QT-interval dispersion in type 2 diabetic and non-diabetic patients with post-myocardial infarction

Background and aimsQT-interval dispersion (QTD), which reflects spatial ventricular repolarization inhomogeneity, has been reported to increase and to have a prognostic value in patients with either myocardial infarction or diabetes. Our aim was to compare increases in QTD in type 2 diabetic and non-diabetic patients following post-myocardial infarction (post-MI). We also compared QTD in type 2 diabetic patients with post-MI treated with insulin, sulfonylurea, or diet alone.Methods and resultsWe determined the rate corrected QT-interval (QTc) dispersion (QTcD) in 178 consecutive post-MI patients, including 48 type 2 diabetic and 130 non-diabetic patients. The QTcD, measured with software (QTD-1), was defined as the difference in the minimum and maximum QTc in any of the 12 standard electrocardiographic leads. There were no significant differences in age, gender, left ventricular end-diastolic diameter, ejection fraction, or minimum QTc between type 2 diabetic and non-diabetic patients with post-MI. Compared with post-MI patients without diabetes, those with type 2 diabetes had higher maximum QTc (481 ± 37 vs. 459 ± 43 ms, P < 0.05) and QTcD (67 ± 18 vs. 58 ± 16 ms, P < 0.05). Among type 2 diabetic patients with post-MI treated with insulin, sulfonylurea, or diet alone, the QTcD (81 ± 18 vs. 64 ± 16 vs. 62 ± 17 ms, P < 0.05, respectively) was significantly greater and the R-R interval was shorter in the insulin therapy group.ConclusionsType 2 diabetes is associated with an additional increase in the QTD in post-MI patients. This additional increase in spatial repolarization inhomogeneity might be implicated in the increased mortality risk in post-MI patients with type 2 diabetes. These findings were thought to be more striking in the insulin therapy group.     

Circulating endothelial cells, arterial stiffness, and cardiovascular risk stratification in hypertension

BACKGROUND: Given the growing burden of cardiovascular disease, there is increasing interest in strategies to help predict future cardiovascular risk. Aims: To investigate the relationship between endothelial damage/dysfunction, arterial stiffness, and their association with predicted risk of future cardiovascular death among patients with hypertension. METHODS: We studied three patient groups 35 to 74 years old: healthy control subjects (n=63), subjects with high-risk hypertension (HHT) [n=65], and patients with treated, previously diagnosed, malignant-phase hypertension (MHT) [n=43]. We measured comparative indexes of arterial stiffness (stiffness index [SI] using digital volume photoplethysmography), endothelial damage/dysfunction (venous circulating endothelial cells [CECs], immunobead technique), and 5-year predictive risk of future cardiovascular death (Pocock scoring system). RESULTS: CEC counts, SI, and 5-year prediction of cardiovascular death were significantly higher in both hypertension groups (HHT and MHT), compared with healthy control subjects. CEC counts were significantly higher in the MHT group (p<0.05). There was a significant correlation between CECs and SI in the HHT group (r=0.61; p<0.0001) and the MHT group (r=0.59, p<0.0001) and between CEC, SI, and predicted 5-year risk of cardiovascular death in the two hypertension groups. On multiple linear regression analysis, arterial SI and CECs remained as significant predictors of the calculated 5-year risk of cardiovascular death (R2=0.37; p<0.0001). CONCLUSION: There is a consistent association between CECs, arterial stiffness, and the predictive risk of cardiovascular death among a group of patients with HHT or previously treated MHT. Registration number 05/Q2709/1.     

Renal function and risk for cardiovascular events in type 2 diabetic patients with hypertension: the RENAAL and LIFE studies

OBJECTIVE: To investigate whether a threshold exists for cardiovascular risk in type 2 diabetic patients with hypertension, the association between renal function and cardiovascular risk was examined across the entire physiological range of serum creatinine. DESIGN AND METHODS: The RENAAL and LIFE studies enrolled 1513 and 1195 patients with type 2 diabetes and hypertension, respectively. The relationship between baseline serum creatinine and the risk for a composite outcome of myocardial infarction, stroke or cardiovascular death was examined using Cox regression models. To adjust for heterogeneity between studies and treatment groups, these factors were included as strata when applicable. The analyses were conducted with adjustment for age, gender, smoking, alcohol use, blood pressure, heart rate, total and high-density lipoprotein (HDL) cholesterol, hemoglobin, albuminuria and prior cardiovascular disease. RESULTS: The hazard ratios across the baseline serum creatinine categories < 0.9 mg/dl, 0.9-1.2 mg/dl, 1.2-1.6 mg/dl, 1.6-2.8 mg/dl and >or= 2.8 mg/dl were 0.51 (95% confidence interval 0.34, 0.74), 0.74 (0.55, 1.00), 1.00 (reference), 1.24 (0.96, 1.59) and 1.67 (1.17, 2.91), respectively. Baseline serum creatinine (per mg/dl) strongly predicted the composite cardiovascular endpoint in LIFE [2.82(1.74,4.56), P < 0.001], RENAAL [1.41(1.12,1.79), P < 0.001], as well as the combined studies [1.51(1.21,1.87), P < 0.001]. CONCLUSION: A progressively higher risk for the composite cardiovascular endpoint was observed with incremental baseline serum creatinine in type 2 diabetic patients with hypertension, even within the normal range. Thus, there appears to be no serum creatinine threshold level for an increased cardiovascular risk. Baseline serum creatinine was a major independent risk factor for cardiovascular disease (www.ClinicalTrials.gov number NCT00308347).     

Vascular ultrasound for cardiovascular risk stratification in asymptomatic patients with type-2 diabetes

AimsTo identify new independent vascular markers to predict cardiovascular events in patients with type-2 diabetes (T2D), and their incremental value compared to the Swedish National Diabetes Register (NDR) risk score.MethodsA retrospective cohort study was conducted on 1332 asymptomatic patients with T2D, free from prior CV event, assessed for a cardiovascular work-up, including Duplex ultrasonography to detect plaque on carotid and femoral arteries. The extent of atherosclerosis was rated as atherosclerosis burden score (ABS). Patients were followed up to 5 years and the occurrence of cardiovascular events recorded.ResultsA total of 82 patients (6.2%) experienced a cardiovascular event, including 34 (2.6%) myocardial infarction, 18 (1.4%) cardiac revascularisation and 17 (1.3%) stroke. The independent determinants of these events were male sex (HR = 1.81 [1.13–2.88], p = 0.013) and ABS ≥ 2 (HR = 1.98 [1.21–3.25], p = 0.007). The NDR risk score performed poorly to predict cardiovascular events (area under the curve = 0.56 [0.49–0.63], p = 0.11), whereas screening for atherosclerotic plaques provided significant incremental prognostic value over the NDR score (model χ2 increase: +231%, p = 0.002).ConclusionDuplex ultrasonography to screen for atherosclerotic plaques improve the estimation of cardiovascular prognosis on top of clinical data and could be routinely used to improve cardiovascular risk stratification.     

Higher risk of hypertension in indigenous type 2 diabetic patients in Taiwan

BACKGROUND: This study compared the risk of hypertension between indigenous and Han adults with type 2 diabetes mellitus (T2DM) in Taiwan. METHODS: The data of 89,857 (747 indigenous and 89,110 Han people) T2DM patients aged > or =18 years were extracted from an established cohort of 93 484 diabetic patients using the National Health Insurance system of Taiwan. The prevalence of hypertension before diabetes diagnosis and at the time of survey, and the incidence of hypertension after diabetes diagnosis were compared between the two ethnicities. RESULTS: The indigenous people had a higher prevalence of hypertension before diabetes diagnosis (39.0% versus 29.4%, P < 0.001) and at the time of survey (66.9% versus 54.4%, P < 0.001); and showed poorer blood pressure control, with systolic pressure > or = 140 mmHg (38.4% versus 30.3%, P < 0.001) and diastolic pressure > or = 90 mmHg (20.4% versus 15.5%, P < 0.001). Logistic and Cox's regression models showed an adjusted risk of hypertension of about twofold in indigenous people compared to the Han people. CONCLUSIONS: The indigenous diabetics are more prone to develop hypertension than their Han counterparts in Taiwan.     

Simplified risk stratification for pulmonary arterial hypertension associated with connective tissue disease

Clinical Rheumatology - To explore the long-term prognostic value of a simplified risk assessment strategy based on the 2015 European Society of Cardiology (ESC)/European Respiratory Society (ERS)...     

Non-traditional cardiovascular risk factors contribute to peripheral arterial disease in patients with type 2 diabetes

OBJECTIVE: This study evaluated the prevalence of peripheral arterial disease (PAD) in type 2 diabetes and its association with traditional and non-traditional cardiovascular (CV) risk factors. SUBJECTS AND METHODS: In 1610 type 2 diabetics PAD was defined as ankle-brachial pressure index (ABPI)<0.9. RESULTS: PAD prevalence was 17%, increased with age, diabetes duration, HbA 1c levels, previous CV events. There were no significant differences in the prevalence of traditional CV risk factors between patients with and without PAD. PAD patients had higher levels of fibrinogen (10.88+/-2.32 versus 10.2+/-2.23micromol/L; p<0.0001), uric acid (327.1+/-89.2 versus 315.2+/-83.3micromol/L, p<0.01), pulse pressure (70+/-18 versus 60+/-16mm Hg, p<0.0001), higher rate of microalbuminuria (21.3% versus 13.7%; p<0.05) and lower glomerular filtration rate (GFR, 80.7+/-24 versus 89.9+/-22 ml/min/1.73 m2; p<0.001) than those without. In age-gender-adjusted analysis, smoking (OR 1.5; CI: 1.07-2.2), HbA 1c (OR 1.45; CI: 1.07-2.08), high pulse pressure (OR 2.81; CI: 1.63-4.82), reduced GFR (OR 2.16; CI: 1.4-3.3), microalbuminuria (OR 1.62; CI: 1.11-2.36), high fibrinogen levels (OR 2.03; CI: 1.34-3.07) were associated with PAD. In multivariate analysis age, male sex, smoking, high pulse pressure, low GFR, high fibrinogen levels, previous CV events were independent risk factors for PAD. CONCLUSIONS: PAD prevalence is high in Type 2 diabetic patients. Non-traditional cardiovascular risk factors may be involved in the development of this complication.     

高血压病亚临床靶器官损害的评估对心血管危险分层的影响

目的:探讨除了血压水平危险分层外,不同亚临床靶器官损害的检测评估对高血压病患者心血管危险分层的影响。方法: 258例住院高血压病患者,除了常规检测项目外,还进行心脏彩超及颈动脉内中膜层厚度的测量,依据2005年中国高血压防治指南,对血压水平及添加亚临床靶器官损害评估后的高血压病患者进行危险分层。结果: 高血压病患者根据血压水平危险分层。低危 60例（23.2%）;中危115例（44.6%）;高危83例（32.2%）。这些低中危的患者通过亚临床靶器官损害评估后再行危险分层,其高危组患者所占比率明显升高,为219例（84.9%）,相比较血压水平危险分层具有明显的统计学差异（P<0.01）。结论: 亚临床靶器官损害的检测评估可提高高血压病高危患者的检出率。     

Peripheral arterial disease in a population of type 2 diabetic patients: its correlation with diabetic microangiopathy and laboratory parameters

BACKGROUND: The aim of this study was to evaluate the incidence of peripheral arterial disease (PAD) in a population of type 2 diabetic patients (NIDDM) and its possible correlation with diabetic nephropathy (DN), diabetic retinopathy (DR) and also with some biochemical parameters of glomerular and tubular renal function. METHODS: The study included a total of 150 NIDDM patients, randomly selected, who have been followed-up at the Metabolic Center of our Division. All patients underwent assessment of the ankle/brachial pressure index (ABI) and Doppler ultrasound of the lower extremities. They were then divided into 2 groups: Group 0 without PAD and Group 1 with PAD. They also underwent a echo color-Doppler study of the renal interlobar arteries in order to evaluate the resistive index (RI), while the retinal vessels were assessed by biomicroscopy and fluorangiography. RESULTS: The incidence of PAD in this study was 30.6%, occurring on average 14 years from the onset of diabetes, and affecting particularly patients with nephropathy. The presence of both albuminuria and retinopathy in the same patient increases by 8.9 times the risk of cardiovascular disease. CONCLUSIONS: The RI, measured at the level of the intrarenal arteries, is of great interest as a marker not only of renal vascular damage in NIDDM patients, but also of a generalized vascular involvement.     

老年高血压颈动脉粥样硬化与心血管危险因素的相关性研究分析

目的研究老年高血压患者颈动脉粥样硬化、斑块形成与心血管危险因素以及脑卒中发生之间的相关性。方法随机调查204例老年高血压患者,用颈动脉超声检查分析颈动脉硬化、斑块形成与心血管病危险因素及脑卒中的相关性。结果颈动脉硬化、斑块形成与收缩压、脉压呈正相关(r=0.21、0.26,P<0.01),与高血压病程、糖化血红蛋白(HbA1c)亦呈正相关(r=0.17、0.30,P<0.05),与尿酸、胆红素、高密度脂蛋白胆固醇(HDL-C)及脑卒中均有关。结论上述心血管危险因素在老年人颈动脉粥样硬化、斑块形成的发生、发展中起到一定的作用,控制这些危险因素有益于减少脑卒中发生。     

Prevalence and risk factors of peripheral arterial obstructive disease in Taiwanese type 2 diabetic patients

The aim of this study was to evaluate the prevalence and risk factors of peripheral arterial obstructive disease (PAD) in Taiwanese type 2 diabetic patients. A total of 610 patients (268 men and 342 women), aged 63.3 +/- 10.8 years, were recruited from a diabetic clinic in a teaching hospital. PAD was diagnosed by an ankle-brachial index (ABI) < 0.9 on either leg. Risk factors studied were age, sex, body mass index (BMI), smoking, diabetes duration, hypertension, insulin therapy, systolic blood pressure (SBP), diastolic blood pressure (DBP), fasting plasma glucose (FPG), serum total cholesterol (TC), and triglyceride (TG). Overall prevalence of PAD was 10.0% without significant sexual difference. Univariate analyses disclosed age, BMI (inverse association), diabetes duration, hypertension, insulin therapy, and SBP as significant risk factors. In stepwise logistic regression, age, SBP, BMI, and insulin therapy were independent risk factors with respective odds ratios (95% confidence intervals, CI) of 1.09 (1.05-1.13), 1.02 (1.01-1.04), 0.88 (0.80-0.96), and 3.37 (1.83-6.19). In conclusion, prevalence of PAD in Taiwanese type 2 diabetic patients was 10.0% and the major risk factors were older age, lower BMI, higher SBP, and insulin therapy. The inverse association between PAD and BMI is contradictory to the general impression that obesity is a risk factor for PAD.     

Adiponectin gene and cardiovascular risk in type 2 diabetic patients: a review of evidences

Diabetic patients have a 3-fold higher risk of developing atherosclerosis and its clinical complications as compared to non-diabetic individuals. Part of the cardiovascular risk associated with diabetes is probably due to genetic determinants influencing both glucose homeostasis and the development of atherosclerosis. However, type 2 diabetes frequently coexists with other cardiovascular risk factors like arterial hypertension, central obesity and dyslipidemia. Genetic variability affecting many areas such as lipid and energy metabolisms, hypertension and haemodynamic mechanisms, blood clotting homeostasis, inflammation, and matrix turnover in the vascular wall will have an impact on the development of macrovascular complications in diabetic patients. Adiponectin is abundantly secreted by adipocytes. It plays important roles in lipid and glucose metabolisms and has direct anti-inflammatory and anti-atherogenic effects. In this review, we summarize recent data from the literature suggesting an implication of allelic variations of the adiponectin gene (ADIPOQ) in the genetic determinants of cardiovascular disease in diabetic subjects.     

Improved cardiovascular risk stratification by a simple ECG index in hypertension

BACKGROUND: We determined the prognostic value of the Cornell/strain [C/S] index, a simple electrocardiographic (ECG) index for left ventricular hypertrophy (LVH) defined by the presence of either a classic strain pattern or a Cornell voltage (sum of R in aVL + S in V(3)) >2.0 mV in women or 2.4 mV in men, or both. METHODS: In a prospective, cohort study, 2190 initially untreated subjects (age 51 [+/- 12], 47% women) with essential hypertension without prior events were followed for up to 14 years (median, 5 years). RESULTS: Prevalence of LVH at entry was 16.3% by using the C/S index, which yielded 33.6% sensitivity and 91.0% specificity. Other ECG criteria for LVH including Sokolow-Lyon, Romhilt-Estes, Framingham, Cornell, and strain alone, achieved a lower sensitivity and prevalence. Over the subsequent follow-up, 244 patients experienced a first major cardiovascular event. Event rate (x 100 person-years) was 2.01 in those without and 4.44 in those with LVH by the C/S index (P <.001). After adjustment for age, sex, smoking, and other counfounders, the C/S index identified subjects at increased risk of events (relative risk 1.76; 95% confidence interval 1.32-2.33). The C/S index achieved the highest population-attributable risk (16.1%) for cardiovascular events. CONCLUSIONS: A simple ECG index that can be quickly measured from nondigital machines and without algorithms identifies LVH in a consistent proportion (16.3%) of hypertensive subjects. The LVH defined by such technique allows identification of individuals at high risk for cardiovascular events.     

Usefulness of beta-blocker therapy and outcomes in patients with pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is a disorder in which pulmonary arterial remodeling and vasoconstriction progressively lead to right heart failure (HF), exercise intolerance, and high mortality. Beta-blockers have been shown to decrease mortality in left-sided HF, but their efficacy in isolated right HF associated with PAH is uncertain. Patients with PAH may have cardiac co-morbidities for which β-blocker therapy is indicated, and the relative risk benefit of this therapy remains to be proved. This is a prospective cohort study of 94 consecutive patients with PAH divided into 2 groups with and without β-blocker use at baseline. Rate of all-cause mortality, PAH-related hospitalization, change in 6-minute walk test, right ventricular structure and function measured by echocardiography, and hemodynamics measured by right heart catheterization were determined between subjects with and without β-blocker use. Beta-blocker use was common (28%) in this cohort. After a median follow-up of 20 months, changes in pulmonary hemodynamics and right ventricular size and function were similar between groups. There were no statistically significant differences in adverse events including PAH-related hospitalization or all-cause mortality (p = 0.19), presence of right HF by last visit (p = 0.75), or change in last 6-minute walk distance (p = 0.92). In conclusion, β-blocker use is not uncommon in a select group of patients with PAH and cardiac co-morbidities and did not appear to exert detrimental effects in clinical, functional, and hemodynamic outcomes. Further randomized data are needed to evaluate the potential benefits and risks of β-blocker use in patients with PAH.     

丙氨酸转移酶升高的2型糖尿病患者伴有更多的心血管风险因素

根据血丙氨酸转氨酶(ALT)水平将4 509例2型糖尿病患者分为A组(n=449,ALT增高)和B组(n=4 060,ALT正常),ALT升高的患者为10%.与B组患者相比,A组患者相对年龄更轻[(48.5±11.3对55.7±11.4)岁,P＜0.01]、糖尿病病程更短[(36.8±45.0对56.2±58.8)个月,P＜0.01]、体重指数以及腰臀比更大[(27.7±3.9对25.8±3.4)kg/m2,P＜0.01;0.95±0.06对0.93±0.07,P＜0.01].两组之间的血压存在差别[收缩压(132±19对131±21)mm Hg,1 mm Hg=0.133 kPa,P=0.60;舒张压(78±10对75±10)mm Hg,P＜0.01].A组的空腹血糖[(9.04±2.91对8.63±3.05)mmol/L,P=0.008]、餐后血糖[(13.85±4.67对13.07±4.92)mmol/L,P=0.002]、HbA1C(8.11%±1.82%对7.74%±1.96%,P＜0.01)、空腹胰岛素[(10.59±7.31对7.97±7.18)mU/L,P＜0.01]和餐后胰岛素[(48.96±43.80对35.25±32.37)mU/L,P＜0.01]及稳态模型评估的胰岛素抵抗指数(HOMA-IR,4.11±2.85对3.00±2.92,P＜0.01)、甘油三酯[(2.77±2.50对2.19±2.99)mmoL/L,P＜0.01]明显增高,高密度脂蛋白胆固醇[HDL-C,(1.20±0.30对1.29±0.83)mmol/L,P=0.01]更低.Logistic回归分析说明,HbA1C、餐后胰岛素、HOMA-IR、尿酸和尿白蛋白与ALT水平正相关,HDL-C则为负相关.提示ALT增高的2型糖尿病患者发病年龄更轻,有更严重的胰岛素抵抗和更多的心血管危险因素.     

Cardiovascular risk factors in diabetic patients with hypertension

Individuals with diabetes mellitus have cardiovascular disease (CVD) mortality comparable to nondiabetics who have suffered a myocardial infarction or stroke. Aggressive management of risk factors such as hypertension, dyslipidemia, and platelet dysfunction in persons with diabetes has been shown to reduce morbidity and mortality in prospective randomized controlled clinical trials. Accordingly, there are national mandates to lower blood pressure to less than 130/85 mm Hg, reduce low-density lipoprotein cholesterol to less than 100 mg/dL, and institute aspirin therapy in adult patients with diabetes. Although not definitively shown to reduce CVD, there are also recommendations to control the level of glycemia, as well. This article discusses CVD risk factors in the diabetic patient with hypertension.