BackgroundWe investigated whether the greater increased risk of ischemic heart disease mortality associated with diabetes among women compared with men could be explained by their more pronounced lipoprotein abnormalities.Methods and ResultsSeventy-six men and 45 women with diabetes and 327 men and 496 women without diabetes were followed for an average of 16 years in a population-based study. Cox proportional hazards models were used to determine the relative hazard of ischemic heart disease mortality for changes in lipoprotein subfractions after adjustment for age, hypertension, obesity, smoking, exercise, alcohol consumption, and estrogen use (among women). The relative hazard of ischemic heart disease mortality among diabetic women was 1.76 (P= .10) for a 10-mg/dL decrement in highdensity lipoprotein cholesterol (HDL-C) and 3.13 (P= .01) for a 1-U increment in log, very-low-density lipoprotein cholesterol (VLDL-C). The risk of ischemic heart disease mortality among diabetic women relative to nondiabetic women for an HDL-C level of 50 mg/dL and a loge VLDL-C of 3 (about 20 mg/dL) were 4.1 and 3.4, respectively (P< .05). These lipoprotein changes were not associated with ischemic heart disease mortality among men or among nondiabetic women.ConclusionsExcess ischemic heart disease mortality among diabetic women is partially explained by deleterious levels of HDL-C and VLDL-C. HDL-C levels of ≤50 mg/dL and VLDL-C levels of ≥20 mg/dL appear to predict ischemic heart disease mortality among these women and may help identify women who would benefit most from intervention.