Journal of Diabetes and Its Complications xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Journal of Diabetes and Its Complications
j o u r n a l h o m e p a g e : W W W. J D C J O U R N A L . C O M
Differences in clinical characteristics between patients with and
without type 2 diabetes hospitalized with a first myocardial infarction
Marise J. Kasteleyn ⁎, Rimke C. Vos, Hanneke Jansen, Guy E.H.M. Rutten
Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands, P.O. Box 8500, 3508 GA Utrecht
a r t i c l e
i n f o
Article history:
Received 10 December 2015
Received in revised form 7 March 2016
Accepted 18 March 2016
Available online xxxx
Keywords:
Myocardial infarction
Type 2 diabetes
Prevention
Clinical characteristics
Cholesterol
a b s t r a c t
Aims: To explore differences in clinical characteristics of patients with and without type 2 diabetes (T2DM)
hospitalized with a first myocardial infarction (MI).
Methods: In this cross-sectional study we examined differences between patients with and without T2DM
hospitalized with a first MI (n = 563). Multiple linear regression modeling was used to examine the association
between T2DM and age of occurrence of MI. We adjusted for gender, systolic blood pressure (BP), lipids and creatinine
level to examine whether these variables explained the association between T2DM and age of occurrence of MI.
Results: Among 563 patients with a first MI, T2DM patients (n = 77) were older than non-diabetic patients
(67.8 ± 10.9 vs. 64.4 ± 13.4 years, p b 0.05), had lower LDL (2.5 ± 0.8 vs. 3.4 ± 1.1 mmol/l, p b 0.001) and
total cholesterol levels (4.4 ± 0.9 vs. 5.4 ± 1.2 mmol/l, p b 0.001), but higher systolic BP (150.3 ± 29.9 vs.
141.7 ± 27.5 mmHg, p b 0.05). The association between T2DM and age of occurrence of MI was largely
explained by cholesterol levels.
Conclusions: T2DM patients were older when hospitalized with a first MI. This difference was largely explained
by differences in cholesterol levels. The lower cholesterol levels in T2DM patients compared to non-diabetic
patients, and maybe also the older age of occurrence of MI, might reflect the results successful primary
prevention and systematic monitoring in T2DM.
© 2016 Elsevier Inc. All rights reserved.
1. Introduction
Type 2 diabetes is associated with an increased risk of cardiovascular events (Huxley, Barzi, & Woodward, 2006), but has improved
significantly during the last decades (Ford, 2011). The rate of
cardiovascular events decreased from 3% to 2% in type 2 diabetes
(Stone et al., 2013). This decrease may be the result of the
implementation of guidelines for type 2 diabetes, which recommend
to aim for an LDL cholesterol below 2.6 mmol/l, by using statins as the
drug of choice. A reduction of 1 mmol/L LDL cholesterol reduces the
incidence of cardiovascular morbidity and mortality in type 2 diabetes
patients by 20% (Baigent et al., 2005).
Good adherence, to key recommended process measures, was
found in a study including eight European countries. This means that
type 2 diabetes patients get their HbA1c, blood pressure and lipid
levels measured on a regular basis (Stone et al., 2013). Lipid lowering
drugs were prescribed in two out of three of the type 2 diabetes
Conflicts of interest: none.
⁎ Corresponding author at: Department of public health and primary care, postzone
V0-P, PO Box 9600, 2300 RC, Leiden University Medical Center, Leiden, The Netherlands.
Tel.: +31 71 5268496; fax: +31 71 5268259.
E-mail addresses: [email protected] (M.J. Kasteleyn),
[email protected] (R.C. Vos), [email protected] (H. Jansen),
[email protected] (G.EHM. Rutten).
patients. In the ADDITION-study, people were screened for type 2
diabetes. After three years of follow-up, patients without diabetes but
with an elevated cardiovascular risk score received a less optimal
control for their cardiovascular risk factors, while screen-detected
diabetic patients were controlled adequately (Janssen, Gorter, Stolk,
Akarsubasi, & Rutten, 2008). This indicates that having the diagnosis
diabetes can be favorable for controlling risk factors and decreasing
the cardiovascular risk. Furthermore, it is known from recent studies
that type 2 diabetes patients were slightly older than non-diabetic
patients when hospitalized with a myocardial infarction (MI)
(Elbarouni et al., 2011; Norhammar et al., 2003), although they had
a worse cardiovascular profile.
This study aimed to explore differences in clinical characteristics of
patients with and without type 2 diabetes hospitalized with a first MI,
to assess whether these differences reflect the results of the
intensified primary in type 2 diabetes. We specifically focused on
the difference in age of occurrence of a first MI.
2. Material and methods
2.1. Study population
Data for this cross-sectional study were collected from three
non-university teaching hospitals in the Netherlands. Data were
http://dx.doi.org/10.1016/j.jdiacomp.2016.03.024
1056-8727/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Kasteleyn, M.J., et al., Differences in clinical characteristics between patients with and without type 2 diabetes
hospitalized with a first myocardial infarction, Journal of Diabetes and Its Complications (2016), http://dx.doi.org/10.1016/j.jdiacomp.2016.03.024
2
M.J. Kasteleyn et al. / Journal of Diabetes and Its Complications xxx (2016) xxx–xxx
obtained from all patients hospitalized with a first or recurrent
ST-elevation MI (STEMI; ICD-10 I21.03–I21.3) or Non-ST-elevation MI
(NSTEMI; ICD-10 I21.4) between June 2010 and June 2011. Patients
were excluded when they had type 2 diabetes de novo, type 1
diabetes and/or were younger than 35 years.
2.2. Measurements
All patient characteristics were extracted from the electronic
medical records. Data on systolic blood pressure (BP), blood lipids
(total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides),
creatinine, non-fasting glucose and HbA1c at hospital admission were
extracted. Biochemical tests were performed in each participating
hospital’s laboratory. LDL cholesterol levels were calculated by the
laboratories with the Friedewald’s formula. Between the types of
intervention we distinguished conservative therapy, percutaneous
coronary intervention (PCI) or coronary artery bypass grafting
(CABG). The age of occurrence of an MI was defined by age at which
the patients were hospitalized with a first MI. Type of MI is used as a
measure of severity of MI. A STEMI is considered more severe and
associated with more cardiovascular damage compared to an NSTEMI
(Johnson et al., 1999). Furthermore, it was evaluated whether a
history of type 2 diabetes, hypertension, hypercholesterolemia or
atrial fibrillation (AF) was reported in the electronic medical file. We
calculated the cardiovascular risk score using the Systematic Coronary
Risk Evaluation (SCORE) algorithm (Conroy et al., 2003). Each
individual was categorized into a risk category based on age, sex,
smoking status, systolic blood pressure and the total cholesterol/HDL
cholesterol ratio. In the Dutch guidelines, for type 2 diabetes, the
patient’s aged used for risk estimation is increased by 15 years.
2.3. Statistical analysis
Multiple imputation modeling was used to impute missing data
(SPSS MVA procedure; SPSS, Inc., Chicago, IL). We generalized 10
imputed datasets and used Rubin rules to combine the estimates of
the parameters (D R, 1987).
For the main analyses, patients with a first MI were included.
Categorical variables were reported as numbers and percentages,
normally distributed continuous variables as means with standard
deviations (SD), and non-normally disturbed continuous variables as
median with interquartile ranges (IQR). We explored differences in
patient characteristics and type of intervention between type 2
diabetes patients and individuals without diabetes with Chi-square
tests, independent T-tests and Mann Whitney U tests. To evaluate
differences on severity of MI between patients with and without
diabetes, we compared proportions of type of MI for the two groups
with a Chi-square test. To determine whether type 2 diabetes is
associated with the age of occurrence of MI, linear regression
modeling was used with age of occurrence of MI as dependent
variable and type 2 diabetes as independent variable. Multiple linear
regression analyses were used to adjust for gender, systolic BP, total
cholesterol, HDL cholesterol, LDL cholesterol, triglycerides and
creatinine level, to evaluate whether these variables explained the
association between type 2 diabetes and age of occurrence of MI.
Furthermore, differences in age between patients with and without
type 2 diabetes hospitalized with a recurrent MI were also explored.
Protocol issues resulted in high amounts of missing biochemical
data. In a sensitivity analysis we excluded patients from the
hospital with a high amount of missing biochemical data to
examine the impact of these missing values. Additional analyses
stratified by gender were performed to examine the impact of gender
on the results.
All analyses were performed using the SPSS version 20.0.
3. Results
Missing data for most parameters were below 5.7%, except for
systolic BP (19.3%), history of hypercholesterolemia (18.5%) and
smoking (19.9%). One hospital did not routinely measure triglycerides, HDL cholesterol, LDL cholesterol and HbA1c. As a result,
triglycerides (35.3%), HDL (35.3%) and LDL cholesterol (36.1%) and
HbA1c (66.7%) measurements showed relatively high levels of
missing values. The presence of missing values was not related to
other variables.
Characteristics of patients hospitalized with a first MI (n = 563),
of which 14% had type 2 diabetes, are presented in Table 1. Type 2
diabetes patients hospitalized with a first MI were significantly older
than non-diabetic patients and had lower LDL and total cholesterol
levels, but had a higher cardiovascular risk score (Fig. 1). The
discrepancy between diabetes patients and non-diabetes patients in
age of occurrence of MI was also found in patients hospitalized with a
recurrent MI (72.5 ± 11.4 years vs. 66.8 ± 13.6 years, p b 0.05).
Furthermore, in the first MI group diabetes patients had a higher
systolic blood pressure, higher levels of triglycerides and higher levels
of creatinine compared to non-diabetic patients. As expected, they
had higher glucose and HbA1c levels. Type 2 diabetes patients more
often had a history of hypertension, hypercholesterolemia and AF.
Type 2 diabetes patients and non-diabetic patients did not differ in
type of MI. Also, no differences in type of intervention were found.
Results of the multiple linear regression analyses are presented in
Table 2. Type 2 diabetes was associated with the occurrence of a first
MI at an older age. After adjusting for total and LDL cholesterol, the
association between diabetes and age of occurrence of MI was no
longer significant. A trend remained after adjusting for systolic BP and
creatinine. The association between type 2 diabetes and age of
occurrence of MI remained significant after adjusting for gender, HDL
cholesterol and triglycerides.
A sensitivity analysis showed that excluding the patients from
the hospital with a high amount of missing values did not
considerably affect the results (data not shown). In analysis stratified
by gender, similar results for men and women were found (data
not shown).
Table 1
Characteristics of patients with a first MI.
Age (years)
Male gender (%)
Smoking (%)
Systolic BP (mmHg)
Total cholesterol (mmol/l)
LDL cholesterol (mmol/l)
HDL cholesterol (mmol/l)
Triglycerides (mmol/l)
Creatinine (μmol/l)
Glucose (mmol/l)
HbA1c (%)
HbA1c (mmol/mol)
Cardiovascular risk SCORE
History of hypertension (%)
History of hypercholesterolemia (%)
History of AF (%)
No monitoring (%)
Type of MI
STEMI (%)
NSTEMI (%)
Intervention
Conservative (%)
PCI (%)
CABG (%)
Non-diabetic
(n = 486)
Type 2 diabetes
(n = 77)
p-value
64.4 ± 13.4
72.8
45.9
141.7 ± 27.5
5.4 ± 1.2
3.4 ± 1.1
1.3 ± 0.4
1.5 (1.1–2.1)
82 (72–95)
6.8 (6.0–7.8)
5.7 (5.5–5.9)
39 (37–41)
22.6
31.4
20.7
1.7
55.0
67.8 ± 10.9
71.4
39.0
150.3 ± 29.9
4.4 ± 0.9
2.5 ± 0.8
1.1 ± 0.4
1.7 (1.2–2.4)
90 (72–110)
9.9 (7.5–13.3)
6.6 (6.2–7.8)
49 (44–62)
36.5
70.7
51.6
6.5
n.a.
b0.05
0.785
0.318
b0.05
b0.001
b0.001
0.065
b0.05
b0.05
b0.001
b0.001
b0.001
b0.001
b0.001
b0.001
b0.05
52.7
47.3
51.9
48.1
26.7
67.1
6.2
31.2
65.0
3.8
0.389
0.306
Please cite this article as: Kasteleyn, M.J., et al., Differences in clinical characteristics between patients with and without type 2 diabetes
hospitalized with a first myocardial infarction, Journal of Diabetes and Its Complications (2016), http://dx.doi.org/10.1016/j.jdiacomp.2016.03.024
M.J. Kasteleyn et al. / Journal of Diabetes and Its Complications xxx (2016) xxx–xxx
3
Fig. 1. Differences between MI patients with and without T2DM.
4. Discussion
In this study, we observed that patients with type 2 diabetes were
older, had higher systolic BP and had lower total and LDL cholesterol
levels than patients without type 2 diabetes at the time they were
hospitalized with their first MI. The association between type 2
diabetes and age of occurrence of MI was largely explained by total
cholesterol and LDL cholesterol levels.
The cardiovascular risk attributable to type 2 diabetes depends on
the overall burden of cardiovascular risk factors in individual patients.
When these factors are controlled, the cardiovascular risk decreases
(Buse et al., 2007; Gaede, Lund-Andersen, Parving, & Pedersen, 2008).
Our finding that patients with type 2 diabetes are confronted with a
first MI at an older age than patients without diabetes might reflect
the results of the close monitoring of these patients (Stone et al.,
2013). According to the guidelines type 2 diabetes patients will
receive primary prevention for controlling both the diabetes and the
co-existing cardiovascular risk factors on a more structured base and
may be more aggressively treated than people without type 2 diabetes
but an elevated cardiovascular risk. Indeed, the lower LDL and total
cholesterol levels in patients with type 2 diabetes point to successful
primary prevention.
Previous studies also showed that type 2 diabetes patients were
older when hospitalized with a MI, although the differences between
diabetic and non-diabetic patients were smaller than in our study
(Elbarouni et al., 2011; Norhammar et al., 2003). Both studies did not
differentiate between patients with a first and recurrent MI. Besides,
they did not adjust for lipid levels. The cross-sectional design of the
study does not allow us to conclude that the association between type
2 diabetes and age of occurrence of MI is caused by primary
prevention and close monitoring. It is known that older people are
at higher risk of having type 2 diabetes. The incidence of diabetes in
Table 2
The association of type 2 diabetes with age of occurrence of a first MI.
Crude (type 2 diabetes)
+ Gender
+ Systolic BP
+ Total cholesterol
+ LDL cholesterol
+ HDL cholesterol
+ Triglycerides
+ Creatinine
β (95% CI)
p-value
3.41
3.29
3.01
1.43
1.63
4.92
4.48
2.57
0.032
0.035
0.059
0.382
0.335
0.002
0.005
0.106
(0.29–6.53)
(0.24–6.34)
(−0.11 to 6.13)
(−1.78 to 4.63)
(−1.68 to 4.94)
(1.86–7.98)
(1.39–7.57)
(−0.54 to 5.69)
the Netherlands is 3.5 per 1000 for men and 2.8 per 1000 for women.
The incidence increases with age till 75 years, and decreases after the
age of 75. The average age of type 2 diabetes patients in the
Netherlands is 64 years for men and 68 years for women (Diabetes
Mellitus, nd). This high average age contributes most likely to the
higher average age of type 2 diabetes patients hospitalized with a first
MI. Ten years ago it was demonstrated that patients with type 2
diabetes had a higher risk of MI than age-matched non-diabetic
persons (Almdal, Scharling, Jensen, & Vestergaard, 2004). Irrespective
of whether people were diagnosed with type 2 diabetes before or
during their hospitalization for a MI, a higher age-matched risk of MI
would lead to a lower average age of occurrence of MI in type 2
diabetes patients compared to non-diabetic patients. We did find the
contrary. Since the association we found between diabetes and age of
occurrence of MI was explained by total and LDL cholesterol levels, it
seems reasonable to assume that the higher age of occurrence of MI in
patients with diabetes reflects the results of successful primary
prevention in type 2 diabetes. Especially because it is known that
lowering LDL cholesterol by 1 mmol/L decreases the incidence of
cardiovascular morbidity and mortality in type 2 diabetes patients by
20% (Baigent et al., 2005). A meta-analysis demonstrated that
treatment with a statin in the primary prevention of major
cardiovascular events results in a significant relative risk reduction
in the first-time occurrence of non fatal myocardial infarction
(de Vries, Denig, Pouwels, Postma, & Hak, 2012). Our study confirms
these findings from RCTs in daily practice. If our assumption that
primary prevention is more vigorous and systematic in T2DM patients
than in ‘only’ hypertension/hypercholesterolemia patients (Janssen
et al., 2008), is true, having a diagnosis of type 2 diabetes can even be
favorable for appropriate preventive treatment, resulting in a delay of
the occurrence of a first MI.
Some limitations need to be addressed. Although patients were
included from three different hospitals, selection bias cannot be ruled
out. We have no information on mortality. Thus we do not know
whether there is a difference in mortality between type 2 diabetes and
non-diabetic patients before hospitalization with a MI. However, the
HbA1c levels of the type 2 diabetes patients in our study are similar to
other diabetic patients in the Netherlands (Stone et al., 2013) and the
proportion of STEMI and non-STEMI in our study did not differ
between patients with and without diabetes and is comparable to
other studies (Kedhi et al., 2012; Nauta, Deckers, Akkerhuis, &
van Domburg, 2012), suggesting that the included MI patients are
representative for the overall MI population in the Netherlands.
Furthermore, we had no information on what kind of medication for
Please cite this article as: Kasteleyn, M.J., et al., Differences in clinical characteristics between patients with and without type 2 diabetes
hospitalized with a first myocardial infarction, Journal of Diabetes and Its Complications (2016), http://dx.doi.org/10.1016/j.jdiacomp.2016.03.024
4
M.J. Kasteleyn et al. / Journal of Diabetes and Its Complications xxx (2016) xxx–xxx
primary prevention patients already used when they were hospitalized with a first MI. Guidelines recommend prescription of statins in
all type 2 diabetes patients, except those with a low cardiovascular
risk (Rutten et al., 2013). In the Netherlands more than 70% of all type
2 diabetes use lipid lowering drugs (Stone et al., 2013; Transparante
ketenzorg diabetes mellitus, 2014). Therefore we think it is justified to
assume that a comparable proportion of the patients in current study
used lipid lowering drug before admission to the hospital. In addition,
without treatment, LDL-levels are likely to be elevated in type 2
diabetes, and for that reason the low LDL cholesterol levels in our
population are suggesting that this risk factor is well monitored and
controlled. Furthermore, data on smoking status were missing in
almost 20% of the patients in the current study. Other studies showed
a lower smoking prevalence in MI patients with type 2 compared to
patients without diabetes (Elbarouni et al., 2011; Norhammar et al.,
2003), which is in line with our results, although the difference in our
study was not significant. Nevertheless, we think the lower proportion of smoking in type 2 diabetes patients could possibly contribute
to the later age of occurrence of MI which is also an indication that
primary prevention is successful, since smoking cessation is an
important goal of the diabetes care (Rutten et al., 2013). There were
also significant amounts of missing biochemical data, but sensitivity
analyses showed that this had no impact on the results. Finally, we
had no information on BMI. Therefore, we were not able to take BMI
into account in the analyses. In the GUIDANCE study patients with a
higher BMI were less likely to meet targets for HbA1c and blood
pressure (Stone et al., 2013).
To conclude, our findings show that currently type 2 diabetes
patients have lower cholesterol levels and experience a first
myocardial infarction at older age than non-diabetic patients. The
association between type 2 diabetes and age of occurrence of MI was
explained by cholesterol levels. This finding might reflect successful
primary prevention and systematic monitoring in type 2 diabetes
patients. Longitudinal studies, for example a matched cohort design
where patients with a first time diagnosis of diabetes are matched to
patients without diabetes and then followed until time of MI, are
needed to examine the exact impact of primary prevention in type 2
diabetes on the difference in age of occurrence of MI between patients
with and without diabetes.
Acknowledgments
The authors thank Amely M.K. Daza Zabaleta (from the University
Medical Center Utrecht, Julius Center for Health Sciences and Primary
Care) for data collection and Joline Beulens (from the University
Medical Center Utrecht, Julius Center for Health Sciences and Primary
Care) for the critical review of the manuscript. This study is funded by
the Dutch Diabetes Research Foundation (no: 2009.70). The funder
had no role in the design or conduct of the study; collection,
management, analysis, or interpretation of the data; or preparation,
review, or approval of the manuscript.
References
Almdal, T., Scharling, H., Jensen, J. S., & Vestergaard, H. (2004). The independent effect of
type 2 diabetes mellitus on ischemic heart disease, stroke, and death: A populationbased study of 13,000 men and women with 20 years of follow-up. Archives of
Internal Medicine, 164(13), 1422–1426.
Baigent, C., Keech, A., Kearney, P. M., Blackwell, L., Buck, G., Pollicino, C., ... Simes, R.
(2005). Efficacy and safety of cholesterol-lowering treatment: Prospective metaanalysis of data from 90,056 participants in 14 randomised trials of statins. Lancet,
366(9493), 1267–1278.
Buse, J. B., Ginsberg, H. N., Bakris, G. L., Clark, N. G., Costa, F., Eckel, R., ... Stone, N. J.
(2007). Primary prevention of cardiovascular diseases in people with diabetes
mellitus: A scientific statement from the American Heart Association and the
American Diabetes Association. Circulation, 115(1), 114–126.
Conroy, R. M., Pyorala, K., Fitzgerald, A. P., Sans, S., Menotti, A., De Backer, G., ... Grahma,
I. M. (2003). Estimation of ten-year risk of fatal cardiovascular disease in Europe:
The SCORE project. European Heart Journal, 24(11), 987–1003.
de Vries, F. M., Denig, P., Pouwels, K. B., Postma, M. J., & Hak, E. (2012). Primary
prevention of major cardiovascular and cerebrovascular events with statins in
diabetic patients: A meta-analysis. Drugs, 72(18), 2365–2373.
Elbarouni, B., Ismaeil, N., Yan, R. T., Fox, K. A., Connelly, K. A., Baer, C., ... Yan, A. T. (2011).
Temporal changes in the management and outcome of Canadian diabetic patients
hospitalized for non-ST-elevation acute coronary syndromes. American Heart
Journal, 162(2), 347–355 e341.
Ford, E. S. (2011). Trends in the risk for coronary heart disease among adults with
diagnosed diabetes in the U.S.: Findings from the National Health and Nutrition
Examination Survey 1999–2008. Diabetes Care, 34(6), 1337–1343.
Gaede, P., Lund-Andersen, H., Parving, H. H., & Pedersen, O. (2008). Effect of a
multifactorial intervention on mortality in type 2 diabetes. The New England Journal
of Medicine, 358(6), 580–591.
Huxley, R., Barzi, F., & Woodward, M. (2006). Excess risk of fatal coronary heart disease
associated with diabetes in men and women: Meta-analysis of 37 prospective
cohort studies. BMJ, 332(7533), 73–78.
Janssen, P. G., Gorter, K. J., Stolk, R. P., Akarsubasi, M., & Rutten, G. E. (2008). Three years
follow-up of screen-detected diabetic and non-diabetic subjects: Who is better off?
The ADDITION Netherlands study. BMC Family Practice, 9, 67.
Johnson, P. A., Goldman, L., Sacks, D. B., Garcia, T., Albano, M., Bezai, M., ... Lee, T. H. (1999).
Cardiac troponin T as a marker for myocardial ischemia in patients seen at the
emergency department for acute chest pain. American Heart Journal, 137(6), 1137–1144.
Kedhi, E., Gomes, M., Joesoef, K. S., Wassing, J., Goedhart, D., McFadden, E., & Smits, P. C.
(2012). Everolimus-eluting stents and paclitaxel-eluting stents in patients
presenting with myocardial infarction: Insights from the two-year results of the
COMPARE prospective randomised controlled trial. EuroIntervention: Journal of
EuroPCR in collaboration with the Working Group on Interventional Cardiology of the
European Society of Cardiology, 7(12), 1376–1385.
Nauta, S. T., Deckers, J. W., Akkerhuis, K. M., & van Domburg, R. T. (2012). Short- and
long-term mortality after myocardial infarction in patients with and without
diabetes: Changes from 1985 to 2008. Diabetes Care, 35(10), 2043–2047.
Norhammar, A., Malmberg, K., Ryden, L., Tornvall, P., Stenestrand, U., & Wallentin, L.
(2003). Register of I, Knowledge about Swedish Heart Intensive Care A: Under
utilisation of evidence-based treatment partially explains for the unfavourable
prognosis in diabetic patients with acute myocardial infarction. European Heart
Journal, 24(9), 838–844.
Rijksinsituut voor Volksgezondheid en Milieu. Diabetes Mellitus. Bilthoven: RIVM.
http://www.nationaalkompas.nl/gezondheid-en-ziekte/ziekten-enaandoeningen/endocriene-voedings-en-stofwisselingsziekten-enimmuniteitsstoornissen/diabetes-mellitus/omvang/.
Rubin, D. B. (1987). Multiple imputation for non-response in surveys. New York: Wiley.
Rutten, G. E. H. M., De Grauw, W. J. C., Nijpels, G., Houweling, S. T., Van de Laar, F. A., Bilo,
H. J., ... Janssen, P. G. H. (2013). NHG-standard diabetes mellitus type 2 (derde
herziening). Huisarts Wet, 56(10), 512–525.
Stone, M. A., Charpentier, G., Doggen, K., Kuss, O., Lindblad, U., Kellner, C., ... Khunti, K.
(2013). Quality of care of people with type 2 diabetes in eight European countries:
Findings from the Guideline Adherence to Enhance Care (GUIDANCE) study.
Diabetes Care, 36(9), 2628–2638.
Transparante ketenzorg diabetes mellitus, COPD en VRM. Rapportage zorggroepen over
(2014). http://ineen.nl/wp-content/uploads/2015/06/150602-TRANSPARANTEKETENZORG-2014.pdf.
Please cite this article as: Kasteleyn, M.J., et al., Differences in clinical characteristics between patients with and without type 2 diabetes
hospitalized with a first myocardial infarction, Journal of Diabetes and Its Complications (2016), http://dx.doi.org/10.1016/j.jdiacomp.2016.03.024