Prevalence of clinical and isolated subclinical cardiovascular disease in older adults with glucose disorders: the Cardiovascular Health Study

Risk factors for cardio-cerebrovascular events among patients undergoing continuous ambulatory peritoneal dialysis and their association with serum magnesium

Serum magnesium levels exceeding 0.9 mmol/L are associated with increased survival rates in patients with CKD. This retrospective study aimed to identify risk factors for cardio-cerebrovascular events among patients receiving continuous ambulatory peritoneal dialysis (CAPD) and to examine their correlations with serum magnesium levels. Sociodemographic data, clinical physiological and biochemical indexes, and cardio-cerebrovascular event data were collected from 189 patients undergoing CAPD. Risk factors associated with cardio-cerebrovascular events were identified by univariate binary logistic regression analysis. Correlations between the risk factors and serum magnesium levels were determined by correlation analysis. Univariate regression analysis identified age, C-reactive protein (CRP), red cell volume distribution width standard deviation, red cell volume distribution width corpuscular volume, serum albumin, serum potassium, serum sodium, serum chlorine, serum magnesium, and serum uric acid as risk factors for cardio-cerebrovascular events. Among them, serum magnesium ≤0.8 mmol/L had the highest odds ratio (3.996). Multivariate regression analysis revealed that serum magnesium was an independent risk factor, while serum UA (<440 μmol/L) was an independent protective factor for cardio-cerebrovascular events. The incidence of cardio-cerebrovascular events differed significantly among patients with different grades of serum magnesium (χ2 = 12.023, p = 0.002), with the highest incidence observed in patients with a serum magnesium concentration <0.8 mmol/L. High serum magnesium levels were correlated with high levels of serum albumin (r = 0.399, p < 0.001), serum potassium (r = 0.423, p < 0.001), and serum uric acid (r = 0.411, p < 0.001), and low levels of CRP (r = -0.279, p < 0.001). In conclusion, low serum magnesium may predict cardio-cerebrovascular events in patients receiving CAPD.

Assessment of subclinical left ventricular systolic and diastolic dysfunction in patients with type 2 diabetes mellitus under follow-up at Tikur Anbessa specialized hospital, Ethiopia: a case-control study

BACKGROUND

Individuals with diabetes mellitus are at increased risk of cardiovascular diseases, which in turn are the most common cause of morbidity and mortality in the diabetic population. A peculiar feature of cardiovascular diseases in this population is that they can have significant cardiac disease while remaining asymptomatic. There is a paucity of data regarding subclinical cardiac imaging features among diabetic adults in Africa, particularly in Ethiopia. This study was conducted to compare the magnitude and spectrum of left ventricular systolic and diastolic dysfunction among asymptomatic type 2 diabetic adults versus a normotensive, non-diabetic control group and to evaluate the determinants of left ventricular diastolic and systolic dysfunction.

METHODS

This was a case-control study conducted at Tikur Anbessa specialized hospital, Addis Ababa, Ethiopia. A standard transthoracic echocardiography was done for all study participants with type 2 diabetes mellitus and their normotensive and non-diabetic controls. Structured questionnaires were used to collect demographic and clinical characteristics and laboratory test results. Statistical analysis was done using the SPSS 25.0 software. The data was summarized using descriptive statistics. Bivariate and multivariate analysis was performed to determine the association between variables and echocardiographic parameters. The strength of statistical association was measured by adjusted odds ratios and 95% confidence intervals, with significant differences taken at p < 0.05.

RESULTS

We analyzed age- and sex-matched 100 participants in the study (diabetic) group and 200 individuals in the control group. Left ventricular systolic and diastolic dysfunction were significantly more prevalent among diabetic adults than their sex and age matched controls. Among diabetic individuals, ages of 60 years and above, dyslipidemia, use of Metformin and Glibenclamide, high serum triglyceride level, presence of neuropathy and use of statins correlated significantly with the presence of left ventricular diastolic dysfunction. Chronic kidney disease and neuropathy were determinants of left ventricular systolic dysfunction.

CONCLUSION

Left ventricular systolic and diastolic dysfunction were significantly more prevalent among diabetic patients than their sex- and age-matched controls in our study. We recommend early screening for subclinical left ventricular dysfunction, especially in the elderly and in those with chronic kidney disease, dyslipidemia, and microvascular complications such as neuropathy.

Leptin in Atherosclerosis: Focus on Macrophages, Endothelial and Smooth Muscle Cells

Increasing adipose tissue mass in obesity directly correlates with elevated circulating leptin levels. Leptin is an adipokine known to play a role in numerous biological processes including regulation of energy homeostasis, inflammation, vascular function and angiogenesis. While physiological concentrations of leptin may exhibit multiple beneficial effects, chronically elevated pathophysiological levels or hyperleptinemia, characteristic of obesity and diabetes, is a major risk factor for development of atherosclerosis. Hyperleptinemia results in a state of selective leptin resistance such that while beneficial metabolic effects of leptin are dampened, deleterious vascular effects of leptin are conserved attributing to vascular dysfunction. Leptin exerts potent proatherogenic effects on multiple vascular cell types including macrophages, endothelial cells and smooth muscle cells; these effects are mediated via an interaction of leptin with the long form of leptin receptor, abundantly expressed in atherosclerotic plaques. This review provides a summary of recent in vivo and in vitro studies that highlight a role of leptin in the pathogenesis of atherosclerotic complications associated with obesity and diabetes.

Large body mass index and waist circumference are associated with high blood pressure and impaired fasting glucose in young Chinese men

BACKGROUND

Obesity is closely related to many chronic diseases and metabolic risk factors. The present study examined the relationship of obesity-related indices to blood pressure (BP) and fasting plasma glucose (FPG) among young Chinese men.

METHODS

A total of 1193 male college students aged 18-22 years participated in the study. Height, weight, waist circumference (WC), body mass index (BMI), waist-to-height ratio (WHtR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and FPG were measured. High BP was defined as SBP ≥140 mmHg and/or DBP ≥90 mmHg. Impaired fasting glucose (IFG) was defined as FPG ≥5.6 mmol/L.

RESULTS

BMI, WC and WHtR were positively correlated with BP and FPG (rBMI-SBP = 0.455, rBMI-DBP = 0.367, rBMI-FPG = 0.113, rWC-SBP = 0.445, rWC-DBP = 0.382, rWC-FPG = 0.115, rWHtR-SBP = 0.396, rWHtR-DBP = 0.302, rWHtR-FPG = 0.106, P all < 0.01). When categorized by BMI (underweight, normal weight, overweight and obesity), the mean values of SBP, DBP, FPG and the prevalence of high BP and IFG increased with BMI, significant differences were observed among the four groups (P < 0.01). When categorized by WC and WHtR, similar differences were observed, with subjects in the large WC/WHtR group had a higher BP and FPG than their counterparts in the low WC/WHtR group (P < 0.01).

CONCLUSION

Large BMI and WC/WHtR are associated with high BP and IFG. Our results suggested that prevention of obesity in youth may be an effective approach for preventing the development of diabetes and hypertension in the future.

Graphene Quantum Dots and Enzyme-Coupled Biosensor for Highly Sensitive Determination of Hydrogen Peroxide and Glucose

In this paper, a simple and specific graphene quantum dots (GQDs)-based fluorescent biosensor adopted for the determination of glucose based on the combination of the enzyme-coupled method and fluorescence quenching mechanism is demonstrated. Glucose was oxidized by the enzyme glucose oxidase (GOx), forming hydrogen peroxide (H 2 O 2 ) via the catalysis by horseradish peroxidase (HRP). H 2 O 2 was then employed to oxidize phenol to quinone, which led to effective quenching effect in the GQDs⁻GOx⁻HRP⁻phenol system. By optimizing the reaction conditions of the GQDs-enzyme system, a linear relationship between the concentration of glucose and the fluorescence intensity over a range of 0.2⁻10 μ mol/L was obtained. The limit of detection for glucose is 0.08 μ mol/L. The present biosensor for the determination of glucose showed satisfactory reproducibility and accuracy in human serum samples. Since the enzymes have high specificity and unique affinity to the certain substance, the enzyme-coupled system promises a sensitive way for further detection of those chemicals which could be oxidized by enzymes and generated H 2 O 2 or glucose. GQDs and other fluorescent materials coupled with several enzymes can be applied to extensive sensing field.

Effect of hyperlipidemia on the incidence of cardio-cerebrovascular events in patients with type 2 diabetes

Background

This study was to explore the effect of hyperlipidemia on the incidence of cardio-cerebrovascular diseases in patients with type 2 diabetes.

Methods

Three hundred ninety five patients with type 2 diabetes in our hospital from January 2012 to January 2016 were followed up with an average of 3.8 years. The incidence of cardio-cerebrovascular diseases between diabetes combined with hyperlipidemia group (195 patients) and diabetes group (200 patients) were made a comparison. Multivariable Cox’s proportional hazards regression model was used to analyze the effect of hyperlipidemia on the incidence of cardio-cerebrovascular diseases in patients with type 2 diabetes.

Results

Diastolic blood pressure, systolic blood pressure, high-density lipoprotein, low-density lipoprotein, body mass index and hyper-sensitive C-reactive protein were higher in diabetes combined with hyperlipidemia group than in diabetes group (P < 0.05). At the end of the follow-up period, all-cause mortality, cardio-cerebrovascular diseases mortality, and the incidence of myocardial infarction, cerebral infarction, cerebral hemorrhage and total cardiovascular events were significantly higher in diabetes combined with hyperlipidemia group than in diabetes group (P < 0.05). The analysis results of multivariable Cox’s proportional hazards regression model showed that the risks of myocardial infarction and total cardiovascular events in diabetes combined with hyperlipidemia group were respectively 1.54 times (95%CI 1.13–2.07) and 1.68 times (95%CI 1.23–2.24) higher than those in diabetes group. Population attributable risk percent of all-cause mortality and total cardiovascular events in patients with type 2 diabetes combined with hyperlipidemia was 9.6% and 26.8%, respectively.

Conclusions

Hyperlipidemia may promote vascular endothelial injury, increasing the risk of cardio-cerebrovascular diseases in patients with type 2 diabetes. Medical staffs should pay attention to the control of blood lipids in patients with type 2 diabetes to delay the occurrence of cardio-cerebrovascular diseases.

Review: Cardiovascular risk and diabetes in old people

he transitions that took place during the second half of the 20th century produced an increase in the prevalence of cardiovascular diseases and demographic changes have brought the focus to older people. The necessity to improve the control of cardiovascular diseases and the unsatisfactory performance of available therapeutic approaches moved some of the attention to cardiovascular risk factors. Among them, one of the most outstanding is diabetes which many consider to be a cardiovascular disease equivalent. It became evident that cardiovascular risk factors act jointly, and the way to tackle them must follow a global strategy. At the end of the last century several cardiovascular risk factor tables were produced with the focus being on middle-age people, who formed the main database for studies in cardiovascular disease. However, an increasing proportion of patients are older and in this group current approaches to cardiovascular risk estimation may not be the most suitable.

Evolution of target organ damage and haemodynamic parameters over 4 years in patients with increased insulin resistance: the LOD-DIABETES prospective observational study

OBJECTIVES

We prospectively examined the impact of type 2 diabetes compared with metabolic syndrome (MetS) on the development of vascular disease over 4 years as determined by anatomic and functional markers of vascular disease. By comparing the vascular outcomes of the 2 disorders, we seek to determine the independent effect of elevated glucose levels on vascular disease.

SETTING

2 primary care centres in Salamanca, Spain.

PARTICIPANTS

We performed a prospective observational study involving 112 patients (68 with type 2 diabetes and 44 with MetS) who were followed for 4 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Measurements included blood pressure, blood glucose, lipids, smoking, body mass index, waist circumference, Homeostasis Model Assessment Insulin Resistance (HOMA-IR), hs-c-reactive protein and fibrinogen levels. We also evaluated vascular, carotid intima media thickness (IMT), pulse wave velocity (PWV) and ankle/brachial index, heart and renal target organ damage (TOD). The haemodynamic parameters were central (CAIx) and peripheral (PAIx) augmentation indices.

RESULTS

In year 4, participants with type 2 diabetes had increased IMT thickness. These patients had more plaques and an IMT>0.90 mm. In participants with MetS, we only found an increase in the number of plaques. We found no changes in PWV, CAIx and PAIx. The patients with diabetes had a greater frequency of vascular TOD. There were no differences neither in renal nor cardiac percentage of TOD in the patients with MetS or diabetes mellitus type 2.

CONCLUSIONS

This prospective study showed that the evolution of vascular TOD is different in participants with type 2 diabetes compared with those with MetS. While IMT and PWV increased in type 2 diabetes, these were not modified in MetS. The renal and cardiac TOD evolution, as well as the PAIx and CAIx, did not change in either group.

TRIAL REGISTRATION NUMBER

NCT01065155; Results.

Imaging of hypoxia in mouse atherosclerotic plaques with (64)Cu-ATSM

INTRODUCTION

Cardiovascular disease is the leading cause of death in the United States. The identification of vulnerable plaque at risk of rupture has been a major focus of research. Hypoxia has been identified as a potential factor in the formation of vulnerable plaque, and it is clear that decreased oxygen plays a role in the development of plaque angiogenesis leading to plaque destabilization. The purpose of this study is to demonstrate the feasibility of copper-64 labeled diacetyl-bis (N(4)-methylthiosemicarbazone) ((64)Cu-ATSM), a positron-emitting radiopharmaceutical taken up in low-oxygen-tension cells, for the identification of hypoxic and potentially unstable atherosclerotic plaque in a mouse model.

METHODS

(64)Cu-ATSM PET was performed in 21 atherosclerotic apolipoprotein E knockout (ApoE(-/-)) mice, 6 of which were fed high-fat diet (HFD) while the others received standard-chow diet (SCD), and 13 control wild type mice fed SCD. 4 SCD ApoE(-/-) mice and 4 SCD wild type mice also underwent (18)F-fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET) imaging one day prior to (64)Cu-ATSM PET.

RESULTS

(64)Cu-ATSM uptake was increased in the aortic arch in SCD ApoE(-/-) mice (average aortic arch/muscle (A/M) standardized uptake value ratio 7.5-30min post injection: (5.66±0.23) compared to control mice (A/M SUV ratio 7.5-30min post injection (3.87±0.22), p<0.0001). HFD ApoE(-/-) mice also showed similarly increased aortic arch uptake on PET imaging in comparison to control mice. Immunohistochemistry in both HFD and SCD ApoE(-/-) mice revealed noticeable hypoxia by pimonidazole stain in atherosclerosis which was co-localized to macrophage by CD68 staining. Autoradiography assessment demonstrated the presence of hypoxia by (64)Cu-ATSM uptake correlated with pimonidazole uptake within the ex vivo atherosclerotic aortic arch specimens. A significant increase in (18)F-FDG uptake in the SCD ApoE(-/-) mice in comparison to controls was also observed at delayed time points.

CONCLUSION

This pre-clinical study suggests that (64)Cu-ATSM is a potential PET tracer for hypoxia imaging in atherosclerosis.

ADVANCES IN KNOWLEDGE AND IMPLICATIONS FOR PATIENT CARE

While studies in humans are necessary for conclusive data, in the long term, a (64)Cu-ATSM PET imaging strategy could help facilitate the study of plaque biology in human patients.

Prevalence of cardiovascular risk factors in youth with type 1 diabetes and elevated body mass index

AIM

The prevalence of cardiovascular risk factors in children with type 1 diabetes and elevated BMI in the USA is poorly defined. We aimed to test the hypothesis that children with type 1 diabetes who are overweight or obese have increased frequencies of hypertension, dyslipidemia, and micro-/macroalbuminuria compared to their healthy weight peers.

METHODS

We studied 11,348 children 2 to <18 years of age enrolled in T1D Exchange between September 2010 and August 2012 with type 1 diabetes for ≥1 year and BMI ≥ 5th age-/sex-adjusted percentile (mean age 12 years, 49 % female, 78 % non-Hispanic White). Overweight and obesity were defined based on Centers for Disease Control and Prevention criteria. Diagnoses of hypertension, dyslipidemia, and micro-/macroalbuminuria were obtained from medical records. Logistic and linear regression models were used to assess factors associated with weight status.

RESULTS

Of the 11,348 participants, 22 % were overweight and 14 % obese. Hypertension and dyslipidemia were diagnosed in 1.0 % and 3.8 % of participants, respectively; micro-/macroalbuminuria was diagnosed in 3.8 % of participants with available data (n = 7,401). The odds of either hypertension or dyslipidemia were higher in obese than healthy weight participants [OR 3.5, 99 % confidence interval (CI) 2.0-6.1 and 2.2, 99 % CI 1.6-3.1, respectively]. Obese participants tended to be diagnosed with micro-/macroalbuminuria less often than healthy weight participants (OR 0.6, 99 % CI 0.4-1.0).

CONCLUSIONS

Obese children with type 1 diabetes have a higher prevalence of hypertension and dyslipidemia than healthy weight children with type 1 diabetes. The possible association of obesity with lower micro-/macroalbuminuria rates warrants further investigation.

Xuezhikang Capsule for Type 2 Diabetes with Hyperlipemia: A Systematic Review and Meta-Analysis of Randomized Clinical Trails

Objective. To evaluate the efficacy and safety of Xuezhikang capsule treating type 2 diabetes with hyperlipidemia. Methods. We searched six databases to identify relevant studies published before January 2015. Two review authors independently extracted data and assessed the Cochrane risk of bias tool. We resolved disagreements with this assessment through discussion and a decision was achieved by consensus. Results. We included 21 studies (1548 participants). Treatment courses were at least 8 weeks. Overall, the risk of bias of included trials was unclear. Among them, 16 studies could conduct meta-analysis. The result showed that compared with routine group (5 studies), Xuezhikang group had more effect on decreasing TC, TG, LDL-C, and rising HDL-C. However, compared with statins group (11 studies), Xuezhikang group has less effect on decreasing TC, TG, and rising HDL-C. Meanwhile, two groups had no statistical differences of LDL-C level. Conclusion. Xuezhikang capsule may be effective for treating type 2 diabetes with hyperlipemia. Our findings should be considered cautiously due to unclear risk of bias of the included studies and low methodological quality. Therefore, more strictly designed large-scale randomized clinical trials are needed to evaluate the efficacy of Xuezhikang capsule in type 2 diabetes with hyperlipemia.

Metabolic Burden and Disease and Mortality Risk Associated with Impaired Fasting Glucose in Elderly Adults

OBJECTIVES

To examine whether impaired fasting glucose (IFG) represents an intermediary condition between normal fasting glucose and diabetes mellitus and, specifically, whether elderly adults with IFG have higher disease burden, cardiovascular risk, and systemic inflammation and higher 2-year mortality and incident disease.

DESIGN

Prospective observational study.

SETTING

Population-derived cohort.

PARTICIPANTS

Individuals with a mean age of 78.6 ± 4.7 (N = 945).

MEASUREMENTS

Disease was ascertained using a standardized questionnaire at baseline and 2 years. Fasting metabolic, inflammatory, and oxidative metabolism markers were measured. Disease prevalence, cardiovascular risk, and biochemical markers were compared to determine disease burden and metabolic disturbances in IFG. Adjusted odds ratios (ORs) for 2-year all-cause mortality and incident disease were determined.

RESULTS

IFG prevalence was 41%. Individuals with IFG had higher baseline rates of heart disease than those with normal fasting glucose (NFG), similar to that in individuals with diabetes mellitus. IFG was characterized by higher inflammatory markers and oxidative metabolism end products and was an intermediary between NFG and diabetes mellitus for triglycerides and malondialdehyde. Discriminant analysis showed that IFG was independently associated with stroke and higher triglycerides and oxidative stress. Two-year all-cause mortality was 3.9%. The 2-year adjusted ORs for all-cause mortality, incident cardiac disease, stroke, and cancer were similar between IFG and NFG, using both American Diabetes Association and World Health Organization IFG criteria. IFG did not predict secondary cardiac events, stroke, or cancer.

CONCLUSION

IFG was an intermediary condition for heart disease, inflammation, and oxidative stress in elderly adults but not for 2-year incident disease or all-cause mortality. Longer-term prospective studies are needed to clarify whether IFG in elderly adults portends greater morbidity and mortality.

Atherosclerotic cardiovascular disease in older adults with diabetes mellitus

Diabetes mellitus exerts a strong effect on atherosclerotic cardiovascular disease risk into older age (beyond ages 70-74 years). This effect is particularly noticeable with regard to coronary artery disease and cerebral microvascular disease. Thus, diabetes mellitus in older adults deserves the same careful medical attention as it does in middle age.

Differential MMP-9 activity in CD34⁺progenitor cell-derived foam cells from diabetic and normoglycemic patients

BACKGROUND

Upon coincubation with platelet aggregates, CD34(+) progenitor cells have the potential to differentiate into foam cells. There is evidence that progenitor cells from diabetic and nondiabetic patients have different properties, which may affect the patients' prognosis. In this study we investigated an in vitro model of foam cell formation based on patient-derived CD34(+) progenitor cells. We analyzed the growth characteristics as well as the M-CSF-release and matrix metalloproteinase (MMP) synthesis from CD34(+) progenitor cell-derived foam cells originating from diabetic and nondiabetic patients.

METHODS AND RESULTS

Bone marrow samples were obtained from 38 patients who were elected for thoracic surgery. CD34(+) progenitor cells from diabetic and nondiabetic patients were isolated and incubated with platelets from healthy volunteers. Foam cell formation was confirmed by immunostaining (CD68) and quantified by light microscopy. Whereas the absolute number of foam cells was not affected, the negative slope in the growth curve was seen significantly later in the diabetic group. In supernatants derived from"diabetic" CD34(+) progenitor cells, MMP-9 was significantly enhanced, whereas MMP-2 activity or M-CSF-release was not affected significantly.

CONCLUSION

In a coculture model of CD34(+) progenitor cells with platelets, we show for the first time that"diabetic" CD34(+) progenitor cells exhibit functional differences in their differentiation to foam cells concerning growth characteristics and release of MMP-9.

Elevated fasting glucose levels within normal range are associated with an increased risk of metabolic syndrome in older women

OBJECTIVE

The prevalence of cardiovascular disease (CVD) and metabolic syndrome (MetS) increases with increasing fasting plasma glucose (FPG) levels in an elderly population with pre-diabetes or diabetes. However, it remains unknown whether the relationship between elevated FPG and increased risks of MetS exists in older women with normoglycemia (FPG<100mg/dL). Therefore, the present study was conducted to fill the lack of information in that area.

MATERIALS AND METHODS

We included 6505 apparently healthy women, aged 65years and older, with normoglycemia who participated in routine health checkups at health screening centers in Taiwan. Components of MetS (FPG, waist circumference (WC), high-density lipoprotein cholesterol (HDL-C), triglycerides, and systolic/diastolic blood pressure), body mass index (BMI), low-density lipoprotein cholesterol (LDL-C), total cholesterol, and percentage body fat (PBF) were examined in all subjects.

RESULTS

Subjects were sub-grouped by FPG levels (<90mg/dL, 91-95mg/dL and >95mg/dL for group 1, group 2 and group 3, respectively). Subjects in group 2 and group 3 were 1.22-fold (P=0.017) and 1.25-fold (P=0.007) more likely to have MetS compared with those in group 1. Age, WC, BMI, PBF, systolic and diastolic blood pressure, total cholesterol, triglycerides, and HDL-C were significantly correlated with FPG, whereas HDL-C was negatively correlated with FPG. In a multivariate stepwise regression analysis, PBF, LDL-C, triglycerides, and age were significantly and independently associated with FPG.

CONCLUSION

Among older women, the risk of MetS was significantly associated with elevated FPG even for subjects with normal FPG. Lifestyle interventions for reducing PBF and controlling dyslipidemia could help reduce the risk of MetS in this population.

Diabetes and stroke prevention: a review

Stroke and diabetes mellitus are two separate conditions which share multiple common threads. Both are increasing in prevalence, both are diseases which affect blood vessels, and both are associated with other vascular risk factors, such as hypertension and dyslipidemia. Abnormal glucose regulation, of which diabetes is one manifestation, is seen in up to two-thirds of people suffering from an acute stroke. Surprisingly, aggressive management of glucose after an acute stroke has not been shown to improve outcome or reduce the incidence of further strokes. More encouragingly, active management of other cardiovascular risk factors has been demonstrated to prevent stroke disease and improve outcome following a stroke in the diabetic person. Hypertension should be treated with a target of 140/80 mmHg, as a maximum. The drug of choice would be an ACE inhibitor, although the priority is blood pressure reduction regardless of the medication chosen. Lipids should be treated with a statin whatever the starting cholesterol. Antiplatelet treatment is also essential but there are no specific recommendations for the diabetic person. As these conditions become more prevalent it is imperative that the right treatment is offered for both primary and secondary prevention in diabetic people, in order to prevent disease and minimize disability.

Lipoprotein-associated phospholipase A(2) and future risk of subclinical disease and cardiovascular events in individuals with type 2 diabetes: the Cardiovascular Health Study

AIMS/HYPOTHESIS

Type 2 diabetes is an established risk factor for cardiovascular disease (CVD). This increased risk may be due in part to the increased levels of inflammatory factors associated with diabetes. Lipoprotein-associated phospholipase A(2) (Lp-PLA(2)) is a risk marker for CVD and has pro-inflammatory effects in atherosclerotic plaques. We therefore sought to determine whether Lp-PLA(2) levels partially explain the greater prevalence of subclinical CVD and greater incidence of CVD outcomes associated with type 2 diabetes in the Cardiovascular Health Study.

METHODS

We conducted a cross-sectional and prospective study of 4,062 men and women without previous CVD from the Cardiovascular Health Study (1989 to 2007). Lp-PLA(2) mass and activity were measured in baseline plasma. Subclinical disease was determined at baseline and incident CVD was ascertained annually. We used logistic regression for cross-sectional analyses and Cox proportional hazards models for incident analyses.

RESULTS

At baseline, Lp-PLA(2) mass did not differ significantly by type 2 diabetes status; however, Lp-PLA(2) activity was significantly higher among type 2 diabetic individuals. Baseline subclinical disease was significantly associated with baseline diabetes and this association was similar in models unadjusted or adjusted for Lp-PLA(2) (OR 1.68 [95% CI 1.31-2.15] vs OR 1.67 [95% CI 1.30-2.13]). Baseline type 2 diabetes was also significantly associated with incident CVD events, including fatal CHD, fatal myocardial infarction (MI) and non-fatal MI in multivariable analyses. There were no differences in these estimates after further adjustment for Lp-PLA(2) activity.

CONCLUSIONS/INTERPRETATION

In this older cohort, differences in Lp-PLA(2) activity did not explain any of the excess risk for subclinical disease or CVD outcomes related to diabetes.

Diabetic retinopathy is associated with subclinical atherosclerosis in newly diagnosed type 2 diabetes mellitus

AIMS

We aimed to evaluate the association between diabetic microangiopathy and subclinical atherosclerosis as a marker of cardiovascular disease (CVD) risk in patients with newly diagnosed type 2 diabetes.

METHODS

A total of 142 newly diagnosed type 2 diabetics who were free from CVD underwent evaluation of diabetic microangiopathy. Subclinical atherosclerosis was assessed by measuring carotid intima-media thickness (IMT), and the 10-year absolute risk of CVD was estimated using the UK Prospective Diabetes Study (UKPDS) Risk Engine.

RESULTS

Subclinical atherosclerosis was found in 27 subjects (19.0%). The rates of hypertension and diabetic retinopathy were significantly higher among patients with subclinical atherosclerosis. The UKPDS 10-year risk for CVD was significantly increased in subjects with subclinical atherosclerosis. Old age, hypertension and the presence of diabetic retinopathy showed a significant association to subclinical atherosclerosis after further adjustments for gender, body mass index, smoking status, HbA1c, HDL cholesterol, LDL cholesterol and the presence of diabetic nephropathy.

CONCLUSIONS

This study shows that diabetic retinopathy is an independent risk marker for subclinical atherosclerosis in patients with newly diagnosed type 2 diabetes. We suggest that a diagnosis of diabetic retinopathy may warrant a more careful cardiovascular assessment even in the early stages of diabetes.

HIV and general cardiovascular risk

The incidence of cardiovascular disease (CVD) is increasing in HIV-infected people. Risk factors such as hyperlipidemia, impaired glucose tolerance, and insulin resistance have become common. CVD in HIV may also be related to nontraditional risk factors including accumulation of visceral fat, inflammation secondary to HIV, and effects of some antiretroviral drugs. This cross-sectional study described the CVD risk factors of 123 adults living with HIV and calculated the 10-year estimate for general cardiovascular risk score. Results showed that approximately 25% of the participants were considered to be at high risk for developing CVD in the next 10 years. Increased waist circumference and longer duration of smoking habit were associated with elevated general cardiovascular risk scores. Similar to the general population, most of the identified risks could be modified through lifestyle management.

A novel transcriptional mechanism of cell type-specific regulation of vascular gene expression by glucose

OBJECTIVE

Vascular diabetic complications are associated with abnormal extracellular matrix and dysfunction of vascular cells, which later result in aberrant angiogenesis and development of atherosclerotic lesions. The tissue and cell specificity of the effects of high glucose are well recognized, but the underlying cell type-specific molecular mechanisms controlled by glucose are still unclear. We sought to identify cell type-specific mechanisms by which high glucose regulates transcription of genes in vascular cells.

METHODS AND RESULTS

Thrombospondin-1 is a potent antiangiogenic protein associated with development of several diabetic complications and regulated by high glucose in multiple cell types. We report that distinct cell type-specific mechanisms regulate thrombospondin-1 gene (THBS1) transcription in endothelial cells (ECs) and vascular smooth muscle cells (VSMCs) in response to high glucose: although a proximal fragment of 280 nucleotides is sufficient to drive transcription in ECs, THBS1 was regulated cooperatively by interaction between proximal (-272 to -275) and distal (-1016 to -1019) promoter elements in VSMCs. Transcription factors activated by high glucose in VSMCs were cell type-specific. The formation of a single complex interacting with both distal and proximal glucose-responsive elements of THBS1 promoter in VSMCs was confirmed using gel-shift assays, binding sequence decoy oligomers, and specific mutant promoter fragments.

CONCLUSIONS

Transcriptional response of vascular cells to high glucose is cell type-specific and involves activation of distinct transcription factors, providing a basis for tissue-specific changes of vasculature in diabetics.

Diabetes, insulin resistance and atherosclerosis surrogates in patients with coronary atherosclerosis

Background and Objectives

Undiagnosed diabetes mellitus (DM) or impaired glucose tolerance (IGT) is not uncommon in patients with coronary atherosclerosis and is known to be associated with abnormal scores for atherosclerosis surrogates. We sought to determine the prevalence of undiagnosed DM or IGT, and the association between insulin resistance (IR) and atherosclerosis surrogates in patients with coronary atherosclerosis.

Subjects and Methods

The study population consisted of 187 consecutive patients with angiographically proven coronary atherosclerosis (mean: 61 years old, 94 males). We measured carotid intima-media thickness (IMT) and flow mediated brachial artery dilatation (FMD). We also did oral glucose tolerance tests (OGTT), quantitative insulin-sensitivity check indexes (QUICKI) and homeostasis model assessment-IR (HOMA-IR).

Results

Abnormal OGTT was found in 164 patients (87.7%), even though there were only 63 known cases of DM (33.7%). There were 58 patients (31%) with newly diagnosed IGT and 43 patients (23%) with newly diagnosed DM. There were 71 patients (38%) who had IR (defined as measured HOMA-R ≥3.0). HOMA-IR showed a positive correlation with body mass index (BMI) (r=0.275, p<0.001) and triglycerides (r=0.2, p=0.01), whereas QUICKI had a negative correlation with BMI (r=-0.26, p<0.001), total cholesterol (r=-0.15, p=0.04), triglycerides (r=-0.21, p=0.004) and low-density lipoprotein-cholesterol (LDL-C) (r=-0.17, p=0.02). HOMA-IR and QUICKI were not significantly correlated with IMT or FMD.

Conclusion

This study suggests that there is a high incidence of undiagnosed DM and IGT, but atherosclerosis surrogates are not associated with IR in patients with coronary atherosclerosis.

Age- and gender-specific awareness, treatment, and control of cardiovascular risk factors and subclinical vascular lesions in a founder population: the SardiNIA Study

AIM

We investigated the gender-specific control of cardiovascular (CV) risk factors and subclinical vascular lesions in a founder population in Italy.

METHODS AND RESULTS

6148 subjects were enrolled (aged 14-102 years) from four towns. Hypertension (HT), diabetes mellitus (DM) and dyslipidemia (LIP) were defined in accordance with guidelines. A self-reported diagnosis defined awareness of these conditions, and the current use of specific medications as treatment. Prevalence was HT 29.2%, DM 4.8%, LIP 44.1% and was higher in men than in women. Disease prevalence increased with age for every CV risk factor. Men were less likely than women to take anti-HT drugs and to reach BP control (9.9% vs. 16%). Only 17.6% of HT > 65 years had a BP < or =140/90 mmHg, though 48.5% were treated. The use of statins was very low (<1/3 of eligible subjects > 65 years, those with the highest treatment rate). The ratio of control-to-treated HT was lower in subjects with, than in those without, thicker carotid arteries (31.5% vs. 38.8%, p < 0.05) or stiffer aortas (26.0% vs. 40.0%, p < 0.05) or carotid plaques (26.3% vs. 41.1%, p<0.05).

CONCLUSION

A large number of subjects at high CV risk are not treated and the management of subclinical vascular lesions is far from optimal.

[Evidence-based recommendations on primary diagnostics of peripheral arterial occlusive disease in geriatric patients]

The prevalence of peripheral arterial occlusive disease (PAOD) is high in elderly patients and its clinical manifestation is often atypical. Comorbidity and morbidity as a consequence of PAOD are significant. Therefore, standardized primary diagnostics are required among geriatric patients. Drawn from a search of the literature, evidence-based recommendations are provided. Pulse palpation and the evaluation of a patient's medical history are obligatory components of primary diagnostics, even in the absence of typical symptoms. In the case of pathological and ambiguous findings, measuring Doppler ankle pressures is suggested as the next diagnostic step. Further measures depend on the following factors: the presence of lesions on the leg with disturbed blood flow, predominantly in the foot and lower leg areas, degree of PAOD-related ailments, and, finally, intended surgery of the affected leg for other medical reasons.

Rosuvastatin treatment is associated with an increase in insulin resistance in hyperlipidaemic patients with impaired fasting glucose

AIM OF THE STUDY

The increase in physician-reported diabetes following rosuvastatin treatment in the Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin study has raised concerns whether this statin exerts a detrimental effect on glucose metabolism. We assessed the effect of rosuvastatin treatment across dose range on glucose homeostasis in hyperlipidaemic patients with impaired fasting glucose (IFG), who are at high risk to develop diabetes mellitus.

METHODS

The medical records of 72 hypelipidaemic patients with IFG on rosuvastatin 10 (RSV10 group), 20 (RSV20 group) and 40 mg/day (RSV40 group) were reviewed. The median follow up was 12.4 weeks. At the first visit, prior to rosuvastatin prescription and at the latest visit, serum lipid profile and indices of glucose metabolism, including fasting glucose, insulin and HOmeostasis Model Assessment (HOMA(IR)) index levels, were assessed.

RESULTS

Rosuvastatin treatment improved lipid profile and was associated with a dose-dependent significant increase in HOMA(IR) values by 25.4%, 32.3% and 44.8% at the dose of 10, 20 and 40 mg/day (p < 0.01 for all, p < 0.05 for the comparison between groups), respectively, mirrored by correspondent increase in plasma insulin levels [by 21.7%, 25.7% and 46.2% in the RSV10, RSV20 and RSV40 group (p < 0.001 for all) respectively]. Baseline HOMA(IR) levels was the most important contributor (R(2) = 68.1%, p < 0.001), followed by the dose of rosuvastatin treatment (R(2) = 23.7%, p < 0.01), in a model that explained 91.8% of the variability in HOMA(IR) increase.

CONCLUSION

In patients with IFG and hyperlipidaemia, rosuvastatin treatment was associated with a dose-dependent increase in insulin resistance.

An evaluation of glucose tolerance in essential hypertension

PURPOSE

This study aimed to determine the impaired glucose tolerance and diabetes prevalence in patients with essential hypertension (HT) and to compare the developed microvascular complications of these groups.

MATERIALS AND METHODS

An oral glucose tolerance test (OGTT) was performed on 338 essential hypertensive cases and glucose tolerances were classified according to ADA-2002 criteria.

RESULTS

Of the 338 cases, 32 people had diabetes (DM, 9.46%), 78 people had glucose intolerance (IGT, 23.1%), and 228 people had only hypertension but not IGT and DM (67.4%). Both the mean ages of the DM group (56.9 +/- 6.7 years, p = 0.002) and IGT group (56.3 +/- 8.4 years, p = 0.003) were older than the mean age of the control group (51.1 +/- 6.4 years). The risk of IGT development was found to be four times greater in male cases than female cases when compared to the control group (p = 0.004, add ratio = 4.194). There were no significant differences in the body mass indexes (BMI's), hypertension durations, and microvascular complications between the groups.

CONCLUSION

In conclusion, the risk of IGT and DM development in hypertensive cases increases with aging and longer hypertension duration. The risk of IGT development in hypertensive cases is four times more in males.

The prevalence of Type 2 diabetes and its associated health problems in a community-dwelling elderly population

AIMS

Prevalence estimates of Type 2 diabetes and its associated health problems in elderly populations are rare, especially in the very elderly.

METHODS

A sample of 15 095 community-dwelling older people aged > or = 75 years were assessed. Type 2 diabetes and associated health problems were identified using self-reporting, general practitioner records, drug histories, and blood and urine measurements.

RESULTS

There were 1177 people identified as having Type 2 diabetes mellitus, giving an overall prevalence of 7.8% (95% confidence interval 7.1, 8.5), 9.4% (8.4, 10.5) for men and 6.8% (6.1, 7.6) for women. The age, sex and smoking adjusted odds ratios for various health problems, comparing people with and without diabetes were: low vision 1.6 (1.3, 1.9), proteinuria 1.7 (1.4, 2.1), chronic kidney disease stage 4 or 5 1.5 (1.0, 2.1), angina 1.3 (1.1, 1.6), myocardial infarction 1.5 (1.2, 1.8), cerebrovascular event 2.0 (1.8, 2.1) and foot ulceration 1.7 (1.2, 2.4).

CONCLUSIONS

The prevalence of Type 2 diabetes is not high in community-dwelling older people, but diabetes was a contributory factor to a number of health problems.

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.

Inflammation and its relationship to insulin resistance, type 2 diabetes mellitus, and endothelial dysfunction

In the past decade, clinical, laboratory, and epidemiological research have coalesced to give rise to a new paradigm for understanding type 2 diabetes mellitus (DM). In this review, we present data that DM has an inflammatory etiology and that inflammation plays a role in diabetic complications, especially cardiovascular disease. This new paradigm offers insight into the relationship between DM and obesity. It also suggests possible new avenues of treatment.

Serum leptin and its relation to anthropometric measures of obesity in pre-diabetic Saudis

Background

Little information is available on leptin concentrations in individuals with IGT. This study aims to determine and correlate leptin levels to anthropometric measures of obesity in pre-diabetic, (IFG and IGT), type 2 diabetic and normoglycaemic Saudis.

Methods

308 adult Saudis (healthy controls n = 80; pre-diabetes n = 86; Type 2 diabetes n = 142) participated. Anthropometric parameters were measured and fasting blood samples taken. Serum insulin was analysed, using a solid phase enzyme amplified sensitivity immunoassay and also leptin concentrations, using radio-immunoassay. The remaining blood parameters were determined using standard laboratory procedures.

Results

Leptin levels of diabetic and pre-diabetic men were higher than in normoglycaemic men (12.4 [3.2–72] vs 3.9 [0.8–20.0] ng/mL, (median [interquartile range], p = 0.0001). In females, leptin levels were significantly higher in pre-diabetic subjects (14.09 [2.8–44.4] ng/mL) than in normoglycaemic subjects (10.2 [0.25–34.8] ng/mL) (p = 0.046). After adjustment for BMI and gender, hip circumference was associated with log leptin (p = 0.006 with R2 = 0.086) among all subjects.

Conclusion

Leptin is associated with measures of adiposity, hip circumference in particular, in the non-diabetic state among Saudi subjects. The higher leptin level among diabetics and pre-diabetics is not related to differences in anthropometric measures of obesity.

High-normal fasting blood glucose in non-diabetic range is associated with increased coronary artery calcium burden in asymptomatic men

OBJECTIVE

: The objective of the study is to evaluate whether high fasting blood glucose (FBG) in the non-diabetic range (<126 mg/dl) is associated with subclinical coronary atherosclerosis as determined by coronary artery calcium (CAC) independent of clustering of metabolic syndrome (MS) risk factors.

METHODS & RESULTS

: Previously non-diabetic, 458 asymptomatic non-diabetic Brazilian men (mean age: 46+/-7 years, range: 29-65) underwent clinical consultation including FBG measurements and electron-beam tomography (EBT). The mean FBG of the study population was 88+/-10mg/dl. Overall, 190 (42%) of men had CAC>0. The prevalence of CAC was significantly higher among men with high-normal FBG (4th quartile: 94-125 mg/dl) versus normal FBG group (lower three quartiles: 66-93 mg/dl) (62% versus 35%, p<0.0001). In age adjusted analyses the odds ratio (OR) for any CAC among men with high-normal FBG versus normal FBG was 2.19 (95% CI: 1.33-3.58). On further adjustment for risk factors the relationship was slightly attenuated, however remained statistically significant (OR=1.78, 95% CI 1.05-3.00, p=0.03). In sub-stratified analyses high-normal FBG was associated with CAC among men without MS (OR: 1.99, 95% CI: 1.04-3.78) and with MS (OR: 2.12, 95% CI: 0.95-4.80). Similar relations with high-normal FBG were observed among individuals classified low risk (OR: 2.34, 95% CI: 1.14-4.83) as well intermediate high-risk men (OR: 1.95, 95% CI: 0.99-3.86) by Framingham risk score (FRS), respectively.

CONCLUSIONS

: Fasting blood glucose in the upper normal range appears to be associated with the presence of CAC in apparently non-diabetic Brazilian men.

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

BACKGROUND

The aim of the present study was to evaluate the risk factors for peripheral arterial disease and the relationship between the ankle - brachial index (ABI) and mortality from all-cause and cardiovascular disease (CVD) in Chinese patients with type 2 diabetes mellitus (DM).

METHODS AND RESULTS

ABI was identified at baseline by measuring systolic pressure in the bilateral brachial and tibial arteries. Mortality surveillance was completed from November 2004 to January 2006. Among 1,647 participants with type 2 DM at baseline, 531 (32.2%) were in the low-ABI group. Older age, female gender, higher serum level of total cholesterol, longer duration of DM and a history of smoking were associated with low ABI. During the 13-month follow-up, there were 132 deaths, of which 47 were from CVD. Low ABI was associated with mortality from all-cause and CVD, the adjusted relative risk of which was 1.851 (95% confidence interval 1.280-2.676) and 3.211 (1.703-6.053), respectively, in Cox regression models. The survival rate was significantly lower in the low-ABI group than in the normal-ABI group.

CONCLUSION

Low ABI was independently associated with a high risk of all-cause and CVD mortality in Chinese patients with type 2 DM. ABI should be promoted as an ideal tool for predicting mortality in diabetic patients.

Evaluation of Medical Treatment for Peripheral Arterial Disease in Chinese High-Risk Patients

BACKGROUND

Peripheral arterial disease (PAD) is an important manifestation of systemic atherosclerosis and is associated with elevated cardiovascular morbidity and mortality. The aim of the present study was to evaluate the use of antiplatelet agents, statins and angiotensin-converting enzyme inhibitors (ACEI) in Chinese high-risk cardiovascular (CV) patients with PAD, with an emphasis on the need for aggressive medical management of all atherosclerotic manifestations.

METHODS AND RESULTS

Medical records from 5,263 Chinese patients at high risk of CV were evaluated for the use of antiplatelet agents, statins and ACEI in patients with and without PAD. PAD was defined as an ankle-brachial index (ABI)<0.9 in either leg. Multivariable logistic regression analyses were performed to compare medication use in the 2 groups. A total of 5,254 patients were analyzed (52.9% male, mean age 67.3 years). The prevalence of PAD in the total patient group was 25.4%; 22.5% of them had PAD only. Overall, 5.7% had PAD only, 19.6% had PAD and coronary heart disease (CHD) or stroke or diabetes, 7.7% had CHD only, 12.6% had stroke only, and 13.6% had diabetes only. The 28.9% subjects having none of PAD, CHD, stroke or diabetes were used as the reference group. Only 65%, 37% and 47% of all patients received antiplatelet agents, statins and ACEI, respectively. Antiplatelets, statins, ACEI and all 3 medications were used less frequently in PAD only patients (58.1%, 35.9, 53.5% and 21.6%) vs CHD only (90.9%, 74.5%, 70.6% and 55.9%, p<0.001). All 3 proven efficacious therapies were prescribed for only 56% of patients with CHD only, 8% with stroke only, 13% with diabetes only and 21% with PAD only.

CONCLUSION

PAD is prevalent in Chinese high-risk CV patients, equivalent to CHD, but these patients receive less intensive treatment than those with CHD. Programs to improve CV risk reduction in these high-risk patients are needed.

Glycosylation mediates up-regulation of a potent antiangiogenic and proatherogenic protein, thrombospondin-1, by glucose in vascular smooth muscle cells

Accelerated development of atherosclerotic lesions remains the most frequent and dangerous complication of diabetes, accounting for 80% of deaths among diabetics. However, our understanding of the pathways mediating glucose-induced gene expression in vascular cells remains controversial and incomplete. We have identified an intracellular metabolic pathway activated by high glucose in human aortic smooth muscle cells that mediates up-regulation of thrombospondin-1 (TSP-1). TSP-1 is a potent antiangiogenic and proatherogenic protein that may represent an important link between diabetes and vascular complications. Using different glucose analogs and metabolites sharing distinct, limited metabolic steps with glucose, we demonstrated that activation of TSP-1 transcription is mediated by the hexosamine pathway of glucose catabolism, possibly resulting in modulation of the activity of nuclear proteins activity through their glycosylation. Specific inhibitors of glutamine: fructose 6-phosphate amidotransferase (GFAT), an enzyme controlling the hexosamine pathway, as well as direct inhibitors of protein glycosylation efficiently inhibited TSP-1 transcription and the activity of a TSP-1 promoter-reporter construct stimulated by high glucose. Overexpression of recombinant GFAT resulted in increased TSP-1 levels. Pharmacological inhibition of GFAT or protein glycosylation inhibited increased proliferation of human aortic smooth muscle cells caused by glucose. We have demonstrated that the hexosamine metabolic pathway mediates up-regulation of TSP-1 by high glucose. Our results suggest that the hexosamine pathway and intracellular glycosylation may control important steps in initiation and development of atherosclerotic lesions.

The association of markers of inflammation with weight change in older adults: the Cardiovascular Health Study

OBJECTIVE

Elevated levels of inflammation factors often precede weight loss and may be causally related to it. Newer studies suggest that elevated levels of inflammation factors also precede weight gain. In this study, we examined whether inflammation factors are elevated in individuals, age >or=65 years, who lost or gained >5% weight over a 3 year follow-up period compared to those with stable weight.

SUBJECTS

In total, 3254 participants in the Cardiovascular Health Study whose weight was stable; 661 who gained >5% weight; and 842 who lost >5% weight.

MEASUREMENTS

C-reactive protein (CRP), fibrinogen, factor VIIIc, white blood cell (WBC) and platelet counts, and interleukin-6 (IL-6) levels.

RESULTS

As compared to participants whose weight was stable, those who lost >5% weight had higher baseline CRP concentration (1.05 (95% CI, 1.02, 1.08) per interquartile increase) and WBC count (1.10 (1.01, 1.19) per interquartile increase) on adjusted analyses. Those who gained >5% weight had higher baseline CRP (1.05 (1.01, 1.08)), fibrinogen (1.13 (1.01, 1.27)), and factor VIIIc (1.15 (1.03, 1.30)).

CONCLUSIONS

Inflammation factors are associated with weight gain and weight loss in older individuals. These findings suggest that subclinical inflammation, or unknown factors associated with subclinical inflammation, contribute to weight change.

Optimal care of cardiovascular disease and type 2 diabetes patients: shared responsibilities between the cardiologist and diabetologist

Type 2 diabetes and cardiovascular disease are inextricably linked. Patients with type 2 diabetes are at increased risk of cardiovascular events and mortality. However, controlling blood glucose, which until recently had often been the focus of the diabetologist, is only one component of optimal cardiovascular risk reduction. Vascular protection of the patient with diabetes also includes management of hypertension and dyslipidaemia and lifestyle changes such as smoking cessation. Now both cardiologists and diabetologists need to optimise all components of vascular protection, including glycaemic control, in patients with diabetes. An elevated blood glucose is predictive of poor outcomes in patients with acute coronary syndromes, even if frank diabetes is not present. Early control of hyperglycaemia should be achieved: a strategy that results in improved outcomes. More than two-thirds of patients with coronary artery disease (CAD) have abnormal glucose regulation, which is a predictor of poor outcome. Therefore, the presence of diabetes (and/or glucose intolerance) should be routinely screened for in cardiac patients on admission to hospital. Early identification and treatment of CAD in patients with diabetes is important for optimal prevention of cardiovascular events. However, screening all diabetes patients for CAD is not feasible, and selection of patients for non-invasive cardiac testing remains a challenge for both the diabetologist and cardiologist. Optimal care of diabetic and cardiac patients requires a multidisciplinary team approach, with key roles for the cardiologist and diabetologist.

Prevalence of glucose metabolism abnormalities and cardiovascular co-morbidity in the US elderly adult population

PURPOSE

To estimate the prevalence of glucose metabolism abnormalities, including diabetes, and its associated cardiovascular risk factors and co-morbidity in the US elderly population.

METHODS

Cross-sectional analysis of data from the Third National Health and Nutrition Examination Survey (NHANES III, 1988-1994) in adults aged 65 years and more. The 1997 American Diabetes Association (ADA) and the 1998 World Health Organization (WHO) criteria were used to classify the subject's glucose metabolism status. The 2-hour oral glucose tolerance test (OGTT) was performed only among those participants aged 40 to 74 years.

RESULTS

The age-adjusted prevalence of diagnosed diabetes was 12.5% (95% CI: 11.4%-13.6%) among US adults aged 65 years or more. According to the ADA definition 40% of men and 28% of women were affected by some degree of glucose metabolism impairment. According to the WHO definition, 55% of men and 50% of women aged 65 to 74 years were affected by glucose metabolism abnormalities. Mexican-Americans were the most affected under both definitions (51% and 77%, respectively). Overall, 72% of elderly diagnosed diabetics had hypertension, 28% had coronary heart disease (CHD), 47% suffered from cardiovascular disease and 80% of them presented known CHD or multiple coronary risk factors, other than age, level of LDL-cholesterol and diabetes. Under both definitions, a trend towards a worsening coronary risk profile with increased glucose metabolism impairment was observed.

CONCLUSION

A notable proportion of elderly people is affected by some degree of glucose metabolism impairment which in turn is associated with cardiovascular co-morbidity.

Ankle Brachial Index as a Marker of Atherosclerosis in Chinese Patients with High Cardiovascular Risk

To obtain reliable data on the epidemiology, co-morbidities and risk factor profile of peripheral arterial disease (PAD), we evaluated the clinical significance of the ankle brachial index (ABI) as an indicator of PAD in Chinese patients at high cardiovascular (CV) risk. ABI was measured in 5,646 Chinese patients at high CV risk, and PAD was defined as an ABI<0.9 in either leg. Multivariable logistic regression analyses were performed to identify factors associated with PAD. A total of 5,263 patients were analyzed, 52.9% male, mean age 67.3 years, mean body mass index (BMI) 24.2 kg/m2, mean systolic/diastolic blood pressure (SBP/DBP) 139/80.7 mmHg. The prevalence of PAD in the total group of patients was 25.4%, and the prevalence was higher in females than in males (27.1% vs. 23.9%; odds ratio [OR]: 1.64). Patients with PAD were older than those without PAD (72.3+/-9.9 years vs. 65.6+/-11.7 years; OR: 1.06), and more frequently had diabetes (43.3% vs. 31.3%; OR: 2.02), coronary heart disease (CHD) (27.0% vs. 18.8%; OR: 1.67), stroke (44.4% vs. 28.3%; OR: 1.78), lipid disorders (57.2% vs. 50.7%; OR: 1.3) and a smoking habit (42.7% vs. 38.6%; OR: 1.52). The ORs for the PAD group compared with the non-PAD group demonstrated that these conditions were inversely related to ABI. Statin, angiotensin-converting enzyme-inhibitors and antiplatelet agents were only used in 40.5%, 53.6% and 69.1% of PAD patients, respectively. The data demonstrated the high prevalence and low treatment of PAD in Chinese patients at high CV risk. A lower ABI was associated with generalized atherosclerosis. Based on these findings, ABI should be a routine measurement in high risk patients. Aggressive medication was required in these patients.

The impact of diabetes or elevated fasting blood glucose on cardiovascular prognosis in patients with stable angina pectoris

AIMS

To examine the influences of diabetes and elevated fasting blood glucose on cardiovascular prognosis in patients with stable angina pectoris.

METHODS

In a prospective study of 809 patients with stable angina pectoris randomized to receive metoprolol or verapamil, a subgroup of 69 diabetic patients was compared with non-diabetic patients with respect to the risk of cardiovascular (CV) death, non-fatal myocardial infarction (MI) and revascularization. We also analysed a subgroup of 67 patients with fasting blood glucose > or = 6.1 mmol/l, defined according to the most recent revised guidelines for the diagnosis of diabetes mellitus. Fasting blood glucose was measured in venous whole blood at baseline.

RESULTS

The diabetic patients had a greater risk-factor burden, with a higher prevalence of hypertension, more likely to be male, a tendency towards a higher prevalence of previous MI, and higher triglyceride and lower high-density lipoprotein (HDL)-cholesterol levels. In multivariate analyses, diabetes was an independent risk factor for CV events with a relative risk of 2.64 (CI 1.39-5.00; P < 0.001) for CV death/MI, and 1.79 (CI 1.02-3.15; P < 0.01) for revascularization. Blood glucose > or = 6.1 mmol/l without a diagnosis of diabetes mellitus was found in 67 patients, and predicted CV death/MI [relative risk 2.76 (CI 1.97-3.84)] in both univariate and multivariate analyses. The prognosis of diabetic or hyperglycaemic patients did not differ significantly with metoprolol compared with verapamil treatment.

CONCLUSIONS

Diabetes mellitus is an independent risk factor for CV death/MI and for revascularization in patients with stable angina pectoris. Elevated fasting blood glucose was seen in 9% of patients without known diabetes and was an equally strong and independent risk factor for CV death/MI as diagnosed and treated diabetes.

The cost-effectiveness of lifestyle modification or metformin in preventing type 2 diabetes in adults with impaired glucose tolerance

BACKGROUND

The Diabetes Prevention Program (DPP) demonstrated that interventions can delay or prevent the development of type 2 diabetes.

OBJECTIVE

To estimate the lifetime cost-utility of the DPP interventions.

DESIGN

Markov simulation model to estimate progression of disease, costs, and quality of life.

DATA SOURCES

The DPP and published reports.

TARGET POPULATION

Members of the DPP cohort 25 years of age or older with impaired glucose tolerance.

TIME HORIZON

Lifetime.

PERSPECTIVES

Health system and societal.

INTERVENTIONS

Intensive lifestyle, metformin, and placebo interventions as implemented in the DPP.

OUTCOME MEASURES

Cumulative incidence of diabetes, microvascular and neuropathic complications, cardiovascular complications, survival, direct medical and direct nonmedical costs, quality-adjusted life-years (QALYs), and cost per QALY.

RESULTS OF BASE-CASE ANALYSIS

Compared with the placebo intervention, the lifestyle and metformin interventions were estimated to delay the development of type 2 diabetes by 11 and 3 years, respectively, and to reduce the absolute incidence of diabetes by 20% and 8%, respectively. The cumulative incidence of microvascular, neuropathic, and cardiovascular complications were reduced and survival was improved by 0.5 and 0.2 years. Compared with the placebo intervention, the cost per QALY was approximately 1100 dollars for the lifestyle intervention and $31 300 for the metformin intervention. From a societal perspective, the interventions cost approximately 8800 dollars and 29,900 dollars per QALY, respectively. From both perspectives, the lifestyle intervention dominated the metformin intervention.

RESULTS OF SENSITIVITY ANALYSIS

Cost-effectiveness improved when the interventions were implemented as they might be in routine clinical practice. The lifestyle intervention was cost-effective in all age groups. The metformin intervention did not represent good use of resources for persons older than 65 years of age.

LIMITATIONS

Simulation results depend on the accuracy of the underlying assumptions, including participant adherence.

CONCLUSIONS

Health policy should promote diabetes prevention in high-risk individuals.

Cardiovascular comorbidities among public health clinic patients with diabetes: the Urban Diabetics Study

Background

We sought to determine the frequency and distribution of cardiovascular comorbidities in a large cohort of low-income patients with diabetes who had received primary care for diabetes at municipal health clinics.

Methods

Outpatient data from the Philadelphia Health Care Centers was linked with hospital discharge data from all Pennsylvania hospitals and death certificates.

Results

Among 10,095 primary care patients with diabetes, with a mean observation period of 4.6 years (2.8 after diabetes diagnosis), 2,693 (14.3%) were diagnosed with heart disease, including 270 (1.4%) with myocardial infarction and 912 (4.8%) with congestive heart failure. Cerebrovascular disease was diagnosed in 588 patients (3.1%). Over 77% of diabetic patients were diagnosed with hypertension. Incidence rates of new complications ranged from 0.6 per 100 person years for myocardial infarction to 26.5 per 100 person years for hypertension. Non-Hispanic whites had higher rates of myocardial infarction, and Hispanics and Asians had fewer comorbid conditions than African Americans and non-Hispanic whites.

Conclusion

Cardiovascular comorbidities were common both before and after diabetes diagnosis in this low-income cohort, but not substantially different from mixed-income managed care populations, perhaps as a consequence of access to primary care and pharmacy services.

Ankle brachial pressure index and carotid intima-media thickness as atherosclerosis markers in Japanese diabetics

The aim of this study was to assess the clinical significance of ankle brachial pressure index (ABI) and carotid intima-media thickness (IMT) in Japanese patients with type 2 diabetes. ABI and ultrasonographic carotid IMT measurements were made in 1311 patients and the relationships between ABI, IMT, and cardiovascular diseases were examined. Patients were assigned to one of three groups depending on their ABI index: (i) ABI > or = 1.0; (ii) ABI from > or = 0.9 to < 1.0; and (iii) ABI < 0.9. The odds ratios (ORs) for groups (ii) and (iii) compared with (i) for the prevalence of coronary heart disease (CHD), cerebrovascular disorder (CVD), and carotid atherosclerosis (mean carotid IMT > or = 1.1mm) demonstrated that these conditions were inversely related to ABI. As the combined ABI/carotid IMT score increased, each OR for the prevalence of CHD and CVD increased significantly. This suggests that a lower ABI is associated with generalized atherosclerosis. Measurements of the ABI and carotid IMT might provide a good prognostic indicator, and both should be assessed during screening for atherosclerosis in Japanese patients with type 2 diabetes.

Peripheral arterial disease, diabetes, and mortality

OBJECTIVE

The aims of this study were to provide estimates of 1) the risk of mortality for individuals with both diabetes and peripheral arterial disease (PAD) relative to that for individuals with either condition alone and 2) the association between PAD progression and mortality for individuals with diabetes, PAD, and both conditions.

RESEARCH DESIGN AND METHODS

This longitudinal cohort study was conducted in Rochester, Minnesota. Local residents age 50-70 years with a prior diagnosis of PAD and/or diabetes were identified from the Mayo Clinic diagnostic registry and invited to a baseline examination (1977-1978). Those who met inclusion criteria were assessed for PAD progression at 2 and 4 years and followed for vital status through 31 December 1999.

RESULTS

The numbers who met criteria for PAD, diabetes, and both conditions at baseline were 149, 238, and 186, respectively. Within each group, observed survival was less than expected (P <0.001). The adjusted risk of death for both conditions was 2.2 times that for PAD alone. Among the 449 who returned at 4 years, the risk of subsequent death was greater for those whose PAD had progressed; among individuals with diabetes alone at baseline, 100% (17 of 17) who met criteria for PAD progression were dead by 31 December 1999 compared with 62% (111 of 178) of those who had not met criteria (adjusted relative hazard 2.29 [95% CI 1.30-4.02], P=0.004). The increased mortality associated with PAD progression was significant only for individuals with diabetes (alone or with PAD).

CONCLUSIONS

Diabetes is a risk factor for both PAD and PAD-associated mortality, emphasizing the critical need to detect and monitor PAD in diabetic patients.