The role of hyperglycemia on the mortality from coronary heart disease (CHD) [1, 2], stroke [3, 4] and other cardiovascular diseases (CVDs) [5–7] has been well investigated. Two-hour plasma glucose (2hPG) is a better predictor than fasting plasma glucose (FPG) for incidence of CHD [8, 9] and ischemic stroke (IS) [10] among individuals with hyperglycemia, but little is known about their impact within normoglycemic range. Previous studies have shown that insulin resistance and declined beta cell function are already presented in subjects with elevated normal FPG and/or 2hPG [11–13]. The upper normal level of the FPG [14, 15] or 2hPG [16] has been found to increase the risk of type 2 diabetes. Our previous finding based on the DECODE (Diabetes Epidemiology: Collaborative analysis Of Diagnostic criteria in Europe) study demonstrated that individuals with normoglycemia, whose 2hPG did not return to the FPG levels during a standard 75 g 2-h oral glucose tolerance test (OGTT) had a higher risk for mortality from CVD and all-cause than individuals whose 2hPG returned to their FPG levels or below them [17]. However, the early DECODE study could not show a causal relationship because individuals with CVD at baseline could not be identified and excluded. The elevated 2hPG could be a consequence of existing CVD rather than a cause. To further clarify the causal relationship between elevated normal 2hPG and the development of the CVD events, the current study is carried out based on the Finnish and the Swedish DECODE cohorts who have complete information on the occurrence of both fatal and non-fatal events.

Since the interaction between the two glucose groups and sex was statistically significant (p < 0.001), data analyses were made separately for men and women. Multivariate-adjusted HRs for IS and composite CVD events were significantly higher in Group II than in Group I in men, but not in women (Table 3). The survival profile was better in group I than in group II for composite CVD events in both sexes (Figure 1). Replacing the hypertension status (yes versus no) with continuous systolic blood pressure in the Cox model did not change the results substantially (data not shown). HRs corresponding to a one unit increase in the difference between 2hPG and FPG concentrations (2hPG-FPG) were significantly increased for the CHD events in women and composite CVD events in all individuals (Table 3).

	CHD		IS		CHD + IS
	HR	95% CI	HR	95% CI	HR	95% CI
Men (n = 3743)
Group II versus Group I	1.13	0.93-1.37	1.40	1.06-1.85	1.20	1.01-1.42
2hPG-FPG (continuous)	1.03	0.95-1.12	1.11	0.99-1.25	1.07	0.99-1.14
Women (n = 3916)
Group II versus Group I	1.33	0.83-2.12	0.94	0.59-1.50	1.10	0.79-1.54
2hPG-FPG (continuous)	1.24	1.03-1.50	1.01	0.83-1.23	1.13	0.99-1.30
Total (n = 7659)
Group II versus Group I	1.15	0.97-1.38	1.27	1.00-1.62	1.18	1.02-1.37
2hPG-FPG (continuous)	1.06	0.98-1.14	1.09	0.98-1.20	1.08	1.01-1.15

Adjusting for age, cohort, body mass index, FPG, total serum cholesterol, smoking status and hypertension status, and sex when men and women combined. CHD, coronary heart disease; 95% CI, 95% confidence interval; FPG, fasting plasma glucose; Group I, 2hPG ≤ FPG; Group II, 2hPG > FPG; 2hPG, 2-hour plasma glucose; 2hPG-FPG, the difference between 2hPG and FPG; HR, hazard ratio; IS, ischemic stroke.

Stratified data analysis was also performed by FPG of ≤ 5.6 mmol/l and 5.6-6.1 mmol/l, and by age of < 60 years and ≥ 60 years for both men and women combined. Multivariate-adjusted HRs (95% CIs) for the composite CVD events for Group II as compared with Group I were 1.09 (0.91-1.30) and 1.41 (1.06-1.86) in the lower and the higher FPG categories; and 1.16 (0.96-1.40) and 1.27 (0.99-1.64), respectively, in the younger and older age groups. In addition, the same data analysis was also made in a subgroup of individuals who had fasting insulin measurements (n = 4082), producing an HR (95% CI) of 1.10 (0.90-1.34) in a model without fasting insulin, to 1.09 (0.89-1.33) when the model fitting with fasting insulin, and to 1.10 (0.90-1.34) when replacing fasting insulin with HOMA-IR. Neither the fasting insulin levels nor the HOMA-IR changed the results substantially. The HR (95% CI) for the composite CVD events was 1.07 (0.89-1.30) and 1.08 (0.89-1.30), respectively in models without and with physical activity and education in a subgroup of participants (n = 5331).

In these prospective cohort studies, 11.0% of the participants who had normoglycemia at baseline developed first CHD or IS events during a median follow-up of 16.4 years. The risk to develop the CHD or IS was increased in people whose 2hPG was higher than whose FPG.

Two-hour plasma glucose concentration is a better predictor than FPG for the incidence of CHD [8, 9] and IS [10] among general populations with hyperglycemia. Moreover, post-challenge glucose concentrations contribute to a greater risk on the patients with CHD [28] or IS [29–31] than slightly elevated FPG. In contrast, FPG was better predictor than 2hPG for total mortality and CVD mortality in the CHD patients in another study [32]. A number of studies have shown that IFG and IGT reflect different pathophysiological mechanisms of abnormal glucose homeostasis [33, 34]. Fasting hyperglycemia is associated with reduced hepatic insulin resistance and decreased first-phase insulin secretion, while elevated post-challenge glucose concentration is associated with peripheral insulin resistance and impairment of both early- and late-phase insulin response [35, 36].

Among individuals with normal glucose range, people whose 2hPG did not return to their FPG levels during a 2-h OGTT had a significantly higher risk for future type 2 diabetes [16], worse cardiovascular risk profile [37] and higher CVD mortality [17] compared with those whose 2hPG were equal to or lower than their FPG levels. This was further confirmed in our current study with incident CVD events. The normoglycemic status is a balance between glucose production and disposal mediated through a synergistic effect of skeletal muscle, pancreas beta cells and liver [38]. Elevated fasting insulin levels have been shown to contribute to the progress to diabetes and CVD among individuals with normoglycemia [16, 37]. Our study showed that normoglycemic individuals whose 2hPG did not return to FPG levels had elevated fasting insulin levels and HOMA-IR compared with those who did. Beta-cell dysfunction and insulin resistance have been suggested to be present already in individuals with normal glucose range [11, 39]. Both insulin resistance and endothelial dysfunction have been considered as the underlying mechanism contributing to the development of atherosclerosis [40–44]. Other proposed factors include elevated plasma free fatty acids concentrations, which appears to be an early trigger for multiple pathways leading to atherogenesis in non-diabetic healthy subjects [45], and elevated fetuin-A levels which are associated with an increased risk of myocardial infarction and IS in the general population [46]. While these have been reported to be associated with development of CVD in non-diabetic individuals, to what extent these factors contribute to the increased risk of CVD in people with high normal 2hPG is not known, and needs to be further investigated.

The strengths of our study include a relatively long duration of follow-up, a large sample size and a standard 2-h OGTT to define normoglycemia. In this collaborative analysis, all studies were population-based with a random sampling method except for the Helsinki Policemen Study. To take into account the discrepancies between cohorts, the cohort was adjusted as a covariate in the data analysis. The Finnish [25, 26] and Swedish [27] Causes of Death Register and Hospital Discharge Register, the source of the data on CHD and IS events in this study, have high coverage and diagnostic accuracy. Our study has also certain limitations. The statistical power of the analysis was relatively lower in women due to small number of incident events. Other known cardiovascular risk factors, such as waist circumference, HbA1c levels and dietary factors were not available for all cohorts included in the current data analysis. Lipid-lowering treatment, types of antihypertensive treatment and hormone replacement therapy for the postmenopausal women were not included in the current database. Furthermore, we did not have any measurements of markers of inflammation and endothelial dysfunction, both of which have been shown to relate more strongly to post-load than to fasting plasma glucose concentrations, and might represent unmeasured confounders which underlie the observed relationships [47, 48]. To what extent these missing variables will affect the results is not known and need to be further investigated.

In the normoglycemic range defined by both 2hPG and FPG criteria, 2hPG after a 75 g OGTT unable to return to the FPG level was associated with worse CVD profile, elevated fasting insulin levels and increased CVD events. The underlying mechanism and clinical implications need to be further investigated.