic Status and Sex


Aim The aim of the study was to evaluate the predictive value of HbA1c for risk of overall mortality or a composite endpoint of death and nonfatal events.

Methods Logistic regression retrospectively assessed the longitudinal association of measured HbA1c with outcome in 746 middle-aged adults, recruited from a tertiary health center and stratified to absence or presence of type 2 diabetes, using the recent American Diabetes Association criteria.

Results A total of 70 deaths and additional incident nonfatal events in 82 cases were recorded at a median of 3.1-year follow-up. Multivariable linear regression revealed among nondiabetic individuals HbA1c to be significantly associated—independent of fasted glucose—inversely with triglycerides and high-density lipoprotein cholesterol, distinct from the diabetic sample. Sex and diabetes status differed in baseline HbA1c values with respect to the development of outcome. Nondiabetic men who subsequently died exhibited significantly lower HbA1c, as did men and women with incident coronary heart disease. Similar difference was observed for incident hypothyroidism and nondiabetic subjects developing malignancy. In logistic regression analysis, adjusted for sex, age, and fasting glucose, each 0.7% (SD, 1) decrement of baseline HbA1c predicted the composite endpoint in the nondiabetic sample (risk estimates, 1.49%; 95% confidence interval, 1.07–2.04), but not in the diabetic sample, whereas overall mortality in the whole sample was increased (risk estimates, 1.51%; 95% confidence interval, 1.05–2.17).

Conclusions Inverse association of HbA1c with adverse outcomes in men and nondiabetic people indicates the involvement of HbA1c levels in autoimmune activation. The weaker inverse association with prevalent diabetes and in women is consistent with the operation of more pronounced confounding autoimmune processes.

Key Words
  • type 2 diabetes
  • chronic kidney disease
  • coronary heart disease
  • glycated hemoglobin

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