Low incidence of fatal coronary heart disease in Pima Indians despite high prevalence of non-insulin-dependent diabetes

Precision prognostics for cardiovascular disease in Type 2 diabetes: a systematic review and meta-analysis

BACKGROUND

Precision medicine has the potential to improve cardiovascular disease (CVD) risk prediction in individuals with Type 2 diabetes (T2D).

METHODS

We conducted a systematic review and meta-analysis of longitudinal studies to identify potentially novel prognostic factors that may improve CVD risk prediction in T2D. Out of 9380 studies identified, 416 studies met inclusion criteria. Outcomes were reported for 321 biomarker studies, 48 genetic marker studies, and 47 risk score/model studies.

RESULTS

Out of all evaluated biomarkers, only 13 showed improvement in prediction performance. Results of pooled meta-analyses, non-pooled analyses, and assessments of improvement in prediction performance and risk of bias, yielded the highest predictive utility for N-terminal pro b-type natriuretic peptide (NT-proBNP) (high-evidence), troponin-T (TnT) (moderate-evidence), triglyceride-glucose (TyG) index (moderate-evidence), Genetic Risk Score for Coronary Heart Disease (GRS-CHD) (moderate-evidence); moderate predictive utility for coronary computed tomography angiography (low-evidence), single-photon emission computed tomography (low-evidence), pulse wave velocity (moderate-evidence); and low predictive utility for C-reactive protein (moderate-evidence), coronary artery calcium score (low-evidence), galectin-3 (low-evidence), troponin-I (low-evidence), carotid plaque (low-evidence), and growth differentiation factor-15 (low-evidence). Risk scores showed modest discrimination, with lower performance in populations different from the original development cohort.

CONCLUSIONS

Despite high interest in this topic, very few studies conducted rigorous analyses to demonstrate incremental predictive utility beyond established CVD risk factors for T2D. The most promising markers identified were NT-proBNP, TnT, TyG and GRS-CHD, with the highest strength of evidence for NT-proBNP. Further research is needed to determine their clinical utility in risk stratification and management of CVD in T2D.

Precision Prognostics for Cardiovascular Disease in Type 2 Diabetes: A Systematic Review and Meta-analysis

Background Precision medicine has the potential to improve cardiovascular disease (CVD) risk prediction in individuals with type 2 diabetes (T2D). Methods We conducted a systematic review and meta-analysis of longitudinal studies to identify potentially novel prognostic factors that may improve CVD risk prediction in T2D. Out of 9380 studies identified, 416 studies met inclusion criteria. Outcomes were reported for 321 biomarker studies, 48 genetic marker studies, and 47 risk score/model studies. Results Out of all evaluated biomarkers, only 13 showed improvement in prediction performance. Results of pooled meta-analyses, non-pooled analyses, and assessments of improvement in prediction performance and risk of bias, yielded the highest predictive utility for N-terminal pro b-type natriuretic peptide (NT-proBNP) (high-evidence), troponin-T (TnT) (moderate-evidence), triglyceride-glucose (TyG) index (moderate-evidence), Genetic Risk Score for Coronary Heart Disease (GRS-CHD) (moderate-evidence); moderate predictive utility for coronary computed tomography angiography (low-evidence), single-photon emission computed tomography (low-evidence), pulse wave velocity (moderate-evidence); and low predictive utility for C-reactive protein (moderate-evidence), coronary artery calcium score (low-evidence), galectin-3 (low-evidence), troponin-I (low-evidence), carotid plaque (low-evidence), and growth differentiation factor-15 (low-evidence). Risk scores showed modest discrimination, with lower performance in populations different from the original development cohort. Conclusions Despite high interest in this topic, very few studies conducted rigorous analyses to demonstrate incremental predictive utility beyond established CVD risk factors for T2D. The most promising markers identified were NT-proBNP, TnT, TyG and GRS-CHD, with the highest strength of evidence for NT-proBNP. Further research is needed to determine their clinical utility in risk stratification and management of CVD in T2D.

Ten things to know about ten cardiovascular disease risk factors - 2022

The American Society for Preventive Cardiology (ASPC) "Ten things to know about ten cardiovascular disease risk factors - 2022" is a summary document regarding cardiovascular disease (CVD) risk factors. This 2022 update provides summary tables of ten things to know about 10 CVD risk factors and builds upon the foundation of prior annual versions of "Ten things to know about ten cardiovascular disease risk factors" published since 2020. This 2022 version provides the perspective of ASPC members and includes updated sentinel references (i.e., applicable guidelines and select reviews) for each CVD risk factor section. The ten CVD risk factors include unhealthful dietary intake, physical inactivity, dyslipidemia, pre-diabetes/diabetes, high blood pressure, obesity, considerations of select populations (older age, race/ethnicity, and sex differences), thrombosis (with smoking as a potential contributor to thrombosis), kidney dysfunction and genetics/familial hypercholesterolemia. Other CVD risk factors may be relevant, beyond the CVD risk factors discussed here. However, it is the intent of the ASPC "Ten things to know about ten cardiovascular disease risk factors - 2022" to provide a tabular overview of things to know about ten of the most common CVD risk factors applicable to preventive cardiology and provide ready access to applicable guidelines and sentinel reviews.

Obesity Pillars Roundtable: Obesity and Diversity

Background

The clinical implications of obesity differ, depending on race, ethnicity, and sexual orientation.

Methods

This roundtable discussion included 4 obesity specialists with expertise in the clinical management of obesity among diverse populations including Blacks, Hispanics/Latinos, Lesbian-Gay-Bisexual-Transgender-Questioning (LGBTQ) individuals, and Native-Americans.

Results

One of the first obstacles towards overcoming disparities in managing obesity and its complications among diverse populations is understanding applicable terminology. This includes categorization terminology relative to Native Americans (for the purpose of assessing culture and possibly genetic predispositions), understanding the differences between Black African Americans and Black Africans, understanding the differences between the terms Hispanic and Latinx, and basic concepts behind different pronouns applicable to Lesbian-Gay-Bisexual-Transgender-Questioning (LGBTQ) individuals. After being better able to grasp the input from patients with diverse backgrounds, universal obesity assessment and management principles can be then tailored utilizing a patient-centered approach.

Conclusion

Understanding the unique genetic, culture, and terminology regarding patients of different races, ethnicities, and sexual orientation may help clinicians better engage patients in managing obesity via utilizing a more patient-centered approach.

Structural Lesions on Kidney Biopsy in Youth-Onset and Adult-Onset Type 2 Diabetes

OBJECTIVE

Type 2 diabetes (T2D) is a leading cause of end-stage kidney disease worldwide. Recent studies suggest a more aggressive clinical course of diabetic kidney disease in youth-onset compared with adult-onset T2D. We compared kidney structural lesions in youth- and adult-onset T2D to determine if youth onset was associated with greater early tissue injury.

RESEARCH DESIGN AND METHODS

Quantitative microscopy was performed on kidney tissue obtained from research kidney biopsies in 161 Pima Indians (117 women, 44 men) with T2D. Onset of T2D was established by serial oral glucose tolerance testing, and participants were stratified as youth onset (age <25 years) or adult onset (age ≥25 years). Associations between clinical and morphometric parameters and age at onset were tested using linear models.

RESULTS

At biopsy, the 52 participants with youth-onset T2D were younger than the 109 with adult-onset T2D (39.1 ± 9.9 vs. 51.4 ± 10.2 years; P < 0.0001), but their diabetes duration was similar (19.3 ± 8.1 vs. 17.0 ± 7.8 years; P = 0.09). Median urine albumin-to-creatinine ratio was higher in the youth-onset group (58 [25th-75th percentile 17-470] vs. 27 [13-73] mg/g; P = 0.02). Youth-onset participants had greater glomerular basement membrane (GBM) width (552 ± 128 vs. 490 ± 114 nm; P = 0.002) and mesangial fractional volume (0.31 ± 0.10 vs. 0.27 ± 0.08; P = 0.001) than adult-onset participants. Glomerular sclerosis percentage, glomerular volume, mesangial fractional volume, and GBM width were also inversely associated with age at diabetes onset as a continuous variable.

CONCLUSIONS

Younger age at T2D onset strongly associates with more severe kidney structural lesions. Studies are underway to elucidate the pathways underlying these associations.

Pima Indian Contributions to Our Understanding of Diabetic Kidney Disease

Prospective studies in informative populations are crucial to increasing our knowledge of disease. In this perspective, we describe a half century of studies in an American Indian population that transformed our understanding of kidney disease in type 2 diabetes, now recognized as the leading cause of kidney failure worldwide. Serial examinations conducted for many years that included the collection of data and samples across multiple domains captured an unprecedented volume of clinical, physiologic, morphometric, genomic, and transcriptomic data. This work permitted us to extensively characterize the course and determinants of diabetic kidney disease, its pathophysiologic underpinnings, and important secular trends of urgent concern to populations worldwide, including the emergence of youth-onset type 2 diabetes and its effect on development of diabetic kidney disease in midlife. By combining these data using the tools of integrative biology, we are developing new mechanistic insights into the development and progression of diabetic kidney disease in type 2 diabetes. These insights have already contributed to the identification and successful therapeutic targeting of a novel pathway in DKD. We anticipate that this work will continue to expand our understanding of this complex disease and influence its management in the coming years.

Ten things to know about ten cardiovascular disease risk factors

Given rapid advancements in medical science, it is often challenging for the busy clinician to remain up-to-date on the fundamental and multifaceted aspects of preventive cardiology and maintain awareness of the latest guidelines applicable to cardiovascular disease (CVD) risk factors. The "American Society for Preventive Cardiology (ASPC) Top Ten CVD Risk Factors 2021 Update" is a summary document (updated yearly) regarding CVD risk factors. This "ASPC Top Ten CVD Risk Factors 2021 Update" summary document reflects the perspective of the section authors regarding ten things to know about ten sentinel CVD risk factors. It also includes quick access to sentinel references (applicable guidelines and select reviews) for each CVD risk factor section. The ten CVD risk factors include unhealthful nutrition, physical inactivity, dyslipidemia, hyperglycemia, high blood pressure, obesity, considerations of select populations (older age, race/ethnicity, and sex differences), thrombosis/smoking, kidney dysfunction and genetics/familial hypercholesterolemia. For the individual patient, other CVD risk factors may be relevant, beyond the CVD risk factors discussed here. However, it is the intent of the "ASPC Top Ten CVD Risk Factors 2021 Update" to provide a succinct overview of things to know about ten common CVD risk factors applicable to preventive cardiology.

Urine albumin dipstick independently predicts cardiovascular and renal outcomes among rural Thai population: a 14-year retrospective cohort study

Background

Albuminuria is an established risk marker for both cardiovascular and renal outcomes. In this study, we expected to use portable and inexpensive test strips to detect urine albumin level for risk stratification in cardiovascular and renal outcomes among rural Thai community.

Objective

To evaluate the relationship between urine albumin dipstick and cardiovascular and renal complications in rural Thai population.

Methods

We conducted a retrospective study in 635 rural Thai adults who tested urine albuminuria by using commercial urine albumin dipstick and the Micral-albumin test II strips at baseline. The subjects were divided into normoalbuminuria (albumin < 20 mg/L), microalbuminuria (albumin 20–200 mg/L), or macroalbuminuria (Urine dipstick at least 1+ or albumin > 200 mg/L). We collected data on the incidences of primary composite outcomes including cardiovascular or renal morbidity and mortality. Incident density and cox regression were analyzed to evaluate the association between albuminuria status and primary composite outcome.

Results

During an average 14-year follow-up, 102 primary composite events occurred including 59 (13.1%), 32 (20.6%) and 11 (39.3%) among 452, 155, and 28 subjects with normoalbuminuria, microalbuminuria, and macroalbuminuria, respectively. Incident densities of primary composite outcome were elevated continually according to the degree of albuminuria (9.36, 17.11 and 38.12 per 1000 person-years). Compared with the subjects without albuminuria, subjects with microalbuminuria and macroalbuminuria at baseline had higher risk for primary composite outcome in univariate model. After multivariate analysis was performed, the effect of macroalbuminuria was only persisted with 3.13-fold risk (adjusted HR 3.13; 95% CI 1.40–6.96, P= 0.005).

Conclusion

Albuminuria from semi-quantitative methods is an important factor predicting cardiovascular and renal risk among subjects in Thai rural population. Our findings support to also incorporating urine albumin dipstick into assessments of cardiovascular risk in the general population.

Ten things to know about ten cardiovascular disease risk factors ("ASPC Top Ten - 2020")

Preventive cardiology involves understanding and managing multiple cardiovascular disease (CVD) risk factors. Given the rapid advancements in medical science, it may be challenging for the busy clinician to remain up-to-date on the multifaceted and fundamental aspects of CVD prevention, and maintain awareness of the newest applicable guidelines. The "American Society for Preventive Cardiology (ASPC) Top Ten 2020" summarizes ten essential things to know about ten important CVD risk factors, listed in tabular formats. The ten CVD risk factors include unhealthful nutrition, physical inactivity, dyslipidemia, hyperglycemia, high blood pressure, obesity, considerations of select populations (older age, race/ethnicity, and gender), thrombosis/smoking, kidney dysfunction and genetics/familial hypercholesterolemia. For the individual patient, other CVD risk factors may be relevant, beyond the CVD risk factors discussed here. However, it is the intent of the "ASPC Top Ten 2020" to provide a succinct overview of things to know about ten common CVD risk factors applicable to preventive cardiology.

Hypertension in Obesity: Novel Insights

BACKGROUND

The relationship between obesity and hypertension has been established in both adults and children. The combination of obesity, hypertension and other cardiovascular risk factors significantly increases the likelihood of adverse cardiovascular effects and raises concerns about aggressive treatment strategies.

OBJECTIVE

Despite the impressive elements which indicate an important role for excessive weight gain in increasing blood pressure, not all obese patients are hypertensive. A subgroup of obese people may not develop hypertension. Furthermore, masked hypertension occurs more common among obese patients, and body fat distribution has a major role in the development of hypertension.

METHOD

We conducted a research of the relevant literature regarding obesity-induced hypertension and possible treatment strategies.

RESULTS

Successful weight loss is correlated with blood pressure reduction and requires a multidisciplinary approach that includes personalized dietary interventions combined with regular exercise and cognitive behavioral therapy.

CONCLUSION

Pharmacological therapy may be considered as part of a comprehensive obesity management strategy. More research and new treatment therapies are required in this field.

Effect of Geography on the Analysis of Coccidioidomycosis-Associated Deaths, United States

Because coccidioidomycosis death rates vary by region, we reanalyzed coccidioidomycosis-associated mortality in the United States by race/ethnicity, then limited analysis to Arizona and California. Coccidioidomycosis-associated deaths were shown to increase among African-Americans but decrease among Native Americans and Hispanics. Separately, in a Native American cohort, diabetes co-varied with coccidioidomycosis-associated death.

Refining Long-Term Prediction of Cardiovascular Risk in Diabetes - The VILDIA Score

Cardiovascular risk assessment in patients with diabetes relies on traditional risk factors. However, numerous novel biomarkers have been found to be independent predictors of cardiovascular disease, which might significantly improve risk prediction in diabetic patients. We aimed to improve prediction of cardiovascular risk in diabetic patients by investigating 135 evolving biomarkers. Based on selected biomarkers a clinically applicable prediction algorithm for long-term cardiovascular mortality was designed. We prospectively enrolled 864 diabetic patients of the LUdwigshafen RIsk and Cardiovascular health (LURIC) study with a median follow-up of 9.6 years. Independent risk factors were selected using bootstrapping based on a Cox regression analysis. The following seven variables were selected for the final multivariate model: NT-proBNP, age, male sex, renin, diabetes duration, Lp-PLA2 and 25-OH vitamin D3. The risk score based on the aforementioned variables demonstrated an excellent discriminatory power for 10-year cardiovascular survival with a C-statistic of 0.76 (P < 0.001), which was significantly better than the established UKPDS risk engine (C-statistic = 0.64, P < 0.001). Net reclassification confirmed a significant improvement of individual risk prediction by 22% (95% confidence interval: 14–30%) compared to the UKPDS risk engine (P < 0.001). The VILDIA score based on traditional cardiovascular risk factors and reinforced with novel biomarkers outperforms previous risk algorithms.

Impact of diabetes duration on 3-year clinical outcomes following coronary revascularization

OBJECTIVE

The aim of this study was to evaluate the impact of diabetes duration on long-term clinical outcomes after drug-eluting stent (DES) implantation or coronary artery bypass grafting (CABG).

METHODS

A total of 820 diabetic patients treated with initial DES (n=451) or CABG (n=369) were consecutively enrolled in this single-center follow-up study. The main outcomes included major adverse cardiac events and major adverse cardiac or cerebrovascular events (MACCEs). Cox regression analysis with propensity adjustment was used for data analysis.

RESULTS

Three-year risks of major adverse cardiac events were significantly higher in the DES group compared with the CABG group irrespective of whether the diabetes durations were less or more than 5 years [hazard ratio (HR) 2.27, 95% confidence interval (CI) 1.19-4.31, P=0.01; HR 3.73, 95% CI 2.72-10.12, P<0.01; P for interaction=0.28]. A similar trend was observed for repeat revascularization. However, CABG was associated with increased risk of stroke, especially in the patients with diabetes duration of at least 5 years (HR 0.02, 95% CI 0.002-0.12, P<0.01). Three-year risk of MACCEs was significantly higher in the DES group in patients with diabetes duration of at least 5 years (HR 2.13, 95% CI 1.34-3.39, P<0.01), but not for those less than 5 years (HR 1.03, 95% CI 0.65-1.63, P=0.91). A statistically significant interaction between diabetes duration and treatment strategy was found for MACCEs (P for interaction=0.04).

CONCLUSION

Short diabetes duration (<5 years) was associated with equal risk of MACCEs among stable coronary artery disease patients with DES and CABG, emphasizing the need to consider the duration of diabetes when determining the best strategy for patients undergoing coronary revascularization.

National Lipid Association Annual Summary of Clinical Lipidology 2016

The National Lipid Association (NLA) Annual Summary of Clinical Lipidology is a yearly updated summary of principles important to the patient-centered evaluation, management, and care of patients with dyslipidemia. This summary is intended to be a "living document," with future annual updates based on emerging science, clinical considerations, and new NLA Position, Consensus, and Scientific Statements, thus providing an ongoing resource that applies the latest in medical science towards the clinical management of patients with dyslipidemia. Topics include the NLA Recommendations for Patient-Centered Management of Dyslipidemia, genetics, Familial Hypercholesterolemia, secondary causes of dyslipidemia, biomarkers and advanced lipid testing, nutrition, physical activity, obesity, adiposopathy, metabolic syndrome, diabetes mellitus, lipid pharmacotherapy, lipid-altering drug interactions, lipoprotein apheresis, dyslipidemia management and treatment based upon age (children, adolescents, and older individuals), dyslipidemia considerations based upon race, ethnicity and gender, dyslipidemia and human immune virus infection, dyslipidemia and immune disorders, adherence strategies and collaborative care, and lipid-altering drugs in development. Hyperlinks direct the reader to sentinel online tables, charts, and figures relevant to lipidology, access to online atherosclerotic cardiovascular disease risk calculators, worldwide lipid guidelines, recommendations, and position/scientific statements, as well as links to online audio files, websites, slide shows, applications, continuing medical education opportunities, and patient information.

Review: The genetics of macrovascular disease in diabetes

Patients with diabetes mellitus show an increased risk of developing macrovascular disease. Although common cardiovascular risk factors are abnormally high in patients with type 2 diabetes compared to the general population, they cannot fully explain the high rate of vascular complications. Indeed the occurrence and the severity of such complications are highly heterogeneous even in patients with comparable levels of glycaemic control and similar prevalence of cardiovascular risk factors. Large-vessel atherosclerosis can precede the clinical manifestation of diabetes. This suggests that both atherosclerosis and type 2 diabetes may have common genetic and environmental antecedents. A large body of evidence supports the possible role of genetics in determining the expression of the ischaemic vascular phenotype in diabetic patients, mainly derived from studies in ethnic groups or in first-degree relatives of diabetic patients and from association studies with genetic polymorphisms. Unravelling the polygenic susceptibility factors for macrovascular complications of diabetes is difficult, since diabetes per se has multifactorial inheritance. Direct evidence is largely based on the candidate gene approach in case-control studies. Several systems provide candidate genes that could by themselves or by interacting with other factors, increase the risk of ischaemic vascular disease in diabetic patients mainly related to lipid metabolism, lipoprotein oxidation and haemostatic processes.

New developments in the pathogenesis of obesity-induced hypertension

Obesity is a disorder that develops from the interaction between genotype and environment involving social, behavioral, cultural, and physiological factors. Obesity increases the risk for type 2 diabetes mellitus, hypertension, cardiovascular disease, cancer, musculoskeletal disorders, chronic kidney and pulmonary disease. Although obesity is clearly associated with an increased prevalence of hypertension, many obese individuals may not develop hypertension. Protecting factors may exist and it is important to understand why obesity is not always related to hypertension. The aim of this review is to highlight the knowledge gap for the association between obesity, hypertension, and potential genetic and racial differences or environmental factors that may protect obese patients against the development of hypertension and other co-morbidities. Specific mutations in the leptin and the melaninocortin receptor genes in animal models of obesity without hypertension, the actions of α-melanocyte stimulating hormone, and SNS activity in obesity-related hypertension may promote recognition of protective and promoting factors for hypertension in obesity. Furthermore, gene-environment interactions may have the potential to modify gene expression and epigenetic mechanisms could also contribute to the heritability of obesity-induced hypertension. Finally, differences in nutrition, gut microbiota, exposure to sun light and exercise may play an important role in the presence or absence of hypertension in obesity.

National Lipid Association Annual Summary of Clinical Lipidology 2015

The National Lipid Association (NLA) Annual Summary of Clinical Lipidology 2015 is a summary of principles important to the patient-centered evaluation, management, and care of patients with dyslipidemia. This summary is intended to be a "living document," with future annual updates based on emerging science, clinical considerations, and new NLA Position and Consensus Statements. The goal is to provide clinicians an ongoing resource that translates the latest advances in medical science toward the evaluation and treatment of patients with dyslipidemia. The 2015 NLA Annual Summary of Clinical Lipidology was founded on the principles of evidence-based medicine and is generally consistent with established national and international lipid guidelines. Topics include a general discussion of the 2014 NLA Recommendations for Patient-Centered Management of Dyslipidemia, genetics, secondary causes of dyslipidemia, biomarkers and "advanced lipid testing," medical nutrition, physical activity, obesity, pharmacotherapy, statin safety, lipid-altering drug interactions, lipoprotein apheresis, dyslipidemia in children and adolescence, dyslipidemia in older individuals, race/ethnicity, and women, health information technology and electronic medical records, as well as investigational lipid-altering drugs in development.

One-hour post-load hyperglycemia by 75g oral glucose tolerance test as a novel risk factor of atherosclerosis

Postprandial hyperglycemia is considered as a risk factor of cardiovascular disease. We hypothesized that early post-load hyperglycemia might be more useful surrogate marker to assess atherosclerosis than plasma glucose (PG) level at 120 minutes because the peak of post-load glucose by 75gOGTT is usually shown at 60 minutes. 75gOGTT and carotid echography were investigated in 108 subjects who visited our hospital to examine impaired glucose tolerance. The association of post-load plasma glucose and insulin levels with intima-media thickness (IMT) was examined. Simple correlation analyses showed that fasting PG (FPG) (r=0.26, p=0.013), PG60 (r=0.40, p<0.001), PG90 (r=0.29, p=0.008), area under curve for PG (AUC-PG) (r=0.33, p=0.003), HbA1c (r=0.30, p=0.005), amount of PG increase at 60 minutes (PGΔ60) (r=0.39, p=0.002), and PGΔ90 (r=0.27, p=0.016), were significantly correlated with IMT. Multiple regression analysis using IMT as a dependent variable and PG60, FPG, HbA1c, and AUC-PG as independent variables showed that PG60 was only significantly and positively correlated with IMT (β=0.59, p=0.042). Moreover, PG60 and PGΔ60 were significantly and positively associated with IMT even after additional adjustment for classical atherosclerosis risk factors (β=0.30, p=0.005 and β=0.50, p=0.037, respectively). The cut-off values of PG60 and PGΔ60 to detect atherosclerosis (IMT > 1.1mm) were 188 and 101 mg/dL, respectively (p<0.01). These findings show that early post-load hyperglycemia, particularly PG60 is a novel risk factor of atherosclerosis and useful to assess it.

Impact of targeted health promotion on cardiovascular knowledge among American Indians and Alaska Natives

The National Heart, Lung, and Blood Institute developed the Honoring the Gift of Heart Health (HGHH) curriculum to promote cardiovascular knowledge and heart-healthy lifestyles among American Indians and Alaska Natives (AI/ANs). Using data from a small randomized trial designed to reduce diabetes and cardiovascular disease (CVD) risk among overweight/obese AI/ANs, we evaluated the impact of an adapted HGHH curriculum on cardiovascular knowledge. We also assessed whether the curriculum was effective across levels of health literacy (defined as the 'capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions'). We examined change in knowledge from baseline to 3 months for two groups: HGHH (N = 89) and control (N = 50). Compared with controls, HGHH participants showed significant improvement in heart attack knowledge and marginally significant improvement in stroke and general CVD knowledge. HGHH participants attending ≥1 class showed significantly greater improvement than controls on all three measures. Although HGHH participants with inadequate health literacy had worse heart attack and stroke knowledge at baseline and 3 months than did participants with adequate skills, the degree of improvement in knowledge did not differ by health literacy level. HGHH appears to improve cardiovascular knowledge among AI/ANs across health literacy levels.

Differences in risk factors for coronary heart disease among diabetic and nondiabetic individuals from a population with high rates of diabetes: the Strong Heart Study

CONTEXT

Coronary heart disease (CHD) is the leading cause of death in the United States.

OBJECTIVE

This study compares differences in risk factors for CHD in diabetic vs. nondiabetic Strong Heart Study participants.

DESIGN

This was an observational study.

SETTING

The study was conducted at three centers in Arizona, Oklahoma, and North and South Dakota.

PARTICIPANTS

Data were obtained from 3563 of 4549 American Indians free of cardiovascular disease at baseline.

INTERVENTION(S)

CHD events were ascertained during follow-up.

MAIN OUTCOME MEASURE

CHD events were classified using standardized criteria.

RESULTS

In diabetic and nondiabetic participants, 545 and 216 CHD events, respectively, were ascertained during follow-up (21,194 and 22,990 person-years); age- and sex-adjusted incidence rates of CHD were higher for the diabetic group (27.5 vs. 12.1 per 1,000 person-years). Risk factors for incident CHD common to both groups included older age, male sex, prehypertension or hypertension, and elevated low-density lipoprotein cholesterol. Risk factors specific to the diabetic group were lower high-density lipoprotein cholesterol, current smoking, macroalbuminuria, lower estimated glomerular filtration rate, use of diabetes medication, and longer duration of diabetes. Higher body mass index was a risk factor only for the nondiabetic group. The association of male sex and CHD was greater in those without diabetes than in those with diabetes.

CONCLUSIONS

In addition to higher incidence rates of CHD events in persons with diabetes compared with those without, the two groups differed in CHD risk factors. These differences must be recognized in estimating CHD risk and managing risk factors.

The association of self-reported coronary heart disease with diabetes duration in Korea

BACKGROUND

This study aimed to investigate the association of diabetes duration with self-reported coronary heart disease (CHD) in Korea.

METHODS

Among data from 34,145 persons compiled in the third Korean National Health and Nutrition Examination Survey in 2005, laboratory test and nutritional survey data from 5,531 persons were examined. The participants were asked to recall a physician's diagnosis of CHD (angina or myocardial infarction).

RESULTS

Age- and sex-adjusted relative risk for CHD was 1.51 (95% confidence interval [CI], 0.64 to 3.59; not significant) for diabetes with duration of <1 year, 2.27 (95% CI, 1.14 to 4.54; P=0.020) for diabetes with a duration of 1 to 5 years, and 3.29 (95% CI, 1.78 to 6.08; P<0.001) for diabetes with a duration >5 years, compared with non-diabetes as a control. Even after adjusting for age, sex, current smoking status, waist circumference, hypertension, triglycerides, high density lipoprotein cholesterol, and fasting plasma glucose, relative risk for CHD was 2.87 (95% CI, 1.01 to 8.11; P=0.047) in diabetes with a duration of 6 to 10 years and 4.07 (95% CI, 1.73 to 9.63; P=0.001) in diabetes with duration of >10 years with non-diabetes as a control.

CONCLUSION

CHD prevalence increased with an increase in diabetes duration in Korean men and women. Recently detected diabetes (duration <1 year) was not significantly associated with CHD prevalence compared to non-diabetes. However, diabetes of a duration of >5 years was associated with an increase in CHD compared to non-diabetics after adjusting for several CHD risk factors.

Duration of type 2 diabetes strongly predicts all-cause and cardiovascular mortality in people referred for coronary angiography

OBJECTIVE

Type 2 diabetes represents a major cardiovascular risk factor. However, few studies have addressed the impact of the disease duration on mortality. Thus, we aimed to investigate the predictive value of diabetes duration for all-cause and cardiovascular mortality in subjects undergoing coronary angiography.

METHODS

We studied 2455 participants of the LUdwigshafen RIsk and Cardiovascular health study (1768 males/687 females). They had a mean ± standard deviation (SD) age of 63.1 ± 9.0 years (range: 40.0-79.9) and a mean ± SD body mass index of 27.7 ± 4.0 kg/m(2). 704 subjects were newly diagnosed with type 2 diabetes according to the 2010 criteria of the American Diabetes Association and 446 subjects had a known history of type 2 diabetes. The mean ± SD duration of the follow-up for all-cause and cardiovascular mortality was 7.4 ± 2.3 years.

RESULTS

A total of 543 deaths occurred during the follow-up. Among these, 343 were accounted for by cardiovascular diseases. The duration of type 2 diabetes was strongly and positively correlated with all-cause and cardiovascular mortality (both P<0.001). The multivariate adjusted hazard ratios (95% confidence intervals) for cardiovascular mortality compared to subjects without diabetes were 1.76 (1.34-2.32), 2.86 (2.00-4.08), 2.96 (1.85-4.74), and 4.55 (3.24-6.39) for subjects with new onset type 2 diabetes and subjects with known type 2 diabetes (duration ≤ 5, >5 and ≤ 10, >10 years), respectively.

CONCLUSIONS

The data emphasise the need to consider the diabetes duration for the prediction of mortality in subjects at intermediate to high cardiovascular risk.

Albuminuria and estimated glomerular filtration rate as predictors of diabetic end-stage renal disease and death

BACKGROUND AND OBJECTIVES

We investigated predictive value of albuminuria and estimated GFR (eGFR) for ESRD in Pima Indians with type 2 diabetes.

DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS

Beginning in 1982, 2420 diabetic Pima Indians ≥18 years old were followed until they developed ESRD or died or until December 31, 2005. Individuals were classified at baseline by urinary albumin-to-creatinine ratio (ACR) and by eGFR, calculated by the Chronic Kidney Disease Epidemiology Collaboration equation. Predictors of ESRD and mortality were examined by proportional hazards regression.

RESULTS

During a mean follow-up of 10.2 years, 287 individuals developed ESRD. Incidence of ESRD among individuals with macroalbuminuria (ACR ≥ 300 mg/g) was 9.3 times that of those with normoalbuminuria (ACR < 30 mg/g), controlled for age, gender, and duration of diabetes. Incidence among individuals with eGFR 15 to 29 ml/min per 1.73 m(2) was 81.9 times that of those with eGFR 90 to 119 ml/min per 1.73 m(2). Models that combined albuminuria and eGFR added significant predictive information about risk of ESRD or death compared with models containing eGFR or albuminuria alone. The hazard ratio for ESRD associated with a 10-ml/min per 1.73 m(2) lower eGFR was 1.36, whereas that associated with an increase in albuminuria category was 2.69; corresponding hazard ratios for death were 1.15 and 1.37.

CONCLUSIONS

These results suggest that incorporation of quantitative information about albuminuria into staging systems based on eGFR adds significant prognostic information about risk for diabetic ESRD and death.

The association between C-reactive protein levels and insulin therapy in obese vs nonobese veterans with type 2 diabetes mellitus

The authors studied the association between insulin use and C-reactive protein (CRP) levels in obese (body mass index > or = 30 kg/m(2)) and nonobese (body mass index <30 kg/m(2)) patients with type 2 diabetes at the Providence Veterans Affairs Medical Center. There were 64 nonobese participants (insulin use and average daily dose, 23.4% and 7.0+/-18.2 units at baseline and 27.1% and 9.3+/-21.0 units at follow-up, respectively) and 106 obese participants (insulin use and daily dose, 39.6% and 28.2+/-47.3 units at baseline and 43.0% and 28.7+/-47.7 units at follow-up, respectively). Both use and daily dose of insulin were modeled with CRP levels of participants upon discharge from an intensive cardiac risk management clinic and at a 1-year follow-up visit using a linear mixed effects model for repeated measures. There was a significant direct association between log CRP and both insulin use and daily dose for nonobese participants (beta=0.3, P=.03 and beta=0.01, P=.02, respectively) but not for obese participants (P=.8 and P=.5, respectively). Due to the association between insulin therapy and CRP in nonobese patients, these results may aid clinicians in deciding on the initiation of insulin therapy for nonobese diabetic patients when noninsulin alternatives are available.

Adiponectin: an independent risk factor for coronary heart disease in men in the Framingham offspring Study

OBJECTIVE

Our aim was to determine whether plasma adiponectin levels were an independent predictor of coronary heart disease (CHD) risk.

METHODS AND RESULTS

Plasma adiponectin levels were measured in 3188 male and female participants from cycle 6 of the Framingham offspring Study (mean age: 57 years in both men and women; BMI: 28.5 kg/m(2) in men and 27.3 kg/m(2) in women), using a novel fully automated assay. Plasma adiponectin levels (median [25th percentile, 75th percentile]) were significantly higher in female than in male CHD-free subjects (14.8 [10.7,20.5] μg/ml versus 9.0 [7.0,12.2] μg/ml, p<0.001). Participants were followed for a mean of 7.5 years. After adjustment for age, BMI, smoking status, systolic blood pressure, treatment for hypertension, diabetes, use of cholesterol-lowering medication, total cholesterol level, high-density lipoprotein cholesterol level, and C-reactive protein levels, a higher plasma adiponectin level was a significant predictor of lower risk of future CHD events (n=117) in men (HR 0.49, p<0.0022). A similar trend was observed in women, but was no longer significant after multivariate adjustments.

CONCLUSIONS

Our data indicate that plasma adiponectin levels are an independent predictor of CHD in Caucasian men initially free of CHD.

Insulin resistance: pathophysiology and rationale for treatment

After binding to its receptor and activating the β-subunit, insulin is faced with two divergent pathways: one is phosphatidylinositol 3-kinase (PI 3-K) dependent, while another is dependent upon activation of mitogen-activated protein kinase (MAP-K). The former is absolutely necessary for mediating most metabolic and antiapoptotic effects; the latter is linked to nonmetabolic, proliferative and mitogenic effects. In obese patients, especially with type 2 diabetes mellitus (DM2), only the PI 3-K, but not the MAP-K, is resistant to insulin stimulation: hence insulin resistance is better defined as metabolic insulin resistance. The resulting 'compensatory hyperinsulinemia' is an unsuccessful attempt to overcome the inhibition of the metabolic pathway at the price of unopposed stimulation of the MAP-K pathway, and the administration of exogenous insulin might worsen the metabolic dysfunction. As the preferential activation of the MAP-K pathway in insulin-resistant patients has atherogenic and mitogenic properties, this leads to atherosclerosis and cancer. Metformin may carry out direct protective action on human β cells, inasmuch as it improves both primary and secondary endpoints through selective inhibition of fatty acyl oxidation.

Cardiovascular knowledge among urban American Indians and Alaska Natives: first steps in addressing cardiovascular health

BACKGROUND

Cardiovascular disease (CVD) is common among American Indians/Alaska Natives (AI/ANs). Given limited access to health care, urban AI/ANs may be at particular risk. Lack of available data, however, limits our understanding of cardiovascular health in this population.

OBJECTIVES

We conducted a survey to characterize CVD-related knowledge, behavior, and risk of urban AI/ANs. Results related to knowledge are reported.

METHODS

In collaboration with the Indian clinics in two urban communities, we surveyed 298 AI/ANs.

RESULTS

Respondents recognized approximately half of the symptoms of heart attack and stroke, and were significantly less likely to recognize each symptom than reported in national studies using the same items. General CVD knowledge (e.g., risks of high blood pressure) was stronger, although areas for improvement were noted.

CONCLUSIONS

Urban AI/ANs would benefit from efforts to enhance CVD knowledge. These preliminary data are providing the foundation for community-based efforts to address CVD risk among urban AI/ANs.

Microarray evidences the role of pathologic adipose tissue in insulin resistance and their clinical implications

Clustering of insulin resistance and dysmetabolism with obesity is attributed to pathologic adipose tissue. The morphologic hallmarks of this pathology are adipocye hypertrophy and heightened inflammation. However, it's underlying molecular mechanisms remains unknown. Study of gene function in metabolically active tissues like adipose tissue, skeletal muscle and liver is a promising strategy. Microarray is a powerful technique of assessment of gene function by measuring transcription of large number of genes in an array. This technique has several potential applications in understanding pathologic adipose tissue. They are: (1) transcriptomic differences between various depots of adipose tissue, adipose tissue from obese versus lean individuals, high insulin resistant versus low insulin resistance, brown versus white adipose tissue, (2) transcriptomic profiles of various stages of adipogenesis, (3) effect of diet, cytokines, adipokines, hormones, environmental toxins and drugs on transcriptomic profiles, (4) influence of adipokines on transcriptomic profiles in skeletal muscle, hepatocyte, adipose tissue etc., and (5) genetics of gene expression. The microarray evidences of molecular basis of obesity and insulin resistance are presented here. Despite the limitations, microarray has potential clinical applications in finding new molecular targets for treatment of insulin resistance and classification of adipose tissue based on future risk of insulin resistance syndrome.

Duration and type of therapy for diabetes: impact on cardiac risk stratification with stress electrocardiographic-gated SPECT myocardial perfusion imaging

BACKGROUND

Stress electrocardiogram(ECG)-gated single photon emission computed tomography (SPECT) imaging is highly effective in risk stratification of diabetic patients for adverse cardiac events. While patients with diabetes are predisposed to a more aggressive progression of vascular disease, the impact of its duration and type of therapy on risk stratification are unknown.

METHODS

From the Hartford Hospital Nuclear Cardiology clinical database, 886 diabetic patients who underwent exercise or pharmacologic stress ECG-gated SPECT were identified, with complete follow-up regarding the occurrence of adverse cardiac events and information regarding the duration of diabetes and the type of therapy (insulin vs oral medication only) at the time of testing. Images were interpreted using the American College of Cardiology/ASNC standard 17-segment scoring model.

RESULTS

Of the 886 diabetic patients, 98 (11%) suffered cardiac death or non-fatal myocardial infarction during follow-up (2.5 ± 1.6 years). A receiver operator characteristics curve demonstrated that diabetes ≥10 years in duration provided the maximal sum of sensitivity and specificity for the prediction of adverse cardiac outcomes. Multivariate analysis identified the following as independent predictors of adverse outcome: Post-stress ejection fraction (EF) <40% (P = .001), age (P = .004), insulin therapy (P = .031), diabetes duration >10 years (P = .038), summed stress score (SSS) >8 (P = .046). For patients with an SSS >8, diabetes duration and type of therapy significantly enhanced risk stratification. Similar findings emerged for patients with a post-stress EF <40%.

CONCLUSION

For diabetic patients undergoing stress ECG-gated SPECT myocardial perfusion imaging, disease duration and type of therapy provide independent and incremental prognostic information. Integration of these variables with this cardiovascular imaging technology significantly enhances cardiac risk stratification.

Secular trends in treatment and control of type 2 diabetes in an American Indian population: a 30-year longitudinal study

OBJECTIVE

Treatment guidelines for diabetes have become increasingly stringent as most research shows that more aggressive intervention reduces the risks for complications. Community data on the effect of these interventions are lacking.

RESEARCH DESIGN AND METHODS

Changes in the pharmacologic treatment of diabetes, blood pressure, and cholesterol in adults with diabetes were analyzed in a longitudinal population-based study of American Indians from 10 independent 3-year time intervals between 1975 and 2004. Trends in drug use were assessed by logistic regression models and trends in glycemia, blood pressure, and cholesterol were assessed by linear models.

RESULTS

Among the study participants, the use of any medicine for the treatment of diabetes increased from 53% in 1975-1978 to 67% in 2002-2004, Ptrend<0.0001. The use of insulin as a single agent declined, and the use of combinations of insulin and oral agents increased. In 1990-1992, 23% of subjects had an A1C<7% and by 2002-2004, the proportion had increased to 33%, Ptrend<0.0001. The use of anti-hypertensive medicine increased from 21% in 1975-1977 to 58% in 2002-2004, Ptrend<0.0001, coincident with a decline in mean systolic blood pressure from 137 mmHg in 1975-1977 to 123 mmHg in 2002-2004, Ptrend<0.0001. The use of lipid-lowering medicine also increased with an accompanying increase in HDL and a decrease in non-HDL cholesterol concentration.

CONCLUSIONS

Major changes in community treatment patterns for diabetes and related conditions coincided with improvements in glycemia, blood pressure, and cholesterol.

Incidence rates of heart failure, stroke, and acute myocardial infarction among Type 2 diabetic patients using insulin glargine and other insulin

PURPOSE

The aim of this study was to compare incidence rates of heart failure, stroke, and acute myocardial infarction (AMI) in Type 2 diabetic patients using different types of insulin.

METHODS

Included were patients with a diagnosis of Type 2 diabetes and at least one insulin prescription from May 2001 to July 2007. Incidence rate ratios (RRs) of heart failure, stroke, and AMI were estimated using Poisson regression with adjustment for age, gender, history of hypertension, dyslipidemia history, days supply, and duration of diabetes.

RESULTS

Incidence rates of heart failure, stroke, and AMI in the insulin glargine group were 306.9 (95%CI: [278.9, 334.8]), 174.8 (95%CI: [153.7, 195.8]), and 105.2 (95%CI: [88.9, 121.5]) cases per 10,000 person-years, respectively. After adjustment for covariates, the incidence rates of CVD events in the insulin glargine were comparable to those in the other long/intermediate acting insulin group (reference), except for AMI, which tended to be lower in the insulin glargine group (RR = 0.81, 95%CI: [0.65, 1.02]). Using the same reference, the incidence rate of stroke was higher in patients taking rapid/short acting insulin, premixed insulin, or mixed use of insulin except insulin glargine (RR = 1.20, 95%CI: [1.04, 1.40]).

CONCLUSION

This study suggested that insulin glargine use might be associated with a lower risk of AMI, compared to the other long/intermediate acting insulin use, and that insulin regimen of rapid/short acting insulin, premixed insulin, or mixed use of insulin except insulin glargine was associated with a higher risk of stroke using the same reference.

Type 2 diabetes mellitus: a high-risk condition for cardiovascular disease irrespective of the different degrees of obesity

BACKGROUND

Measurement of body weight with body mass index (BMI) is often utilized to stratify cardiovascular disease (CVD) risk.

AIM

To determine CVD risk profile and disease burden in subjects with type 2 diabetes mellitus (T2DM) across different categories of body weight as defined by BMI.

DESIGN

Prospective observational study.

METHODS

CVD risk including metabolic syndrome (MetS) and prevalence of macrovascular complications were determined for each category of body weight as defined by the World Health Organisation (WHO) classification.

RESULTS

A total of 390 subjects were included in this study of which 35.9% were non-obese (BMI <30 kg/m(2)). Although increasing obesity as defined by BMI was associated with higher prevalence of central abdominal obesity, hypertension and MetS (P < 0.05), dyslipidaemia and macrovascular complications were not significantly different across the various body weight categories (P = NS). Similar observation was seen in non-obese (BMI <30 kg/m(2)) and obese subjects (BMI >30 kg/m(2)). Among non-obese (including normal weight) cohort, the majority of these subjects had adverse CVD risk profile including presence of at least two co-existing risk factors.

CONCLUSION

Subjects with T2DM possess adverse CVD risk factors with significant burden of macrovascular disease irrespective of their baseline body weight.

Global complication rates of type 2 diabetes in Indigenous peoples: A comprehensive review

INTRODUCTION AND OBJECTIVE

The world's Indigenous peoples are experiencing an unprecedented epidemic of type 2 diabetes [T2DM] but little has been published describing the complications burden. The objective of this paper was to conduct a systematic review of T2DM complications in Indigenous populations worldwide.

METHODS

A literature review was conducted using PubMed and EMBASE to examine available complications data. Country, Indigenous population, authors, publication year, total sample size, Indigenous sample size, age, methodology, and prevalence of nephropathy, end-stage renal disease, retinopathy, neuropathy, lower extremity amputations, cardiovascular disease, hospitalizations and mortality due to diabetes were recorded.

RESULTS

One-hundred and eleven studies were selected. Results revealed a disproportionate burden of disease complications among all Indigenous peoples regardless of their geographic location. Complication rates were seen to vary widely across Indigenous groups.

DISCUSSION

Gaps were found in the published literature on complications among Indigenous populations, especially those living in underdeveloped countries. These gaps may be in part due to the challenges caused by varying operational practices, research methodologies, and definitions of the term Indigenous, making documentation of rates among these peoples problematic. Comprehensive surveillance applying standardized definitions and methodologies is needed to design targeted prevention and disease management strategies for Indigenous peoples with T2DM.

Effects of chronic hyperinsulinemia in insulin-resistant patients

Selective insulin resistance influences pathogenesis and treatment of type 2 diabetes and metabolic syndrome. Downregulation of the antiatherogenic pathway and maintained activity of the proatherogenic and cancerogenic pathways lead to atherosclerosis and cancer. Exogenous insulin added to "compensatory" hyperinsulinemia might worsen the primary end points, resulting in potential increase in cardiovascular and cancer events in spite of improvement of surrogate metabolic end points. Conversely, metformin can improve primary and surrogate end points.

Pathogenic potential of adipose tissue and metabolic consequences of adipocyte hypertrophy and increased visceral adiposity

When caloric intake exceeds caloric expenditure, the positive caloric balance and storage of energy in adipose tissue often causes adipocyte hypertrophy and visceral adipose tissue accumulation. These pathogenic anatomic abnormalities may incite metabolic and immune responses that promote Type 2 diabetes mellitus, hypertension and dyslipidemia. These are the most common metabolic diseases managed by clinicians and are all major cardiovascular disease risk factors. 'Disease' is traditionally characterized as anatomic and physiologic abnormalities of an organ or organ system that contributes to adverse health consequences. Using this definition, pathogenic adipose tissue is no less a disease than diseases of other body organs. This review describes the consequences of pathogenic fat cell hypertrophy and visceral adiposity, emphasizing the mechanistic contributions of genetic and environmental predispositions, adipogenesis, fat storage, free fatty acid metabolism, adipocyte factors and inflammation. Appreciating the full pathogenic potential of adipose tissue requires an integrated perspective, recognizing the importance of 'cross-talk' and interactions between adipose tissue and other body systems. Thus, the adverse metabolic consequences that accompany fat cell hypertrophy and visceral adiposity are best viewed as a pathologic partnership between the pathogenic potential adipose tissue and the inherited or acquired limitations and/or impairments of other body organs. A better understanding of the physiological and pathological interplay of pathogenic adipose tissue with other organs and organ systems may assist in developing better strategies in treating metabolic disease and reducing cardiovascular disease risk.

Plasma glucose regulation and mortality in pima Indians

OBJECTIVE

To evaluate whether impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT) are associated with increased risk of mortality and prevalent ischemic heart disease (IHD) and to analyze if the increased risk of death is dependent on subsequent development of diabetes in Pima Indians.

RESEARCH DESIGN AND METHODS

A total of 2,993 Pima Indians aged >or=35 years were included. Prevalent IHD, defined by major ischemic electrocardiogram changes, was evaluated according to the following glucose/diabetes categories: normal glucose regulation (NGR), IFG and/or IGT, and diabetic groups by duration. During a median follow-up of 10.4 years, 780 subjects died from natural causes and 156 of these died from IHD. Mortality was analyzed according to the same glucose/diabetes categories at baseline and then as time-dependent variables.

RESULTS

Only subjects with diabetes >or=15 years of duration have a higher prevalence of IHD (odds ratio 1.9 [95% CI 1.4-2.5]) relative to NGR. In baseline and time-dependent models, age- and sex-adjusted death rates from natural causes and from IHD were similar among the nondiabetic groups. Among diabetic subjects, natural mortality was higher in those with >or=15 years diabetes duration (death rate ratio [DRR] relative to NGR = 2.6 [95% CI 2.1-3.3]). IHD mortality was higher in subjects with long diabetes duration (DRR for diabetes 10-15 years = 3.8 [1.5-9.5]; DRR for diabetes >or=15 years = 8.6 [3.8-19.4]) in the time-dependent model.

CONCLUSIONS

Natural and IHD mortality are not increased in Pima Indians with IFG and/or IGT. Only after the onset of diabetes do the rates of these events increase relative to NGR.

Effect of periodontitis on overt nephropathy and end-stage renal disease in type 2 diabetes

OBJECTIVE

The purpose of this study was to investigate the effect of periodontitis on development of overt nephropathy, defined as macroalbuminuria, and end-stage renal disease (ESRD) in type 2 diabetes.

RESEARCH DESIGN AND METHODS

Individuals residing in the Gila River Indian Community aged > or =25 years with type 2 diabetes, one or more periodontal examination, estimated glomerular filtration rate > or =60 ml/min per 1.73 m(2), and no macroalbuminuria (urinary albumin-to-creatinine ratio > or =300 mg/g) were identified. Periodontitis was classified as none/mild, moderate, severe, or edentulous using number of teeth and alveolar bone score. Subjects were followed to development of macroalbuminuria or ESRD, defined as onset of renal replacement therapy or death attributed to diabetic nephropathy.

RESULTS

Of the 529 individuals, 107 (20%) had none/mild periodontitis, 200 (38%) had moderate periodontitis, 117 (22%) had severe periodontitis, and 105 (20%) were edentulous at baseline. During follow-up of up to 22 years, 193 individuals developed macroalbuminuria and 68 developed ESRD. Age- and sex-adjusted incidence of macroalbuminuria and ESRD increased with severity of periodontitis. After adjustment for age, sex, diabetes duration, BMI, and smoking in a proportional hazards model, the incidences of macroalbuminuria were 2.0, 2.1, and 2.6 times as high in individuals with moderate or severe periodontitis or those who were edentulous, respectively, compared with those with none/mild periodontitis (P = 0.01). Incidences of ESRD in individuals with moderate or severe periodontitis or in those who were edentulous were 2.3, 3.5, and 4.9 times as high, respectively, compared with those with none/mild periodontitis (P = 0.02).

CONCLUSIONS

Periodontitis predicts development of overt nephropathy and ESRD in individuals with type 2 diabetes. Whether treatment of periodontitis will reduce the risk of diabetic kidney disease remains to be determined.

Ethnicity and diabetic heart disease

Ethnicity is a complex yet important construct and an independent risk factor for diabetic heart disease (DHD) with paramount clinical significance. Clinicians should try to better understand the role of ethnicity through more questions. The risk of DHD is modified by ethnicity through more questions. The risk of DHD is modified by ethnicity, and its management may require a culturally sensitive individualized approach. Findings from Caucasian populations cannot be fully extrapolated to other ethnic groups, thereby emphasizing the importance of future research with ethnicity-based threshold for obesity. Available limited data support the interaction between genetic predisposition, environmental risk, and lifestyle choices and disparities based on ethnicity as the likely cause for ethnic variations in DHD.

Electrocardiographic abnormalities predict deaths from cardiovascular disease and ischemic heart disease in Pima Indians with type 2 diabetes

BACKGROUND

The association between electrocardiographic (ECG) abnormalities and deaths from cardiovascular diseases (CVD) and ischemic heart disease (IHD) has been reported in the general population, but there is little information regarding persons with type 2 diabetes.

METHODS

Minor and major ECG abnormalities were identified and classified according to the Minnesota Code in a longitudinal study of 1605 Pima Indians aged > or =35 years with type 2 diabetes. Underlying causes of death were determined by review of all available clinical records, autopsy reports, medical examiners' findings, and death certificates.

RESULTS

During a median follow-up of 14.1 years (range 0.1 to 33.8 years), there were 190 CVD deaths, 135 (71.1%) of which were attributable to IHD. The age-adjusted CVD death rates in men with none, minor, and major ischemic ECG abnormalities were 7.3, 12.2 and 27.8, and in women, 4.3, 4.8 and 12.5 per 1000 person-years, respectively. After adjustment for other co-variables in a multiple proportional hazards model, subjects with minor and major ischemic abnormalities on ECG had 1.22 (95% CI, 0.76-1.97) and 1.83 (95% CI, 1.21-2.76) times the CVD death rate, and 1.32 (95% CI, 0.70-2.50) and 2.12 (95% CI, 1.26-3.57) times the IHD death rate of those with no ischemic ECG abnormalities, respectively.

CONCLUSIONS

The CVD and IHD death rates were higher in men and in subjects with major ischemic ECG abnormalities. Major ischemic abnormalities on ECG predicted death after accounting for other cardiovascular risk factors, including proteinuria.

Cardiac procedure use following acute myocardial infarction among American Indians

BACKGROUND

The prevalence of coronary heart disease is rising among American Indians (AIs), but there is limited evidence describing processes of care for AI with acute myocardial infarction (AMI). We compared rates of cardiac catheterization, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) surgery between AI and whites with AMI.

METHODS

Using data from the Nationwide Inpatient Sample and the Indian Health Service National Patient Information Reporting System, we identified 2511 AI and 316,526 whites older than 30 years admitted with AMI during 1998 to 2001. Comparisons of cardiac procedure use between AI and whites were performed after adjusting for comorbid conditions and after stratifying by geographic region.

RESULTS

American Indians were less likely than whites to undergo cardiac catheterization and PCI in 3 of 4 geographic regions, with the largest difference occurring in the West South Central region (OR 0.32, 95% CI 0.24 to 0.43 for catheterization; OR 0.43, 95% CI 0.31 to 0.57 for PCI). American Indians were less likely than whites to undergo CABG surgery among diabetic patients (OR 0.48, 95% CI 0.32-0.73), but not among nondiabetic patients (OR 0.90, 95% CI 0.72-1.12). There were no differences in rates of PCI and CABG surgery between AIs and whites among those receiving cardiac catheterization.

CONCLUSIONS

Differences in the performance of coronary procedures are concentrated in western regions of the United States and are especially related to access to cardiac catheterization. Future studies are indicated to elucidate the mechanisms of these differences in care and their impact on clinical outcomes.

The adipocyte life cycle hypothesis

The adipocyte life cycle hypothesis states that the metabolic properties of an adipocyte vary predictably during its life cycle: that as an adipocyte matures, it accumulates triacylglycerol (triglyceride) and becomes larger; that the rates of triacylglycerol synthesis and lipolysis are matched within adipocytes and that larger adipocytes, in general, have greater rates of triacylglycerol synthesis and, concurrently, greater rates of lipolysis and, therefore, larger adipocytes have greater rates of transmembrane fatty acid flux; and that the secretion of cytokines can also be related to adipocyte size with larger adipocytes having a more unfavourable profile of cytokine secretion than smaller adipocytes. Adipocyte location is an important modifier of this relationship and the favoured sites of adipocyte proliferation are a function of gender and the position within the life cycle of the organism at which proliferation occurs. The adipocyte life cycle hypothesis posits that the metabolic consequences of obesity depend on whether expansion of adipose tissue is achieved primarily by an increase in adipocyte number or adipocyte size. This hypothesis may explain a variety of previously unanswered clinical puzzles such as the vulnerability of many peoples from South East Asia to the adverse metabolic consequences of obesity.

CVD risk factors and ethnicity--a homogeneous relationship?

Current understanding of cardiovascular disease risk (CVD) is derived largely from studies of Caucasians of European origin. However, people of certain ethnic groups experience a disproportionately greater burden of CVD including coronary heart disease (CHD) and stroke. Adoption of a Westernised lifestyle has different effects on metabolic and vascular dysfunction across populations, e.g. South Asians have a higher prevalence of coronary heart disease (CHD) and cardiovascular mortality compared with Europeans. African-Americans demonstrate higher rates of CHD and stroke while African/Caribbeans in the UK have lower CHD rates and higher stroke rates than British Europeans. Other non-European groups such as the Chinese and Japanese exhibit consistently high rates of stroke but not CHD, while Mexican Americans have a higher prevalence of both stroke and CHD, and North American native Indians also have high rates of CHD. While conventional cardiovascular risk factors such as smoking, blood pressure and total cholesterol predict risk within these ethnic groups, they do not fully account for the differences in risk between ethnic groups, suggesting that alternative explanations might exist. Ethnic groups show differences in levels of visceral adiposity, insulin resistance, and novel risk markers such as C-reactive protein (CRP), adiponectin and plasma homocysteine. The marked differences across racial and ethnic groups in disease risk are likely due in part to each of genetic, host susceptibility and environmental factors, and can provide valuable aetiological clues to differences in patterns of disease presentation, therapeutic needs and response to treatment. Ongoing studies should increase understanding of ethnicity as a potential independent risk factor, thus enabling better identification of treatment targets and selection of therapy in specific populations.

Trends in heart disease death rates in diabetic and nondiabetic Pima Indians

BACKGROUND

Secular trends over 34 years (1965-1998) in overall and cause-specific mortality were examined in 4,623 Pima Indians >or=35 years old.

METHODS

The underlying and contributing causes of the 1,363 deaths were determined from a review of all available clinical records; 540 of the deaths occurred in the 2,528 nondiabetic participants and 823 in the 2,095 participants who had diabetes during all or part of the study period. Age/sex-adjusted death rates were calculated across four 8.5-year time intervals.

RESULTS

In the nondiabetic participants, the rate of death from natural causes declined gradually over time (20.4, 17.3, 17.3, and 16.0 deaths per 1,000 persons/year; P=.11); deaths from ischemic heart disease (IHD) were uncommon (n=22), and the rate did not change appreciably, remaining as the fifth leading natural cause of death. In the diabetic participants, the rate of death from natural causes was unchanged over time, but the rate of death from IHD (n=141) increased nearly twofold (3.3, 4.2, 6.4, and 6.4 deaths per 1,000 persons/year; P<.01), becoming the leading cause of death in the third and fourth time intervals.

CONCLUSIONS

The rate of death from IHD remained stable in nondiabetic Pima Indians but increased among those with diabetes. This finding suggests that, in the absence of diabetes, the underlying susceptibility to IHD in this population has not changed.

High cumulative insulin exposure: a risk factor of atherosclerosis in type 1 diabetes?

BACKGROUND

Since insulin therapy might have an atherogenic effect, we studied the relationship between cumulative insulin dose and atherosclerosis in type 1 diabetes. We have focused on patients with type 1 diabetes instead of type 2 diabetes to minimise the effect of insulin resistance as a potential confounder.

METHODS

An observational study was performed in 215 subjects with type 1 diabetes treated with multiple insulin injection therapy. Atherosclerosis was assessed by measurement of carotid intima-media thickness (CIMT).

RESULTS

The cumulative dose of regular insulin showed a positive and significant relation with CIMT: increase of 21 microm in CIMT per S.D. of insulin use (95% CI: 8-35 adjusted for gender and age), which remained unchanged after adjustment for duration of diabetes, HbA1c, BMI, pulse pressure, physical activity and carotid lumen diameter. A similar relation was found for intermediate-acting insulin: 15.5 microm per S.D. (2-29), which was no longer present after further adjustment.

CONCLUSIONS

These findings provide evidence that a high cumulative dose of regular insulin is a risk factor for atherosclerosis.

Predominant effect of kidney disease on mortality in Pima Indians with or without type 2 diabetes

BACKGROUND

We examined the effect of kidney disease (KD) on mortality in nondiabetic and diabetic Pima Indians aged > or = 45 years old.

METHODS

Deaths and person-years of follow-up were stratified in a time-dependent fashion into categories of (1) no proteinuria and normal serum creatinine (SCr); (2) proteinuria and normal SCr; (3) high SCr [SCr > or = 133 micromol/L (1.5 mg/dL) in men, > or = 124 micromol/L (1.4 mg/dL) in women] but not on renal replacement therapy (RRT); or (4) RRT.

RESULTS

Among 1993 subjects, 55.8% had type 2 diabetes at baseline. Overall death rates increased with declining kidney function in both the nondiabetic and diabetic subjects (P < 0.0001). Death rates were similar in nondiabetic and diabetic subjects with comparable levels of kidney function, although the number of deaths among nondiabetic subjects with advanced KD was small. Infections and malignancy were the leading causes of death in nondiabetic subjects with KD. Among diabetic subjects, overall mortality increased with diabetes duration (P = 0.0001) and was highest in those on RRT (P < 0.0001). High SCr was associated with higher death rates from cardiovascular disease (CVD), diabetic nephropathy (DN), infections, and malignancy.

CONCLUSION

Death rates increased comparably with worsening kidney function in both nondiabetic and diabetic subjects and were similar in nondiabetic and diabetic subjects without KD. KD was associated with excess mortality from DN, CVD, infections, and malignancy in diabetic subjects, and from infections in those without diabetes.

Prevalence and risk factors for prolonged QTc in a multiethnic cohort in rural Hawaii

BACKGROUND

Few studies have examined the biochemical risk factors for prolonged QTc, a predictor of mortality in numerous studies. We report on the prevalence and risk factors for prolonged QTc in a multiethnic population in rural Hawaii.

METHODS

Electrocardiograms were collected from 1415 participants in a cross-sectional survey. The QT interval lengths were corrected for heart rate using Bazett's formula. Linear and logistic regression models were used to examine associations between various cardiovascular risk factors with QTc.

RESULTS

Among the CVD risk factors examined, only age, gender, 2-h glucose, and systolic blood pressure (SBP) were independently associated with QTc interval length. Significant ethnic differences in prevalence were also observed, which persisted after controlling for other risk factors.

CONCLUSIONS

Significant associations between prolonged QTc and ethnic ancestry, but not cholesterol or triglyceride levels, suggest that genetic factors may play a more important role in determining QTc interval length than conventional biochemical and metabolic CVD risk factors.

Insulin treatment and cardiovascular disease; friend or foe? A point of view

BACKGROUND

Several observational studies have shown that higher insulin levels are associated with an increased risk of cardiovascular disease. If higher endogenous insulin levels are causally related to cardiovascular disease, one might expect an increased risk of cardiovascular disease in patients treated with insulin, as this results in high circulating insulin levels. Such risk elevation might counteract the benefits of tight glucose control. Our objective was to explore the relationship between insulin therapy and cardiovascular disease in Type 1 and Type 2 diabetes mellitus using information from available literature.

SUMMARY OF COMMENT

Several experimental studies in animals and humans support the presence of a harmful effect of insulin on the vascular endothelium. In prospective follow-up studies increased insulin dosage was associated with increased risks of cardiovascular disease, although confounding by indication could not be excluded. Randomized controlled trials in diabetic patients, comparing conventional with intensive glucose-lowering treatment, although showing a reduction in microvascular disease, showed no significant difference in the incidence of cardiovascular disease. The results with respect to exposure to insulin are, however, difficult to interpret due to insufficient information on exposure to insulin levels as well as confounding by glycaemic control and body mass index. In addition, these studies were not designed to address the question whether higher insulin use relates to increased cardiovascular risk.

CONCLUSION

Published research provides conflicting evidence as to whether exposure to high levels of exogenous insulin in diabetes mellitus affects the risk of cardiovascular disease. The currently available studies have a number of serious methodological restraints that limit accurate interpretation and conclusions in this area.