Longitudinal association of electrocardiogram abnormalities with major adverse cardiac events in people with Type 2 diabetes: the Hoorn Diabetes Care System cohort


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Aims To investigate the association of (changes in) electrocardiogram (ECG) abnormalities with incident major adverse cardiac events (MACE) in people with Type 2 diabetes (T2D) without pre-existing cardiovascular disease (CVD). Methods A prospective longitudinal study of 11 993 people with T2D without known CVD from the Hoorn Diabetes Care System cohort. and results Annually repeated measurements (1998–2018), included cardiovascular risk factors, over 70 000 ECG, and self-reported cardiovascular events. ECG abnormalities were classified according to the Minnesota Classification as prolonged PR duration, prolonged QRS duration, left QRS-axis, QS pattern, ST-segment/T-wave abnormalities, or tall R-wave. The association of ECG abnormalities with MACEs was assessed using time-dependent Cox-regression models, adjusted for time-varying cardiovascular risk factors, and medication use [hazard ratios (HRs) with 95% confidence intervals (CIs)]. During a median follow-up of 6.6 (IQR, 3.1–10.7) years, 5445 (45.4%) of the participants had an ECG abnormality (prevalent or incident) at any of the median 6 (IQR, 3–10) annual ECG recordings, and 905 people (7.5%) had a MACE (529 coronary heart disease (CHD), 250 heart failure (HF), and 126 sudden cardiac arrest (SCA)). After adjustment, most ECG abnormalities were associated with HF: prolonged QRS duration [HR, 4.01 (95% CI, 2.67–6.03)], QS pattern [2.68 (0.85–8.49)], ST-segment/T-wave abnormalities [4.26 (2.67–6.80)], and tall R-wave [2.23 (1.33–3.76)]. Only QS pattern [2.69 (1.20–6.03)] and ST-segment/T-wave abnormalities [2.11 (1.48–3.02)] were associated with CHD. These associations were robust across age, sex, hypertension, or estimated CVD risk subgroups. Conclusion In people with T2D without pre-existing CVD, ECG abnormalities related to decelerated conduction, ischaemia, and hypertrophy are predominantly early signs of emerging HF, while only abnormalities related to ischaemic disorders are signs of CHD.
Original languageEnglish
Pages (from-to)624-633
Number of pages10
JournalEuropean journal of preventive cardiology
Issue number8
Early online date10 Jan 2023
Publication statusPublished - 1 Jun 2023


  • Coronary heart disease
  • Diabetes
  • Electrocardiogram
  • Heart failure
  • Ischaemic heart disease
  • Sudden cardiac arrest

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