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Graveling AJ, Frier BM. The risks of nocturnal hypoglycaemia in insulin-treated diabetes. Diabetes Res Clin Pract 2017; 133:30-39. [PMID: 28888993 DOI: 10.1016/j.diabres.2017.08.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 08/17/2017] [Indexed: 12/29/2022]
Abstract
Over half of all episodes of severe hypoglycaemia (requiring external help) occur during sleep, but nocturnal hypoglycaemia is often asymptomatic and unrecognised. The precise incidence of nocturnal hypoglycaemia is difficult to determine with no agreed definition, but continuous glucose monitoring has shown that it occurs frequently in people taking insulin. Attenuation of the counter-regulatory responses to hypoglycaemia during sleep may explain why some episodes are undetected and more prolonged, and modifies cardiovascular responses. The morbidity and mortality associated with nocturnal hypoglycaemia is probably much greater than realised, causing seizures, coma and cardiovascular events and affecting quality of life, mood and work performance the following day. It may induce impaired awareness of hypoglycaemia. Cardiac arrhythmias that occur during nocturnal hypoglycaemia include bradycardia and ectopics that may provoke dangerous arrhythmias. Treatment strategies are discussed that may help to minimise the frequency of nocturnal hypoglycaemia.
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Affiliation(s)
- Alex J Graveling
- JJR Macleod Centre for Diabetes & Endocrinology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZP, UK.
| | - Brian M Frier
- The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK.
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2
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Koivikko ML, Kenttä T, Salmela PI, Huikuri HV, Perkiömäki JS. Changes in cardiac repolarisation during spontaneous nocturnal hypoglycaemia in subjects with type 1 diabetes: a preliminary report. Acta Diabetol 2017; 54:251-256. [PMID: 27933514 DOI: 10.1007/s00592-016-0941-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 11/05/2016] [Indexed: 10/20/2022]
Abstract
AIMS Experimental studies have revealed that hypoglycaemia can result in morphological changes in electrocardiographic repolarisation in subjects with type 1 diabetes. However, the influence of spontaneous nocturnal hypoglycaemia on repolarisation morphology in a 'real life' situation is not clear. METHODS Adults with type 1 diabetes (n = 11) underwent continuous glucose monitoring with a subcutaneous sensor and digital 12-lead ECG recording for three nights. T-wave morphology was analysed with custom-made software during both hypoglycaemia (glucose <3.5 mmol/l at least 20 min) from ten consecutive heart beats in the middle of the deepest hypoglycaemia and from a control nonhypoglycaemic period (glucose ≥5.0 mmol/l) from the same recording. RESULTS In the comparison of 10 hypoglycaemia-control pairs, heart rate (65 ± 12 beats/min during normoglycaemia versus 85 ± 19 beats/min during hypoglycaemia, p = 0.028) increased and the QTc interval (439 ± 5 vs. 373 ± 5 ms, respectively, p = 0.025) decreased significantly during hypoglycaemia. The spatial QRS-T angle (TCRT) was reduced, and the roughness of the T-wave loop (T-E) increased significantly (p = 0.037 for both) in the patients during hypoglycaemia. CONCLUSIONS In adults with type 1 diabetes, spontaneous nocturnal hypoglycaemia results in morphological changes and increased heterogeneity of global cardiac repolarisation. These changes may contribute to the risk of 'dead in bed' syndrome encountered in young individuals with type 1 diabetes.
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Affiliation(s)
- Minna L Koivikko
- Department of Internal Medicine, Institute of Clinical Medicine, University of Oulu, P.O.Box 5000, Kajaanintie 50, Oulu, Finland.
| | - Tuomas Kenttä
- Department of Internal Medicine, Institute of Clinical Medicine, University of Oulu, P.O.Box 5000, Kajaanintie 50, Oulu, Finland
| | - Pasi I Salmela
- Department of Internal Medicine, Institute of Clinical Medicine, University of Oulu, P.O.Box 5000, Kajaanintie 50, Oulu, Finland
| | - Heikki V Huikuri
- Department of Internal Medicine, Institute of Clinical Medicine, University of Oulu, P.O.Box 5000, Kajaanintie 50, Oulu, Finland
| | - Juha S Perkiömäki
- Department of Internal Medicine, Institute of Clinical Medicine, University of Oulu, P.O.Box 5000, Kajaanintie 50, Oulu, Finland
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3
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Davis IC, Ahmadizadeh I, Randell J, Younk L, Davis SN. Understanding the impact of hypoglycemia on the cardiovascular system. Expert Rev Endocrinol Metab 2017; 12:21-33. [PMID: 29109754 PMCID: PMC5669378 DOI: 10.1080/17446651.2017.1275960] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Hypoglycemia occurs commonly in insulin requiring individuals with either Type 1 or Type 2 Diabetes. AREAS COVERED This article will review recent information on the pro-inflammatory and pro-atherothrombotic effects of hypoglycemia. Additionally, effects of hypoglycemia on arrhythmogenic potential and arterial endothelial dysfunction will be discussed. Effects of hypoglycemia on cardiovascular morbidity and mortality from large clinical studies in Type 1 and Type 2 DM will also be reviewed. EXPERT COMMENTARY The relative and absolute risk of severe hypoglycemia leading to death and serious adverse events in both cardiovascular and other organ systems has been highlighted following the publication of recent large clinical trials focused on glucose control and outcomes. It would be helpful if future studies could develop broader end points to include minor and moderate hypoglycemia as well as more robust methods for capturing hypoglycemia contemporaneously with adverse events. In addition, perhaps consideration of including hypoglycemia as a primary outcome, may help identify the possible cause and effect of hypoglycemia on cardiovascular morbidity and mortality.
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Affiliation(s)
- Ian Charles Davis
- University of Maryland School of Medicine, Baltimore, Maryland 21201-1544, United States
| | - Ida Ahmadizadeh
- University of Maryland School of Medicine, Baltimore, Maryland 21201-1544, United States
| | | | - Lisa Younk
- University of Maryland School of Medicine, Baltimore, Maryland 21201-1544, United States
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4
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Bonaventura A, Montecucco F, Dallegri F. Update on strategies limiting iatrogenic hypoglycemia. Endocr Connect 2015; 4:R37-45. [PMID: 26099256 PMCID: PMC4512278 DOI: 10.1530/ec-15-0044] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 06/19/2015] [Indexed: 12/17/2022]
Abstract
The prevalence of type 2 diabetes mellitus (T2DM) is increasing all over the world. Targeting good glycemic control is fundamental to avoid the complications of diabetes linked to hyperglycemia. This narrative review is based on material searched for and obtained via PubMed up to April 2015. The search terms we used were: 'hypoglycemia, diabetes, complications' in combination with 'iatrogenic, treatment, symptoms.' Serious complications might occur from an inappropriate treatment of hyperglycemia. The most frequent complication is iatrogenic hypoglycemia that is often associated with autonomic and neuroglycopenic symptoms. Furthermore, hypoglycemia causes acute cardiovascular effects, which may explain some of the typical symptoms: ischemia, QT prolongation, and arrhythmia. With regards to the latter, the night represents a dangerous period because of the major increase in arrhythmias and the prolonged period of hypoglycemia; indeed, sleep has been shown to blunt the sympatho-adrenal response to hypoglycemia. Two main strategies have been implemented to reduce these effects: monitoring blood glucose values and individualized HbA1c goals. Several drugs for the treatment of T2DM are currently available and different combinations have been recommended to achieve individualized glycemic targets, considering age, comorbidities, disease duration, and life expectancy. In conclusion, according to international guidelines, hypoglycemia-avoiding therapy must reach an individualized glycemic goal, which is the lowest HbA1c not causing severe hypoglycemia and preserving awareness of hypoglycemia.
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Affiliation(s)
- Aldo Bonaventura
- Department of Internal MedicineFirst Clinic of Internal Medicine, University of Genoa School of Medicine, IRCCS Azienda Ospedaliera Universitaria San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, ItalyDivision of CardiologyFoundation for Medical Researches, Department of Medical Specialties, University of Geneva, Geneva, SwitzerlandDivision of Laboratory MedicineDepartment of Genetics and Laboratory Medicine, Geneva University Hospitals, 4 rue Gabrielle-Perret-Gentil, Avenue de la Roseraie 64, 1205 Geneva, Switzerland
| | - Fabrizio Montecucco
- Department of Internal MedicineFirst Clinic of Internal Medicine, University of Genoa School of Medicine, IRCCS Azienda Ospedaliera Universitaria San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, ItalyDivision of CardiologyFoundation for Medical Researches, Department of Medical Specialties, University of Geneva, Geneva, SwitzerlandDivision of Laboratory MedicineDepartment of Genetics and Laboratory Medicine, Geneva University Hospitals, 4 rue Gabrielle-Perret-Gentil, Avenue de la Roseraie 64, 1205 Geneva, Switzerland Department of Internal MedicineFirst Clinic of Internal Medicine, University of Genoa School of Medicine, IRCCS Azienda Ospedaliera Universitaria San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, ItalyDivision of CardiologyFoundation for Medical Researches, Department of Medical Specialties, University of Geneva, Geneva, SwitzerlandDivision of Laboratory MedicineDepartment of Genetics and Laboratory Medicine, Geneva University Hospitals, 4 rue Gabrielle-Perret-Gentil, Avenue de la Roseraie 64, 1205 Geneva, Switzerland Department of Internal MedicineFirst Clinic of Internal Medicine, University of Genoa School of Medicine, IRCCS Azienda Ospedaliera Universitaria San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, ItalyDivision of CardiologyFoundation for Medical Researches, Department of Medical Specialties, University of Geneva, Geneva, SwitzerlandDivision of Laboratory MedicineDepartment of Genetics and Laboratory Medicine, Geneva University Hospitals, 4 rue Gabrielle-Perret-Gentil, Avenue de la Roseraie 64, 1205 Geneva, Switzerland
| | - Franco Dallegri
- Department of Internal MedicineFirst Clinic of Internal Medicine, University of Genoa School of Medicine, IRCCS Azienda Ospedaliera Universitaria San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, ItalyDivision of CardiologyFoundation for Medical Researches, Department of Medical Specialties, University of Geneva, Geneva, SwitzerlandDivision of Laboratory MedicineDepartment of Genetics and Laboratory Medicine, Geneva University Hospitals, 4 rue Gabrielle-Perret-Gentil, Avenue de la Roseraie 64, 1205 Geneva, Switzerland
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5
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Heller S, Darpö B, Mitchell MI, Linnebjerg H, Leishman DJ, Mehrotra N, Zhu H, Koerner J, Fiszman ML, Balakrishnan S, Xiao S, Todaro TG, Hensley I, Guth BD, Michelson EL, Sager P. Considerations for assessing the potential effects of antidiabetes drugs on cardiac ventricular repolarization: A report from the Cardiac Safety Research Consortium. Am Heart J 2015; 170:23-35. [PMID: 26093861 DOI: 10.1016/j.ahj.2015.03.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 03/16/2015] [Indexed: 10/23/2022]
Abstract
Thorough QT studies conducted according to the International Council on Harmonisation E14 guideline are required for new nonantiarrhythmic drugs to assess the potential to prolong ventricular repolarization. Special considerations may be needed for conducting such studies with antidiabetes drugs as changes in blood glucose and other physiologic parameters affected by antidiabetes drugs may prolong the QT interval and thus confound QT/corrected QT assessments. This review discusses potential mechanisms for QT/corrected QT interval prolongation with antidiabetes drugs and offers practical considerations for assessing antidiabetes drugs in thorough QT studies. This article represents collaborative discussions among key stakeholders from academia, industry, and regulatory agencies participating in the Cardiac Safety Research Consortium. It does not represent regulatory policy.
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6
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Abstract
Soon after the discovery that insulin regulates blood glucose by Banting and Best in 1922, the symptoms and risks associated with hypoglycemia became widely recognized. This article reviews devices to warn individuals of impending hypo- and hyperglycemia; biosignals used by these devices include electroencephalography, electrocardiography, skin galvanic resistance, diabetes alert dogs, and continuous glucose monitors (CGMs). While systems based on other technology are increasing in performance and decreasing in size, CGM technology remains the best method for both reactive and predictive alarming of hypo- or hyperglycemia.
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Affiliation(s)
- Daniel Howsmon
- Department of Chemical and Biological Engineering, Rensselaer Polytechnic Institute, Troy, NY, USA
| | - B Wayne Bequette
- Department of Chemical and Biological Engineering, Rensselaer Polytechnic Institute, Troy, NY, USA
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7
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Christensen TF, Cichosz SL, Tarnow L, Randløv J, Kristensen LE, Struijk JJ, Eldrup E, Hejlesen OK. Hypoglycaemia and QT interval prolongation in type 1 diabetes--bridging the gap between clamp studies and spontaneous episodes. J Diabetes Complications 2014; 28:723-8. [PMID: 24666922 DOI: 10.1016/j.jdiacomp.2014.03.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 03/05/2014] [Accepted: 03/05/2014] [Indexed: 01/18/2023]
Abstract
AIMS We propose a study design with controlled hypoglycaemia induced by subcutaneous injection of insulin and matched control episodes to bridge the gap between clamp studies and studies of spontaneous hypoglycaemia. The observed prolongation of the heart rate corrected QT interval (QTc) during hypoglycaemia varies greatly between studies. METHODS We studied ten adults with type 1 diabetes (age 41±15years) without cardiovascular disease or neuropathy. Single-blinded hypoglycaemia was induced by a subcutaneous insulin bolus followed by a control episode on two occasions separated by 4weeks. QT intervals were measured using the semi-automatic tangent approach, and QTc was derived by Bazett's (QTcB) and Fridericia's (QTcF) formulas. RESULTS QTcB increased from baseline to hypoglycaemia (403±20 vs. 433±39ms, p<0.001). On the euglycaemia day, QTcB also increased (398±20 vs. 410±27ms, p<0.01), but the increase was less than during hypoglycaemia (p<0.001). The same pattern was seen for QTcF. Plasma adrenaline levels increased significantly during hypoglycaemia compared to euglycaemia (p<0.01). Serum potassium levels decreased similarly after insulin injection during both hypoglycaemia and euglycaemia. CONCLUSIONS Hypoglycaemia as experienced after a subcutaneous injection of insulin may cause QTc prolongation in type 1 diabetes. However, the magnitude of prolongation is less than typically reported during glucose clamp studies, possible because of the study design with focus on minimizing unwanted study effects.
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Affiliation(s)
- T F Christensen
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark; Novo Nordisk A/S, Hilleroed, Denmark
| | - S L Cichosz
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark; Department of Endocrinology and Internal Medicine/Medical Research Laboratory, Aarhus University Hospital, Denmark.
| | - L Tarnow
- Steno Diabetes Center, Gentofte, Denmark; Nordsjaellands Hospitaler, Hilleroed, Denmark
| | - J Randløv
- Novo Nordisk A/S, Hilleroed, Denmark
| | | | - J J Struijk
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - E Eldrup
- Steno Diabetes Center, Gentofte, Denmark
| | - O K Hejlesen
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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8
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Hsieh A, Twigg SM. The enigma of the dead-in-bed syndrome: challenges in predicting and preventing this devastating complication of type 1 diabetes. J Diabetes Complications 2014; 28:585-7. [PMID: 24972763 DOI: 10.1016/j.jdiacomp.2014.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 04/10/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Albert Hsieh
- Sydney Medical School, University of Sydney and Department of Endocrinology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Stephen M Twigg
- Sydney Medical School and Charles Perkins Centre, University of Sydney, Department of Endocrinology, Royal Prince Alfred Hospital, Sydney, NSW 2006, Australia.
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9
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Lee SA, Cho SJ, Jeong MH, Kim YJ, Kim CJ, Cho MC, Kim HS, Ahn Y, Koh G, Lee JM, Oh SK, Yun KH, Kim HY, Cho CG, Lee DH. Hypoglycemia at admission in patients with acute myocardial infarction predicts a higher 30-day mortality in patients with poorly controlled type 2 diabetes than in well-controlled patients. Diabetes Care 2014; 37:2366-73. [PMID: 24914243 DOI: 10.2337/dc13-2856] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We aimed to evaluate the association between hypoglycemia at admission and 30-day mortality in patients with acute myocardial infarction (AMI) and to determine whether these associations differed according to diabetes-control status in AMI patients with diabetes. RESEARCH DESIGN AND METHODS We analyzed the prognostic significance of hypoglycemia and hyperglycemia in 34,943 AMI patients with or without type 2 diabetes from two AMI registries: the Korea Acute Myocardial Infarction Registry (KAMIR) and the Korea Working Group on Myocardial Infarction (KorMI). RESULTS The patients were divided into five groups according to serum-glucose levels at admission: <3.9 mmol/L (<70 mg/dL); 3.9-7.72 mmol/L (70-139 mg/dL); 7.78-11.06 mmol/L (140-199 mg/dL); 11.11-14.39 mmol/L (200-259 mg/dL); and ≥14.44 mmol/L (≥260 mg/dL). The 30-day mortality rates in the lowest and highest glucose groups were higher than those in other groups; the lowest glucose group had the highest mortality for patients with type 2 diabetes, after adjusting for multiple factors. We also extracted and compared four subgroups from the patients with type 2 diabetes, based on hemoglobin A1c and serum-glucose levels at admission: group A, <6.5% (48 mmol/mol) and <3.9 mmol/L; group B, <6.5% (48 mmol/mol) and ≥11.11 mmol/L; group C, ≥8% (64 mmol/mol) and <3.9 mmol/L; and group D, ≥8% (64 mmol/mol) and ≥11.11 mmol/L. Group C had the highest 30-day mortality rate among the groups. CONCLUSIONS These data suggest that hypoglycemia at admission affects clinical outcomes differently in AMI patients with type 2 diabetes depending on the diabetes-control status.
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Affiliation(s)
- Sang Ah Lee
- Department of Internal Medicine, Jeju National University Hospital, Jeju National School of Medicine, Jeju, Republic of Korea
| | - Suk Ju Cho
- Department of Anesthesiology, Jeju National University Hospital, Jeju National School of Medicine, Jeju, Republic of Korea
| | - Myung Ho Jeong
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Young Jo Kim
- Department of Internal Medicine, Yeungnam University Hospital, Daegu, Republic of Korea
| | - Chong Jin Kim
- Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Myeong Chan Cho
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Youngkeun Ahn
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Gwanpyo Koh
- Department of Internal Medicine, Jeju National University Hospital, Jeju National School of Medicine, Jeju, Republic of Korea
| | - Jeong Mi Lee
- Department of Public Health, Wonkwang University, Iksan, Republic of Korea
| | - Seok Kyu Oh
- Department of Internal Medicine, Wonkwang University School of Medicine, Iksan, Republic of Korea
| | - Kyeong Ho Yun
- Department of Internal Medicine, Wonkwang University School of Medicine, Iksan, Republic of Korea
| | - Ha Young Kim
- Department of Internal Medicine, Wonkwang University School of Medicine, Iksan, Republic of Korea
| | - Chung Gu Cho
- Department of Internal Medicine, Wonkwang University School of Medicine, Iksan, Republic of Korea
| | - Dae Ho Lee
- Department of Internal Medicine, Wonkwang University School of Medicine, Iksan, Republic of Korea
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10
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Færch LH, Thorsteinsson B, Tarnow L, Holst JJ, Kjær T, Kanters J, Larroude C, Dela F, Pedersen-Bjergaard U. Effects of angiotensin II receptor blockade on cerebral, cardiovascular, counter-regulatory, and symptomatic responses during hypoglycaemia in patients with type 1 diabetes. J Renin Angiotensin Aldosterone Syst 2014; 16:1036-45. [DOI: 10.1177/1470320314529356] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Louise H Færch
- Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital – Hillerød, Denmark
| | - Birger Thorsteinsson
- Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital – Hillerød, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Lise Tarnow
- HIH Research Unit, Nordsjællands Hospital – Hillerød, Denmark
- Department of Health, University of Aarhus, Denmark
| | - Jens Juul Holst
- NNF Centre for Basic Metabolic Research, Department of Biomedical Sciences, the Panum Institute, University of Copenhagen, Denmark
| | - Troels Kjær
- Clinic of Neurophysiology, The Neuroscience Centre, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Jørgen Kanters
- Danish National Research Foundation Centre for Cardiac Arrhythmia, Department of Biomedical Sciences, The Panum Institute, University of Copenhagen, Denmark
- Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital – Frederikssund, Denmark
| | - Charlotte Larroude
- Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital – Frederikssund, Denmark
- Department of Cardiology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Flemming Dela
- Xlab, Centre for Healthy Ageing, University of Copenhagen, Denmark
| | - Ulrik Pedersen-Bjergaard
- Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital – Hillerød, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
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11
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Abstract
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.
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Affiliation(s)
- Janet K Snell-Bergeon
- Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Medical Center, Aurora, Colorado 80045, USA.
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12
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Cardiovascular disease risk in young people with type 1 diabetes. J Cardiovasc Transl Res 2012; 5:446-62. [PMID: 22528676 DOI: 10.1007/s12265-012-9363-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 03/20/2012] [Indexed: 02/07/2023]
Abstract
Cardiovascular disease (CVD) is the most frequent cause of death in people with type 1 diabetes (T1D), despite modern advances in glycemic control and CVD risk factor modification. CVD risk identification is essential in this high-risk population, yet remains poorly understood. This review discusses the risk factors for CVD in young people with T1D, including hyperglycemia, traditional CVD risk factors (dyslipidemia, smoking, physical activity, hypertension), as well as novel risk factors such as insulin resistance, inflammation, and hypoglycemia. We present evidence that adverse changes in cardiovascular function, arterial compliance, and atherosclerosis are present even during adolescence in people with T1D, highlighting the need for earlier intervention. The methods for investigating cardiovascular risk are discussed and reviewed. Finally, we discuss the observational studies and clinical trials which have thus far attempted to elucidate the best targets for early intervention in order to reduce the burden of CVD in people with T1D.
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13
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Abstract
Strict glycaemic control is strongly advocated in people with type 2 diabetes to prevent vascular disease. However, the outcomes of two large clinical trials have indicated the potential dangers of pursuing this policy in those at high risk of cardiovascular disease, with an excess of fatal vascular events being associated with a higher frequency of severe hypoglycaemia. Hypoglycaemia secondary to insulin and sulphonylurea therapy is often associated with serious morbidity; anecdotal evidence has long implicated hypoglycaemia as a potential cause of myocardial ischaemia or a cardiac arrhythmia. Hypoglycaemia provokes sympatho-adrenal activation and counterregulatory hormone secretion, which exert pronounced cardiovascular effects. Although well tolerated in healthy people, the superimposition of these profound physiological effects on a diseased coronary vasculature and a dysfunctional cardiac conductive system may induce serious or even fatal cardiovascular events. These risks should influence therapeutic targets and the approach to diabetes management in people with diabetes with established vascular disease in whom exposure to severe hypoglycaemia could be dangerous.
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14
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Abstract
Hypoglycemia is a common and serious problem among patients with diabetes mellitus. It is also perceived as the most important obstacle to tight glucose control using intensive insulin therapy in critically ill patients. Because glucose is an obligatory metabolic fuel for the brain, hypoglycemia always represents an emergency that signals the inability of the brain to meet its energy needs. When left untreated, hypoglycemia can result in permanent brain damage and ultimately, death. In the context of critical illness that limits endogenous glucose production and increases glucose utilization, inadequate nutrition, or insufficient provision of glucose, intensive insulin therapy is the most frequent cause of hypoglycemia. Neurogenic and neuroglycopenic symptoms of hypoglycemia can remain unknown because of the underlying critical illness and sedation. Thus, close and reliable monitoring of the glycemic level is crucial in detecting hypoglycemia. In prospective randomized controlled studies comparing the effects of two glucose regimens, intensive insulin therapy aimed to reach strict glucose control (<110 mg/dl) but increased the incidence of severe hypoglycemia (<40 mg/dl) by four- to sixfold. Severe hypoglycemia is statistically associated with adverse outcomes in intensive care unit patients, although a direct causal relationship has not been demonstrated.
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15
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Current literature in diabetes. Diabetes Metab Res Rev 2009; 25:i-xii. [PMID: 19405078 DOI: 10.1002/dmrr.973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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