Silent coronary artery disease in patients with diabetes mellitus

Coronary artery disease (CAD) represents the leading cause of death in diabetic patients. Silent myocardial ischaemia more often occurs in diabetics than in non-diabetics. It has been well recognised that silent myocardial ischaemia is not different from symptomatic ischaemia with respect to prognosis and adverse events. Asymptomatic high-risk diabetic patients therefore might benefit from routine screening for silent ischaemia and risk stratification; furthermore, silent ischaemia has to be treated accordingly.     

Under-diagnosis of diabetes mellitus in patients with coronary artery disease

BACKGROUND: The uptake of medical treatment in patients with coronary artery disease may be suboptimal. Our intention was to review the medical treatment of these patients in the light of current evidence. METHODS: One hundred ninety six consecutive patients with known or suspected coronary artery disease attending a tertiary centre for day case cardiac catheterisation were assessed. Fasting blood samples were sent for glucose and cholesterol. The results of coronary angiography and left ventriculography and any changes in medications were noted. RESULT: One hundred eighty two patients (93%) had fasting blood samples taken. The management of cholesterol in patients with coronary artery disease has improved since 1994. We have demonstrated the benefit of taking fasting blood samples in patients attending for day case angiography: 10% of non-diabetics actually had fasting blood glucose levels of greater than 7.0 mmol/l. All of these newly diagnosed diabetics had coronary artery disease. A further 9% of non-diabetics had impaired fasting glycaemia; 69% had coronary artery disease and 8% had left ventricular dysfunction. Among patients with coronary artery disease, there was a statistically significant increase on most categories of medications on discharge compared to admission. For those with left ventricular dysfunction, there was a statistically significant increase in the use of Angiotensin-Converting-Enzyme (ACE)-inhibitors. CONCLUSION: Diabetes mellitus is under-diagnosed in patients with coronary heart disease. They are at higher risk of coronary artery disease and therefore need intensive management. Testing all patients attending for day case cardiac catheterisation for fasting glucose would enable diagnosis and initiation of treatment of a high-risk group.     

Oxidative stress markers in coronary artery disease patients with diabetes mellitus

Coronary artery disease (CAD) is the major cause of morbidity and mortality. Diabetes is one of the powerful and independent risk factor for CAD. Hyperglycemia and hypercholesterolemia initiate the oxidative stress and complications like atherosclerosis which induces poor prognosis in diabetic CAD patients. The aim of the present study was to assess oxidative stress by comparing the levels of malondialdehyde and comet tail length in diabetic CAD patients, non-diabetic CAD patients and healthy controls. The study included 400 subjects of which 200 were healthy controls, 100 were diabetic CAD patients, and 100 were non-diabetic CAD patients. Fasting and postprandial glucose levels, glycosylated hemoglobin, serum lipid levels, malondialdehyde, and DNA damage were estimated in all subjects by using commercially available kits and standard protocols. FBS (185.60 ± 6.0 mg/dL), PPG (250 ± 7.06 mg/dL), HbA1c (10.65 ± 2.01 %), TC (280.72 ± 5.25 mg/dL), TG (195.11 ± 5.99 mg/dL), LDL (163.28 ± 5.68 mg/dL), MDA (9.74 ± 2.33 n moles/mL), and comet tail length (21.60 ± 5.69 μm) were significantly high in diabetic CAD patients (p < 0.05) compared to non-diabetic CAD patients and controls. Fasting and postprandial blood sugar levels significantly correlated with oxidative stress markers like MDA (r = 0.553, r = 0.557, p < 0.01) and comet tail length (r = 0.489, r = 0.626, p < 0.01) in diabetic CAD patients compared to non-diabetic CAD patients. Our study showed that diabetic CAD patients with increased levels of oxidative stress markers (MDA and DNA damage) might have the poor prognosis than non-diabetic CAD patients.     

Silent coronary artery disease in patients with type 2 diabetes mellitus

Abstract. The purpose of this study was to estimate the prevalence and risk factors of silent CAD in asymptomatic type 2 diabetic patients aged over 40 years. A total of 172 asymptomatic type 2 diabetic patients, mean age 54.42 years, with normal resting electrocardiogram were included in the study. Technetium-99m (Tc-99m) tetrofosmin cardiac single photon emission computed tomography myocardial scintigraphy with exercise testing or dipyridamole injection was performed on all patients. If this test was positive, coronary angiography was carried out and was considered to be positive with a stenosis of 70%. Abnormal perfusion pattern was found in 14 patients (8.14%). Significant coronary artery stenosis was found in 13 subjects (7.56%), confirming a high positive predictive value (92.86%) of this diagnostic procedure. A significant correlation was observed between silent CAD and male sex, retinopathy, hypertension, post-prandial blood glucose level, and low HDL-cholesterol level. Sex (OR=4.026; 95% CI, 1.187–13.659), hypertension (OR=5.564; 95% CI, 1.446–21.400) and retinopathy (OR=3.766; 95% CI, 1.096–12.948) were risk factors for CAD. Overall, 14.06% of asymptomatic male patients with type 2 diabetes mellitus presented silent CAD with significant angiographically documented coronary stenosis. This finding, along with the high positive predictive value of a noninvasive technique, indicates that routine screening for silent CAD would be useful in this patient subgroup especially when they have retinopathy or hypertension.     

Soluble P-selectin levels in diabetes mellitus patients with coronary artery disease

Type 2 (non-insulin-dependent) diabetes is associated with a marked increase in the risk of coronary heart disease. Platelets play a significant role in coronary artery disease. Soluble P-selectin is an index of platelets activation. In this study, Soluble P-selectin levels were measured by ELISA in the peripheral blood of 55 diabetic patients with coronary artery disease [21 acute myocardial infarction (AMI), 20 with unstable angina (UA), 14 with stable angina (SA)], 20 patients with diabetes mellitus without coronary artery disease (DM without), and 10 healthy controls.Soluble P-selectin level was significantly higher in patients with AMI (M+/-SD; 239.3+/-13.0 ng/ml), than those with UA (141.5+/-15.2 ng/ml), SA (92.1+/-7.7 ng/ml), DM without (89.8+/-7.1 ng/ml), and healthy control (86.1+/-4.5 ng/ml) (P < 0.001). In patients with US, sP-selectin was found to be significantly elevated as compared to the SA, DM without and control group. sP-selectin was not significantly different in DM without as compared to healthy controls. The sP-selectin levels was correlated to the duration of diabetes mellitus(R=0.33, P=0.03 ). Moreover, sP-selectin level was significantly higher in AMI patients with recurrent anginal attack as compared to that in those with single attack Multivariate analysis revealed that sP-selectin level at presentation had high adverse influence on coronary artery insult compared to healthy LDL cholesterol level, and the degree of hypertension. IN CONCLUSION: Plasma levels of soluble P-selectin were increased in patients with AMI, and UA compared to patients with SA and normal controls. Measurement of soluble P-selectin may be helpful marker of impending coronary artery insult in diabetic patients.     

Diagnostic and prognostic testing to evaluate coronary artery disease in patients with diabetes mellitus

Coronary artery disease (CAD) continues to be the most common cause of morbidity and mortality in patients with diabetes mellitus (DM). In recent years, the strategies for treatment of CAD in DM have undergone much evolution. Currently, all patients with DM, regardless of symptoms or diagnosed CAD, are treated aggressively for CAD risk factor reduction. In this clinical climate, the ability to specifically identify patients with disease that will benefit from more aggressive and invasive therapies remains a challenge. In this article we review the current literature on diagnostic and prognostic utility of conventional non-invasive modalities for assessment of CAD in patients with DM, as well as on novel and emerging methods for CAD risk stratification.     

冠心病合并糖尿病冠状动脉介入治疗与冠状动脉旁路移植术对比研究

目的 比较经皮冠状动脉介入治疗(PCI)支架术与冠状动脉旁路移植术(CABG)治疗冠心痛合并糖尿病患者住院与临床随访结果.方法 入选2001年7月至2004年6月在DESIRE注册的1040例冠心病合并糖尿病的患者,分别接受PCI治疗和CABG治疗,对所有患者的临床情况与冠状动脉造影特征、血运重建情况、住院临床结果以及临床随访结果进行回顾性分析.结果 与CABG组相比,PCI组的院内主要不良心脑血管事件(MACCE)发生率较低(P＜0.01);院内病死率较低(P＜0.01);多因素Logistic回归分析显示,CABG组院内MACCE发生的风险显著高于PCI组(P=0.002).平均随访22个月,两组随访MACCE发生率差异无统计学意义(P＞0.05);PCI组再次血运重建率高于CABG组(P＜0.01).多因素Cox回归分析表明,两组随访MACCE风险差异无统计学意义(P＞0.05).结论 冠心病合并糖尿病患者PCI术后院内MACCE发生率较低,但PCI后随访再次血运重建率高于CABG.广泛应用药物洗脱支架有望改善PCI的长期结果.     

Management of coronary artery disease in patients with type 2 diabetes mellitus

Diabetes mellitus is as much a vascular disease as it is a metabolic disorder. The metabolic abnormalities associated with diabetes include hyperglycemia, and abnormal carbohydrate, fat, and protein handling. These abnormalities increase oxidative stress and activate the renin angiotensin system, which subsequently causes endothelial dysfunction and predisposes to atherosclerosis. Type 2 diabetes has reached epidemic proportions and because of its strong association with coronary artery disease (CAD), it is responsible for increasing cardiovascular morbidity and mortality in the United States. In this article we review some of the evidence and the rationale for comprehensive risk reduction to prevent and treat CAD in individuals with diabetes mellitus. The comprehensive risk reduction strategy includes lifestyle changes, glycemic control, and control of dyslipidemia and hypertension. Advances in revascularization techniques, and superior outcomes of coronary artery bypass grafting as an interventional modality over percutaneous coronary intervention, are discussed. We also identify controversies and issues that currently remain unresolved.     

Relation of microalbuminuria and coronary artery disease in patients with and without diabetes mellitus

Microalbuminuria (MA) is a well-known risk factor for coronary artery disease (CAD) in diabetics and nondiabetics. It is associated with higher cardiovascular mortality, especially in diabetics. However, there are few data linking angiographic severity of CAD to microalbuminuria. We examined coronary angiograms for extent of severe CAD (luminal narrowing > or = 50%) in patients with type 2 diabetes mellitus (DM) and MA (DM+MA+, n = 101), patients with DM and without MA (DM+MA-, n = 101), patients without DM and with MA (DM-MA+, n = 64), and patients without DM and MA (DM-MA-, n = 64). We also evaluated fasting glucose levels in all patients and glycosylated hemoglobin in diabetics. Patients' mean age in the DM+MA+, DM+MA-, DM-MA+, and DM-MA- groups was similar. Gender distribution across the 4 groups was also not significantly different. There were no significant differences in the prevalence of hypertension, hypercholesterolemia, and current smoking across the 4 groups. The presence of 2- or 3-vessel CAD showed a linear increase from group DM-MA- to group DM+MA+ (p < 0.001). Diabetics with MA had higher fasting glucose and glycosylated hemoglobin levels than diabetics without MA (p < 0.001). Thus, patients with MA have more severe angiographic CAD than those without MA. This relation is independent of other risk factors and is particularly evident in patients with DM.     

Clinical impact of borderline and undiagnosed diabetes mellitus in patients with coronary artery disease

The present study was aimed to evaluate the prevalence and prognostic significance of unrecognized and newly defined borderline diabetes (with fasting blood sugar 126 to 139 mg/dl) by the American Diabetes Association criteria in coronary patients over a 7.7-year follow-up. Both undiagnosed and newly diagnosed borderline diabetes were associated with an unfavorable metabolic profile. The mortality of the borderline diabetics tended to be higher than in their nondiabetic counterparts. but this tendency did not reach statistical significance. A significant excess in long-term mortality was observed among the undiagnosed diabetes group.     

冠心病合并2型糖尿病患者临床及血运重建特点分析

目的 分析冠心病合并2型糖尿病患者的临床和血运重建特点.方法 以2011年9月至2012年4月于天津市胸科医院心内科住院,并行冠状动脉造影确诊为冠心病的215例患者作为观察对象,分为2型糖尿病组77例和非糖尿病组138例,分析临床和冠状动脉血运重建特点.结果 与非糖尿病组比较:(1)2型糖尿病组合并高血压的患者比例较高(87.0％比74.6％,P＜0.05),三酰甘油水平较高[(2.03 ± 1.22) mmol/L比(1.65±0.78) mmol/L,P＜0.01],左心室射血分数较低(58.03％±9.80％比61.07％±7.35％,P＜0.05);(2)2型糖尿病组单支病变发生率低(16.9％比43.5％,P＜0.01),多支病变发生率高(39.0％比25.4％,P＜0.05);(3)两组患者血运重建策略差异有统计学意义,2型糖尿病组患者行冠状动脉旁路移植术者比例较高(17.2％比7.3％,P＜0.05),选择行经皮冠状动脉介入治疗者平均置入支架数目较多[(2.06±0.95)枚比(1.66±0.83)枚,P＜0.01].结论 冠心病合并2型糖尿病患者高血压及血脂异常的发生率高,冠状动脉病变严重且弥漫,血运重建方式更复杂.     

Dendritic cell activation is blunted in patients with coronary artery disease and diabetes mellitus

Background

It has been shown that functional status of dendritic cells (DCs) in diabetic patients with unstable angina pectoris (UAP) are more mature and activated than diabetic patients without coronary artery disease (CAD) and none diabetic patients with UAP. Accordingly we aimed to assess the activation of DCs in patients with CAD with/and without Diabetes Mellitus (DM) and compare to those in subjects with normal coronary arteries (NCA).

2型糖尿病冠心病患者的临床及冠状动脉造影特点

目的探讨2型糖尿病冠心病患者的临床特征和冠状动脉造影特点。方法357例经冠状动脉造影确诊冠心病的患者，根据1999年WHO标准分为2型糖尿病冠心病组189例，单纯冠心病组168例，对所有研究对象均进行口服75g葡萄糖耐量试验，检测血糖、胰岛素、HbA1C、血脂、24h尿白蛋白／肌酐比值（24h-Alb／Cr），采用稳态模型计算胰岛素抵抗指数（HOMA—IR）和胰岛素分泌指数（HOMA—IS）。对比分析两组患者的临床和冠状动脉造影资料。结果与单纯冠心病组比较，2型糖尿病冠心病组HOMA—IR和24h-Alb／Cr明显增高（均P〈0．05），HOMA—IS明显降低（P〈0．01）。2型糖尿病冠心病组发生3支病变较多（P〈0．05），冠状动脉重度狭窄、完全闭塞、弥漫病变比例较高（P〈0．05或P〈0．01），冠状动脉病变程度总评分较高（P〈0．01）。结论2型糖尿病冠心病组冠状动脉病变累及范围广且程度重。     

冠心病合并糖尿病患者冠状动脉支架术后炎症因子的变化及临床意义

目的 观察冠心病合并糖尿病患者冠状动脉支架术前、后血清中炎症因子的变化,并探讨其临床意义.方法 连续选取因冠心病心绞痛住院并成功接受冠状动脉支架术的患者87例,其中合并糖尿病者(糖尿病组)31例,未合并糖尿病者(非糖尿病组)56例.分别于术前、术后24小时和1个月抽取外周血,采用标准的酶联免疫法测定超敏C-反应蛋白(hsCRP)、可溶性CD40配体(sCD40L)、细胞间黏附因子-1(ICAM-1)和基质金属蛋白酶(MMP-9),分析和比较两组各时间点上述指标的变化.结果 糖尿病组hsCRP在术后24小时浓度达到高峰(14.35±6.22μg/L),与术前(9.35±5.23μg/L)、术后1个月(7.19±5.32μg/L)相比,差异具有统计学意义(P＜0.05);但与非糖尿病组(12.68±6.07μg/L)相比,差异无统计学意义(P＞0.05).两组sCD40L、ICAM-1在术前和术后均没有明显的变化.糖尿病组MMP-9在术后持续升高,1个月时达到高峰(34.74±10.70μg/L),与术前(19.64±6.03μg/L)和术后24小时(20.00±7.06 μg/L)相比,差异具有统计学意义(均为P＜0.05),且术后1个月时MMP-9的水平明显高于非糖尿病组(29.83±8.51μg/L,P＜0.05).结论 冠状动脉支架术后各种炎症因子的表达存在差异,其中MMP-9在冠心病合并糖尿病患者支架置入术后存在较长时间持续增高的现象,其可能与糖尿病患者支架置入术后不良事件增加有关.     

分站式杂交技术治疗冠状动脉多支病变合并糖尿病患者的效果分析

目的比较分站式杂交(Hybrid)技术与非体外循环冠状动脉旁路移植术(OPCAB)治疗冠状动脉多支病变合并糖尿病(DM)患者的近中期临床效果。方法 2011年1月至2015年6月于郑州市第七人民医院共30例冠状动脉多支血管病变(包括前降支病变)合并DM患者接受了分站式Hybrid手术治疗,应用倾向性评分(Propensity score)方法,与同期实施孤立OPCAB的冠状动脉多支病变(包括前降支病变)合并DM患者相匹配,按1∶2比例选取60例患者,构成病例对照匹配样本。研究主要终点为患者随访期间的主要不良心脑血管事件(MACCE),次要终点为术后住院期间情况(包括24 h胸腔引流量、总引流量、红细胞输注率、呼吸机辅助时间、为控制出血的非计划二次手术、术后新发心房颤动等)。结果 Hybrid组术后24 h胸腔引流量、总引流量、呼吸机辅助时间和红细胞输注率均显著低于OPCAB组(均为P<0.05)。经过平均(22.0±8.4)个月的随访,Hybrid组与OPCAB组患者的MACCE(6.7%比11.7%)、全因死亡(0比1.7%)、心肌梗死(0比1.7%)及靶血管再血管化(6.7%比6.7%)发生率均相似(均为P>0.05),而Hybrid组的脑血管意外发生率显著减少(0比3.3%,P=0.037)。结论对于冠状动脉多支病变合并DM患者,分站式Hybrid技术是一种安全有效的冠状动脉再血管化治疗方式。