Revista Española de Cardiología (English Version) Revista Española de Cardiología (English Version)
Rev Esp Cardiol. 2008;8(Supl C):50-8. - Vol. 8 Num.Supl.C

Type 2 Diabetes Mellitus and Cardiovascular Disease in Spain: A Narrative Review

Rubén Hernáeza, Héctor Buenob, Adrián V Hernándezc

a Department of Cardiology. Hospital General Universitario Gregorio Marañón. Madrid. Spain.
b Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health. Baltimore. MD. USA.
c Department of Quantitative Health Sciences. Cleveland Clinic. Cleveland. OH. USA. and Clinical Epidemiology Unit. Department of Cardiology. Thoraxcentre. Erasmus Medical Centre. Rotterdam. The Netherlands.


Diabetes mellitus. Cardiovascular disease. Prevention. Epidemiology. Spain.


Introduction. In spite of having a high prevalence of diabetes mellitus the prevalence of ischemic heart disease is low in Spain. Methods. A narrative review of the bibliography was performed to search for potential particularities in the epidemiology, pathogenecity, and care of diabetes mellitus in Spain. Results. The age-adjusted prevalence of diabetes in Spain is close to 10% (90% type 2) ranging from 6.1% to 13.3% (higher in Canary Islands), with an increased North-to-South gradient. Men have a 27%-42% higher prevalence than women. The incidence ranges from 5 to 8 cases per 1000 inhabitants-year. Spanish patients with diabetes have similar incidences and prevalences of cardiovascular complications and related mortality compared with those reported in other countries. Several studies have shown a consistent underuse of preventive therapies both in patients with and without cardiovascular diseases, and low rates of achievement of therapeutic goals. Despite their much worse prognosis, and contrary to current recommendations, diabetic patients with acute vascular events are not treated differently compared with non-diabetics. Conclusions. The age-adjusted prevalence and incidence estimates of diabetes mellitus in Spain appear to be similar to those in high-incidence countries. Diabetic patients show a high cardiovascular risk profile but the control of risk factors is poor, particularly in women and in patients with established cardiovascular disease. Initial and later care of diabetic patients with acute vascular events in Spain is far away from optimal. There is a huge opportunity for improving cardiovascular prevention and care in diabetic patients with and without cardiovascular disease in Spain.



Type 2 diabetes mellitus (DM) is a strong cardiovascular risk factor. Spain is a country with a high prevalence of DM1 but one of the lowest of ischemic heart disease in the Western world.2 Due to this apparent paradox, we tried to address whether there is any specific feature in the epidemiology, pathogenecity or care of type 2 DM in Spain, the most common phenotype of diabetes. Type 1 diabetes is beyond the scope of this paper and can be reviewed elsewhere.3-5


Prevalence and incidence of type 2 diabetes mellitus in Spain

DM is among the diseases with the greatest impact on the Spanish population and healthcare system due to its high prevalence, the frequency of chronic complications and its high mortality. According to the World Health Organization (WHO), diabetes prevalence is expected to increase in Spain 40% by 2025 compared to year 2000.6

A number of epidemiological studies have shown that Spain is a country with an intermediate to high prevalence of DM compared with other nations.7-10 However, prevalence comparisons within and between populations must be made with caution due to the potential use of different diagnostic criteria (eg, American Diabetes Association, WHO), screening tests (eg, self reported, physician based, prescription records), populations (eg, general population, population at risk for type 2 diabetes, different population structure), designs and sampling techniques. As a result, eight studies using similar methodology were identified in the literature to assess the prevalence of diabetes in Spain (Table 1).11-18 The age-adjusted prevalence ranged from 6.1% to 13.3% showing an increased North-to-South gradient, with higher prevalence in men compared to women (27%-42% higher). Overall, these data are consistent with the 2003 IDF estimations, in which Spain was ranked as the tenth country with the highest prevalence of diabetes in the 20-79 age group in the world.1 According to the same report, the overall prevalence of diabetes is 9.9% (90% of whom were type 2 diabetes mellitus). This implied that Spain had to spend in 2003 the 6% of total healthcare budget (2.4-2.6 million euros) to treat nearly 3 million patients with DM.1 Although not strictly comparable due to the use of different standard populations and ethnic differences, the total prevalence of diabetes in the US was 9.3% between 1999 and 2002 (7.9% for non-Hispanic whites), suggesting that Spain and the U.S. probably have similar prevalences of DM.19 As far as incidence of type 2 DM is concerned, of the published papers providing an estimate,9,20-23 only a few accounted for age structure in Spain.20-23 Vázquez et al.22 showed an annual age-adjusted cumulative incidence of 8 cases per 1000 inhabitants-year, using WHO-1985 criteria after 10 years of follow-up.22 Another study, using similar diagnostic criteria and methodology in the Basque Country, found an age-standardized cumulative incidence of 5 per 1000 inhabitants-year.22 Finally, Valdes et al.23 showed that incidence of type 2 diabetes adjusted for the age and sex structure of Asturias was 10.8 cases/1,000 persons years (95% CI 7.8-14.6) after 6.3 years of mean follow-up, using WHO 1999 criteria. These results are also comparable with the United States for similar populations, where an estimated age-adjusted annual cumulative incidence of 6.0 per 1000.24

Type 2 diabetes mellitus and cardiovascular disease

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality among individuals with diabetes. Adults with DM have a two- to fourfold higher risk of CVD compared with those without diabetes.25 In Spain, published longitudinal studies reporting the incidence of cardiovascular events in individuals with diabetes are scarce. Tomas et al.26 (n=1059 men) showed in the Manresa Study that the estimated age-adjusted 28-years cumulative incidence for coronary heart disease (CHD) was 17.6% for individuals with basal glycemia greater than 110 mg/dL or previously diagnosed diabetes. Rius et al27 reported an outpatient-based clinic longitudinal study (6.3 years of mean follow-up) with 176 patients free of CVD. They observed a cumulative incidence of macroangiopathy, defined as CHD, stroke and intermittent claudication of 15.9% and, specifically, 6.3% of CHD, 8% of cerebrovascular disease and 4% of peripheral arterial disease. Cañón-Barroso et al28 retrospectively identified in a general practice clinic a cohort of patients with type 2 DM free of CVD at baseline. They observed a 14.7%, 10-year cumulative incidence of CHD (angina, fatal, and non-fatal myocardial infarction), 13.3% for men and 16.0% for women. Using a similar design, Jimeno et al29 found a 17% cumulative incidence of CHD (18.5% in men and 15.2% in women) after 10 years of follow-up. Overall, these data are consistent with Morrish et al,30 who showed in a cohort (n=497) over a period of 8.33 years of follow-up for patients with type 2 DM a 18.8 incidence of myocardial infarction, 5.9 of cerebrovascular disease, and 5.2 of peripheral arterial disease.

On the other hand, several cross-sectional studies reported crude prevalence estimates of macrovascular complications in Spain.31-38 These studies reported a wide prevalence range for peripheral arterial disease (5.6%-24.5%). Estimates for CHD ranged between 10.5% and 19.8%, and between 3.3% and 11.8% for stroke. Obviously, prevalence rates vary according to different methodologies and clinical characteristics of the population such as the duration of the disease. Arteagoitia et al20 studied 2920 diabetic patients in the Basque Country using a sentinel practice network during year 2000. They found a 21.6% prevalence of macroangiopathy in new onset cases (12.4% of CHD, 9.8% of stroke, and 14.1% of peripheral vascular disease), and 33% among cases of known diabetes (7% CHD, 4% stroke, and 14% peripheral artery disease). They showed that macrovascular disease was more likely to be reported in men compared to women (odds ratio [OR] for incident DM, 2.3; 95% confidence interval, 1.2-4.6; OR for prevalent DM, 1.5; 95% CI, 1.5-2.1).

Type 2 diabetes mellitus, cardiovascular risk factors and risk of coronary heart disease

The prevalence of CHD disease in Spain is among the lowest in the Western countries2 despite the high prevalence of risk factors.39,40 However, individuals with type 2 DM usually have higher prevalence of traditional risk factors posing them into the highest risk category for CVD and, particularly for ischemic heart disease, in the "coronary risk equivalence."41,42 In terms of cardiovascular risk estimation, several Spanish authors28,29,35,43 examined the risk of coronary events using available risk engines in order to predict the most common complication in this population.44 For the Framingham-REGICOR risk engine45, the 10-year likelihood of coronary events were between 5.6% and 15% in men, and between 6% and 10% in women. Using the diabetes-specific risk engine UKPDS,46 they found that men had a 10-year risk of CHD between 19% and 38%, while the risk ranged from 11% and 28% for women. Finally, when the SCORE calculator to estimate 10-year risk of fatal coronary disease47 was applied, Lahoz35 found that women had a 2% compared to 4% in men.

Mortality and impact of type 2 diabetes mellitus in Spain

In Spain, CVD are the cause of death in at least half of type 2 DM,30,48 although other reports find it up to 75%-80%.9 In 2005, CVD was the leading cause of death, accounting in Spain for 32.8% of the deaths.49 Diabetes constituted the seventh cause of death, raking the 8th-9th for men and 5th-6th for women depending on the year.49,50 These estimates are also very similar to the United States, where diabetes was the sixth leading cause of death.51 However, it must be acknowledged that direct comparison of these mortality rates is incorrect due to the lack of standardization to the same population.

According to the Spanish National Institute of Statistics, ischemic heart disease accounted for 90.98 deaths and cerebrovascular disease 80.23 per 100 000 habitants-year compared to the diabetes-specific death rate of 23.3 deaths per 100 000 inhabitants-year. Concordantly with the prevalence estimates for DM, diabetes-related mortality showed an increasing North-South gradient.49,50,52 Locally, Ruiz et al53 analyzed the trends of mortality due to diabetes in Andalusia during 1975-1994. Using age standardization (direct method) from European population, they found that mortality due to DM decreased from 24.45 to 19.15 deaths per 100 000 persons-year in men, and from 33.55 to 22.43 in women, in that time period. Compared to the United States, the diabetes-specific age standardized mortality rate for whites, using U.S. population as standard, was 27.0 for males and 19.9 for females per 100 000 habitants/year.51 In the U.K. a recent study showed that for the period of 1993-1999, the specific age-standardized mortality rate (using European population as the reference), was 32.0 for women and 38.7 per 100 000 habitants-years for men.54 Considering the important limitations of the population attributable fraction,55 Banegas et al56 suggested that the attributable population fraction for diabetes is approximately 8.3% for CHD and 3.7% for cerebrovascular disease. They estimated that 2% of coronary mortality and 1.6% of cerebrovascular mortality was attributable to diabetes in men, but as much as 10.4% and 3.9%, respectively, in women.

Whereas CHD mortality is decreasing among diabetic men over the last three decades, it seems to be increasing among women.57 In Spain, available data suggest a similar pattern. However, while the prevalence of diabetes is slightly superior in men, Spanish women tend to have a worse control of their risk factors compared to men.58 Moreover, women have a worse prognosis once they are affected by cardiovascular diseases.59 According to an Andalusian study, unadjusted mortality rate is higher in women compared to men, especially when cohorts become older.53 These results are comparable with those reported in other countries.30


Glycemic control, detection, and treatment of associated co-morbidities are essential to prevent future macrovascular complications. A number of Spanish studies have addressed the health status of diabetic patients at a national31,32,60 and local level.35,61,62 They consistently showed a suboptimal control of cardiovascular risk factors in this patient population. In average, one quarter of patients had glycosilated hemoglobin (A1C) levels >8%; at least half of the individuals were diagnosed of hypertension and between 50%-70% were above optimal levels (>130/85 mm Hg); LDL-C levels were elevated (>115 mg/dL)63 in up to 90% of patients; current smokers accounted for 9%-17%; obesity, defined as a body mass index >30 kg/m2, was present in 30%-60% of subjects; and when physical activity was reported,31,60 between 60%-80% of patients had a sedentary lifestyle. These data are consistent with other European64 and American studies.65,66

In primary prevention, a subanalysis of the 316 diabetic and 345 non-diabetic patients without prior CVD enrolled in the Trans-STAR study--a Spanish national prospective case-control study performed in 326 primary care centers during a week in October 2001 that recruited 776 patients (388 diabetics and 388 non-diabetics)32--has shown a low rate of use of pharmacological preventive therapies (Table 2) in spite of the high prevalence of known dyslipidemia (50%) and hypertension (51%) among diabetics. In addition, a low proportion of these patients had their risk factors measured during the year previous to the interview (Table 3). When the control of risk factors was ascertained in the diabetic group according to the JNC VI and NCEP III recommendations, extremely low rates of LDL-C and systolic blood pressure control were found (Table 3). Interestingly, fewer patients (7%) with known high LDL levels reached established goals in comparison to those without high LDL levels (10%). Similarly, fewer patients with known systolic or diastolic hypertension (6% vs 33%) reached goals in comparison to those without known hypertension (28% and 45%, P<.001). Underuse of lipid-lowering and antihypertensive therapies in diabetic patients as well as low proportions of patients reaching therapeutic goals have been described throughout the world.67-70

The degree of control of cardiovascular risk factors in patients with established cardiovascular disease is particularly disturbing. González-Juanatey et al71 in a nationwide sample of clinics involving 1275 patients showed that blood pressure was controlled (<130/80 mm Hg) in less than 30%, LDL-C levels were above 100 mg/dL in more than 90% of patients, and use of current established therapies for secondary prevention were underused in 60%-74% depending on the drug. The DIETRIC study72 showed similar results among 628 patients. Although more than 60% of patients presented 3 or more related risk factors, only 15% had adequate control of blood pressure (<139/80 mm Hg), 7.5% had adequate control of plasma lipids (LDL-C<100 mg/dL, and triglycerides <150 mg/dL), and 57.2% had A1c> 6.5%. The same direction showed a major study in the field. Mostaza et al73 included 8,817 patients from primary care clinics who were hospitalized for a coronary event. They found that only 7% had optimum control of all their risk factors. Specifically, "the percentage of diabetic subjects attaining objectives for smoking habit, low-density lipoprotein cholesterol, blood pressure, and glycated hemoglobin were 90.7%, 29%, 38.2%, and 49.7%, respectively." Even more, recent data suggests that Spanish women have worse control of cardiovascular risk factors compared to men.59


There is scarce information about the management of acute vascular events in Spanish diabetic patients. A small study performed in the Canary Islands showed that the subgroup of diabetic patients with for non ST-segment elevation acute coronary syndromes (ACS) were older, had a higher prevalence of risk factors and had higher incidences of heart failure, 28-day, and 6-month mortality. Despite these facts, they did not find different patterns of use of coronary angiography, angioplasty or surgical revascularization.74 DESCARTES (Descripción del Estado de los Síndromes Coronarios Agudos en un Registro Temporal ESpañol), a Spanish nation-wide registry of patients hospitalized for suspected ACS performed by the Working Group on Ischemic Heart Disease of the Spanish Society of Cardiology, recruited 1877 consecutive patients with ACS in 45 randomly selected hospitals in Spain stratified by 3 different levels of care between April and May, 2002.75 The results of DESCARTES have shown a significative underutilisation of evidence-based therapies among patients with ACS in Spain, particularly those at higher risk.75,76 Diabetes mellitus is considered as a high-risk feature in patients with ACS by the 2002 European Society of Cardiology task force, and an intermediate risk by the contemporary Spanish guidelines. According to these recommendations, diabetic patients with ACS should undergo an aggressive pharmacological management including upstream use of glycoprotein IIb/IIIa inhibitors and an early (within 48 hours) invasive strategy. When the baseline clinical characteristics, hospital management and outcomes of the diabetic patients enrolled in DESCARTES with those without DM were compared (data not shown), diabetic patients were found at a significantly higher predicted risk regardless the way it was addressed (clinical characteristics, TIMI risk score, ESC criteria), and actually showed a higher short-term incidence of heart failure and death (figure 1). Despite this features, during hospitalization diabetic patients only received clopidogrel and angiotensin-converting enzyme inhibitors slightly more frequently than non diabetics, and the latter difference was attributed to the higher prevalence of hypertension among diabetics. On the contrary, none of the interventions recommended specifically for high-risk patients, i.e. glycoprotein IIb/IIIa inhibitors, early coronary angiography, and coronary revascularization were not used more frequently in diabetic patients. At 6 months, diabetic patients showed nearly a 3-fold increase in mortality compared with non-diabetics.77 A small angiographic study on diabetic ACS confirmed the lack of use of early coronary angiography among these patients, despite the high prevalence of severe diffuse coronary artery disease.78 Diabetic patients hospitalised for stroke do not receive a different treatment compared with non-diabetics, although DM seems not to have an impact on prognosis in stroke patients.79

Fig. 1. Survival according to diabetes status in patients with non ST-segment elevation acute coronary syndromes in Spain (year 2002). Despite their worse prognosis, diabetic patients did not receive a more aggressive treatment than non-diabetics.


In summary, the age-adjusted prevalence and incidence estimates of type 2 diabetes mellitus in Spain appear to be similar to those in the United States. Diabetes mellitus is one of the leading causes of death, but most patients die as a consequence of cardiovascular disease. Diabetic patients in Spain show a high cardiovascular risk profile, and furthermore, the control of risk factors is poor, particularly in women, and in patients with established cardiovascular disease. Acute care of diabetic patients with acute vascular events in Spain is far away from optimal, There is a huge opportunity for improving cardiovascular prevention and care in diabetic patients with and without cardiovascular disease is Spain.


We appreciate the contribution the DESCARTES and TranSTAR steering committee members and investigators, of BMS and of Gemma Gambús of NOVARTIS, for sharing the results of the studies.


ACS: acute coronary syndromes
ADA: American Diabetes Association
CHD: coronary heart disease
CVD: cardiovascular disease
DM: diabetes mellitus
IDF: International Diabetes Federation
LDL-C: LDL-cholesterol
WHO: World Health Organization

Dr. Hernáez was a scholar of the Fundación Caja Madrid and is a current postdoctoral fellow of the American Diabetes Association.

Correspondence: Dr. H.Bueno.
Servicio de Cardiología.
Hospital General Universitario Gregorio Marañón.
Dr. Esquerdo, 46. 28007-Madrid, Spain.


1.The global burden of diabetes. In: Diabetes Atlas, second edition. International Diabetes Federation, 2003.
2.Tunstall-Pedoe H, Kuulasmaa K, Amouyel P, Arveiler D, Rajakangas AM, Pajak A. Myocardial infarction and coronary deaths in the World Health Organization MONICA Project. Registration procedures, event rates, and case-fatality rates in 38 populations from 21 countries in four continents. Circulation. 1994;90:583-612.
3.Ruppert K, Roberts MS, Orchard TJ, Zgibor JC. Cardiovascular disease risk prediction in type 1 diabetes: accounting for the differences. Diabetes Res Clin Pract. 2007;78:234-7.
4.Pambianco G, Costacou T, Orchard TJ. The prediction of major outcomes of type 1 diabetes: a 12-year prospective evaluation of three separate definitions of the metabolic syndrome and their components and estimated glucose disposal rate: the Pittsburgh Epidemiology of Diabetes Complications Study experience. Diabetes Care. 2007;30:1248-54.
5.Wadwa RP. Cardiovascular disease risk in youth with diabetes mellitus. Rev Endocr Metab Disord. 2006;7:197-204.
6.World Health Organization. Diabetes programme. Facts and figures. WHO European Region, 2000. Available from:
7.Goday A, Serrano-Ríos M. Epidemiology of diabetes mellitus in Spain. Critical review and new perspectives. Med Clin (Barc). 1994;102:306-15.
8.Goday A. Epidemiology of diabetes and its non-coronary complications. Rev Esp Cardiol. 2002;55:657-70.
9.Goday A, Delgado E, Díaz-Cardorniga FJ, de Pablos P, Vázquez JA, Soto E. Epidemiología de la diabetes tipo 2 en España. Endocrinol Nutr. 2002;49:113-26.
10.Ruiz-Ramos M, Escolar-Pujolar A, Mayoral-Sánchez E, Corral-San Laureano F, Fernández-Fernández I. Mellitus diabetes in Spain: death rates, prevalence, impact, costs and inequalities. Gac Sanit. 2006;20 Suppl 1:15-24.
11.Boronat M, Varillas VF, Saavedra P, Suarez V, Bosch E, Carrillo A, el al. Diabetes mellitus and impaired glucose regulation in the Canary Islands (Spain): prevalence and associated factors in the adult population of Telde, Gran Canaria. Diabet Med. 2006; 23:148-55.
12.Botas P, Delgado E, Castaño G, Díaz de Grenu C, Prieto J, Díaz-Cadorniga FJ. Comparison of the diagnostic criteria for diabetes mellitus, WHO-1985, ADA-1997 and WHO-1999 in the adult population of Asturias (Spain). Diabet Med. 2003;20:904-8.
13.Castell C, Tresserras R, Serra J, Goday A, Lloveras G, Salleras L. Prevalence of diabetes in Catalonia (Spain): an oral glucose tolerance test-based population study. Diabetes Res Clin Pract. 1999;43:33-40.
Medline Pablos-Velasco PL, Martínez-Martín FJ, Rodríguez-Pérez F, Ania BJ, Losada A, Betancor P. Prevalence and determinants of diabetes mellitus and glucose intolerance in a Canarian Caucasian population-comparison of the 1997 ADA and the 1985 WHO criteria. The Guia Study. Diabet Med. 2001;18:235-41.
15.Masiá R, Sala J, Rohlfs I, Piulats RR, Manresa JM, Marrugat J. Prevalence of diabetes mellitus in the province of Girona, Spain: the REGICOR study. Rev Esp Cardiol. 2004;57:261-4.
16.Soriguer-Escofet F, Esteva I, Rojo-Martínez G, Ruiz de Adana S, Catalá M, et al. Prevalence of latent autoimmune diabetes of adults (LADA) in Southern Spain. Diabetes Res Clin Pract. 2002; 56:213-20.
17.Tamayo-Marco B, Faure-Nogueras E, Roche-Asensio MJ, Rubio-Calvo E, Sánchez-Ortiz E, Salvador-Oliván JA. Prevalence of diabetes and impaired glucose tolerance in Aragon, Spain. Diabetes Care. 1997;20:534-6.
18.Valverde JC, Tormo MJ, Navarro C, Rodríguez-Barranco M, Marco R, Egea JM, et al. Prevalence of diabetes in Murcia (Spain): a Mediterranean area characterised by obesity. Diabetes Res Clin Pract. 2006;71:202-9.
19.Cowie CC, Rust KF, Byrd-Holt DD, Eberhardt MS, Flegal KM, Engelgau MM, et al. Prevalence of diabetes and impaired fasting glucose in adults in the U.S. population: National Health And Nutrition Examination Survey 1999-2002. Diabetes Care. 2006;29:1263-8.
20.Arteagoitia JM, Larrañaga MI, Rodríguez JL, Fernández I, Pinies JA. Incidence, prevalence and coronary heart disease risk level in known type 2 diabetes: a sentinel practice network study in the Basque Country, Spain. Diabetologia. 2003;46:899-909.
21.Costa B, Piñol JL, Martin F, Donado A, Castell C. Significant incidence of type 2 diabetes on high-risk Spanish population. The IGT Study (2). Med Clin (Barc). 2002;118:287-93.
22.Vazquez JA, Gaztambide S, Soto-Pedre E. 10-year prospective study on the incidence and risk factors for type 2 diabetes mellitus. Med Clin (Barc). 2000;115:534-9.
23.Valdes S, Botas P, Delgado E, Alvarez F, Cadorniga FD. Population-based incidence of type 2 diabetes in northern Spain: the Asturias Study. Diabetes Care. 2007;30:2258-63.
24.Fox CS, Pencina MJ, Meigs JB, Vasan RS, Levitzky YS, Agostino RBS. Trends in the incidence of type 2 diabetes mellitus from the 1970s to the 1990s: the Framingham Heart Study. Circulation. 2006;113:2914-8.
25.Eckel RH, Kahn R, Robertson RM, Rizza RA. Preventing cardiovascular disease and diabetes: a call to action from the American Diabetes Association and the American Heart Association. Circulation. 2006;113:2943-6.
26.Tomás-Abadal L, Varas-Lorenzo C, Pérez I, Puig T, Balaguer-Vintro I. Risk factors and coronary morbimortality in a Mediterranean industrial cohort over 28 years of follow-up. The Manresa Study. Rev Esp Cardiol. 2001;54:1146-54.
27.Ríus-Riu F, Salinas Vert I, Lucas-Martín A, Romero-González R, Sanmartí-Sala A. A prospective study of cardiovascular disease in patients with type 2 diabetes. 6.3 years of follow-up. J Diabetes Complications. 2003;17:235-42.
28.Cañón-Barroso L, Cruces-Muro E, Fernández-Ochoa G, Nieto-Hernández T, García-Vellido A, Buitrago F. Validation of 3 equations of coronary risk in diabetic population of a primary care center. Med Clin (Barc). 2006;126:485-90.
29.Jimeno-Mollet J, Molist-Brunet N, Franch-Nadal J, Serrano-Borraz V, Serrano-Barragán L, Gracia-Giménez R. Variability in the calculation of coronary risk in type-2 diabetes mellitus. Aten Primaria. 2005;35:30-6.
30.Morrish NJ, Wang SL, Stevens LK, Fuller JH, Keen H. Mortality and causes of death in the WHO Multinational Study of Vascular Disease in Diabetes. Diabetologia. 2001;44 Suppl 2:S14-S21.
31.Arroyo J, Badía X, de la Calle H, Díez J, Esmatjes E, Fernández I, et al. Management of type 2 diabetic patients in primary care in Spain. Med Clin (Barc). 2005;125:166-72. la Calle H, Costa A, Díez-Espino J, Franch J, Goday A. Evaluation on the compliance of the metabolic control aims in outpatients with type 2 diabetes mellitus in Spain. The TranSTAR study. Med Clin (Barc). 2003;120:446-50.
33.Esmatjes E, Castell C, Franch J, Puigoriol E, Hernaez R. Acetylsalicylic acid consumption in patients with diabetes mellitus. Med Clin (Barc). 2004;122:96-8.
34.Hernández JM, Costa B. Diagnosis of the health of a diabetic population in the county of Priorato in Tarragona province. Aten Primaria. 1991;8:668-74.
35.Lahoz-Rallo B, Blanco-Gonzalez M, Casas-Ciria I, Marín-Andrade JA, Méndez-Segovia JC, Moratalla-Rodríguez G, et al. Cardiovascular disease risk in subjects with type 2 diabetes mellitus in a population in southern Spain. Diabetes Res Clin Pract. 2006 [Epub ahead of print].
36.Lara-Surinach N, Franch-Nadal J, Morató-Griera J, Egido-Polo A, Puig-Galy J, Castillejo-Medina J. Dyslipemia in type-2 diabetes. A risk factor for macroangiopathy? Aten Primaria. 1996;18:3-8.
37.Mur-Martí T, Franch-Nadal J, Morató-Griera J, MENA-González A, Vilarrubias-Calaf M, Llobera-Serentill A. Macroangiopathy in type II diabetes. The Raval South study. Aten Primaria. 1995; 16:67-72.
38.Zorrilla-Torras B, Cantero-Real JL, Martínez-Cortes M. Study of non-insulin-dependent diabetes mellitus in primary care in the community of Madrid using the network of sentinel physicians. Aten Primaria. 1997;20:543-8.
39.Masiá R, Peña A, Marrugat J, Sala J, Vila J, Pavesi M, et al. High prevalence of cardiovascular risk factors in Gerona, Spain, a province with low myocardial infarction incidence. REGICOR Investigators. J Epidemiol Community Health. 1998;52:707-15.
40.Medrano MJ, Cerrato E, Boix R, Delgado-Rodríguez M. Cardiovascular risk factors in Spanish population: metaanalysis of cross-sectional studies. Med Clin (Barc). 2005;124:606-12.
41.Grundy SM, Howard B, Smith SJ, Eckel R, Redberg R, Bonow RO. Prevention Conference VI: Diabetes and Cardiovascular Disease: executive summary: conference proceeding for healthcare professionals from a special writing group of the American Heart Association. Circulation. 2002;105:2231-9.
42.González-Clemente JM, Palma S, Arroyo J, Vilardell C, Caixas A, Giménez-Palop and Delgado-Rodríguez M. La diabetes mellitus es un equivalente de riesgo coronario? Resultados de un metanalisis de estudios prospectivos. Rev Esp Cardiol. 2007; 60:1167-76.
43.Hernaez R, Choque L, Giménez M, Costa A, Márquez JI, Conget I. Coronary risk assessment in subjects with type 2 diabetes mellitus. General population-based scores or specific scores? Rev Esp Cardiol. 2004;57:577-80.
44.Rosamond W, Flegal K, Friday G, Furie K, Go A, Greenlund K, et al. Heart Disease and Stroke Statistics--2007 Update. A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007;115:e69-171.
45.Marrugat J, D´Agostino R, Sullivan L, Elosua R, Wilson P, Ordovas J, et al. Coronary risk estimation in Spain using a calibrated Framingham function. Rev Esp Cardiol. 2003;56:253-61.
46.Stevens RJ, Kothari V, Adler AI, Stratton IM, United Kingdom Prospective Diabetes Study (UKPDS) Group. The UKPDS risk engine: a model for the risk of coronary heart disease in Type II diabetes (UKPDS 56). Clin Sci (Lond). 2001;101:671-9.
47.Conroy RM, Pyorala K, Fitzgerald AP, Sans S, Menotti A, de Backer G, et al. Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J. 2003;24:987-1003.
48.Esmatjes E, Vidal J. Heart pathology of extracardiac origin. XI. Cardiac repercussions of diabetes mellitus. Rev Esp Cardiol. 1998;51:661-70.
49.Instituto Nacional de Estadística. Defunciones según la causa de muerte 2004. Resultados básicos. Estadísticas del movimiento natural de la población. Available from:
50.Instituto Nacional de Estadística. Defunciones según la causa de muerte 2005 (datos provisionales). Resultados básicos. Estadísticas del movimiento natural de la población. Available from:
51.Hoyert DL, Heron MP, Murphy SL, Kung HC. Deaths: final data for 2003. Natl Vital Stat Rep. 2006;54:1-120.
52.Orozco D, Gil V, Pico JA, Tobias J, Quirce F, Merino J. Diabetes mellitus mortality in Spain: a comparative analysis between Spanish provinces in the period of 1981-1986. Aten Primaria. 1995;15:349-6.
53.Ruiz-Ramos M, Fernández-Fernández I, Hermosín-Bono T, Viciana-Fernández F. Trends in mortality due to diabetes mellitus. Andalusia, 1975-1994. Rev Clin Esp. 1998;198:496-501.
54.Goldacre MJ, Duncan ME, Cook-Mozaffari P, Neil HA. Trends in mortality rates for death-certificate-coded diabetes mellitus in an English population 1979-99. Diabet Med. 2004;21:936-9.
55.Rockhill B, Newman B, Weinberg C. Use and misuse of population attributable fractions. Am J Public Health. 1998;88:15-9.
56.Banegas JR, Rodríguez-Artalejo F, Graciani A, Villar F, Herruzo R. Mortality attributable to cardiovascular risk factors in Spain. Eur J Clin Nutr. 2003;57 Suppl 1:S18-S21.
57.Gu K, Cowie CC, Harris MI. Diabetes and decline in heart disease mortality in US adults. JAMA. 1999;281:1291-7.
58.Conthe P, Lobos-Bejarano JM, González-Juanatey JR, Gil-Núñez A, Pajuelo-Fernández FJ, Novials Sarda A. Different approach in high-cardiovascular-risk women, compared to men: a multidisciplinary study-Spain. Med Clin (Barc). 2003;120:451-5.
59.Marrugat J, Sala J, Aboal J. Epidemiology of cardiovascular disease in women. Rev Esp Cardiol. 2006;59:264-74.
60.Benito-López P, García-Mayor R, Puig-Domingo M, Mesa-Manteca J, Palelardo-Sánchez LF, Faure-Nogueras E, et al. Pathological characteristics of patients with diabetes mellitus type 2, in Spanish Primary Care. Rev Clin Esp. 2004;204:18-24.
61.Grupo ELIP. Effectiveness of control of cardiovascular risk factors in type 2 diabetic population of Ciudad Real province. Rev Clin Esp. 2005;205:218-22.
62.Mena-Martín FJ, Martín-Escudero JC, Simal-Blanco F, Carretero-Ares JL, Herreros-Fernández V. Cardiovascular risk factors in diabetic patients. Cross-sectional study in general population: Hortega study. An Med Intern. 2003;20:292-6.
63.European Diabetes Policy Group. A desktop guide to type 2 diabetes mellitus. European Diabetes Policy Group 1999. Diabet Med. 1999;16:716-30.
64.Liebl A, Mata M, Eschwege E, Advisory Board. Evaluation of risk factors for development of complications in type II diabetes in Europe. Diabetologia. 2002;45:S23-S28.
65.Chin MH, Auerbach SB, Cook S, Harrison JF, Koppert J, Jin L, et al. Quality of diabetes care in community health centers. Am J Public Health. 2000;90:431-4.
66.Coon P, Zulkowski K. Adherence to American Diabetes Association standards of care by rural health care providers. Diabetes Care. 2002;25:2224-9.
67.Pearson TA, Laurora I, Chu H, Kafonek S. The lipid treatment assessment project (L-TAP): a multicenter survey to evaluate the percentages of dyslipemic patients receiving lipid-lowering therapy and achieving low-density lipoprotein cholesterol goals. Arch Intern Med. 2000;160:459-67.
68.Thomas MC, Nestel PJ. Management of dyslipidaemia in patients with type 2 diabetes in Australian primary care. Med J Aust. 2007;186:128-30.
69.Ubink-Velmaat LJ, Bilo HJ, Groenier KH, Rischen RO, Meyboom-de Jong B. Challenges in preventing cardiovascular complications in type 2 diabetes in primary care. Eur J Gen Pract. 2005;11:11-6.
70.Charpentier G, Genes N, Vaur L, Charpentier G, Genes N, Vaur L, et al. Control of diabetes and cardiovascular risk factors in patients with type 2 diabetes: a nationwide French survey. Diabetes Metab. 2003;29:152-8.
71.González-Juanatey JR, Alegría E, García-Acuña JM, González-Maqueda I, Lozano JV. The role of diabetes mellitus in cardiac disease in Spain. The CARDIOTENS Study 1999. Med Clin (Barc). 2001;116:686-91.
72.Rodríguez-Padial L, Maicas-Bellido C, Cala-López J, Velázquez-Martín M, Gil-Polo B. Limited application of prevention measures in patients with diabetes mellitus type 2 and coronary artery disease in Spain. DIETRIC study. Rev Clin Esp. 2005;205:14-8.
73.Mostaza-Prieto JM, Martín-Jadraque L, López I, Tranche S, Lahoz C, Taboada M, et al. Evidence-based cardiovascular therapies and achievement of therapeutic goals in diabetic patients with coronary heart disease attended in primary care. Am Heart J. 2006;152:1064-70.
74.Ferrer-Hita JJ, Domínguez-Rodríguez A, García-González MJ, Abreu-González P, Bethencourt-Muñoz M, Marrero-Rodríguez F. Influencia de la diabetes mellitus en el tratamiento y el pronóstico del síndrome coronario agudo sin elevación del segmento ST. Rev Esp Cardiol. 2006;59:383-6.
75.Bueno H, Bardají A, Fernández-Ortiz A, Marrugat J, Martí H, Heras M. Descripción del Estado de los Síndromes Coronarios Agudos en un Registro Temporal ESpañol. Estudio DESCARTES. Rev Esp Cardiol. 2005;58:242-50.
76.Heras M, Bueno H, Bardají A, Fernández-Ortiz A, Martí H, Marrugat J, on behalf of the DESCARTES investigators. Magnitude and consequences of undertreatment in high-risk patients with non-ST-segment elevation acute coronary syndromes. Insights from the DESCARTES Registry. Heart. 2006;92:1571-6.
77.Bueno H, Heras M, Bardají A, Fernández-Ortiz A, Martí H, Marrugat J, et al. Diabetic patients hospitalised for ACS are not treated more aggresively despite their worse prognosis. Results of the DESCARTES registry. Eur Heart J. 2004; [Abstract suppl.].
78.Sanchís J, Bertomeu V, Bodí V, Nunez J, Lauwers C, Ruiz-Nodar JM, et al. Invasive strategy in patients with advanced diabetes and non-ST-segment elevation acute coronary syndrome. Angiographic findings and clinical follow-up. PREDICAR study results. Rev Esp Cardiol. 2006;59:321-8.
79.Arboix A, Rivas A, García-Eroles L, de Marcos L, Massons J, Oliveres M. Cerebral infarction in diabetes: clinical pattern, stroke subtypes, and predictors of in-hospital mortality. BMC Neurol. 2005;5:9.