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Background  Biomarkers may contribute to improved cardiovascular risk estimation. Glycated hemoglobin A 1c  (HbA 1c ) is used to monitor the quality of diabetes treatment. Its strength of association with cardiovascular outcomes in the general population remains uncertain. This study aims to assess the association of HbA 1c  with cardiovascular outcomes in the general population.    Methods  Data from six prospective population-based cohort studies across Europe comprising 36,180 participants were analyzed. HbA 1c  was evaluated in conjunction with classical cardiovascular risk factors (CVRFs) for association with cardiovascular mortality, cardiovascular disease (CVD) incidence, and overall mortality in subjects without diabetes (N = 32,496) and with diabetes (N = 3684).    Results  Kaplan–Meier curves showed higher event rates with increasing HbA 1c  levels (log-rank-test: p < 0.001). Cox regression analysis revealed significant associations between HbA 1c  (in mmol/mol) in the total study population and the examined outcomes. Thus, a hazard ratio (HR) of 1.16 (95% confidence interval (CI) 1.02–1.31, p = 0.02) for cardiovascular mortality, 1.13 (95% CI 1.03–1.24, p = 0.01) for CVD incidence, and 1.09 (95% CI 1.02–1.17, p = 0.01) for overall mortality was observed per 10 mmol/mol increase in HbA 1c . The association with CVD incidence and overall mortality was also observed in study participants without diabetes with increased HbA 1c  levels (HR 1.12; 95% CI 1.01–1.25, p = 0.04) and HR 1.10; 95% CI 1.01–1.20, p = 0.02) respectively. HbA 1c  cut-off values of 39.9 mmol/mol (5.8%), 36.6 mmol/mol (5.5%), and 38.8 mmol/mol (5.7%) for cardiovascular mortality, CVD incidence, and overall mortality, showed also an increased risk.    Conclusions  HbA 1c  is independently associated with cardiovascular mortality, overall mortality and cardiovascular disease in the general European population. A mostly monotonically increasing relationship was observed between HbA 1c  levels and outcomes. Elevated HbA 1c  levels were associated with cardiovascular disease incidence and overall mortality in participants without diabetes underlining the importance of HbA 1c  levels in the overall population.    Supplementary Information  The online version contains supplementary material available at 10.1186/s12933-021-01413-4.

cardiovascular diabetology

Association of glycated hemoglobin A1c levels with cardiovascular outcomes in the general population: results from the BiomarCaRE (Biomarker for Cardiovascular Risk Assessment in Europe) consortium