Temporal changes in risk of cardiovascular events in people with newly diagnosed type 2 diabetes with and without cardiovascular disease

AimsExamine temporal changes in the risk of cardiovascular events in people with newly diagnosed type 2 diabetes with and without cardiovascular disease (CVD).Methods283,600 individuals with newly diagnosed type 2 diabetes and age-, sex-, and CVD-matched controls without diabetes were identified through Danish nationwide registries between 1997 and 2014. Using Cox regression models, we report the standardized absolute 5-year risk of cardiovascular death, myocardial infarction, stroke, and heart failure for people with diabetes and controls.ResultsIndividuals with newly diagnosed diabetes were at increased risk of cardiovascular events compared to controls. From 1997–2002 to 2009–2014 reductions in cardiovascular events for people with diabetes were: cardiovascular death; 26.5% to 13.8% in people with CVD and from 7.3% to 3.2% in people without CVD, myocardial infarction; 13.1% to 6.5% in people with CVD and from 4.1% to 1.9% in people without CVD, stroke; 14.2% to 8.8% in people with CVD and from 4.9% to 2.2% in people without CVD, and heart failure; 21.0% to 13.8% in people with CVD and from 5.0% to 2.6% in people without CVD. The risk of cardiovascular events declined more among people with diabetes than controls.ConclusionsNewly diagnosed type 2 diabetes was associated with an increased risk of cardiovascular events, and the risk decreased significantly 1997–2014 in both people with and without CVD. Furthermore, the excess risk associated with type 2 diabetes decreased significantly during the study period.     

Atrial fibrillation and its association with type 2 diabetes and hypertension in a Swedish community

AIM: To explore the prevalence of atrial fibrillation in patients with hypertension and type 2 diabetes and to identify possible mechanisms for the development of atrial fibrillation. METHODS: A community-based, cross-sectional observational study was conducted in the primary health care in Skara, Sweden, and 1739 subjects (798 men, 941 women) were surveyed. Patients were categorized as those with hypertension only (n = 597); those with both hypertension and type 2 diabetes (n = 171), and those with type 2 diabetes only (n = 147). In the reference population, 824 normotensive subjects without diabetes were identified and used as controls. Participants were examined for cardiovascular risk factors including fasting blood glucose, serum insulin, blood pressure, lipids and anthropometric measures. Resting electrocardiogram (ECG) was recorded and Minnesota-coded. Insulin resistance was measured by the homeostasis model assessment (HOMA). RESULTS: Age-adjusted prevalence of atrial fibrillation was 2% in patients with hypertension only, 6% in patients with both hypertension and type 2 diabetes, 4% in patients with type 2 diabetes only and 2% in controls, respectively. Age and sex adjusted odds ratios (OR) (95% CI) were; hypertension 0.7 (0.30-1.5), combined hypertension and type 2 diabetes 3.3 (1.6-6.7), and type 2 diabetes 2.0 (0.9-4.7). The association with combined hypertension and type 2 diabetes remained significant when adjusted for cardiovascular disease (CVD) risk factors and body mass index (BMI), was attenuated with adjustment for ischemic ECG; 2.4 (1.1-5.0) and lost significance with adjustment for insulin resistance; 1.3 (0.5-3.1). CONCLUSIONS: Atrial fibrillation is associated with the combined occurrence of type 2 diabetes and hypertension. Insulin resistance may be a common underlying mechanism.     

The association between erectile dysfunction and cardiovascular risk in men with Type 2 diabetes in primary care: it is a matter of age

AimsErectile dysfunction (ED) prevalence is usually based on questionnaires, too elaborate for daily practice. The single question for ED prevalence is unknown. Literature reports an independent association between ED and both cardiovascular disease (CVD) and diabetes. Whether routinely asking men with Type 2 diabetes (DM2) about ED identifies those at elevated risk for CVD is unknown. We assessed cardiovascular risk of DM2 men with ED.Design and MethodsThis was a cross-sectional study in primary care. During annual check-up, the practice nurse asked 1823 DM2 men: “Do you have erection problems? Yes/no.” ED prevalence rate was calculated. Age, medication, and other known factors associated with ED and/or CVD were used in univariate analysis (odds ratio [OR], Student's t test, and Mann–Whitney test). This revealed confounding variables used in the multivariable analysis. The association between ED and history of cardiovascular disease (HCVD) was assessed by logistic regression analysis. In patients with no HCVD, we assessed the association between ED and 10-year United Kingdom Prospective Diabetes Study (UKPDS) coronary heart disease risk by linear regression analysis.ResultsThe prevalence of ED in DM2 patients was 41.3%. There was no independent association between ED and HCVD [adjusted OR, 1.2 (95% CI, 0.9–1.5)]. The 10-year UKPDS CHD risk difference between men with and without ED was 5.9% (95% CI, 3.2–8.7), but after adjustment for age, this association disappeared [adjusted risk difference, 0.6% (95% CI, ?1.5 to 2.7)].ConclusionThe ED prevalence rate assessed by a single question was comparable to that assessed by questionnaires. ED neither did independently relate to patients' cardiovascular history nor to cardiovascular risk.     

Cardiovascular events in patients with over 10 years history of type 2 diabetes mellitus

BackgroundDiabetes is one of the concerns of today's public health and patients with type 2 diabetes are at increased risk of death due to cardiovascular diseases. The aim of this study was to evaluate the prevalence of cardiovascular diseases in patients with over 10 years history of type 2 diabetes mellitus referred to the Sanandaj Diabetes Clinic.MethodsIn this study, 400 patients with type 2 diabetes who had over 10 years history of diabetes were selected and the required information was prepared based on taking their history and files. Finally data were analyzed using T-test, Chi-square and Fisher test methods.ResultsIn this the mean duration of diabetes was 14.59 ± 4.07 years. 95.25% of patients had dyslipidemia. The frequency of history of cardiovascular events was 78.25%. 12.25% of patients had a history of ischemic heart disease and 82.75% had a history of high blood pressure. There was a significant relationship between the incidence of cardiovascular events with hypertension, HDL level and family history of early cardiovascular disease (p < 0.05).ConclusionThe high risk of cardiovascular events in diabetic patients it strongly emphasizes the need for quick and serious approaches to prevent cardiovascular events in diabetic patients.     

Parents' cardiovascular risk factors are related to overweight and obesity in young Brazilians with type 1 diabetes

AimTo identify family background characteristics and cardiovascular disease (CVD) risk factors linked to overweight and obesity in Brazilian with type 1 diabetes (T1D).MethodsWe performed cross-sectional anthropometric and laboratory analyses in young individuals with T1D.ResultsAmong 181 participants, 87 were women and 94 were men (64%/78% normal weight, 27%/15% overweight and 9%/7% obese). Obese men were older; were more likely to be Black; had higher triglyceride levels and diastolic blood pressure (BP), lower estimated glucose disposal rate (eGDR) and higher prevalence of first-degree relatives (FDR) with hypertension and early CVD. Overweight and obese women were more likely to have lower eGDR, and obese women were more likely to have FDR with obesity.ConclusionOne third of young people with T1D were overweight or obese. Excess weight was associated with family history (FH) of obesity for women and FH of early CVD or hypertension for men. BMI was related to decreased insulin sensitivity in both genders, but only men with T1D had metabolic impairment. Our data highlight the importance of considering family background in individuals with T1D.     

Electrocardiogram abnormalities and risk of cardiovascular mortality and all-cause mortality in old age: The Kahrizak Elderly Study (KES)

Resting electrocardioghic (ECG) abnormalities might be value for mortality prediction. The aim of this study is to evaluate whether ECG abnormalities are associated with increased mortality in older residents of Kahrizak Charity Foundation (KCF). A total of 247 participants ≥60-years of KES were enrolled in this study. Adjudicated all cause mortality was collected over 3 years between 2006 and 2009. The subjects were classified as having major, minor or no ECG abnormalities according to the Minnesota Code. The addition of ECG to risk factors were examined to predict cardiovascular diseases (CVD) and all-cause mortality by using Cox proportional hazards regression models. At baseline, 104(42.1%) had major ECG abnormalities and 73(29.6%) had minor abnormalities. During a median follow-up of 3.2 years, 73 participants died from all-cause mortality and 31deaths from CVD. Major ECG abnormalities were associated with an increased risk of CVD mortality in all models. The associations between minor ECG abnormalities at baseline and CVD mortality were not statistically significant. After adjustment for age and sex, Body mass index (BMI), smoking, diabetes, hypertension (HTN), hyperlipidemia and history of CVD, the participants with the major ECG abnormalities had higher risks of CVD mortality (HR: 3.12(95% CI, 1.02-9.57) and all-cause mortality (HR: 2.45(95% CI, 1.23–4.85) compared with those with normal ECG.     

Screen-detected diabetes, hypertension and hypercholesterolemia as predictors of cardiovascular mortality in five populations of Asian origin: the DECODA study.

BACKGROUND: The World Health Organization (WHO) predicts that the Asia Pacific region will experience an increase in cardiovascular disease (CVD) as a result of demographic changes and an increasing prevalence of diabetes. The aims of this study were to assess the predictive value of glucose tolerance status as a risk factor for CVD and identify a high-risk group for fatal CVD in population-based studies of Asians. DESIGN: A meta-analysis of five prospective cohort studies of Japanese and Asian Indian origin from five countries. METHODS: A total of 6573 subjects without a history of CVD from five prospective studies were followed for 5-10 years. Diabetes at baseline was diagnosed according to 1999 WHO criteria. Hazard ratios for death from CVD were estimated using a Cox proportional hazard model, adjusting for glucose tolerance status together with established risk factors for CVD. RESULTS: The meta-analysis showed that the overall hazard ratios (95% confidence interval) for CVD mortality corresponding to the presence of screen-detected diabetes, hypertension and hypercholesteremia were 3.42 (2.23-5.23), 1.57 (1.10-2.24) and 1.49 (1.05-2.10), respectively. Stratified multivariate analysis of the pooled data showed that subjects with screen-detected diabetes in the presence of hypertension or hypercholesteremia had the highest risk of CVD in individuals without previous CVD or diabetes. Subjects with screen-detected diabetes in the presence of hypertension or hypercholesteremia comprised 78% of CVD deaths that occurred in all subjects with screen-detected diabetes. CONCLUSIONS: The early detection of undiagnosed diabetes in hypertension or hypercholesteremia may have clinical and public health implications for the primary prevention of rapidly increasing diabetes-related atherosclerotic CVD in Asian populations.     

Cardiovascular disease in diabetes mellitus: classical and non-classical risk factors

Cardiovascular disease, which includes coronary heart disease (CHD), cerebrovascular disease (CVD), and peripheral vascular disease (PVD), is the leading cause of mortality in populations, particularly in the diabetic one. Individuals with diabetes have at least a two-fold to four-fold increased risk of having cardiovascular events and a double risk of death compared with age-matched subjects without diabetes. A decline in mortality from CVD has been shown, but decline due to CHD is consistently lower in individuals with diabetes when compared with non-diabetics. The presence of several factors in diabetes leads to high occurrence of CVD such as hyperglycemia, insulin resistance, and classical and non-classical risk factors (systemic hypertension, dyslipidemia, obesity, proinflammatory condition and others). It is possible that the atherogenic role of obesity may be at least in part due to increased adipocyte production of cytokines. Considering the marked association of diabetes and CVD and unfavorable prognosis following an event, it is important to identify who is at high risk and how to screen. The American Heart Association and American Diabetes Association recommend risk stratification using diagnostic tests. However, the challenge is to accurately identify patients without a prior history of an event and those without symptoms strongly suggesting CVD, in whom additional testing would be indicated in order to achieve the most effective prevention. The benefits of glycemic control and the other risk factors have already been shown and justify optimization of the management of this high-risk population, aiming to reduce cardiovascular mortality disease and improve quality of life.     

Effects of glycaemic control on cardiovascular disease in diabetic American Indians: the Strong Heart Study.

AIMS: Diabetes increases the risk of cardiovascular disease (CVD). Only part of this excess risk is explained by diabetes-associated hypertension, obesity, and lipid disorders. Poor glycaemic control may help explain the residual CVD risk. The aim of this study was to determine whether variations in glycaemic control are associated with CVD risk in diabetic individuals. METHODS: We examined longitudinal data from the Strong Heart Study, a population-based study of CVD and its risk factors among American Indians (a population with a high prevalence of diabetes). Diabetes was defined using the 1998 World Health Organization criteria: fasting plasma glucose >/= 126 mg/dl or 2-h plasma glucose >/= 200 mg/dl. American Diabetes Association guidelines for glycaemic control were used: good, A(1c) < 7%; fair, 7-7.9%; and poor, >/= 8%. The analysis was based on data from diabetic individuals with no CVD at baseline. RESULTS: During 9 years of follow-up, 494 of the 2011 diabetic participants developed CVD. Although Cox multivariate regression modelling showed dose-response effects of glycaemic control on overall CVD and coronary heart disease (CHD) incidence, the relationships were weakened when adjusted for confounding variables. Kaplan-Meier analysis, however, showed that diabetic individuals with poor baseline glycaemic control had significantly increased proportions of overall CVD and CHD (P = 0.001) during the 9 years of follow-up, compared with those who had good or fair control. CONCLUSIONS: These findings highlight the importance of risk factors, such as high blood pressure and dyslipidaemia, in increasing CVD risk in those with diabetes.     

Prognostic value of ST-T abnormalities and left high R waves with cardiovascular mortality in Japanese (24-year follow-up of NIPPON DATA80)

Little is known about the prognostic value of ST-segment depression and/or T wave (ST-T abnormalities) with or without left high R waves on electrocardiogram recorded at rest for death from cardiovascular disease (CVD) in Asian populations. Japanese participants without a history of CVD and free of major electrocardiographic (ECG) abnormalities were followed for 24 years. Subjects were divided into 4 groups based on baseline ECG findings: isolated left high R waves, isolated ST-T abnormalities, ST-T abnormalities with left high R waves, and normal electrocardiogram. Cox proportional hazard model was used to estimate risk of CVD mortality in groups with ECG abnormalities compared to the normal group. Of 8,572 participants (44.4% men, mean age 49.5 years; 55.6% women, mean age 49.4 years), 1,142 had isolated left high R waves, 292 had isolated ST-T abnormalities, and 128 had ST-T abnormalities with left high R waves at baseline. Multivariable-adjusted hazard ratios of ST-T abnormalities with left high R waves for CVD mortality were 1.95 (95% confidence interval 1.25 to 3.04) in men and 2.68 (95% confidence interval 1.81 to 3.97) in women. Isolated ST-T abnormalities increased the risk for CVD death by 1.66 times (95% confidence interval 1.01 to 2.71) in men and 1.62 times (95% confidence interval 1.18 to 2.24) in women. Association of ECG abnormalities with CVD mortality was independent of age, body mass index, systolic blood pressure, serum cholesterol, blood glucose, smoking and drinking, and antihypertensive medication. In conclusion, ST-T abnormalities with or without left high R waves on electrocardiogram recorded at rest constitute an independent predictor of CVD mortality in Japanese men and women.     

Comparison of the prevalence of metabolic syndrome and its association with diabetes and cardiovascular disease in the rural population of Bangladesh using the modified National Cholesterol Education Program Expert Panel Adult Treatment Panel III and International Diabetes Federation definitions

Aims/Introduction

To compare the prevalence of metabolic syndrome (MS) using the modified National Cholesterol Education Program Adult Treatment Plan III (NCEP) and the International Diabetes Federation (IDF) definitions and, using both definitions, determine and compare the association of MS, prediabetes, type 2 diabetes, hypertension (HTN) and cardiovascular disease risk (CVD).

Materials and Methods

A total of 2,293 randomly selected participants (aged ≥20 years) in a rural community in Bangladesh were investigated in a population-based cross-sectional study. Sociodemographic and anthropometric characteristics, blood pressure, blood glucose, and lipid profiles were studied. Age-adjusted data for MS and cardiometabolic risk factors were assessed, and their relationships were examined.

Results

The age-adjusted prevalence of MS was 30.7% (males 30.5%; females 30.5%) using the NCEP definition, and 24.5% (males 19.2%, females 27.5%) using the IDF definition. The prevalence of MS using the NCEP definition was also higher in study participants with prediabetes, type 2 diabetes, HTN and CVD risk. The agreement rate between both definitions was 92% (k = 0.80). The NCEP definition had a stronger association with type 2 diabetes and HTN (odds ratio 12.4 vs 5.2; odds ratio 7.0 vs 4.7, respectively) than the IDF definition. However, the odds ratios for prediabetes and CVD risk were not significantly different.

Conclusions

The prevalence of MS was higher using the NCEP definition, and was more strongly associated with prediabetes, type 2 diabetes, HTN and CVD in this Bangladeshi population.     

Prevalence of Metabolic Syndrome by different definitions,and its association with type 2 diabetes,pre-diabetes,and cardiovascular disease risk in Brazil

Background and aimsMetabolic Syndrome (MS) is increasing in developing countries. Different definitions of MS lead to discrepancies in prevalence estimates and applicability. We assessed the prevalence of MS as defined by the International Diabetes Federation (IDF), modified National Cholesterol Education Program Adult Treatment Plan III (Modified NCEP) and Joint Interim Statement (JIS); compared the diagnostic performance and association of these definitions of MS with pre-diabetes, type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD) risk.MethodsA total of 714 randomly selected subjects from Northeastern Brazil were investigated in a cross-sectional study. Sociodemographic, anthropometric, and clinical data were recorded. Diagnostic test performance measures assessed the ability of the different MS definitions to identify those with pre-diabetes, T2DM and increased CVD risk.ResultsThe adjusted prevalence of MS was 36.1% applying the JIS criteria, 35.1% the IDF and 29.5% Modified NCEP. Women were more affected by MS according to all definitions. MS was significantly associated with pre-diabetes, T2DM and CVD risk following the three definitions. However, the JIS and IDF definitions showed higher sensitivity than the Modified NCEP to identify pre-diabetes, T2DM and CVD risk. The odds ratios for those conditions were not significantly different when comparing the definitions.ConclusionsMS is highly prevalent in Brazil, particularly among those with pre-diabetes, T2DM, and high CVD risk. The IDF and JIS criteria may be better suited in the Brazilian population to identify pre-diabetes, T2DM and CVD risk. This may also signify the importance of the assessment of MS in clinical practice.     

Prevalence of silent myocardial ischaemia in new-onset middle-aged Type 2 diabetic patients without other cardiovascular risk factors.

AIMS: Coronary artery disease (CAD) is the leading cause of death in patients with Type 2 diabetes and is often asymptomatic. Silent myocardial ischaemia (SMI) is frequent in diabetic subjects and is responsible for a late diagnosis of CAD; its early detection is important. There are some data about the prevalence of SMI in Type 2 diabetic patients at high risk for cardiovascular disease, while no data are available in subjects at the onset of diabetes without other cardiovascular risk factors. METHODS: We screened 274 consecutive patients (mean age 64.3 +/- 8.4 years, 66% male) at the time of diagnosis of Type 2 diabetes; we enrolled 111 subjects without other cardiovascular disease risk factors (dyslipidaemia, hypertension, peripheral vascular disease, retinopathy, microalbuminuria, history of heart disease) and with normal resting electrocardiogram (ECG). Participants performed a maximal ECG exercise protocol and, if positive, underwent coronary angiography. RESULTS: The ECG exercise test was positive in 19 patients (17.1%); of those 14 (13%) had angiographic coronary disease (one with three-vessel disease, three with two vessels and 10 with one vessel involved). The positive predictive value of the exercise ECG for predicting angiographic coronary disease was 73%. CONCLUSIONS: The prevalence of SMI was 17% and angiographic coronary disease was found in 13% of middle-aged subjects with new-onset Type 2 diabetes without other cardiovascular risk factors. This prevalence is similar to that observed in studies of subjects with long duration diabetes who have additional cardiovascular risk factors.     

Comparison of WHO and ADA criteria for diagnosis of glucose status in adults

The aim was to compare the 1997 American Diabetes Association (ADA) and 1985 and 1998 World Health Organisation (WHO) criteria for the diagnosis of diabetes and impaired glucose tolerance (IGT) by ethnicity and cardiovascular risk factors. We analysed the oral glucose tolerance tests carried out in a cross-sectional survey of 5816 New Zealand workers aged 22-78 years (4211 men, 1605 women) carried out between 1988 and 1990. Prevalence of diabetes was similar using ADA (3.1%) compared with the 1998 WHO criteria (3.0%). The overall prevalence rate of diabetes using the 1985 WHO criteria was only 1.5%. The prevalence rate of impaired fasting glucose (IFG) was the lowest in Europeans (7.3%) and highest in Asians (15.0%). The overall weighted kappa for agreement between the 1997 ADA and 1998 WHO criteria was moderate (0.59), but varied between ethnic groups. Cardiovascular disease (CVD) risk factors were approximately more adverse across groups with IFG, normal (ADA)/IGT (WHO), IFG/IGT and diabetes compared with normal subjects. Compared to those with IFG, participants with the normal (ADA)/IGT (WHO) criteria differed in fasting and 2-h glucose, diastolic blood pressure, and urinary albumin levels, and the proportions of males and number with hypertension, but had a significantly adverse pattern of CVD risk factors compared to those with normal glycaemia. The 1988 WHO criteria using the OGTT provides additional information for classifying various categories of glucose intolerance that is not captured using the 1997 ADA fasting glucose criteria alone.     

Cardiovascular risk factor progression in adolescents and young adults with youth-onset type 2 diabetes

AimsYouth-onset type 2 diabetes (T2D) confers a high risk of early adverse cardiovascular morbidity. We describe the cumulative incidence and prevalence of cardiovascular risk factors over time and examine relationships with diabetes progression in young adults with youth-onset T2D from the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) study.MethodsLongitudinal data was used to evaluate the relationships between hypertension, LDL-C dyslipidemia, hypertriglyceridemia, and smoking with risk factors in 677 participants.ResultsBaseline mean age was 14 ± 2 years and mean follow-up 10.2 ± 4.5 years. The 14-year cumulative incidence of hypertension, LDL-C dyslipidemia, and hypertriglyceridemia was 59%, 33%, and 37% respectively. Average prevalence of reported smoking was 23%. Male sex, non-Hispanic white race/ethnicity, obesity, poor glycemic control, lower insulin sensitivity, and reduced beta-cell function were significantly associated with an unfavorable risk profile. At end of follow-up, 54% had ≥2 cardiovascular risk factors in addition to T2D.ConclusionsCardiovascular risk factor incidence and prevalence was high over a decade of follow-up in young adults with youth-onset T2D. Glucose control and management of cardiovascular risk factors is critical in youth with T2D for prevention of cardiovascular morbidity and mortality.     

The Metabolic Syndrome is an independent predictor of cardiovascular disease in Type 2 diabetic subjects. Prospective data from the Verona Diabetes Complications Study.

AIMS: To evaluate the cardiovascular risk associated with the presence of the Metabolic Syndrome in Type 2 diabetic subjects. METHODS: Subjects with the Metabolic Syndrome, defined by WHO criteria, were identified in a large sample of non-insulin-treated Type 2 diabetic patients examined within the Verona Diabetes Complications Study (n = 946). At baseline and after a mean of 4.5 years follow-up, cardiovascular disease (CVD) was assessed by medical history, physical examination, electrocardiogram (ECG) and echo-duplex of carotid and lower limb arteries. Death certificates and medical records of subjects who died during the follow-up were scrutinized in order to identify CVD deaths. In statistical analyses, CVD was considered as an aggregate end-point, including fatal and non-fatal coronary, cerebrovascular and peripheral vascular disease as well as ischaemic ECG abnormalities and vascular lesions at the echo-duplex. RESULTS: The proportion of subjects with the Metabolic Syndrome was very high (92.3%). At the baseline, 31.7% of subjects were coded positive for CVD, which was more prevalent in subjects with the Metabolic Syndrome (32.9 vs. 17.8%, P = 0.005). Among subjects free of CVD at the baseline (n = 559), CVD events during the follow-up were significantly increased in patients with the Metabolic Syndrome as compared with those without it (19.9% vs. 3.9%, P < 0.001). Multiple logistic regression analysis showed that, along with sex, age, smoking and HbA1c, the presence of the Metabolic Syndrome independently predicted prevalent (OR 2.01, P = 0.045) and incident CVD (OR 4.89, P = 0.031). CONCLUSIONS: In Type 2 diabetes, the presence of the Metabolic Syndrome is associated with an almost 5-fold increase in CVD risk.     

Relation of reduction in urinary albumin excretion to ten-year cardiovascular mortality in patients with type 2 diabetes and systemic hypertension

Microalbuminuria is one of the strongest predictors of both adverse renal and cardiovascular disease (CVD) outcomes in patients with type 2 diabetes mellitus. Although measurement of urinary albumin excretion (UAE) is widely recommended, limited data are available to suggest that reducing UAE translates into a reduction in long-term cardiovascular mortality, particularly among patients without overt nephropathy, who constitute most patients with type 2 diabetes worldwide. We assessed whether changes in the UAE at 1 year were associated with cardiovascular mortality in 393 patients with hypertension and type 2 diabetes during a 10-year period. On univariate analysis, CVD history, age, diabetes duration, and change in UAE at 1 year were associated with cardiovascular mortality risk (hazard ratio 2.60 for those with CVD history, 95% confidence interval [CI] 1.47 to 4.62; hazard ratio 1.59 per 10 years of diabetes duration, 95% CI 1.12 to 2.25; and hazard ratio 1.49 per log UAE increase, 95% CI 1.13 to 1.96). In a stepwise Cox regression model that included baseline UAE and CVD history, the 10-year predicted mortality of those with a decrease in UAE of 2 logs at 1 year was 4.7% (95% CI 1.4% to 7.8%). For those with an increase in UAE of 2 logs at 1 year, it was 24.5% (95% CI 10.1% to 36.5%). In conclusion, these data support current guideline recommendations to screen for UAE in all patients with type 2 diabetes, even in the absence of nephropathy, and suggest that serial UAE measurements even after the initiation of antihypertensive therapy has prognostic value independent of traditional cardiovascular risk factors.     

Hypoglycemia, diabetes, and cardiovascular disease

Cardiovascular disease (CVD) remains the leading cause of death in people with diabetes, and the risk of CVD for adults with diabetes is at least two to four times the risk in adults without diabetes. Complications of diabetes, including not only CVD but also microvascular diseases such as retinopathy and nephropathy, are a major health and financial burden. Diabetes is a disease of glucose intolerance, and so much of the research on complications has focused on the role of hyperglycemia. Clinical trials have clearly demonstrated the role of hyperglycemia in microvascular complications of diabetes, but there appears to be less evidence for as strong of a relationship between hyperglycemia and CVD in people with diabetes. Hypoglycemia has become a more pressing health concern as intensive glycemic control has become the standard of care in diabetes. Clinical trials of intensive glucose lowering in both type 1 and type 2 diabetes populations has resulted in significantly increased hypoglycemia, with no decrease in CVD during the trial period, although several studies have shown a reduction in CVD with extended follow-up. There is evidence that hypoglycemia may adversely affect cardiovascular risk in patients with diabetes, and this is one potential explanation for the lack of CVD prevention in trials of intensive glycemic control. Hypoglycemia causes a cascade of physiologic effects and may induce oxidative stress and cardiac arrhythmias, contribute to sudden cardiac death, and cause ischemic cerebral damage, presenting several potential mechanisms through which acute and chronic episodes of hypoglycemia may increase CVD risk. In this review, we examine the risk factors and prevalence of hypoglycemia in diabetes, review the evidence for an association of both acute and chronic hypoglycemia with CVD in adults with diabetes, and discuss potential mechanisms through which hypoglycemia may adversely affect cardiovascular risk.     

Major electrocardiographic abnormalities among American Indians aged 45 to 74 years (the strong heart study)

As part of the Strong Heart Study assessment of prevalent cardiovascular disease in middle-aged to elderly American Indians, the prevalence of major Minnesota code electrocardiographic (ECG) abnormalities was assessed in 4,531 participants aged 45 to 74 years (59% women) in selected tribal communities in Arizona, South and North Dakota, and Oklahoma. The overall prevalence of major ECG abnormalities was lowest in Arizona participants, (e.g., definite ECG myocardial infarction in 0.3% vs 1.8% in the other centers), although nearly two thirds of them had diabetes. One or more major ECG abnormality occurred in progressively more women (10.4% to 21.2%) and men (13.3% to 32%) (both p < 0.0001) from 45- to 54- to 55- to 64- and 65- to 74year age groups, with the latter prevalence rates exceeding those in predominately white age peers in the Cardiovascular Health Study. Diabetes in women, but not in men, and hypertension in both genders showed positive associations with prevalence rates of major ECG abnormalities compatible with coronary artery disease or hypertensive cardiac hypertrophy. Hypercholesterolemia was not associated with ECG abnormalities except for definite myocardial infarction in women. In conclusion, major ECG abnormalities are common in middleaged to elderly American Indians, consistent with recent documentation of higher cardiovascular mortality in this population than in similar-aged U.S. whites.     

Update on the Prevention of Type 2 Diabetes

Diabetes has emerged as the modern day epidemic that is currently affecting over 220 million people worldwide and claiming at least 1.1 million lives in 2005 alone. The rise in diabetes is largely attributed to the epidemic of obesity together with sedentary lifestyle as well as unhealthy dietary habits. Despite evidence that glycemic control as well as control of other cardiovascular disease (CVD) risk factors such as hypertension and dyslipidemia decreases morbidity and mortality in the diabetic population, control of glycemia and other CVD risk factors remains largely suboptimal making the concept of prevention of diabetes very appealing to control CVD risk, especially that such a risk is already increased in people in the prediabetic stage. Several large controlled trials have been completed testing various options for diabetes prevention. In this paper we present an update on prevention of type 2 diabetes highlighting the major recent trials completed to date in this very important area of investigation.