International variation in characteristics and clinical outcomes of patients with type 2 diabetes and heart failure: Insights from TECOS

Am Heart J. 2019 Dec:218:57-65. doi: 10.1016/j.ahj.2019.08.016. Epub 2019 Aug 28.


International differences in management/outcomes among patients with type 2 diabetes and heart failure (HF) are not well characterized. We sought to evaluate geographic variation in treatment and outcomes among these patients. METHODS AND RESULTS: Among 14,671 participants in the Trial Evaluating Cardiovascular Outcomes with Sitagliptin (TECOS), those with HF at baseline and a documented ejection fraction (EF) (N = 1591; 10.8%) were categorized by enrollment region (North America, Latin America, Western Europe, Eastern Europe, and Asia Pacific). Cox models were used to examine the association between geographic region and the primary outcome of all-cause mortality (ACM) or hospitalization for HF (hHF) in addition to ACM alone. Analyses were stratified by those with EF <40% or EF ≥40%. The majority of participants with HF were enrolled in Eastern Europe (53%). Overall, 1,267 (79.6%) had EF ≥40%. β-Blocker (83%) and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (86%) use was high across all regions in patients with EF <40%. During a median follow-up of 2.9 years, Eastern European participants had lower rates of ACM/hHF compared with North Americans (adjusted hazard ratio: 0.45; 95% CI: 0.32-0.64). These differences were seen only in the EF ≥40% subgroup and not the EF <40% subgroup. ACM was similar among Eastern European and North American participants (adjusted hazard ratio: 0.79; 95% CI: 0.44-1.45). CONCLUSIONS: Significant variation exists in the clinical features and outcomes of HF patients across regions in TECOS. Patients from Eastern Europe had lower risk-adjusted ACM/hHF than those in North America, driven by those with EF ≥40%. These data may inform the design of future international trials.

Publication types

  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adrenergic beta-Antagonists / therapeutic use
  • Aged
  • Angiotensin-Converting Enzyme Inhibitors / therapeutic use
  • Asia
  • Cause of Death
  • Diabetes Mellitus, Type 2 / complications
  • Diabetes Mellitus, Type 2 / drug therapy
  • Diabetes Mellitus, Type 2 / mortality*
  • Diuretics / therapeutic use
  • Double-Blind Method
  • Europe
  • Female
  • Follow-Up Studies
  • Heart Failure / complications
  • Heart Failure / drug therapy
  • Heart Failure / mortality*
  • Hospitalization
  • Humans
  • Hypoglycemic Agents / therapeutic use
  • Kaplan-Meier Estimate
  • Latin America
  • Male
  • Middle Aged
  • North America
  • Proportional Hazards Models
  • Sitagliptin Phosphate / therapeutic use
  • Stroke Volume
  • Treatment Outcome


  • Adrenergic beta-Antagonists
  • Angiotensin-Converting Enzyme Inhibitors
  • Diuretics
  • Hypoglycemic Agents
  • Sitagliptin Phosphate