Risk factors of peripheral arterial disease and relationship between low ankle - brachial index and mortality from all-cause and cardiovascular disease in Chinese patients with type 2 diabetes

Adiponectin rs1501299 and chemerin rs17173608 gene polymorphism in children with type 1 diabetes mellitus: relation with macroangiopathy and peripheral artery disease

AIM

Although macrovascular complications represent the leading cause of mortality in type 1 diabetes mellitus (T1DM), the prevalence of subtle macrovascular affection including peripheral artery disease (PAD) among children with T1DM and its genetic predictors remains to be unraveled. Increasing evidence suggests a link between adiponectin rs1501299 and chemerin rs17173608 gene polymorphism and atherogenesis, and insulin resistance. Hence, this study assess the prevalence of these variants among children with T1DM in comparison to healthy controls and their association with macrovascular complications, namely PAD and hyperlipidemia.

METHODS

Fifty children with T1DM and 50 matched controls underwent a thorough assessment including adiponectin rs1501299 and chemerin rs17173608 gene polymorphisms, fasting lipids, glycated hemoglobin (HbA1c), and ankle-brachial index (ABI). Cochran-Armitage trend test was used to decide the risk allele and evaluate the association between the candidate variant and PAD using a case-control design.

RESULTS

Children with T1DM were found to have significantly higher ABI (p = 0.011) than controls. Chemerin gene polymorphism was detected in 41 children with T1DM (82.0%), while adiponectin gene polymorphism was detected in 19 children (38.0%). Children with T1DM having GG chemerin variant and those having TT adiponectin variant had significantly higher cholesterol with significantly lower HDL-C and ABI than those having the other two variants (p < 0.005). Children with T1DM having abnormal ABI had significantly higher chemerin G (p = 0.017) and adiponectin T (p = 0.022) alleles than those with normal ABI. Cholesterol and ABI were independently associated with chemerin and adiponectin gene polymorphism by multivariable regression analysis.

CONCLUSION

Children with T1DM having chemerin and adiponectin gene polymorphisms have significantly higher cholesterol and ABI than those without these polymorphisms and controls.

TRIAL REGISTRATION

The Research Ethics Committee of Ain Shams University, approval number R 31/2021.

2023 UPDATE: Luso-Brazilian evidence-based guideline for the management of antidiabetic therapy in type 2 diabetes

BACKGROUND

The management of antidiabetic therapy in people with type 2 diabetes (T2D) has evolved beyond glycemic control. In this context, Brazil and Portugal defined a joint panel of four leading diabetes societies to update the guideline published in 2020.

METHODS

The panelists searched MEDLINE (via PubMed) for the best evidence from clinical studies on treating T2D and its cardiorenal complications. The panel searched for evidence on antidiabetic therapy in people with T2D without cardiorenal disease and in patients with T2D and atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), or diabetic kidney disease (DKD). The degree of recommendation and the level of evidence were determined using predefined criteria.

RESULTS AND CONCLUSIONS

All people with T2D need to have their cardiovascular (CV) risk status stratified and HbA1c, BMI, and eGFR assessed before defining therapy. An HbA1c target of less than 7% is adequate for most adults, and a more flexible target (up to 8%) should be considered in frail older people. Non-pharmacological approaches are recommended during all phases of treatment. In treatment naïve T2D individuals without cardiorenal complications, metformin is the agent of choice when HbA1c is 7.5% or below. When HbA1c is above 7.5% to 9%, starting with dual therapy is recommended, and triple therapy may be considered. When HbA1c is above 9%, starting with dual therapyt is recommended, and triple therapy should be considered. Antidiabetic drugs with proven CV benefit (AD1) are recommended to reduce CV events if the patient is at high or very high CV risk, and antidiabetic agents with proven efficacy in weight reduction should be considered when obesity is present. If HbA1c remains above target, intensification is recommended with triple, quadruple therapy, or even insulin-based therapy. In people with T2D and established ASCVD, AD1 agents (SGLT2 inhibitors or GLP-1 RA with proven CV benefit) are initially recommended to reduce CV outcomes, and metformin or a second AD1 may be necessary to improve glycemic control if HbA1c is above the target. In T2D with HF, SGLT2 inhibitors are recommended to reduce HF hospitalizations and mortality and to improve HbA1c. In patients with DKD, SGLT2 inhibitors in combination with metformin are recommended when eGFR is above 30 mL/min/1.73 m2. SGLT2 inhibitors can be continued until end-stage kidney disease.

Prediction of all-cause and cardiovascular mortality using ankle-brachial index and brachial-ankle pulse wave velocity in patients with type 2 diabetes

Ankle-brachial index (ABI) and brachial-ankle pulse wave velocity (baPWV) are used as non-invasive indicators for detecting atherosclerosis and arterial stiffness, two well-known predictors of mortality in patients with type 2 diabetes mellitus (T2DM). ABI and baPWV have independent associations with mortality; however, their joint and interactive effects on mortality have not been assessed in patients with T2DM. This work aims to evaluate the independent, joint, and interactive associations of ABI and baPWV with all-cause and expanded cardiovascular disease (CVD) mortality in patients with T2DM. This observational study included 2160 patients with T2DM enlisted in the Diabetes Care Management Program database of China Medical University Hospital from 2001 to 2016 and then followed their death status until August 2021. Cox proportional hazard models were used to evaluate the independent, joint, and interactive effects of ABI and baPWV on the risk of all-cause and expanded CVD mortality. A total of 474 patient deaths occurred after a mean follow-up of 8.4 years, and 268 of which were attributed to cardiovascular events. Abnormal ABI (≤ 0.9) and highest baPWV quartile were independently associated with increased risks of all-cause [ABI: hazard ratio (HR) 1.67, 95% confidence interval (CI) 1.30–2.11; baPWV: 1.63, 1.16–2.27] and expanded CVD mortality (ABI: 2.21, 1.62–3.02; baPWV: 1.75, 1.09–2.83). The combination of abnormal ABI (≤ 0.9) and highest baPWV quartile was associated with a significantly higher risk of all-cause (4.51, 2.50–8.11) and expanded CVD mortality (9.74, 4.21–22.51) compared with that of the combination of normal ABI and lowest baPWV quartile. Significant interactions were observed between ABI and baPWV in relation to all-cause and expand CVD mortality (both p for interaction < 0.001). Through their independent, joint, and interactive effects, ABI and baPWV are significant parameters that can improve the prediction of all-cause and expanded CVD mortality in patients with T2DM and help identify high-risk patients who may benefit from diabetes care.

The Predictability of Cystatin C for Peripheral Arterial Disease in Chinese Population with Type 2 Diabetes Mellitus

OBJECTIVES

Peripheral artery disease (PAD) in diabetic populations is a vital chronic disease all over the world due to its high morbidity and mortality. It is important to find early simple screening biomarkers and find residual risk factors that may provide a new target for prevention and treatment of PAD in diabetic patients besides traditional cardiometabolic risk factors.

METHODS

We performed a cross-sectional retrospective study, and a total of 1671 T2DM participants were recruited. Receiver operating characteristic analysis, stepwise logistic regression analysis, points score system, and decision curve analysis were performed to assess the risk factors for PAD.

RESULTS

The prevalence of PAD in the study was 7.18% (n = 120). Compared to the participants with the lowest quartile of cystatin C (CysC), the risk of developing PAD in participants with the highest quartile of CysC increased 6.339-fold. The CysC was the superior indicators to distinguish participants with PAD from those without PAD, with an AUC of 0.716. Stepwise logistic regression analysis showed that CysC was independent risk factor for PAD besides traditional risk factors. Combined exposure to these traditional risk factors and CysC was associated with a stepwise increase in the risk of developing PAD and even increased 11.976-fold in participants with the highest quintiles of combined exposure score (CES) based on traditional risk factors and CysC compared to the participants with the lowest quintiles of CES.

CONCLUSIONS

CysC was associated with PAD independent of potential risk factors in diabetic populations. The CysC was a reliable marker for the early screening of PAD in diabetic patients besides traditional cardiometabolic risk factors.

Correlation between the ankle-brachial index and microalbuminuria with certain risk factors in type 2 diabetes patients

The ankle-brachial index (ABI) is a fast, simple, noninvasive method that provides accurate results in the early diagnosis of peripheral artery disease. Microalbuminuria is considered a predictor of renal and cardiovascular complications in patients with diabetes. This study was conducted to determine the correlation between ABI and microalbuminuria with certain risk factors in patients with type 2 diabetes.

Subjects and research methods

A cross-sectional descriptive study was performed on 62 inpatients with type 2 diabetes. All patients were measured for ABI as well as microalbuminuria, HbA1c, glucose and lipidemia in the blood.

Results

The study results showed that in patients with dyslipidemia, the risk of having microalbuminuria (+) increased 5.7 times and ABI ≤0.90 increased 8.6 times (P = 0.004 and 0.021, respectively). Fasting blood glucose >7.2 mmol/L had 5.7 times higher microalbuminuria (+) risk and 8.6 times higher ABI ≤0.90 (P = 0.004 and 0.021, respectively). Patients with HbA1c ≥7% were 2.9 times more likely to have microalbuminuria (+) and ABI ≤0.90 (P = 0.043 and 0.048, respectively).

Conclusions

Peripheral vascular disease risk factors such as hypertension, dyslipidemia and waist circumference and the effectiveness of fasting blood glucose and HbA1c control increased the risk of high microalbuminuria and ABI in patients with type 2 diabetes.

Case Report: Diabetic nephropathy aggravates the progression and prognosis of COVID-19-associated acute limb ischemia

Hypercoagulation is a hallmark of both the novel coronavirus disease (COVID-19) and type 2 diabetes mellitus (T2DM). It increases the risk for vascular thrombosis, including peripheral artery diseases. Among others, acute limb ischemia (ALI) is one of most common complications that requires immediate and prompt treatments to reduce morbidity and mortality. However, the complex interplay between COVID-19, T2DM and its complications (e.g., diabetic nephropathy), and ALI creates a great challenge in the management of the disease. Here, we present a case of a 59-year-old diabetic female with progressive pain in her left leg in the last five years, which was significantly intensified following COVID-19 diagnosis. Bluish coloration, numbness and functional impairments were observed during examinations with no palpable pulsation on left posterior tibial and dorsalis pedis arteries. The patient also had diabetic nephropathy (stage III), hypoalbuminemia, anemia and a urinary tract infection that complicated the management of the disease. Due to the excruciating pain and the worsening of the limb conditions, right leg revascularization and left leg amputation were performed at day 14 after admission. Following the surgeries, no more pain was observed and patient was discharged for further follow-up at the outpatient clinic.

Diabetic patients with chronic kidney disease: Non-invasive assessment of cardiovascular risk

The prevalence and burden of diabetes mellitus and chronic kidney disease on global health and socioeconomic development is already heavy and still rising. Diabetes mellitus by itself is linked to adverse cardiovascular events, and the presence of concomitant chronic kidney disease further amplifies cardiovascular risk. The culmination of traditional (male gender, smoking, advanced age, obesity, arterial hypertension and dyslipidemia) and non-traditional risk factors (anemia, inflammation, proteinuria, volume overload, mineral metabolism abnormalities, oxidative stress, etc.) contributes to advanced atherosclerosis and increased cardiovascular risk. To decrease the morbidity and mortality of these patients due to cardiovascular causes, timely and efficient cardiovascular risk assessment is of huge importance. Cardiovascular risk assessment can be based on laboratory parameters, imaging techniques, arterial stiffness parameters, ankle-brachial index and 24 h blood pressure measurements. Newer methods include epigenetic markers, soluble adhesion molecules, cytokines and markers of oxidative stress. In this review, the authors present several non-invasive methods of cardiovascular risk assessment in patients with diabetes mellitus and chronic kidney disease.

The risk of micro and macrovascular disease in Egyptian patients with diabetes and peripheral arterial disease

Aim: The aim of this study was to assess the prevalence of micro- and macrovascular disease in Egyptian patients with diabetes mellitus (DM) and peripheral arterial disease (PAD). Methods: The study included 161 Egyptian patients with DM and PAD (91.3% had type 2 DM and 67.1% were females). Mean diabetes duration was 14.2 ± 5.2 years. Full history, clinical and fundus examination as well as laboratory investigations were done. PAD was diagnosed through assessment of ankle/brachial index (ABI) by Doppler ultrasonography. Results: ABI was <0.9 in 33.5% and >1.3 in 66.5% of patients. A significant positive correlation was found between abnormal ABI and diabetes duration, ischemic heart disease (IHD), diabetic retinopathy and neuropathy, foot ulcers, elevated blood pressure (BP), creatinine, urine albumin/creatinine ratio (ACR) and triglycerides and a significant negative correlation with HDL. Multivariate regression analysis revealed that the independent predictors for PAD in patients with ABI< 0.9 were neuropathy, creatinine, triglyceride, LDL, urine ACR and low HDL, and in patients with ABI >1.3 were IHD, neuropathy, elevated diastolic BP and triglyceride. Conclusion: The risk of micro- and macrovascular disease is high in Egyptian patients with diabetes and PAD. Early diagnosis and good control of risk factors could reduce PAD progression.

Associations Between Systolic Interarm Differences in Blood Pressure and Cardiovascular Disease Outcomes and Mortality: Individual Participant Data Meta-Analysis, Development and Validation of a Prognostic Algorithm: The INTERPRESS-IPD Collaboration

Systolic interarm differences in blood pressure have been associated with all-cause mortality and cardiovascular disease. We undertook individual participant data meta-analyses to (1) quantify independent associations of systolic interarm difference with mortality and cardiovascular events; (2) develop and validate prognostic models incorporating interarm difference, and (3) determine whether interarm difference remains associated with risk after adjustment for common cardiovascular risk scores. We searched for studies recording bilateral blood pressure and outcomes, established agreements with collaborating authors, and created a single international dataset: the Inter-arm Blood Pressure Difference - Individual Participant Data (INTERPRESS-IPD) Collaboration. Data were merged from 24 studies (53 827 participants). Systolic interarm difference was associated with all-cause and cardiovascular mortality: continuous hazard ratios 1.05 (95% CI, 1.02-1.08) and 1.06 (95% CI, 1.02-1.11), respectively, per 5 mm Hg systolic interarm difference. Hazard ratios for all-cause mortality increased with interarm difference magnitude from a ≥5 mm Hg threshold (hazard ratio, 1.07 [95% CI, 1.01-1.14]). Systolic interarm differences per 5 mm Hg were associated with cardiovascular events in people without preexisting disease, after adjustment for Atherosclerotic Cardiovascular Disease (hazard ratio, 1.04 [95% CI, 1.00-1.08]), Framingham (hazard ratio, 1.04 [95% CI, 1.01-1.08]), or QRISK cardiovascular disease risk algorithm version 2 (QRISK2) (hazard ratio, 1.12 [95% CI, 1.06-1.18]) cardiovascular risk scores. Our findings confirm that systolic interarm difference is associated with increased all-cause mortality, cardiovascular mortality, and cardiovascular events. Blood pressure should be measured in both arms during cardiovascular assessment. A systolic interarm difference of 10 mm Hg is proposed as the upper limit of normal. Registration: URL: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42015031227.

Risk factors for peripheral arterial disease in elderly patients with Type-2 diabetes mellitus: A clinical study

Objectives:

To determine risk factors for peripheral arterial disease (PAD) in elderly patients with Type-2 diabetes mellitus.

Methods:

The elderly patients with Type-2 diabetes treated in the Central Hospital of Cangzhou were enrolled and divided into PAD group and non-PAD group between October 2016 and November 2019, The data of the patients including age, gender, body mass index, blood pressure, hemoglobin A1c, high-density lipoprotein-cholesterol, low-density lipoprotein-cholesterol, total cholesterol, triglyceride, white cell count, lymphocyte count, high-sensitivity C-reactive protein, uric acid as well as living habits and complications of Type-2 diabetes mellitus were recorded to determine the risk factors for PAD.

Results:

One thousand four hundred seventy six (1476) patients were enrolled, in which 465 patients were included in group of PAD, and 1011 in non-PAD group. The univariate analysis revealed that the two groups significantly differed in age (p=0.003), course of T2DM (p=0.001), hypertension (p=0.006), smoking habits (p<0.001), hyperuricemia (p<0.01), high-sensitivity C-reactive protein (p<0.01), white cell count (p<0.001), lymphocyte count (p<0.001) and diabetic neuropathy (p<0.001). In the multivariate analysis, age (OR: 1.56, 95% CI: 1.21-1.89), smoking habit (OR: 1.37, 95% CI: 1.19-1.68), hypertension (OR: 1.44, 95% CI: 1.15-1.98), diabetic neuropathy (OR: 3.55, 95% CI: 2.14-4.29), high-sensitivity C-reactive protein (OR: 1.74, 95% CI: 1.39-2.61) and hyperuricemia (OR: 2.71, 95% CI: 1.66-3.87) were significant risk factors for PAD.

Conclusions:

Age, smoking habit, hypertension, diabetic neuropathy, high-sensitivity C-reactive protein and hyperuricemia were independent risk factors for peripheral arterial disease in elderly patients with Type-2 diabetes mellitus.

Prediction and early detection of cardiovascular disease in South Asians with diabetes mellitus

BACKGROUND

Although diabetes mellitus (DM) is no longer considered "coronary heart disease risk equivalent", the risk remains sufficiently high, necessitating early recognition and management of cardiovascular disease (CVD) in these patients. Despite this understanding, the optimum strategy for prediction and early detection of CVD in DM remains debatable.

METHODS

Major societal guidelines for prediction and evaluation of CVD in subjects with or without DM were reviewed. Available evidence about various risk stratification strategies-their advantages, disadvantages and current role in clinical practice-were extensively reviewed. Special emphasis was placed on evidence from South Asian/Indian populations.

RESULTS

The inconsistency and variability inherent to the clinical risk algorithms, lack of consensus regarding the incremental value of subclinical atherosclerosis imaging and the lack of sufficient data to demonstrate the benefits of recognizing asymptomatic atherosclerotic disease are some of the reasons underlying prevailing uncertainty about the optimum approach for cardiovascular risk assessment in DM. These challenges notwithstanding, an evidence-based cardiovascular risk stratification strategy incorporating clinical risk algorithms, biomarkers, atherosclerosis imaging, and cardiac stress testing is proposed.

CONCLUSIONS

The proposed algorithm should help clinicians in optimizing cardiovascular evaluation and management of their patients with DM. However, this remains a dynamic field; further research into different risk assessment tools, esp. focusing on their impact on improving clinical outcomes, should help refine the evaluation strategy in future.

The Impact of High-Intensity Interval Training Versus Moderate-Intensity Continuous Training on Carotid Intima-Media Thickness and Ankle-Brachial Index in Middle-Aged Women

Objective:

Obesity has been linked to cardiovascular risk factors characterized by endothelial dysfunction and arterial wall thickening. Regular exercise training is recognized as a powerful tool to improve endothelial function and cardiovascular risk profile, but it is unknown which of high-intensity interval training or moderate-intensity continuous training is the best exercise.

Materials and Methods:

A total of 33 inactive and overweight women aged 40–50 years old and body mass index >27 kg/m² were randomized to high-intensity interval training, moderate-intensity continuous training, or control. The exercise intervention consisted of 12 weeks of training and three supervised sessions per week. The moderate-intensity group was trained continuously for 47 min at 60–70% of maximal heart rate. High-intensity interval training consisted of four interval bouts of 4 min at 85%–95% of maximal heart rate with 3 min breaks at 50%–60% of maximal heart rate between the intervals. For all analyses, statistical significance was assigned at P < 0.05.

Results:

According to our findings, while carotid intima-media thickness decreased in both training groups, this reduction was not statistically significant. In the high-intensity training group, the right ankle-brachial index increased significantly (P = 0.007).

Conclusion:

Twelve weeks of exercise training, especially in high-intensity interval training, have led to improving lipid profiles and endothelial function, it can be said that regular and prolonged exercise can probably be a preventive factor in cardiovascular disease in overweight women.

Prevalence and incidence of atherosclerotic cardiovascular disease and its risk factors in Korea: a nationwide population-based study

Background

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death in Korea. According to a report of published by Statistics Korea in 2014, cerebrovascular disease and cardiovascular disease were the major/leading causes of mortality. However, it is more difficult to identify prevalence and incidence of a disease than the mortality owing to the lack of national-level statistics. Few studies have examined the prevalence and incidence of ASCVD and its risk factors since 2012. This study aimed to estimate the prevalence and incidence of ASCVD and its risk factors in Korea using national claims data.

Methods

We conducted a retrospective analysis using the national claims data of the Health Insurance Review and Assessment Service. Patients aged ≥18 years with ASCVD (defined as myocardial infarction, angina, coronary revascularization, peripheral artery disease, ischemic stroke, and transient ischemic attack) were identified between January 1, 2014 and December 31, 2015. Patients at high risk for ASCVD (defined as hypertension, diabetes mellitus, and dyslipidemia without ASCVD during the baseline period) were identified between January 1, 2015 and December 31, 2015. We estimated the prevalence, cumulative incidence, and incidence density. These were further stratified by age and sex. The respective denominators for prevalence and incidence were the census population and the at-risk population (defined as the population without respective disease 1 year prior to the respective disease identification).

Results

Among the included Korean adult patients, the overall prevalence of clinical ASCVD per 1000 individuals was 98.25 in 2014 and 101.11 in 2015. The respective cumulative incidence and incidence density rates of ASCVD per 1000 individuals were 65.30 and 68.03 in 2014, and 67.05 and 69.94 in 2015, respectively. Peripheral artery disease seemed to drive the increase in the total prevalence and incidence of ASCVD. The prevalence and incidence of ASCVD continued to increase with age until 79 years.

Conclusions

This national population-based study confirmed the high prevalence and incidence of ASCVD and its risk factors in the adult population of South Korea. We suggest that more intensive treatment and prevention are needed to prevent ASCVD.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7439-0) contains supplementary material, which is available to authorized users.

Prognostic impact of the ankle-brachial index on the development of micro- and macrovascular complications in individuals with type 2 diabetes: the Rio de Janeiro Type 2 Diabetes Cohort Study

AIMS/HYPOTHESIS

The prognostic importance of the ankle-brachial index (ABI) in individuals with diabetes is controversial. We aimed to evaluate the relationship between the ABI and the occurrence of micro- and macrovascular complications in individuals with type 2 diabetes.

METHODS

The ABI was measured at baseline in 668 individuals with type 2 diabetes, and the individuals were followed-up for a median of 10 years. Multivariate Cox analysis was used to examine associations between the ABI and the occurrence of microvascular (retinopathy, microalbuminuria, renal function deterioration and peripheral neuropathy) and macrovascular (total cardiovascular events, major adverse cardiovascular events [MACE] and cardiovascular mortality) complications, and all-cause mortality. The improvement in risk stratification was assessed using the C statistic and the integrated discrimination improvement (IDI) index.

RESULTS

During follow-up, 168 individuals had a cardiovascular event (140 MACE) and 191 individuals died (92 cardiovascular deaths); 156 individuals newly developed or experienced worsening diabetic retinopathy, 194 achieved the renal composite outcome (122 with newly developed microalbuminuria and 93 with deteriorating renal function) and 95 newly developed or experienced worsening peripheral neuropathy. The ABI, either analysed as a continuous or as a categorical variable, was significantly associated with all macrovascular and mortality outcomes, except for non-cardiovascular mortality. Individuals with a baseline ABI of ≤0.90 had a 2.1-fold increased risk of all-cause mortality (95% CI 1.3, 3.5; p = 0.004), a 2.7-fold excess risk of cardiovascular mortality (95% CI 1.4, 5.4; p = 0.004) and a 2.5-fold increased risk of MACE (95% CI 1.5, 4.4; p = 0.001). The ABI improved risk discrimination over classical risk factors, with relative IDIs ranging from 6.3% (for all-cause mortality) to 31% (for cardiovascular mortality). In addition, an ABI of ≤0.90 was associated with the development or worsening of peripheral neuropathy (2.1-fold increased risk [95% CI 1.1, 4.3]; p = 0.033), but not with retinopathy or renal outcomes.

CONCLUSIONS/INTERPRETATION

A low ABI is associated with excess risk of adverse cardiovascular outcomes, mortality and peripheral neuropathy development or worsening, and improves cardiovascular risk stratification. The ABI should therefore be routinely evaluated in individuals with type 2 diabetes.

The First Harmonic of Radial Pulse as an Early Predictor of Silent Coronary Artery Disease and Adverse Cardiac Events in Type 2 Diabetic Patients

Background

It has been reported that harmonics of radial pulse is related to coronary artery disease (CAD) in patients with type 2 diabetes mellitus (T2DM). It is still unclear whether or not the first harmonics of the radial pulse spectrum is an early independent predictor of silent coronary artery disease (SCAD) and adverse cardiac events (ACE).

Objectives

To measure the risk of SCAD in patients with T2DM and also to survey whether or not an increment of the first harmonic (C1) of the radial pulse increases ACE.

Methods

1968 asymptomatic individuals with T2DM underwent radial pulse wave measurement. First harmonic of the radial pressure wave, C1, was calculated. Next, the new occurrence of ACE and the new symptoms and signs of coronary artery disease were recorded. The follow-up period lasted for 14.7 ± 3.5 months.

Results

Out of 1968 asymptomatic individuals with T2DM, ACE was detected in 239 (12%) of them during the follow-up period. The logrank test demonstrated that the cumulative incidence of ACE in patients with C1 above 0.96 was greater than that in those patients with C1 below 0.89 (P < 0.01). By comparing the data of patients with C1 smaller than the first quartile and the patients with C1 greater than the third quartile, the hazard ratios were listed as follows: ACE (hazard ratio, 2.29; 95% CI, 1.55–3.37), heart failure (hazard ratio, 2.22; 95% CI, 1.21–4.09), myocardial infarction (hazard ratio, 2.44; 95% CI, 1.51–3.93), left ventricular dysfunction (Hazard ratio, 2.01; 95% CI, 0.86–4.70), and new symptoms and signs for coronary artery disease (hazard ratio, 2.03; 95% CI, 1.45–2.84). As C1 increased, the risk for composite ACE (P < 0.001 for trend) and for coronary disease (P < 0.001 for trend) also increased. The hazard ratio and trend for cardiovascular-cause mortality were not significant.

Conclusions

This study showed that C1 of the radial pulse wave is correlated with cardiovascular events. Survival analysis showed that C1 value is an independent predictor of ACE and SCAD in asymptomatic patients with T2DM. Thus, screening for the first harmonic of the radial pulse may improve the risk stratification of cardiac events and SCAD in asymptomatic patients although they had no history of coronary artery disease or angina-related symptom.

Brazilian guidelines on prevention of cardiovascular disease in patients with diabetes: a position statement from the Brazilian Diabetes Society (SBD), the Brazilian Cardiology Society (SBC) and the Brazilian Endocrinology and Metabolism Society (SBEM)

BACKGROUND

Since the first position statement on diabetes and cardiovascular prevention published in 2014 by the Brazilian Diabetes Society, the current view on primary and secondary prevention in diabetes has evolved as a result of new approaches on cardiovascular risk stratification, new cholesterol lowering drugs, and new anti-hyperglycemic drugs. Importantly, a pattern of risk heterogeneity has emerged, showing that not all diabetic patients are at high or very high risk. In fact, most younger patients who have no overt cardiovascular risk factors may be more adequately classified as being at intermediate or even low cardiovascular risk. Thus, there is a need for cardiovascular risk stratification in patients with diabetes. The present panel reviews the best current evidence and proposes a practical risk-based approach on treatment for patients with diabetes.

MAIN BODY

The Brazilian Diabetes Society, the Brazilian Society of Cardiology, and the Brazilian Endocrinology and Metabolism Society gathered to form an expert panel including 28 cardiologists and endocrinologists to review the best available evidence and to draft up-to-date an evidence-based guideline with practical recommendations for risk stratification and prevention of cardiovascular disease in diabetes. The guideline includes 59 recommendations covering: (1) the impact of new anti-hyperglycemic drugs and new lipid lowering drugs on cardiovascular risk; (2) a guide to statin use, including new definitions of LDL-cholesterol and in non-HDL-cholesterol targets; (3) evaluation of silent myocardial ischemia and subclinical atherosclerosis in patients with diabetes; (4) hypertension treatment; and (5) the use of antiplatelet therapy.

CONCLUSIONS

Diabetes is a heterogeneous disease. Although cardiovascular risk is increased in most patients, those without risk factors or evidence of sub-clinical atherosclerosis are at a lower risk. Optimal management must rely on an approach that will cover both cardiovascular disease prevention in individuals in the highest risk as well as protection from overtreatment in those at lower risk. Thus, cardiovascular prevention strategies should be individualized according to cardiovascular risk while intensification of treatment should focus on those at higher risk.

Cardiovascular risk assessment in patients with diabetes

Although patients with diabetes have 2 to 4 times increased risk of cardiovascular morbidity and mortality than individuals without diabetes, recent studies indicate that a significant part of patients are in a lower cardiovascular risk category. Men younger than 35 years, women younger than 45 years, patients with diabetes duration of less than 10 years without other risk factors have a much lower risk than patients who have traditional cardiovascular risk factors, and subclinical or established coronary artery disease (CAD). These patients are not risk equivalent as stated in previous studies. On the contrary, when in the presence of traditional risk factors or evidence of subclinical coronary disease (e.g. high coronary calcium score), the coronary risk is much increased and patients may be classified at a higher-risk category. Recent guidelines do not anymore consider diabetes as a CAD risk equivalent and recommend cardiovascular risk stratification for primary prevention. Stratification of diabetic patients improves accuracy in prediction of subclinical CAD, silent ischemia and future cardiovascular events. Stratification also discriminates higher from lower risk patients who may need intensive statin or aspirin prevention, while avoiding overtreatment in lower risk cases. It may also allow the clinician to decide whether to intensify risk reduction actions through specific newer drugs for glucose control such as SGLT-2 inhibitors or GLP-1 agonists, which recently have shown additional cardiovascular protector effect. This review addresses the assessment of cardiovascular disease risk using traditional and non-traditional cardiovascular risk factors. It also reviews the use of risk calculators and new reclassification tools, focusing on the detection of subclinical atherosclerosis as well as silent ischemia in the asymptomatic patients with diabetes.

Imaging Subclinical Atherosclerosis: Where Do We Stand?

The age of initiation and the rate of progression of atherosclerosis vary markedly among individuals and have been difficult to predict with traditional cardiovascular risk assessment models. Although these risk models provide good discrimination and calibration in certain populations, cardiovascular disease (CVD) risk may not be accurately estimated in low- and intermediate risk individuals. Therefore, imaging techniques such as Ankle-Brachial Index (ABI), Coronary Artery Calcium score (CAC), carotid Intima-Media Thickness (cIMT), flow mediated dilation (FMD) and Positron Emission Tomography (PET) have been developed and used to reclassify these individuals. In the present article we review the role of the most commonly used imaging techniques for CVD risk assessment.

Predictive models for all-cause and cardiovascular mortality in type 2 diabetic inpatients. A cohort study

BACKGROUND

Many authors have analysed premature mortality in cohorts of type 2 diabetic patients, but no analyses have assessed mortality in hospitalised diabetic patients.

AIM

To construct predictive models to estimate the likelihood of all-cause mortality and cardiovascular mortality in type 2 diabetic inpatients.

DESIGN

Cohort study with follow-up from 2010 to 2014.

METHODS

We evaluated mortality in a randomly selected cohort of 112 type 2 diabetic inpatients at the Hospital of Elda (Spain) in 2010-2012.

OUTCOMES

all-cause mortality and cardiovascular mortality during the follow-up. Other variables: gender, age, depression, asthma/chronic obstructive pulmonary disease, hypertension, dyslipidemia, insulin, pills, smoking, walking, baseline blood glucose and creatinine. Predictive tables with risk groups were constructed to estimate the likelihood of all-cause mortality and cardiovascular mortality. Calculations were made of the area under the ROC curve (AUC).

RESULTS

During the follow-up, 52 inpatients died (46.4%, 95% CI, confidence interval: 37.2-55.7%), 22 because of cardiovascular causes (19.6%, 95% CI: 12.3-27.0%). The mean follow-up time was 2.7 ± 1.5 years. The AUC for the all-cause mortality model was 0.84 (95% CI: 0.77-0.92, p < 0.001). Associated parameters: pills, smoking, walking, gender, insulin and age. The AUC for the cardiovascular mortality model was 0.79 (95% CI: 0.67-0.91, p < 0.001). Associated parameters: age, pills, walking, smoking, depression and insulin.

CONCLUSIONS

This study provides tools to predict premature mortality in type 2 diabetic inpatients. However, before their general application they require joint validation by the internal medicine unit, emergency department, primary healthcare unit and endocrinology service to enable better prediction of the prognosis and more adequate decision-taking.

High Ankle-Brachial Index Indicates Cardiovascular and Peripheral Arterial Disease in Patients With Type 2 Diabetes

We assessed the association between high ankle-brachial index (ABI) and cardiovascular disease (CVD) and peripheral arterial disease (PAD) in Chinese patients with type 2 diabetes mellitus (T2DM). The ABI was measured, and foot inspection was performed in 2080 outpatients with T2DM. The clinical characters in different ABI levels were analyzed, and the diagnostic value of high ABI to CVD and PAD was determined. Compared with the normal ABI group, the high ABI (>1.3) group had a higher prevalence of CVD and PAD but less than the low ABI (≤0.9) group. High ABI was an independent risk factor for the development of CVD and PAD. Receiver-operating characteristic curve analysis showed that the optimal cutoff of high ABI to predict CVD and PAD was 1.43 and 1.45, respectively. The odds ratio of high ABI for CVD and PAD was 2.25 and 6.97, respectively, after adjusting for other confounding risk factors. In conclusion, high ABI indicated the risk of CVD and PAD in Chinese populations with T2DM.

Cardiovascular, diabetes, and cancer strips: evidences, mechanisms, and classifications

OBJECTIVES

To report and name firstly that there are cardiovascular disease (CVD), diabetes mellitus (DM) and cancers (CDC) strips; and disclose their mechanisms, classifications, and clinical significances.

STUDY DESIGN

Narrative and systematic review study and interpretive analysis.

METHODS

DATA SOURCES AND STUDY SELECTION

to collect and present related evidences on CDC strips from evidence-based, open-access, both Chinese- and English-language literatures in recent 10 years on clinical trials from PubMed according to keywords "CVD, DM and cancers" as well as authors' extensive clinical experience with the treatment of more than fifty thousands of patients with CVD, diabetes and cancers over the past decades, and analyze their related mechanisms and categories which based on authors' previous works.

DATA EXTRACTION

data were mainly extracted from 48 articles which are listed in the reference section of this review. Qualitative, quantitative and mixed data were included, narratively and systematically reviewed.

RESULTS

With several conceptual and technical breakthrough, authors present related evidences on CDC strips, these are, CVD and DM, DM and cancers, cancers and CVD linked, respectively; And "Bad SEED" +/- "bad soil" theory or doctrine may explain this phenomenon due to "internal environmental injure, abnormal or unbalance" in human body resulting from the role of risk factors (RFs) related multi-pathways and multi-targets, which including organ & tissue (e.g., vascular-specific), cell and gene-based mechanisms. Their classifications include main strips/type B, and Branches/type A as showed by tables and figures in this article.

CONCLUSIONS

There are CDC strips and related mechanisms and classifications. CDC strips may help us to understand, prevent, and control related common non-communicable diseases (NCDs) as well as these high risk strips.

Prospective relationship of low cardiovascular risk factor profile at younger ages to ankle-brachial index: 39-year follow-up--the Chicago Healthy Aging Study

Background

Data are sparse regarding the long-term association of favorable levels of all major cardiovascular disease risk factors (RFs) (ie, low risk [LR]) with ankle-brachial index (ABI).

Methods and Results

In 2007–2010, the Chicago Healthy Aging Study reexamined a subset of participants aged 65 to 84 years from the Chicago Heart Association Detection Project in Industry cohort (baseline examination, 1967–1973). RF groups were defined as LR (untreated blood pressure ≤120/≤80 mm Hg, untreated serum cholesterol <200 mg/dL, body mass index <25 kg/m², not smoking, no diabetes) or as 0 RFs, 1 RF, or 2+ RFs based on the presence of blood pressure ≥140/≥90 mm Hg or receiving treatment, serum cholesterol ≥240 mg/dL or receiving treatment, body mass index ≥30 kg/m², smoking, or diabetes. ABI at follow-up was categorized as indicating PAD present (≤0.90), as borderline PAD (0.91 to 0.99), or as normal (1.00 to 1.40). We included 1346 participants with ABI ≤1.40. After multivariable adjustment, the presence of fewer baseline RFs was associated with a lower likelihood of PAD at 39-year follow-up (P for trend is <0.001). Odds ratios (95% CIs) for PAD in persons with LR, 0 RFs, or 1 RF compared with those with 2+ RFs were 0.14 (0.05 to 0.44), 0.28 (0.13 to 0.59), and 0.33 (0.16 to 0.65), respectively; findings were similar for borderline PAD (P for trend is 0.005). The association was mainly due to baseline smoking status, cholesterol, and diabetes. Remaining free of adverse RFs or improving RF status over time was also associated with PAD.

Conclusions

LR profile in younger adulthood (ages 25 to 45) is associated with the lowest prevalence of PAD and borderline PAD 39 years later.

Change in ankle-brachial index over time and mortality in diabetics with proteinuria

Peripheral arterial disease is common in diabetic chronic kidney disease (CKD) and is characterized either by abnormally low or high ankle-brachial index (ABI). Whether low or high ABI carries similar prognostic value is unknown. The association of baseline ABI with all-cause mortality over 40 ± 21 months (mean ± SD) was ascertained in 167 proteinuric diabetics (age 57 ± 7 years; median urine protein-creatinine, 2.5 mg/mg). Association of change in ABI with all-cause mortality was determined in 75 subjects with normal ABI (0.9 - 1.3) at baseline. Among 167 participants, 41% had an abnormal ABI: < 0.9, 18%; and > 1.3 or non-compressible arteries, 23%. Only individuals with low ABI had a significantly higher risk for all-cause mortality (hazards ratio (95% confidence interval), HR: 2.23 (1.07, 4.65)). In subjects with normal ABI at baseline with follow-up measurement (n = 75), vascular disease worsened in 39% over 23 ± 6 months: 17% had either a decrease in ABI by ≥ 0.1 or a final ABI < 0.9, and 21% had a final ABI > 1.3 or noncompressible arteries. Only individuals who had a decrease in ABI over time had a significantly higher risk for death (adjusted HR, 7.41 (1.63, 33.65)). Peripheral arterial disease is not uncommon and progresses rapidly in individuals with diabetes and proteinuria. Low or declining ABI is a strong predictor of all-cause mortality. Routine measurement of ABI is a simple bed-side procedure that may permit easy risk-stratification in diabetic CKD patients.

An analysis of the relationship between ankle-brachial index and estimated glomerular filtration rate in type 2 diabetes

We investigated the relationship between peripheral arterial disease (PAD) and renal function in patients with type 2 diabetes mellitus (T2DM). We enrolled 2057 hospitalized patients with T2DM and measured kidney function and ankle-brachial index (ABI). The estimated glomerular filtration rate (eGFR) was derived using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and ABI was grouped as low (<0.9), low-normal (0.9-1.09), normal (1.1-1.3), and high (>1.3). Logistic regression was used to evaluate the associations of eGFR with ABI. Generally speaking, the ABI was negatively correlated with systolic blood pressure, fasting C-peptide, total cholesterol, and low-density lipoprotein cholesterol while positively correlated with body mass index (P < .05 to <.01). Only a low ABI was positively correlated with eGFR (P < .01). In addition to the association of the ABI with cardiovascular events, stroke, and PAD, ABI may also predict the change in renal function in patients with T2DM.

Prevalence of and risk factors for abnormal ankle-brachial index in patients with type 2 diabetes

BACKGROUND

The aim of the present study was to examine abnormalities in the ankle-brachial index (ABI) and related risk factors in patients with type 2 diabetes.

METHODS

Between September 2003 and June 2010, the ABI was determined in 3924 outpatients attending the Diabetes Center of the People's Liberation Army 306th Hospital. In addition, demographic and laboratory data were collected. The risk factors for an abnormal ABI were determined using univariate and stepwise logistic regression analysis.

RESULTS

The ABI was normal (0.91-1.3) in 93.1% of patients, low (<0.9) in 5.2%, and high (>1.3) in 1.7%. The prevalence of abnormal lower ABI was greater in elderly (≥ 65 years) patients (12.2%) than in younger (< 65 years) patients (3.6%). Using normal ABI as the reference, low ABI in younger patients was found to be independently associated with HbA1c, the urinary albumin:creatinine ratio, diabetic peripheral neuropathy, diabetic retinopathy, and cerebrovascular disease. A low ABI in elderly patients was found to be independently associated with age, smoking, HbA1c, uric acid, total cholesterol, diabetic peripheral neuropathy, diabetic retinopathy, diabetic nephropathy and cerebrovascular disease. A high ABI in younger patients was associated with being male.

CONCLUSIONS

The prevalence of an abnormal ABI was high in patients with type 2 diabetes, especially elderly patients. Early identification and intensive treatment are needed to improve the quality of life and overall prognosis of patients with type 2 diabetes.

Ischemia-modified albumin in type 2 diabetic patients with and without peripheral arterial disease

OBJECTIVE:

To determine whether there is an association between serum ischemia-modified albumin and the risk factor profile in type 2 diabetic patients with peripheral arterial disease and to identify the risk markers for peripheral arterial disease.

METHODS:

Participants included 290 patients (35.2% women) with type 2 diabetes. The ankle-brachial pressure index was measured using a standard protocol, and peripheral arterial disease was defined as an ankle-brachial index <0.90 or ≥1.3. The basal ischemia-modified albumin levels and clinical parameters were measured and analyzed. The risk factors for peripheral arterial disease were examined by multiple logistic analyses.

RESULTS:

Age, systolic blood pressure, total cholesterol, low-density lipoprotein cholesterol, urine albumin, homocysteine, and ischemia-modified albumin were significantly higher in patients with peripheral arterial disease than in disease-free patients (p<0.05), while ankle-brachial index was lower in the former group (p<0.05). Ischemia-modified albumin was positively associated with HbA1c and homocysteine levels (r = 0.220, p = 0.030; r = 0.446, p = 0.044, respectively), while no correlation was found with ankle-brachial index. Multiple logistic analyses indicated that HbA1c, systolic blood pressure, homocysteine and ischemia-modified albumin were independent risk factors for peripheral arterial disease in the diabetic subjects.

CONCLUSION:

The baseline ischemia-modified albumin levels were significantly higher and positively associated with HbA1c and homocysteine levels in type 2 diabetic patients with peripheral arterial disease. Ischemia-modified albumin was a risk marker for peripheral arterial disease. Taken together, these results might be helpful for monitoring diabetic peripheral arterial disease.

The prevalence of peripheral arterial disease in korean patients with type 2 diabetes mellitus attending a university hospital

BACKGROUND

Peripheral arterial disease (PAD) is a common manifestation of systemic atherosclerosis and is associated with significant morbidity and mortality. Diabetes is known to increase the risk of PAD two- to four-fold. The prevalence of PAD in Korean diabetic patients has not been established. In this study, we investigated the prevalence of PAD in Korean patients with type 2 diabetes attending a large university hospital and analyzed the factors associated with PAD.

METHODS

A total of 2,002 patients with type 2 diabetes who underwent ankle-brachial index (ABI) measurement in an outpatient clinic were enrolled. PAD was defined as an ABI ≤0.9. Clinical characteristics of 64 patients with PAD were compared with those of 192 age- and sex-matched control patients without PAD.

RESULTS

Of the 2,002 type 2 diabetic patients, 64 (3.2%) were diagnosed as having PAD. PAD was associated with higher prevalences of retinopathy, nephropathy, neuropathy, cerebrovascular and coronary artery disease. Patients with PAD had higher systolic blood pressure and serum triglyceride level and reported higher pack-years of smoking. Multivariate analysis showed that the presence of micro- and macrovascular complications and high systolic blood pressure are factors independently associated with PAD.

CONCLUSION

The prevalence of PAD in diabetic patients was 3.2%, suggesting that the prevalence in Korean diabetic patients is lower than that of patients in Western countries.

Use and utility of ankle brachial index in patients with diabetes

Ankle brachial index (ABI) is a simple method to screen peripheral arterial disease (PAD) and to evaluate cardiovascular (CV) prognosis in the general population. Measuring it requires a hand-held Doppler probe but it can be done also with an automatic device. ABI is an effective tool for clinical practice or clinical studies. However, in diabetic patients, it has some specific caveats. Sensitivity of the standard threshold of 0.9 appears to be lower in diabetic patients with complications. Moreover, highly frequent arterial medial calcifications in diabetes increase ABI. It has been demonstrated that measurements >1.3 are well correlated with both an increased prevalence of PAD and CV risk. Therefore, ABI thresholds of less than 0.9 and more than 1.3 are highly suspicious for PAD and high CV risk in diabetic patients. However, when there is concomitant clinical peripheral neuropathy or high risk of arterial calcification, the efficiency of ABI seems to be limited. In this case, other methods should be applied, toe pressure, in particular. Thus, the ABI could be used in patients with diabetes, but values should be interpreted with precision, according to the clinical situation.

Ankle–Brachial Index Screening for Peripheral Artery Disease in Asymptomatic Patients between 50 and 70 Years of Age

Asymptomatic peripheral arterial disease (PAD) can be easily identified using the ankle–brachial index (ABI). This study was designed to investigate the benefits of performing ABI in patients aged 50-70 years. A random sample of 107 patients was chosen and data on gender, age, risk factors and laboratory tests were collected and the ABI measured. Twenty (19%) patients were found to have PAD. Smoking, high total cholesterol, high triglycerides and diabetes mellitus were shown to be associated with a low ABI and the presence of PAD. Age, diabetes and smoking were identified as the strongest predictors of PAD. Having more risk factors for PAD also predicted a lower ABI. These results suggest that measuring ABI is not necessary in patients aged 50-70 years if they only have one risk factor, with the exception of patients with diabetes and those who smoke. In contrast, measuring ABI seems to be useful for patients with multiple risk factors for PAD, although additional studies are required.

Role of ankle-brachial pressure index as a predictor of coronary artery disease severity in patients with diabetes mellitus

BACKGROUND

Previous studies have reported a close correlation between low ankle-brachial pressure index (ABPI) and various cardiovascular risk factors. However, despite the well-established potential hazards of consequent coronary artery disease (CAD), no data exist on the relationship between ABPI and the severity of CAD, particularly in patients with diabetes mellitus (DM).

METHODS

A total of 840 patients ranging from 35 to 87 years of age (mean [+/- SD] 63.9+/-10.2 years) with suspected CAD in a clinical practice were enrolled. All patients underwent ABPI measurements and coronary angiography. Patients were divided into four groups according to the results of ABPI measurements and the presence or absence of DM: group A had an ABPI value of at least 0.9 but no DM (A-/D-); group B had an ABPI value of at least 0.9 and DM (A-/D+); group C had an ABPI of less than 0.9 but no DM (A+/D-); and group D had an ABPI value of less than 0.9 and DM (A+/D+).

RESULTS

Age was significantly higher in the A+ (groups C and D) than the A- patients (groups A and B). Moreover, men predominated in all four groups. Comparisons of sex distribution among the four groups revealed that group D had the highest percentage of women, while group A had the lowest. Total cholesterol level did not differ among the four groups, although group D tended to have the highest result. Patients in group D had the highest percentages of hypertension, hypercholesterol, hypertriglyceride, low high-density lipoprotein cholesterol and high low-density lipoprotein cholesterol among the four groups. Group D exhibited the highest triglyceride and uric acid levels, the lowest high-density lipoprotein cholesterol level, and the highest metabolic syndrome criteria number and percentage of metabolic syndrome. Furthermore, group D had the highest mean lesion numbers, mean numbers of target vessel involvement, stenoses with type C classification and complex morphology lesions (chronic total occlusion, diffuse or calcified lesions) among the four groups. There were still significant differences in lesion numbers (P<0.001) and numbers of target vessel involvement (P<0.001) for ABPI predicting CAD severity after controlling for the effects of DM and age. The sensitivity, specificity, positive predictive value and negative predictive value of using an ABPI of less than 0.9 to predict CAD differed significantly between patients with and without DM.

CONCLUSIONS

ABPI is a useful noninvasive tool for predicting CAD severity, even in patients with DM.

Prevalence and risk factors for peripheral artery disease in an Asian population with diabetes mellitus

We describe the prevalence and risk factors for PAD in Asian Malays with diabetes. A population-based study of 3,280 (78.7% response) Malay persons aged 40-80 years in Singapore was conducted. ABI was measured in all participants with a history of diabetes (N=634). PAD was defined to be present if ABI <or= 0.9. All participants had standardised interviews, clinical examinations and laboratory investigation for risk factor assessment. The crude prevalence of PAD was 10.4% (95% CI: 8.3%-13.0%). After age standardisation to the 2000 Singapore Census population, the prevalence was 5% (95% CI: 3.8-8.6). In multivariate analyses, the presence of PAD was associated with older age (OR 1.05; 95% CI: 1.01-1.09, per year increase), female gender (OR 4.18; 95% CI: 1.67-10.43), cigarette smoking (OR 2.55; 95% CI: 1.05-6.20), higher systolic blood pressure (OR 1.28; 95% CI: 1.13-1.45), a history of myocardial infarction (OR 3.69; 95% CI: 1.79-7.61) and stroke (OR 3.06 95% CI: 1.25-7.50). In this Asian Malay population with diabetes, we found a high prevalence of PAD.The major risk factors for PAD among persons with diabetes are similar to studies in Caucasian populations, suggesting that strategies aimed at controlling the modifiable factors may reduce the prevalence of PAD in Asian populations.

Diabetic nephropathy and risk factors for peripheral artery disease in Chinese with type 2 diabetes mellitus

The risk for peripheral arterial disease (PAD) is increased in patients with chronic kidney disease. We investigated the effects of renal function on PAD in Chinese with type 2 diabetes mellitus. This study enrolled a total of 2983 (1342 men and 1641 women) Chinese adults with diabetes. The mean age was 63.2 +/- 11.9 years. Peripheral arterial disease was diagnosed by an ankle-brachial index less than 0.9. Renal function was evaluated by serum creatinine (SCr), estimated glomerular filtration rate, and urinary albumin-creatinine ratio (ACR). Risk factors for PAD were evaluated using multiple logistic regression analysis. Age, cholesterol, and high-density lipoprotein cholesterol (HDL-C) (inverse association) were significant risk factors in men, whereas age, body mass index (inverse association), low-density lipoprotein cholesterol, and HDL-C (inverse association) were significant risk factors for diabetic women. After adjustment for age, body mass index, blood pressure, glycosylated hemoglobin, cholesterol, HDL-C, low-density lipoprotein cholesterol, and triglyceride levels, we found that SCr levels greater than 1.5 mg/dL, estimated glomerular filtration rate less than 60 mL/min, and urinary ACR greater than 30 mg/g were independent risk factors for PAD in diabetic men and that SCr levels greater than 1.4 mg/dL and urinary ACR greater than 30 mg/g were independently associated with PAD in diabetic women. The risk factors for PAD are somewhat different between men and women with diabetes in Chinese population in Taiwan. Diabetic nephropathy is significantly associated with PAD in this patient population.

A propensity-matched study of the association of peripheral arterial disease with cardiovascular outcomes in community-dwelling older adults

The association between peripheral arterial disease (PAD) and outcomes has not been studied in a propensity-matched population of community-dwelling older adults. A public-use copy of the Cardiovascular Health Study (CHS) data was analyzed to test the hypothesis that baseline PAD is associated with increased all-cause mortality and cardiovascular morbidity. Of the 5,795 CHS participants, 5,630 had data on baseline ankle-brachial index, and 767 had PAD, defined as ankle-brachial index <0.9. Propensity scores for PAD were calculated for each participant using 66 baseline covariates and were used to match 679 pairs of participants with and without PAD. Matched Cox regression models were used to estimate associations of PAD with outcomes during a median follow-up period of 7.5 years. Overall, 55% of matched participants died from all causes during 9,958 patient-years of follow-up. All-cause mortality occurred in 61% (rate 8,710/100,000 patient-years) and 50% (rate 6,503/100,000 patient-years) of participants, respectively, with and without PAD (matched hazard ratio for PAD vs no PAD 1.47, 95% confidence interval (CI) 1.23 to 1.76, p <0.0001). Prematch unadjusted, multivariable-adjusted, and propensity-adjusted hazard ratios for PAD-associated all-cause mortality were 2.90 (95% CI 2.61 to 3.21, p <0.0001), 1.53 (95% CI 1.36 to 1.71, p <0.0001), and 1.57 (95% CI 1.39 to 1.78, p <0.0001), respectively. Matched hazard ratios for PAD for incident heart failure and symptomatic PAD were 1.32 (95% CI 1.00 to 1.73, p = 0.052) and 3.92 (95% CI 2.13 to 7.21, p <0.0001), respectively. In conclusion, in a propensity-matched well-balanced population of community-dwelling older adults, baseline PAD was associated with increased all-cause mortality and cardiovascular morbidity.

Subclinical Peripheral Artery Disease in Patients Undergoing Peritoneal Dialysis: Risk Factors and Outcome

Background

Peripheral artery disease (PAD) is highly prevalent among patients in end-stage renal disease. The ankle–brachial index (ABI) is believed to be highly correlated with the subclinical PAD of lower extremities but little is known about the associated risk factors and outcome for PAD and ABI in patients on peritoneal dialysis (PD).

Methods

We performed a cohort study of 153 patients from a single center receiving stable PD for more than 3 months. These patients were screened for subclinical PAD using the ABI measurement. The ABI was measured and a ratio of <0.9 was considered abnormal. Clinical outcomes included actuarial patient and technique survival in this study.

Results

30 patients were classified into a subclinical PAD group. The prevalence of PAD (subclinical and overt) in our PD center was 19.61% (30/153). Advanced age, preexisting diabetes, preexisting cardiovascular and/or cerebrovascular disease (CVD), lower renal Kt/V urea, lower renal creatinine clearance (WCrCl), lower serum albumin level, and higher serum triglyceride level were risk factors for PAD in our PD center. Bivariate analysis showed that ABI was positively correlated with residual renal Kt/V urea and WCrCl, but was not correlated with peritoneal Kt/V urea and WCrCl. Patient and technique survival rates were significantly lower in the low ABI group than in the normal ABI group.

Conclusions

ABI is highly correlated with advanced age, preexisting diabetes, preexisting CVD, serum albumin, serum triglyceride, and residual renal clearance in PD patients. Also, lower ABI is independently associated with a high risk of patient mortality and PD technique failure.

Passive smoking and risk of peripheral arterial disease and ischemic stroke in Chinese women who never smoked

BACKGROUND

The association between secondhand smoke (SHS) and risk of peripheral arterial disease (PAD) and stroke remains uncertain.

METHODS AND RESULTS

We examined the relationship between SHS and cardiovascular diseases, particularly PAD and stroke, in Chinese women who never smoked from a population-based cross-sectional study in Beijing, China. SHS exposure was defined as exposure to another person's tobacco smoke at home or in the workplace. Cardiovascular disease events included coronary heart disease, stroke, and PAD. PAD was defined by signs of intermittent claudication as measured by the World Health Organization Rose questionnaire and an ankle-brachial index of <0.90. Among 1209 women who never smoked, 39.5% were exposed to SHS at home or in workplaces. Those individuals who were exposed to SHS had a significantly higher risk of coronary heart disease (adjusted odds ratio [OR], 1.69; 95% CI, 1.31 to 2.18) and ischemic stroke (OR, 1.56; 95% CI, 1.03 to 2.35) than those never exposed to SHS after adjustment for 13 potential risk factors. The adjusted ORs of PAD defined by intermittent claudication, by ankle-brachial index <0.90, and by either intermittent claudication or ankle-brachial index <0.90 were 1.87 (95% CI, 1.30 to 2.68), 1.47 (95% CI, 1.07 to 2.03), and 1.67 (95% CI, 1.23 to 2.16), respectively. Dose-response relationships were found between SHS exposure amount (cigarettes per day) and duration (minutes per day) and increasing prevalence of coronary heart disease, ischemic stroke, and PAD.

CONCLUSIONS

In China, SHS exposure in women is highly prevalent. In addition to being a risk factor for coronary heart disease, SHS should be considered an important risk factor for ischemic stroke and PAD in nonsmoking women.