Lower Extremity Peripheral Arterial Disease Is an Independent Predictor of Coronary Heart Disease and Stroke Risks in Patients with Type 2 Diabetes Mellitus in China

Presence of asymptomatic Peripheral Arterial Disease in combination with common risk factors elevates the cardiovascular risk Substantially

Background and aims

This study evaluates the risks for adverse cardiovascular (CV) events in Asymptomatic Peripheral Arterial Disease (APAD) combined with different traditional CV risk factors.

Methods

A population-based observational study of 8000 subjects, identified 559 subjects as having APAD through ankle-brachial index (ABI) measurements and questionnaires regarding limb symptoms. This cohort and subgroups classified by presence of different traditional CV risk factors at baseline were assessed for 10 years on CV outcome. The recorded endpoints were all-cause mortality, CV mortality and non-fatal CV events.

Results

Before subdividing the APAD subjects, the CV mortality incidence was 28.5 deaths per 1000 person-years as compared to 8.7 deaths for references without APAD. For subjects with hypertension at baseline the CV mortality incidence was 35.4 when combined with APAD and 11.7 without. In women with hypertension but without other risk factors, presence of APAD increased the age-adjusted Hazard Ratio (HR) for fatal and non-fatal CV events by 1.86 [CI 1.54,2.24, p < 0.001].

Conclusions

ABI measurements should be considered an important indication for aggressive multifactorial risk factor reduction in populations with any other prevalent CV risk factor. In hypertension, diabetes mellitus and a smoking history, coexisting APAD contributes significantly to the increased age-adjusted CV risk.

Characteristics of patients with hypertension in a population with type 2 diabetes mellitus. Results from the Turkish Nationwide SurvEy of Glycemic and Other Metabolic Parameters of Patients with Diabetes Mellitus (TEMD Hypertension Study)

BACKGROUND

The present survey aimed to find out the demographical and clinical characteristics of patients with hypertension in a population with type 2 diabetes mellitus (T2DM) in Turkey.

METHODS

Patients with T2DM who were followed-up in tertiary endocrine units for at least last one year were recruited. Demographic, clinical and biochemical data of the patients were collected. Hypertension was defined as taking anti-hypertensive medications or having office arterial blood pressure (ABP) ≥140/90 mmHg or home ABP ≥ 130/80 mmHg.

RESULTS

A total of 4756 (58.9% women) diabetic patients were evaluated. The percentage of patients with hypertension was 67.5% (n = 3212). Although 87.4% (n = 2808) of hypertensive patients were under treatment, blood pressure was on target in 52.7% (n = 1479) of patients. Hypertension proportions were higher in woman (p = 0.001), older, more obese, and those who had longer diabetes duration, lower education levels, higher frequency of hypoglycemic events (all p < 0.001) and higher triglyceride levels (p = 0.003). LDL cholesterol level and the percentage of smokers were lower in hypertensive group than in non-hypertensive group (both p < 0.001). The percentage of macro and microvascular complications was higher in the hypertensive group than in the normotensive one (both p < 0.001). In multivariate logistic regression analysis, being a woman (OR: 1.26, 95% CI: 1.04-1.51, p = 0.016), smoking (OR: 1.38, 95% CI: 1.05-1.80, p = 0.020), regular physical activity (OR: 1.24, 95% CI: 1.01-1.53, p = 0.039) and the presence of macrovascular complications (OR: 1.38 95% CI: 1.15-1.65, p = 0.001) were the significant predictors of good ABP regulation. The ratios of masked and white coat hypertension were 41.2% and 5.7%, respectively.

CONCLUSION

Our findings indicate that two-thirds (67.5%) of adult patients with T2DM have hypertension. Co-existence of hypertension increases the frequency of macro and microvascular diabetic complications in these patients. Despite the critical role of hypertension in morbidity and mortality, only half of the patients have favorable ABP levels. Masked hypertension seems to be another important issue in this population.

Ankle brachial index as a surrogate to vascular imaging in evaluation of peripheral artery disease in patients with type 2 diabetes

BACKGROUND

Peripheral artery disease (PAD) is common in persons with type 2 diabetes (T2DM) and contributes significantly to cardiovascular morbidity and mortality. Controversy exists regarding the utility of ankle brachial index (ABI) for clinical diagnosis of PAD in persons with diabetes. The aim of this study was to evaluate the reliability of ABI for diagnosis of PAD in patients with T2DM using duplex ultrasonography (DUS) as the gold standard.

RESULTS

A total of 319 legs from 163 patients comprising of 156 subjects with intact legs and 7 patients who had undergone unilateral lower limb amputations were studied. The mean age of the participants was 56.1 ± 17.3 years. One hundred and ninety-five legs (61.1%) had sonographically confirmed PAD which was mild, moderate and severe in 40%, 41.5% and 18.5% respectively. The accuracy of ABI in detecting PAD was 76.7% for mild stenosis, 91.7% for moderate stenosis and 93.1% for severe stenosis. The sensitivity of ABI improved with increasing severity of arterial stenosis, reaching 100% in severe cases. ABI demonstrated good agreement with DUS [kappa = 0.65 (95% CI 0.49-0.88), P < 0.001].

CONCLUSION

In comparison to DUS, the ABI demonstrated good reliability for diagnosis of PAD in high risk T2DM patients. The utility of this simple and non-invasive procedure should therefore be maximized in clinical practice.

Association of Time in Range levels with Lower Extremity Arterial Disease in patients with type 2 diabetes

BACKGROUND AND AIMS

Time in range (TIR) is a new metric of glycemic control, assessed by continuous glucose monitoring (CGM). Previous studies have shown that is associated with microvascular complications of diabetes. We aimed to investigate the relationship between TIR levels and Lower Extremity Arterial Disease (LEAD) in patients with type 2 diabetes (T2DM).

METHODS

This cross-sectional study evaluated a total of 336 patients with T2DM, including 179 patients with LEAD and 157 without patients. Analysis of covariance was performed after adjusting for confounders. A logistic regression model was used to evaluate the relationship between TIR levels and LEAD.

RESULTS

The results of our tests indicate that TIR levels were significantly lower in T2DM with LEAD than in those without (73.05 ± 18.13 versus 65.62 ± 16.43, P < 0.01). Furthermore, the prevalence of LEAD by severity decreased with ascending quartiles of TIR (P < 0.05). After adjusting for other covariates, TIR were independent determinants for LEAD occurrence in patients with T2DM (OR = 0.979, 95%CI: 0.965, 0.992) and the TIR levels were significantly different according to the severity of LEAD.

CONCLUSIONS

TIR is significantly and independently associated with diabetic lower artery extremity disease in Type 2 Diabetes. We suggest that TIR should be more broadly accepted as a research endpoint or clinical measure.

How to manage patients with polyvascular atherosclerotic disease. Position paper of the International Union of Angiology

Atherosclerosis is a systemic disease affecting multiple arterial territories. Patients with clinical atherosclerotic disease in one vascular bed are likely to have asymptomatic or symptomatic atherosclerotic lesions in other vascular beds. Specifically, peripheral arterial disease (PAD) often coexists with coronary and carotid disease. With progression of atherosclerotic disease in one vascular bed, the risk of clinical manifestations in other territories increases and the incidence of adverse cardiovascular events increases substantially with the number of affected vascular beds. Classical risk factors are associated with the development of polyvascular atherosclerotic disease (PVD) in different territories; however, to a different extent. Risk modification represents basic treatment of patients with PVD. All modifiable risk factors should be aggressively controlled by lifestyle modification and medication. Particular attention should be directed to patients with PAD who are often undertreated in spite of the proven benefits of guideline-based approach. There is currently no proof that identification of asymptomatic atherosclerosis and PVD improves clinical outcomes in patients who are already in prevention programs. Revascularization should be performed only in symptomatic vascular beds, using the least aggressive method according to consensual decision of a multidisciplinary vascular team.

Association of severity of coronary artery disease by SYNTAX score (SS) and lower extremity arterial disease by duplex ultrasound (DUS) study-an Indian perspective

Background

Coronary artery disease (CAD) and lower extremity artery disease (LEAD) often coexist. Ankle brachial index (ABI) has been shown to be an independent predictor of CAD. Studies have reported correlation of CAD and LEAD on the basis of ABI and also invasive angiography. But rigorous searching did not reveal any similar research where severity of LEAD was assessed by duplex ultrasound (DUS).

In this study, we assessed the association of severity and localisation of LEAD by DUS with SYNTAX score (SS).

Results

A total of 637 subjects above 45 years of age with coronary angiographic confirmation of CAD were studied in this single centre cross-sectional, descriptive and analytical research. High SS was significantly more common in subjects with LEAD (p = 0.04). In the femoro-popliteal segment, total occlusion of arteries was found in significantly more proportion of subjects with high SS. A progressive increase in mean SS was noted across the grades of arterial disease in the femoro-popliteal segment (p = 0.007). 85.2% of the LEAD was in the femoro-popliteal segment, while below-knee arterial disease was present in 98.5% of subjects with LEAD. Hypertension, smoking, history of CVE and presentation with ACS independently increased the risk of LEAD.

Conclusion

High prevalence of asymptomatic LEAD and association of high SS with LEAD as a whole as well as femoro-popliteal involvement suggests the need for a point of care DUS study (POCUS) since treatment varies with location and extent of disease which cannot be fathomed by ABI alone. Being the largest study on association of CAD and LEAD from Indian subcontinent till date and also the first study to use non-invasive tool as DUS for LEAD assessment while studying its association with CAD makes this a landmark experience.

The 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guidelines on the Management of Blood Cholesterol in Diabetes

The American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines recently published its 2018 recommendations on management of LDL cholesterol (LDL-C) in people with diabetes. For primary prevention, moderate-intensity statin therapy is recommended for those aged 40-75 years, with a preference for high-intensity statin treatment for older subjects and for those with higher estimated risk or risk-enhancing factors following a patient-clinician discussion. Statin therapy may be reasonable in adults <40 years or >75 years of age where there is less evidence for benefit. For people with diabetes and established atherosclerotic cardiovascular disease, high-intensity statin therapy is recommended. The majority of these subjects have very high risk, and an LDL-C goal of <70 mg/dL is recommended. If this target is not achieved, ezetimibe and/or a proprotein convertase subtilisin/kexin type 9 inhibitor may be added.

Nomogram Based on Risk Factors for Type 2 Diabetes Mellitus Patients with Coronary Heart Disease

INTRODUCTION

This study aimed to study risk factors for coronary heart disease (CHD) in type 2 diabetes mellitus (T2DM) patients and establish a clinical prediction model.

RESEARCH DESIGN AND METHODS

A total of 3402 T2DM patients were diagnosed by clinical doctors and recorded in the electronic medical record system (EMRS) of six Community Health Center Hospitals from 2015 to 2017, including the communities of Huamu, Jinyang, Yinhang, Siping, Sanlin and Daqiao. From September 2018 to September 2019, 3361 patients (41 patients were missing) were investigated using a questionnaire, physical examination, and biochemical index test. After excluding the uncompleted data, 3214 participants were included in the study and randomly divided into a training set (n = 2252) and a validation set (n = 962) at a ratio of 3:1. Through lead absolute shrinkage and selection operator (LASSO) regression analysis and logistic regression analysis of the training set, risk factors were determined and included in a nomogram. The C-index, receiver operating characteristic (ROC) curve, calibration plot and decision curve analysis (DCA) were used to validate the distinction, calibration and clinical practicality of the model.

RESULTS

Age, T2DM duration, hypertension (HTN), hyperuricaemia (HUA), body mass index (BMI), glycosylated haemoglobin A1c (HbA1c), high-density lipoprotein (HDL-C) and low-density lipoprotein (LDL-C) were significant factors in this study. The C-index was 0.750 (0.724-0.776) based on the training set and 0.767 (0.726-0.808) based on the validation set. Through ROC analysis, the set area was 0.750 for the training set and 0.755 for the validation set. The calibration test indicated that the S:P of the prediction model was 0.982 in the training set and 0.499 in the validation set. The decision curve analysis showed that the threshold probability of the model was 16-69% in the training set and 16-73% in the validation set.

CONCLUSION

Based on community surveys and data analysis, a prediction model of CHD in T2DM patients was established.

2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Geriatrics Society, the American Society of Preventive Cardiology, and the Preventive Cardiovascular Nurses Association

2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

1. The most important way to prevent atherosclerotic vascular disease, heart failure, and atrial fibrillation is to promote a healthy lifestyle throughout life.

2. A team-based care approach is an effective strategy for the prevention of cardiovascular disease. Clinicians should evaluate the social determinants of health that affect individuals to inform treatment decisions.

3. Adults who are 40 to 75 years of age and are being evaluated for cardiovascular disease prevention should undergo 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimation and have a clinician–patient risk discussion before starting on pharmacological therapy, such as antihypertensive therapy, a statin, or aspirin. The presence or absence of additional risk-enhancing factors can help guide decisions about preventive interventions in select individuals, as can coronary artery calcium scanning.

4. All adults should consume a healthy diet that emphasizes the intake of vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish and minimizes the intake of trans fats, processed meats, refined carbohydrates, and sweetened beverages. For adults with overweight and obesity, counseling and caloric restriction are recommended for achieving and maintaining weight loss.

5. Adults should engage in at least 150 minutes per week of accumulated moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity.

6. For adults with type 2 diabetes mellitus, lifestyle changes, such as improving dietary habits and achieving exercise recommendations are crucial. If medication is indicated, metformin is first-line therapy, followed by consideration of a sodium-glucose cotransporter 2 inhibitor or a glucagon-like peptide-1 receptor agonist.

7. All adults should be assessed at every healthcare visit for tobacco use, and those who use tobacco should be assisted and strongly advised to quit.

8. Aspirin should be used infrequently in the routine primary prevention of ASCVD because of lack of net benefit.

9. Statin therapy is first-line treatment for primary prevention of ASCVD in patients with elevated low-density lipoprotein cholesterol levels (≥190 mg/dL), those with diabetes mellitus, who are 40 to 75 years of age, and those determined to be at sufficient ASCVD risk after a clinician–patient risk discussion.

10. Nonpharmacological interventions are recommended for all adults with elevated blood pressure or hypertension. For those requiring pharmacological therapy, the target blood pressure should generally be <130/80 mm Hg.

The Potential Role of Biomarkers Associated with ASCVD Risk: Risk-Enhancing Biomarkers

Serum cholesterol is major risk factor and contributor to atherosclerotic cardiovascular disease (ASCVD). Therapeutic cholesterol-lowering drugs, especially statin, revealed that reduction in low-density lipoprotein cholesterol (LDL-C) produces marked reduction of ASCVD events. In the preventive scope, lower LDL-C is generally accepted as better in proven ASCVD patients and high-risk patient groups. However, in patients with low to intermediate risk without ASCVD, risk assessment is clinically guided by traditional major risk factors. In this group, the complement approach to detailed risk assessment about traditional major risk factors is needed. These non-traditional risk factors include ankle-brachial index (ABI), high-sensitivity C-reactive protein (hsCRP) level, lipoprotein(a) (Lp[a]), apolipoprotein B (apoB), or coronary artery calcium (CAC) score. CAC measurements have an additive role in the decision to use statin therapy in non-diabetic patients 40–75 years old with intermediate risk in primary prevention. This review comprises ASCVD lipid/biomarkers other than CAC. The 2013 and 2018 American College of Cardiology/American Heart Association (ACC/AHA) guidelines suggest these factors as risk-enhancing factors to help health care providers better determine individualized risk and treatment options especially regarding abnormal biomarkers. The recent 2018 Korean guidelines for management of dyslipidemia did not include these biomarkers in clinical decision making. The current review describes the current roles of hsCRP, ABI, LP(a), and apoB in personal modulation and management of health based on the 2018 ACC/AHA guideline on the management of blood cholesterol.

Predicting the risk of stroke among patients with type 2 diabetes: a systematic review and meta-analysis of C-statistics

OBJECTIVE

Stroke is a major cause of disability and death worldwide. People with diabetes are at a twofold to fivefold increased risk for stroke compared with people without diabetes. This study systematically reviews the literature on available stroke prediction models specifically developed or validated in patients with diabetes and assesses their predictive performance through meta-analysis.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

A detailed search was performed in MEDLINE, PubMed and EMBASE (from inception to 22 April 2019) to identify studies describing stroke prediction models.

ELIGIBILITY CRITERIA

All studies that developed stroke prediction models in populations with diabetes were included.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently identified eligible articles and extracted data. Random effects meta-analysis was used to obtain a pooled C-statistic.

RESULTS

Our search retrieved 26 202 relevant papers and finally yielded 38 stroke prediction models, of which 34 were specifically developed for patients with diabetes and 4 were developed in general populations but validated in patients with diabetes. Among the models developed in those with diabetes, 9 reported their outcome as stroke, 23 reported their outcome as composite cardiovascular disease (CVD) where stroke was a component of the outcome and 2 did not report stroke initially as their outcome but later were validated for stroke as the outcome in other studies. C-statistics varied from 0.60 to 0.92 with a median C-statistic of 0.71 (for stroke as the outcome) and 0.70 (for stroke as part of a composite CVD outcome). Seventeen models were externally validated in diabetes populations with a pooled C-statistic of 0.68.

CONCLUSIONS

Overall, the performance of these diabetes-specific stroke prediction models was not satisfactory. Research is needed to identify and incorporate new risk factors into the model to improve models' predictive ability and further external validation of the existing models in diverse population to improve generalisability.

Prevalence and Associations of Subclinical Peripheral Artery Disease among Patients with Type 2 Diabetes without Clinical Macrovascular Disease

Background:

Peripheral arterial disease (PAD) is an important marker of cardiovascular (CV) risk and the risk of PAD is markedly increased in patients with type 2 diabetes mellitus (T2DM). Consequently, early diagnosis and treatment of PAD in patients with T2DM are critically important to reduce the risk of CV events. The aim of this study was to determine the prevalence of asymptomatic PAD in patients with T2DM and to investigate the demographic and clinical associations of PAD among them.

Methods:

This cross-sectional study included 2423 diabetic patients >20 years old, who were regularly followed up at the regional diabetes clinic, Galle, Sri Lanka. Data were obtained using structured questionnaires for information on demographic characteristics and risk factors. Assessment of ankle-brachial pressure index (ABPI) was performed in all. PAD was diagnosed when ABPI was < 0.9 on either leg.

Results:

The overall prevalence of PAD was 15.3% with no significant age or gender difference. Patients with PAD had significantly higher systolic blood pressure (SBP) (127 vs 125 mmHg, P = 0.002) and diastolic blood pressure (DPB) (80 vs 78 mmHg, P = <0.001) and significantly lower estimated glomerular filtration rate (eGFR) (80 vs 84 ml/min, P = 0.007) than those without PAD. No significant relationships were found between the duration of diabetes mellitus, hypertension, dyslipidemia, and PAD.

Conclusions:

Prevalence of PAD was relatively high in the diabetic population of this study when compared with findings from other countries. There is a significant association of subclinical PAD with reduced eGFR among patients with T2DM.

Prevalence of peripheral arterial disease among diabetic patients in Santo Domingo, Dominican Republic and associated risk factors

Introduction

Peripheral arterial disease (PAD) is a major risk factor of coronary artery disease and a major complication of atherosclerosis. Peripheral arterial disease can be diagnosed with simple and low cost techniques. There are major risk factors of PAD that have been studied for different countries. However, no such study has been done for the Dominican Republic. We conducted a cross-sectional study to determine the prevalence of PAD and the risk factors among patients with diabetes in Santo Domingo, Dominican Republic.

Material and methods

Six hundred randomly chosen patients with previously diagnosed diabetes were enrolled in our study. Their blood pressure and ankle brachial index were calculated and a questionnaire was provided to gather information regarding gender, age, weight, ethnicity, known duration of diabetes along with any history of smoking, hypertension and hyperlipidemia. A physical examination was also done to assess for any active diabetic ulcers, previous foot ulcers and non-traumatic amputation. A microfilament test was conducted to check for peripheral neuropathy.

Results

Eighty-four diabetic patients were diagnosed with PAD with a prevalence of 14% in Santo Domingo, Dominican Republic. Statistically significant associations (p < 0.05) was found for female gender, presence of active foot ulcers, history of past foot ulcer, non-traumatic amputation, hypertension, hyperlipidemia and peripheral neuropathy. Glycated hemoglobin (HbA_1c), age and smoking were not statistically significant in our study.

Conclusions

Diabetic patients who are either female, have active foot ulcers, a history of past foot ulcer, non-traumatic amputation, hypertension, hyperlipidemia or peripheral neuropathy are more at risk of developing PAD.