Increased cardiovascular events in hypertensive patients with insulin resistance: a 13-year follow-up

Insulin resistance (IR) is commonly associated with other cardiovascular risk factors and is considered an independent risk factor for cardiovascular disease and events. The hyperinsulinemic euglycemic clamp technique is considered the gold standard for evaluating IR, but this technique is cumbersome and not easily applicable in large studies. Therefore, there are no long-term follow-up published studies on the relationship between IR determined by this technique and cardiovascular outcome. Thirteen years ago we performed a hyperinsulinemic euglycemic clamp in 31 hypertensive patients, 16 of whom manifested IR and 15 had normal insulin sensitivity.Thirteen years later we were able to re-evaluate or obtain medical records for all these patients. Over these years, 11 of the 16 insulin resistant patients developed cardiovascular disease and events, including two cardiovascular deaths, two myocardial infarctions, one angina pectoris, one peripheral vascular disease, and five carotid plaques or stenosis. Moreover, two patients developed new onset diabetes, one proteinuria and two impaired kidney function. Among insulin-sensitive patients, one developed peripheral vascular disease, one new onset diabetes and one proteinuria.In conclusion, this is the first longitudinal study of the relationship between insulin resistance, measured by the hyperinsulinemic euglycemic clamp and cardiovascular disease and events in a small cohort of patients with essential hypertension. The data suggest that hypertensive patients with IR are at greater risk of developing cardiovascular disease and events than hypertensive patients with normal insulin sensitivity.     

Risk for cardiovascular events in an Italian population of patients with type 2 diabetes

Background and aim

This study aims to analyse the risk of cardiovascular events in a local cohort of patients with type 2 diabetes, and to evaluate the prognostic accuracy of four algorithms used to estimate cardiovascular risk: the Framingham study, United Kingdom Prospective Diabetes Study (UKPDS), Riskard study and Progetto Cuore.

Method and results

We analysed clinical charts of the Diabetes Clinics of Modena for the period 1991–95. Patients in the age range of 35–65 with type 2 diabetes and no previous cardiovascular disease were eligible. The incidence of new cardiovascular disease was compared with estimated rates deriving from the different functions. A stratification was obtained in subgroups at different cardiovascular risk, allowing comparison between the algorithms. A total of 1532 patients were eligible; women presented a worse cardiovascular risk profile. An absolute 10-year rate of cardiovascular events of 14.9% was observed. Comparing patients with events with event-free subjects, we found significant differences in systolic blood pressure, age at visit, smoking, high-density lipoprotein (HDL)-cholesterol, duration of diabetes, glycosylated haemoglobin (HbA1c) and co-morbidities. Comparing the estimated risk rate according to the different functions, Italian algorithms were more consistent with observed data; however, Progetto Cuore and Riskard show underestimation of events when applied to females.

Conclusions

Estimation of cardiovascular risk is dependent on the algorithm adopted and on the baseline risk of the reference cohort. Functions designed for a specific population, including risk variables peculiar for diabetes, should be adopted to increase the performance of such functions which is clearly unsatisfactory at present.     

我国中年人群糖尿病和空腹血糖异常对心血管病发病的预测价值

目的 采用前瞻性研究分析糖尿病在我国中年人群中是否心血管病发病的独立危险因素。方法 中国和美国心血管病和心肺疾病流行病学合作研究1983—1984年在北京和广州工农人群(35—54岁)中用国际标准化的方法进行了心血管病危险因素基线调查。对10076人的队列按照统一的方案每2年随访一轮到1997年底，根据美国糖尿病协会空腹血糖的分类标准对于基线血糖水平进行分层，用Cox回归调整年龄和调整相关因素后，计算糖尿病和空腹血糖异常对于冠心病和脑卒中发病的相对危险。结果 在除外基线时有心肌梗死和脑卒中史资料完整的9111人中，按照世界卫生组织MONICA方案的诊断标准，共计发生冠心病事件72例，脑卒中事件259例。心血管病的其他危险因素在空腹血糖异常组和糖尿病组高于正常组。经年龄调整和多因素调整后，糖尿病对冠心病和脑卒中发病的相对危险在女性(3．78和4．20)和性别合并组(3．22和2．50)显著高于血糖正常组，男性未达到统计学显著水平，空腹血糖异常组未见相对危险的增高。糖尿病对于冠心病和脑卒中发病的相对危险度仅低于高血压而高于血清总胆固醇和吸烟。结论 在我国中年人群中糖尿病是冠心病和脑卒中发病的重要危险因素之一。     

Plaque assessment by coronary CT angiography may predict cardiac events in high risk and very high risk diabetic patients: A long-term follow-up study

Background and aimsThe aim of the present study is to evaluate whether advanced coronary atherosclerosis analysis by CCTA may improve prognostic stratification among diabetic patients at high cardiovascular risk (CV risk).Methods and resultsThe study population consisted of 265 consecutive diabetic patients at high CV risk who underwent CCTA for suspected CAD between January 2011 and December 2016. For every patients both traditional and advanced, qualitative and quantitative coronary plaque analysis were performed. The occurrence of cardiac death, ACS, and non-urgent revascularization were recorded at follow-up.Among the 265 patients enrolled, 21 were lost to follow-up, whereas 244 (92%) had a complete follow-up (mean 45 ± 22 months) and were classified at high (n = 67) or very high cardiovascular risk (n = 177), according to ESC Guidelines. A total of 63 events were recorded (3 Cardiac Death, 3 NSTEMI, 8 unstable angina, 36 late non-urgent revascularization and 13 non-cardiac death) in 57 different patients. Elevated fibro-fatty plaque volume was the only predictor of events over age, gender and traditional risk factor when ACS and MACE were considered as end-points [HR (95% CI) 6.01 (1.65–21.87), p = 0.006 and 3.46 (2.00–5.97); p < 0.001].ConclusionThe present study confirms the prognostic role of advance coronary atherosclerosis evaluation beyond risk factors and stenosis severity, even in diabetics. Despite the very high cardiovascular risk of study population, a not negligible portion (23%) of patients exhibited totally normal coronaries.     

糖尿病并发心血管疾病的研究进展

糖尿病目前已成为危害人类健康的严重的公共卫生问题,其患病率急剧上升,且长期高血糖带来的慢性血管并发症是该病最严重的表现,特别是心血管并发症是导致患者预期寿命受损的主要原因.本文就糖尿病心血管并发症发生的危险因素、可能的发生机制及风险评估做一综述.     

Joint effects of history of hypertension at baseline and type 2 diabetes at baseline and during follow-up on the risk of coronary heart disease.

AIMS: To evaluate the joint associations of history of hypertension at baseline and type 2 diabetes at baseline and during follow-up on the incidence of coronary heart disease (CHD) and CHD mortality. METHODS AND RESULTS: Study cohorts included 49 775 Finnish subjects aged 25-74 without history of CHD and stroke. The multivariable-adjusted hazard ratios (HRs) of CHD incidence were 1.25, 1.69, 1.25, 1.83, 1.85, 2.39, 2.15, and 3.31 (P-value for trend <0.001), respectively, among men with hypertension I (blood pressure 140-159/90-94 mmHg or using antihypertensive drugs at baseline but blood pressure <160/95 mmHg) only, with hypertension II (blood pressure > or =160/95 mmHg) only, with incident diabetes during follow-up only, with both hypertension I and incident diabetes, with both hypertension II and incident diabetes, with history of diabetes at baseline only, with both hypertension I and history of diabetes, and with both hypertension II and history of diabetes compared with men without either of these diseases. The corresponding HRs of CHD incidence among women were 1.52, 2.37, 2.45, 3.78, 4.56, 5.63, 6.10, and 7.41 (P-value for trend <0.001), respectively. The impact on CHD mortality associated with the different strata of hypertension and diabetes was almost the same or a little stronger compared with that on the CHD incidence. CONCLUSION: Hypertension and type 2 diabetes increase the CHD risk independently, and their combination increases the risk dramatically, particularly in women.     

Higher heart rates increase risk of diabetes and cardiovascular events: A prospective cohort study among Inner Mongolians

AimThe study examined the association between resting heart rate and risk of type 2 diabetes (T2D) and cardiovascular events in an Inner Mongolian population.MethodsBased on a cross-sectional survey carried out in 2003, 2530 participants were reinvestigated between 2013 and 2014. All participants were classified into four groups (quartiles) according to heart rate. Primary outcomes were hypertension, T2D, major macrovascular events and all-cause deaths. Logistic regression models were used to estimate odds ratios (ORs), and shape-restricted cubic spline regressions were conducted to investigate the associations between resting heart rate and study outcomes.ResultsDuring the 10-year follow-up, 502 (41.6%) patients developed hypertension, 200 (10.4%) had diabetes, 464 (18.3%) experienced major macro-vascular events and 306 (14.3%) died. Resting heart rate was significantly associated with an increased risk of hypertension, T2D, major macro-vascular events and all-cause deaths: adjusted ORs (95% CI) for the highest vs lowest quartiles of heart rate were 1.51 (1.06–2.15), 2.44 (1.54–3.85), 1.55 (1.14–2.10) and 1.57 (1.05–2.34), respectively. Multivariable-adjusted restricted cubic spline regression models showed a linear association between heart rate and the four outcomes (all P < 0.05 for linearity). The addition of heart rate to basic risk factors improved the prediction of risk of diabetes and all-cause deaths [indices of continuous net reclassification improvement and of integrated discrimination improvement were 21.92% (P = 0.002) and 22.69% (P < 0.001), and 0.72% (P = 0.01) and 0.58% (P = 0.03), respectively].ConclusionHigher heart rates were associated with an increased risk of hypertension, T2D, major macro-vascular events and all-cause deaths among Inner Mongolians, suggesting that heart rate measurement may be of value as a potential clinical and diagnostic marker.     

原发性高血压并发心脑血管疾病患者的危险因素分析

目的：研究原发性高血压（EH）伴冠心病和／或脑血管病患者的临床特点，分析其相关的危险因素。方法：对55例EH伴冠心病和／或脑血管病患者，进行动脉硬化指数（ASI）测定，并检测患者的血尿酸、血糖、血脂、肌酐、尿素氮等血液生化指标及一般情况。另选不伴有冠心病、脑血管病的高血压患者63例作为对照。结果：与单纯高血压对照组比较，EH伴冠心病和／或脑血管的年龄大、病史时间长，ASI、脉压、血尿素氮水平明显升高（均P〈0.01）；收缩压、血尿酸、总胆固醇、肌酐水平也升高（均P〈0．05）；而舒张压（P〈0．01），心率（P〈0．05）却较低。多因素logistic回归分析显示：EH并发心脑血管疾病的相关危险因素有脉压、血肌酐、年龄（OR=1．204，1．120，1．099,P=0．028，0．045，0．039）；而血尿酸是负相关因素（OR=0．974，P=0．022）。结论：脉压、血肌酐水平和年龄可能是高血压患者并发心脑血管疾病的危险因素；血尿酸可能是一种保护因素。     

Impact of diabetes on hospital adverse cardiovascular outcomes in acute coronary syndrome patients: Data from the Saudi project of acute coronary events

BackgroundDiabetes mellitus (DM) is a major public health problem in Saudi Arabia. DM patients who present with acute coronary syndrome (ACS) have worse cardiovascular outcomes. We characterized clinical features and hospital outcomes of diabetic patients with ACS in Saudi Arabia.MethodsACS patients enrolled in the Saudi Project for Assessment of Acute Coronary Syndrome (SPACE) study from December 2005 to December 2007, either with DM or newly diagnosed during hospitalization were eligible. Baseline demographics, clinical presentation, therapies, and in-hospital outcomes were compared with non-diabetic patients.ResultsOf the 5055 ACS patients enrolled in SPACE, 2929 (58.1%) had DM (mean age 60.2 ± 11.5, 71.6% male, and 87.6% Saudi nationals). Diabetic patients had higher risk-factor (e.g., hypertension, hyperlipidemia) prevalences and were more likely to present with non–ST-elevation myocardial infarction (40.2% vs. 31.4%, p < 0.001), heart failure (25.4% vs. 13.9%, p < 0.001), significant left ventricular systolic dysfunction and multi-vessel disease. Diabetic patients had higher in-hospital heart failure, cardiogenic shock, and re-infarction rates. Adjusted odds ratio for in-hospital mortality in diabetic patients was 1.83 (95% CI, 1.02–3.30, p = 0.042).ConclusionsA substantial proportion of Saudi patients presenting with ACS have DM and a significantly worse prognosis. These data highlight the importance of cardiovascular preventative interventions in the general population.     

Obesity and cardiovascular events in patients with established coronary disease.

AIMS: To explore the association between obesity and major adverse coronary events (MACE) in patients with established coronary artery disease (CAD). METHODS AND RESULTS: The Prevention of Events with Angiotensin Converting Enzyme-Inhibition (PEACE) Trial randomized 8290 patients with stable CAD and left ventricular (LV) ejection fraction (EF) (LVEF) > or =0.40 to trandolapril or placebo and followed them for a median of 4.8 years. In PEACE patients who were non-diabetic at baseline (5693 men and 1171 women), we used proportional hazards models to conduct a post hoc analysis to examine whether obesity, defined as a body mass index (BMI) > or =30 kg/m(2), is an independent risk factor for the composite endpoint of MACE, defined as cardiovascular death, non-fatal myocardial infarction, coronary revascularization, or stroke. The analysis was conducted separately for men and women. The baseline prevalence of obesity was 28.5% in men and 28.9% in women. After adjusting for significant confounders, obesity was associated with MACE in men [hazard ratio (HR) = 1.28, 95% CI 1.13-1.46, P < 0.01], but not in women (HR = 0.96, 95% CI 0.70-1.31, P = 0.77). Further categorization of BMI showed a J-shaped association between BMI and MACE in the men, and no association in the women. CONCLUSION: In the presence of established CAD, obesity is associated with risk for MACE in men, but there is no support of an association in women. This finding requires further evaluation.     

Carotid intima-media thickness, but not visceral fat area or adiponectin, correlates with intracoronary stenosis detected by multislice computed tomography in people with type 2 diabetes and hypertension

We investigated the relationship between intracoronary stenosis detected by multislice computed tomography and various clinical parameters in type 2 diabetic patients with hypertension treated with candesartan (n = 42). The results showed that carotid intima-media thickness, but not visceral fat area or adiponectin, correlated significantly with intracoronary stenosis (p < 0.05).     

冠心病合并糖尿病患者冠状动脉旁路移植术围手术期的处理

目的:研究伴冠心病合并糖尿病患者冠状动脉旁路移植术(CABG)围手术期的处理。方法:以2000年1月至2006年5月的189例冠心病行CABG患者为研究对象,按是否同时合并有糖尿病分为糖尿病组(56例)和无糖尿病组(133例),对比两组临床特点,搭桥支数,术后处理及术后并发症。结果:冠心病合并糖尿病患者冠脉病变广泛而严重(P<0.01),搭桥4支的比例明显高于非糖尿病组(56.3%∶19.63%,P<0.01)),术后并发症的发生率明显高于非糖尿病例组(P<0.01)。结论:冠心病合并糖尿病患者较无糖尿病患者冠脉病变更加严重,合并症更多,需认真、积极对待。     

Cardiovascular events in type 2 diabetes: comparison with nondiabetic individuals without and with prior cardiovascular disease. 10-year follow-up of the Hoorn Study.

AIMS: We questioned whether prior cardiovascular disease has the same impact on risk of cardiovascular events as type 2 diabetes, and whether this differed between men and women. METHODS AND RESULTS: To address these issues we compared the 10-year risk of cardiovascular events among 208 Caucasian individuals with diabetes to that of 2253 Caucasian individuals without diabetes, in a population-based cohort study. Gender significantly modified the association between type 2 diabetes and cardiovascular events (p=0.01). The hazard ratio of cardiovascular events associated with the presence of diabetes was higher in women (adjusted hazard ratio, 1.8; 95% CI, 1.2 to 2.7) than in men (adjusted hazard ratio, 1.3; 0.9 to 2). As compared to men without diabetes but with prior cardiovascular disease, risk of cardiovascular events was significantly lower in men with diabetes but without prior cardiovascular disease (adjusted hazard ratio, 0.5; 0.3 to 0.9). In contrast, this risk was equal in women with diabetes but without prior cardiovascular disease and women without diabetes but with prior cardiovascular disease (adjusted hazard ratio, 1.0; 0.6 to 1.7; P for interaction between gender and diabetes=0.05). CONCLUSIONS: Women with diabetes but without prior cardiovascular disease have a risk of cardiovascular events that is similar to that of women without diabetes but with prior cardiovascular disease, whereas in men the presence of prior cardiovascular disease conferred a higher risk. These data emphasise the necessity of aggressive treatment of cardiovascular risk factors in women with type 2 diabetes.     

糖尿病高血压对心血管病变的影响及其干预治疗

目的 探讨糖尿病(DM)和(或)高血压(EH)对心血管病变的影响，以及降压和控制血糖的意义。方法 选择2型DM患者168例，EH患者112例，DM EH患者120例，正常对照组110例，4组均测定空腹及餐后2小时血糖和C肽、糖化血红蛋白、血脂谱。EH患者采用非洛地平为主的治疗方案，控制血压达目标值。随诊3年观察心血管病变发生情况。结果 DM EH组、DM组、EH组心血管并发症患病率依次为22．5％、15．5％、11．2％，治疗血压达目标值后，DM EH组、EH组心血管并发症总发生率为2．6％。结论 对DM EH患者，在良好控制血糖的同时强化血压达标，可减缓心血管并发症发生。     

Angiographic characteristics of the coronary artery in patients with type 2 diabetes

OBJECTIVES:

To investigate the adverse effect of type 2 diabetes on coronary artery anatomy.

PATIENTS AND METHODS:

The coronary angiograms of 1564 consecutive patients were analyzed. The coronary lesions of patients with and without type 2 diabetes were compared.

RESULTS:

Seventy-four diabetic and 824 nondiabetic patients were found to have coronary artery disease. Diabetic patients had more multivessel (48.7% versus 34.7%, P<0.01), multilesion (64.9% versus 46.1%, P<0.05), extensive (51.4% versus 7.8%, P<0.01) and small vessel disease (95.2% versus 39.8%, P<0.01) than nondiabetic patients.

CONCLUSIONS:

Type 2 diabetes is a significant risk factor for coronary artery disease. These findings may provide useful information for the future development of therapeutic strategies.     

长春市公务员原发性高血压流行病学研究

目的：了解长春市直机关公务员中原发性高血压的发病及相关疾病的发生情况，以利针对性的预防与保健。方法：对长春市直机关公务员进行健康体检，包括一般情况及相关危险因素分析；分析血压对冠心病和脑卒中事件发病的影响；老年人高血压分型情况及对靶器官的损害。结果：该类人群中，原发性高血压患病率为：22．4％；由高血压引起的心、脑、肾靶器官损害率分别为：31．3％、18％、14．7％；老年人原发性高血压以非杓型高血压为主，靶器官损害明显。结论：长春市直机关公务员高血压患病率为22．4％、，高于全国水平，应加强防治。     

Low short-term and long-term cardiovascular and all-cause mortality in absence of coronary artery calcium: A 22-year follow-up observational study from large cohort

ObjectivesWe sought to evaluate the gender-specific predictive value of coronary artery calcium (CAC) score on all-cause mortality and cardiovascular disease (CVD) mortality in individuals with and without diabetes mellitus (DM).BackgroundCAC score is a robust predictor of CVD and all-cause mortality during long-term follow-up in large cohorts in adults with DM. However, less is known about its sex-specific impact on all-cause mortality in DM.MethodsWe evaluated 25,563 asymptomatic participants with no known history of coronary artery disease (CAD) who underwent clinically indicated CAC. 1999 (7.8%) individuals had diabetes. CAC was characterized as an Agatston score of 0, 1–99, 100–300, and ?300. We evaluated the association between CAC and all-cause mortality and CVD mortality.ResultsOverall, 1345 individuals died (5.3%) from all causes during a mean follow-up of 14.7 ± 3.8 years. CAC score was 0 in 57.5% females and 34.4% of males without DM, while 36.6% females and 20.3% males with DM had CAC-0. The frequency of CAC ? 300 was 18% and 36% in females and males with DM, respectively. CAC score of zero was associated with low all-cause mortality event rate in females and males with diabetes (1.7 and 2.5 events per 1000 person-years, respectively). Cardiovascular mortality per 1000 person years was ?1 in females and males with CAC score of 0 irrespective of their diabetes. Adjusted multivariable analysis, compared to CAC-0, HR for all-cause mortality associated with CAC 1–99, 100–299 and ?300 were 1.74(95% CI 0.65, 4.63, P-0.20), 5.54(95% CI 2.16, 14.22, P ? 0.001) and 5.75(95% CI 2.30, 14.37, P ? 0.001) in females with DM respectively; in males with DM HR associated with CAC 1–99, 100–299 and ?300 were 1.87(95% CI 0.95, 3.66, P-0.06), 2.15(95% CI 1.05, 4.38, P-0.035) and 2.60(95% CI 1.34, 5.0, P-0.004), respectively.ConclusionPresence of subclinical atherosclerosis varies among individuals with DM. The absence of CAC was associated with very low cardiovascular as well as all-cause mortality events in all subgroups during long term follow-up.