Prognostic Effect of the Nocturnal Blood Pressure Fall in Hypertensive Patients: The Ambulatory Blood Pressure Collaboration in Patients With Hypertension (ABC-H) Meta-Analysis

The prognostic importance of the nocturnal systolic blood pressure (SBP) fall, adjusted for average 24-hour SBP levels, is unclear. The Ambulatory Blood Pressure Collaboration in Patients With Hypertension (ABC-H) examined this issue in a meta-analysis of 17 312 hypertensives from 3 continents. Risks were computed for the systolic night-to-day ratio and for different dipping patterns (extreme, reduced, and reverse dippers) relative to normal dippers. ABC-H investigators provided multivariate adjusted hazard ratios (HRs), with and without adjustment for 24-hour SBP, for total cardiovascular events (CVEs), coronary events, strokes, cardiovascular mortality, and total mortality. Average 24-hour SBP varied from 131 to 140 mm Hg and systolic night-to-day ratio from 0.88 to 0.93. There were 1769 total CVEs, 916 coronary events, 698 strokes, 450 cardiovascular deaths, and 903 total deaths. After adjustment for 24-hour SBP, the systolic night-to-day ratio predicted all outcomes: from a 1-SD increase, summary HRs were 1.12 to 1.23. Reverse dipping also predicted all end points: HRs were 1.57 to 1.89. Reduced dippers, relative to normal dippers, had a significant 27% higher risk for total CVEs. Risks for extreme dippers were significantly influenced by antihypertensive treatment (P<0.001): untreated patients had increased risk of total CVEs (HR, 1.92), whereas treated patients had borderline lower risk (HR, 0.72) than normal dippers. For CVEs, heterogeneity was low for systolic night-to-day ratio and reverse/reduced dipping and moderate for extreme dippers. Quality of included studies was moderate to high, and publication bias was undetectable. In conclusion, in this largest meta-analysis of hypertensive patients, the nocturnal BP fall provided substantial prognostic information, independent of 24-hour SBP levels.

Prevalence and associated factors of non-alcoholic fatty liver disease in patients with type-2 diabetes mellitus

BACKGROUND/AIMS

Diabetic patients have an increased prevalence and severity of non-alcoholic fatty liver disease (NAFLD). We aimed to investigate the prevalence and the factors associated with the presence of ultrasonographic NAFLD in type-2 diabetic individuals.

METHODS

In a cross-sectional design study, 180 type-2 diabetic patients were submitted to a complete clinical and laboratory evaluation and abdominal ultrasonography for NAFLD detection and grading. Statistical analysis included bivariate tests, analysis of variance (anova, for increasing severity of steatosis) and multivariate logistic regression.

RESULTS

The prevalence of ultrasonographic NAFLD was 69.4% [95% confidence interval (CI): 58.3-82.7%]. Patients with NAFLD were more obese, had a higher waist circumference and serum triglyceride and alanine aminotransferase (ALT) levels than those without steatosis. Neither diabetic degenerative complication, nor glycaemic control was associated with liver steatosis. On multivariate analysis, a high serum triglycerides level [>2.82 mmol/L, odds ratio (OR): 3.7-4.1, 95% CI: 1.2-13.3] and a high-normal ALT level (> or =40 U/L, OR: 2.5-2.7, 95% CI: 1.2-5.9) were independently associated with hepatic steatosis, together with either the presence of obesity (OR: 7.1, 95% CI: 3.0-17.0) or of increased waist circumference (OR: 4.8, 95% CI: 1.9-12.2).

CONCLUSIONS

Type-2 diabetic patients have a high prevalence of ultrasonographic NAFLD and its presence is associated with obesity, mainly abdominal, hypertriglyceridaemia and high-normal ALT levels. Non-alcoholic fatty liver disease in diabetic patients may develop and progress independent of the diabetes progression itself.

Prognostic influence of office and ambulatory blood pressures in resistant hypertension

BACKGROUND

The prognostic value of office and ambulatory blood pressures (BPs) in patients with resistant hypertension is uncertain.

METHODS

This prospective study investigates the importance of office and ambulatory BPs as predictors of cardiovascular morbidity and mortality. At baseline, 556 resistant hypertensive patients underwent clinical-laboratory and 24-hour ambulatory BP monitoring examinations. Primary end points were a composite of fatal and nonfatal cardiovascular events and all-cause and cardiovascular mortalities. Multiple Cox regression was used to assess associations between BP and subsequent end points.

RESULTS

After median follow-up of 4.8 years, 109 patients (19.6%) reached the primary end point, and 70 all-cause deaths (12.6%) occurred (46 had cardiovascular causes). After adjustment for age, sex, body mass index, diabetes mellitus, smoking, physical inactivity, dyslipidemia, previous cardiovascular diseases, serum creatinine level, and number of antihypertensive drugs in use, no office BP showed any prognostic value. After further adjustment for office BP, higher mean ambulatory BPs were independent predictors of the composite end point. The hazard ratios associated with a 1-SD increment in daytime and nighttime systolic BP were 1.26 (95% confidence interval, 1.04-1.53) and 1.38 (1.13-1.68), respectively; the corresponding values for diastolic BP were 1.31 (1.05-1.63) and 1.36 (1.10-1.69). Ambulatory systolic and diastolic BP were equivalent predictors, and both were better than pulse pressure; nighttime BP was superior to daytime BP. For all-cause mortality, only the ambulatory BP monitoring diagnosis of true resistant hypertension was an independent predictor.

CONCLUSION

Higher ambulatory BP predicts cardiovascular morbidity and mortality in resistant hypertensive patients, whereas office BP has no prognostic value.

Long-term visit-to-visit glycemic variability as predictor of micro- and macrovascular complications in patients with type 2 diabetes: The Rio de Janeiro Type 2 Diabetes Cohort Study

BACKGROUND

Long-term visit-to-visit glycemic variability is an additional measure of glycemic control. We aimed to evaluate the prognostic value of several measures of glycemic variability for the occurrence of micro- and macrovascular complications, and all-cause mortality in patients with type 2 diabetes.

METHODS

654 individuals were followed-up over a median of 9.3 years. Glycemic variability (SDs and coefficients of variation of HbA1c and fasting glycaemia) was measured during the first 12- and 24-months. Multivariate Cox analysis, adjusted for risk factors and mean HbA1c and fasting glycaemia levels, examined the associations between glycemic variability and the occurrence of microvascular (retinopathy, microalbuminuria, renal function deterioration, peripheral neuropathy) and macrovascular complications [total cardiovascular events (CVE), major adverse CVEs (MACE) and cardiovascular mortality], and of all-cause mortality.

RESULTS

During follow-up, 128 patients had a CVE (96 MACE), and 158 patients died (67 from cardiovascular diseases); 152 newly-developed or worsened diabetic retinopathy, 183 achieved the renal composite outcome (89 newly developed microalbuminuria and 91 deteriorated renal function), and 96 newly-developed or worsened peripheral neuropathy. Glycemic variability, particularly the 24-month parameters either estimated by HbA1c or by fasting glycemia, predicted all endpoints, except for retinopathy and peripheral neuropathy development/progression, and was a better predictor than mean HbA1c. Glycemic variability predicted retinopathy development/progression in patients with good glycemic control (HbA1c ≤ 7.5%, 58 mmol/mol) and predicted new-incident peripheral neuropathy.

CONCLUSIONS

Long-term visit-to-visit glycemic variability is an additional and frequently a better glycemic parameter than mean HbA1c levels for assessing the risk of future development of micro- and macrovascular complications in patients with type 2 diabetes.

Histopathological stages of nonalcoholic fatty liver disease in type 2 diabetes: prevalences and correlated factors

BACKGROUND/AIMS

Nonalcoholic fatty liver disease (NAFLD) is highly prevalent in type 2 diabetes mellitus (T2DM). However, data regarding the prevalence and correlates of its histopathological stages are scarce. The aim was to investigate the prevalence and correlates of the more severe histopathological features of NAFLD, nonalcoholic steatohepatitis (NASH) and advanced fibrosis, in T2DM.

METHODS

From 125 patients with ultrasonographic evidence of NAFLD, 98 patients underwent liver biopsies, which were examined by two independent pathologists regarding the presence of NASH and graded according to the NASH Clinical Research Network scoring system. Agreement between pathologists was assessed by weighted κ coefficients and independent correlates of NASH and advanced fibrosis (grade ≥ 2) by multivariate logistic regression.

RESULTS

Ninety-two (94%) patients presented histological NAFLD. Interobserver agreement was substantial to excellent for NASH diagnosis (κ=0.82) and steatosis grading (κ=0.76), and moderate for the NAFLD activity score (κ=0.58) and fibrosis grading (κ=0.52). The prevalence of NASH was 78%, and its independent correlates were hypertriglyceridaemia (P=0.034), high alanine aminotranferase level (P=0.044) and low serum high-density lipoprotein-cholesterol (P=0.079). The prevalence of advanced fibrosis ranged from 34% in the best scenario (lowest fibrosis score) to 60% in the worst scenario (highest score). Its independent correlates were a high serum γ-glutamyl transferase (P=0.002), older age (P=0.022) and male gender (P=0.064). No diabetes-related clinical characteristic was associated with NASH or advanced liver fibrosis.

CONCLUSIONS

The prevalence of the severe features of NAFLD is high in T2DM patients. Liver biopsy shall be considered in all diabetic patients with ultrasonographic evidence of NAFLD.

Prognostic value of nocturnal blood pressure reduction in resistant hypertension

BACKGROUND

The prognostic value of nocturnal blood pressure (BP) reduction in resistant hypertension (RH) is unknown. The objective of this prospective study was to evaluate its importance as a predictor of cardiovascular morbidity and mortality.

METHODS

At baseline, 556 patients with RH underwent clinical and laboratory examinations and 24-hour ambulatory BP monitoring. The primary end points were a composite of fatal or nonfatal cardiovascular events, all-cause mortality, and cardiovascular mortality. Multiple Cox regression was used to assess associations between the nocturnal BP reduction and the subsequent end points.

RESULTS

After a mean follow-up of 4.8 years (range, 1-103 months), 109 patients (19.6%) reached the composite end point, with 70 all-cause and 46 cardiovascular deaths. A nondipping pattern was present in 360 patients (65.0%). After adjustment for age, sex, body mass index, diabetes, smoking status, physical inactivity, dyslipidemia, previous cardiovascular disease, number of antihypertensive drugs in use, and office and 24-hour ambulatory BP readings, the nondipping pattern was an independent predictor of the composite end point (hazard ratio [HR], 1.74; 95% confidence interval [CI], 1.12-2.71) and of cardiovascular mortality (HR, 2.31; 95% CI, 1.09-4.92). In subgroup analysis, the reduced (HR, 1.71; 95% CI, 1.03-2.83) and reverted (HR, 1.89; 95% CI, 1.04-3.43) dipping patterns were predictive of total cardiovascular events. The effect of the nondipping pattern on cardiovascular prognosis was stronger in younger patients and in those with true RH.

CONCLUSIONS

The nocturnal BP variability patterns provide valuable prognostic information for stratification of cardiovascular morbidity and mortality risk in patients with RH, above and beyond other traditional cardiovascular risk factors and mean ambulatory BP levels.

Effects of continuous positive airway pressure treatment on clinic and ambulatory blood pressures in patients with obstructive sleep apnea and resistant hypertension: a randomized controlled trial

The effect of continuous positive airway pressure (CPAP) on blood pressures (BPs) in patients with resistant hypertension and obstructive sleep apnea is not established. We aimed to evaluate it in a randomized controlled clinical trial, with blinded assessment of outcomes. Four hundred thirty-four resistant hypertensive patients were screened and 117 patients with moderate/severe obstructive sleep apnea, defined by an apnea-hypopnea index ≥15 per hour, were randomized to 6-month CPAP treatment (57 patients) or no therapy (60 patients), while maintaining antihypertensive treatment. Clinic and 24-hour ambulatory BPs were obtained before and after 6-month treatment. Primary outcomes were changes in clinic and ambulatory BPs and in nocturnal BP fall patterns. Intention-to-treat and per-protocol (limited to those with uncontrolled ambulatory BPs) analyses were performed. Patients had mean (SD) 24-hour BP of 129(16)/75(12) mm Hg, and 59% had uncontrolled ambulatory BPs. Mean apnea-hypopnea index was 41 per hour and 58.5% had severe obstructive sleep apnea. On intention-to-treat analysis, there was no significant difference in any BP change, neither in nocturnal BP fall, between CPAP and control groups. The best effect of CPAP was on night-time systolic blood pressure in per-protocol analysis, with greater reduction of 4.7 mm Hg (95% confidence interval, -11.3 to +3.1 mm Hg; P=0.24) and an increase in nocturnal BP fall of 2.2% (95% confidence interval, -1.6% to +5.8%; P=0.25), in comparison with control group. In conclusion, CPAP treatment had no significant effect on clinic and ambulatory BPs in patients with resistant hypertension and moderate/severe obstructive sleep apnea, although a beneficial effect on night-time systolic blood pressure and on nocturnal BP fall might exist in patients with uncontrolled ambulatory BP levels.

Prognostic value of QT interval parameters for mortality risk stratification in Chagas' disease: results of a long-term follow-up study

BACKGROUND

QT interval parameters are potential prognostic markers of arrhythmogenicity risk and cardiovascular mortality and have never been evaluated in Chagas' disease.

METHODS AND RESULTS

Outpatients (738) in the chronic phase of Chagas' disease were enrolled in a long-term follow-up study. Maximal heart rate-corrected QT (QTc) and T-wave peak-to-end (TpTe) intervals and QRS, QT, JT, QTapex, and TpTe dispersions and variation coefficients were measured manually and calculated from 12-lead ECGs obtained on admission. Clinical, radiological, and 2-dimensional echocardiographic data were also recorded. Primary end points were all-cause, Chagas' disease-related, and sudden cardiac mortalities. During a follow-up of 58+/-39 months, 62 patients died, 54 of Chagas' disease-related causes and 40 suddenly. Multivariate Cox survival analysis revealed that the QT-interval dispersion (QTd) (hazard ratio, 1.45; 95% confidence interval, 1.29 to 1.63; P<0.001, for 10-ms increments) and left ventricular (LV) end-systolic dimension (hazard ratio, 1.36; 95% confidence interval, 1.21 to 1.53; P<0.001, for 5-mm increments) were the strongest independent predictors for all end points. The maximum QTc interval (QTcmax) could substitute for QTd with a worse predictive performance. Other predictors were heart rate, presence of pathological Q waves, frequent premature ventricular contractions (PVCs), and isolated left anterior fascicular block (LAFB) on the ECGs. Kaplan-Meier survival curves demonstrated that a QTd > or =65 ms or a QTcmax > or =465 ms1/2 discriminated the 2 groups with significantly different prognoses.

CONCLUSIONS

Electrocardiographic QTd and echocardiographic LV end-systolic dimension were the most important mortality predictors in patients with Chagas' disease. Heart rate, the presence on ECG of pathological Q waves, frequent PVCs, and isolated LAFB refined the mortality risk stratification.

Prognostic impact of aortic stiffness in high-risk type 2 diabetic patients: the Rio deJaneiro Type 2 Diabetes Cohort Study

OBJECTIVE

The prognostic importance of carotid-femoral pulse wave velocity (PWV), the gold standard measure of aortic stiffness, has been scarcely investigated in type 2 diabetes and never after full adjustment for potential confounders. The aim was to evaluate the prognostic impact of carotid-femoral PWV for cardiovascular morbidity and all-cause mortality in a cohort of 565 high-risk type 2 diabetic patients.

RESEARCH DESIGN AND METHODS

Clinical, laboratory, ambulatory blood pressure (BP) monitoring, and carotid-femoral PWV data were obtained at baseline. The primary end points were a composite of fatal and nonfatal cardiovascular events and all-cause mortality. Multiple Cox survival analysis was used to assess the associations between carotid-femoral PWV, as a continuous variable and categorized at 10 m/s, and the end points.

RESULTS

After a median follow-up of 5.75 years, 88 total cardiovascular events and 72 all-cause deaths occurred. After adjustments for potential cardiovascular risk factors, including micro- and macrovascular complications, ambulatory BP, and metabolic control, carotid-femoral PWV was predictive of the composite end point but not of all-cause mortality both as a continuous variable (hazard ratio 1.13 [95% CI 1.03-1.23], P = 0.009 for increments of 1 m/s) and as categorized at 10 m/s (1.92 [1.16-3.18], P = 0.012). On sensitivity analysis, carotid-femoral PWV was a better predictor of cardiovascular events in younger patients (<65 years), in those with microvascular complications, and in those with poorer glycemic control (HbA1c ≥7.5% [58.5 mmol/mol]).

CONCLUSIONS

Carotid-femoral PWV provides cardiovascular risk prediction independent of standard risk factors, glycemic control, and ambulatory BPs and improves cardiovascular risk stratification in high-risk type 2 diabetes.

Relation of left ventricular hypertrophy with systemic inflammation and endothelial damage in resistant hypertension

The relation between left ventricular hypertrophy (LVH) and unfavorable cardiovascular prognosis may involve systemic inflammation and endothelial dysfunction/damage. The aim of this study was to investigate in a cross-sectional design the relationships of LVH with C-reactive protein (CRP) levels (a marker of systemic low-grade inflammation) and with microalbuminuria (a marker of glomerular endothelial damage) in 705 patients with resistant hypertension. At baseline, all were submitted to a laboratory evaluation including 24-hour urinary albumin excretion, 2D echocardiogram, and 24-hour ambulatory blood pressure monitoring. A total of 463 patients also had high-sensitivity CRP levels determined. LVH was defined as an indexed left ventricular mass >110 g/m(2) in women and >125 g/m(2) in men. Microalbuminuria was evaluated in 3 categories: low normal (<15 mg/24 hours), high normal (between 15 and 29 mg/24 hours), and abnormal (between 30 and 299 mg/24 hours). CRP was dichotomized at the median value (3.7 mg/L). Associations with LVH were examined after adjustment for all of the potential confounders by multivariate logistic regression. A total of 534 patients (75.7%) had LVH. After full adjustment, both abnormal microalbuminuria (odds ratio: 1.97; 95% CI: 1.04 to 3.73) and high CRP (OR: 1.76; 95% CI: 1.06 to 2.93) were independently associated with LVH occurrence. The high-normal albuminuria was associated with a borderline significant 46% increased chance of having LVH. Furthermore, the association between high CRP and LVH was observed exclusively in the subgroup with normal albuminuria. In conclusion, both systemic inflammation and endothelial damage were associated with LVH occurrence. These relationships offer insight into the pathophysiological mechanisms linking LVH to atherosclerosis and to increased cardiovascular morbidity and mortality.

Microvascular degenerative complications are associated with increased aortic stiffness in type 2 diabetic patients

OBJECTIVE

Diabetes is a risk factor for increased arterial stiffness; however, few studies had investigated its associated factors. The aim was to evaluate the correlates of increased arterial stiffness in type 2 diabetes, particularly the relationships with microvascular complications.

METHODS

482 type 2 diabetic patients without peripheral arterial disease were evaluated in a cross-sectional study. Clinical (including tests of cardiovascular dysautonomy), laboratory, ECG, echocardiographic and 24h ambulatory blood pressure monitoring data were obtained. Arterial stiffness was assessed by carotid-femoral (aortic) and carotid-radial (peripheral) pulse wave velocity (PWV) measurements. Statistics included multivariate linear and logistic regressions to investigate the independent correlates of increased arterial stiffness.

RESULTS

No diabetes-related variable was associated with peripheral arterial stiffness. 148 patients (31%) had increased aortic PWV (>12m/s). On multiple linear regression, retinopathy and nephropathy, besides age, heart rate, 24h pulse pressure, diabetes duration, dyslipidemia and number of antihypertensive drugs in use, were independently associated with aortic PWV. On multivariate logistic regression increased aortic stiffness was associated with retinopathy (odds ratio: 3.83, 95% confidence interval [CI]: 2.24-6.56, p<0.001) and peripheral neuropathy (odds ratio: 1.79, 95%CI: 1.06-3.02, p=0.03) after adjusting for possible confounding variables. Other variables associated with increased aortic stiffness were older age, heart rate, diabetes duration, 24h pulse pressure, dyslipidemia and physical inactivity.

CONCLUSIONS

In type 2 diabetic patients, increased central arterial stiffness is associated with the presence of microvascular complications independent of other established determinants of aortic stiffness.

Non-alcoholic fatty liver disease and diabetes: from physiopathological interplay to diagnosis and treatment

Non-alcoholic fatty liver disease (NAFLD) is highly prevalent in patients with diabetes mellitus and increasing evidence suggests that patients with type 2 diabetes are at a particularly high risk for developing the progressive forms of NAFLD, non-alcoholic steatohepatitis and associated advanced liver fibrosis. Moreover, diabetes is an independent risk factor for NAFLD progression, and for hepatocellular carcinoma development and liver-related mortality in prospective studies. Notwithstanding, patients with NAFLD have an elevated prevalence of prediabetes. Recent studies have shown that NAFLD presence predicts the development of type 2 diabetes. Diabetes and NAFLD have mutual pathogenetic mechanisms and it is possible that genetic and environmental factors interact with metabolic derangements to accelerate NAFLD progression in diabetic patients. The diagnosis of the more advanced stages of NAFLD in diabetic patients shares the same challenges as in non-diabetic patients and it includes imaging and serological methods, although histopathological evaluation is still considered the gold standard diagnostic method. An effective established treatment is not yet available for patients with steatohepatitis and fibrosis and randomized clinical trials including only diabetic patients are lacking. We sought to outline the published data including epidemiology, pathogenesis, diagnosis and treatment of NAFLD in diabetic patients, in order to better understand the interplay between these two prevalent diseases and identify the gaps that still need to be fulfilled in the management of NAFLD in patients with diabetes mellitus.

Prognostic value of QT interval parameters in type 2 diabetes mellitus: results of a long-term follow-up prospective study

The prognostic importance of electrocardiographic ventricular repolarization QT parameters (maximum rate-corrected QT interval-QTcmax, QT interval dispersion-QTd, and QTcd), in relation to other risk markers, on cardiovascular and cardiac mortality, and on total fatal or nonfatal cardiovascular events, was evaluated prospectively in 471 type 2 diabetic outpatients. During a median follow-up of 57 months (range: 2-84), 121 (25.7%), patients died, 44 (36.3% of them) from cardiovascular causes and 106 (22.5%) fatal or nonfatal cardiovascular events were observed. In Cox proportional hazards multivariate analysis, both QTd and QTcmax were independent predictors of cardiovascular and cardiac mortality (hazard ratio [HR]: 1.34, 95% confidence interval [95% CI]: 1.12-1.59, for each 10-ms increments in QTd and HR: 1.17, 95% CI: 1.03-1.21 for 10-ms increments in QTcmax, for cardiovascular mortality). They were also predictors of total fatal or nonfatal cardiac and cardiovascular events (HR: 1.18, 95% CI: 1.05-1.33 for QTd and HR: 1.09, 95% CI: 1.04-1.15 for QTcmax). Additional independent prognostic markers for total cardiovascular events were the presence of previous cardiac disease, cerebral or peripheral vascular disease, age, male gender, known diabetes duration, heart rate, and serum triglycerides. Excluding patients with prior cardiac disease did not change significantly the prognostic performance of QTd but decreased that of QTcmax. In conclusion, QT interval parameters give additional prognostic information in patients with type 2 diabetes mellitus, beyond that obtained from traditional risk factors. QT interval dispersion seems a better prognostic marker than maximum QT interval, particularly in patients without previous cardiac diseases.

Correlates of aortic stiffness progression in patients with type 2 diabetes: importance of glycemic control: the Rio de Janeiro type 2 diabetes cohort study

OBJECTIVE

The correlates of serial changes in aortic stiffness in patients with diabetes have never been investigated. We aimed to examine the importance of glycemic control on progression/regression of carotid-femoral pulse wave velocity (cf-PWV) in type 2 diabetes.

RESEARCH DESIGN AND METHODS

In a prospective study, two cf-PWV measurements were performed with the Complior equipment in 417 patients with type 2 diabetes over a mean follow-up of 4.2 years. Clinical laboratory data were obtained at baseline and throughout follow-up. Multivariable linear/logistic regressions assessed the independent correlates of changes in cf-PWV.

RESULTS

Median cf-PWV increase was 0.11 m/s per year (1.1% per year). Overall, 212 patients (51%) increased/persisted with high cf-PWV, while 205 (49%) reduced/persisted with low cf-PWV. Multivariate linear regression demonstrated direct associations between cf-PWV changes and mean HbA1c during follow-up (partial correlation 0.14, P = 0.005). On logistic regression, a mean HbA1c ≥7.5% (58 mmol/mol) was associated with twofold higher odds of having increased/persistently high cf-PWV during follow-up. Furthermore, the rate of HbA1c reduction relative to baseline levels was inversely associated with cf-PWV changes (partial correlation -0.11, P = 0.011) and associated with reduced risk of having increased/persistently high aortic stiffness (odds ratio 0.82 [95% CI 0.69-0.96]; P = 0.017). Other independent correlates of progression in aortic stiffness were increases in systolic blood pressure and heart rate between the two cf-PWV measurements, older age, female sex, and presence of dyslipidemia and retinopathy.

CONCLUSIONS

Better glycemic control, together with reductions in blood pressure and heart rate, was the most important correlate to attenuate/prevent progression of aortic stiffness in patients with type 2 diabetes.

QTc interval prolongation is a predictor of future strokes in patients with type 2 diabetes mellitus

BACKGROUND AND PURPOSE

QTc interval prolongation is a predictor of cardiovascular morbidity and mortality in general populations and in patients with diabetes. The aim of this study was to investigate the predictors of stroke in patients with type 2 diabetes, with particular emphasis on the independent role of QT interval parameters.

METHODS

We carried out a long-term follow-up study with 471 type 2 diabetics. Several clinical, laboratory, ECG, and echocardiographic variables were recorded at baseline. Predictive factors for stroke were evaluated by Kaplan-Meier estimation of survival curves and by univariate and multivariate Cox survival analyses.

RESULTS

After a median follow-up of 57 months (range, 2 to 84 months), 40 incident strokes were observed. QTc interval prolongation (>or=470 ms1/2) was an independent predictor of stroke, with adjusted hazard ratios ranging from 2.2 to 2.9 (95% confidence intervals, 1.1 to 6.0). Other independent factors associated with stroke were older age; the presence of cerebrovascular disease at baseline; increased 24-hour proteinuria, serum triglycerides, and left ventricular mass; and decreased high-density lipoprotein cholesterol. Excluding patients with previous cerebrovascular disease from the analysis did not change the results significantly.

CONCLUSIONS

QTc interval prolongation is a predictor of future stroke in patients with type 2 diabetes. Intervention studies are needed to assess whether this factor could be modified.

Predictors of Development and Progression of Retinopathy in Patients with Type 2 Diabetes: Importance of Blood Pressure Parameters

Diabetic retinopathy (DR) is a chronic microvascular complication associated a worse prognosis. We aimed to evaluate the predictors of development/progression of DR in a cohort of 544 high-risk patients with type 2 diabetes who had annual ophthalmologic examinations over a median follow-up of 6 years. Ambulatory blood pressure (BP) monitoring and aortic stiffness by carotid-femoral pulse wave velocity were performed. Multivariate Cox survival analysis examined the independent predictors of development or progression of DR. During follow-up, 156 patients either newly-developed or worsened DR. Patients who developed/progressed DR had longer diabetes duration, higher ambulatory and clinic BP levels, higher aortic stiffness, and poorer glycemic control than patients who did not developed/progressed DR. After adjustments for baseline retinopathy prevalence, age and sex, a longer diabetes duration (p < 0.001), higher baseline ambulatory BPs (p = 0.013, for 24-hour diastolic BP), and higher mean cumulative exposure of HbA1c (p < 0.001), clinic diastolic BP (p < 0.001) and LDL-cholesterol (p = 0.05) during follow-up were the independent predictors of development/progression of DR. BP parameters were only predictors of DR development. In conclusion, a longer diabetes duration, poorer glycemic and lipid control, and higher BPs were the main predictors of development/progression of DR. Mean cumulative clinic diastolic BP was the strongest BP-related predictor.

Prognostic impact of carotid intima-media thickness and carotid plaques on the development of micro- and macrovascular complications in individuals with type 2 diabetes: the Rio de Janeiro type 2 diabetes cohort study

BACKGROUND

The prognostic importance of carotid atherosclerosis in individuals with diabetes is unsettled. We aimed to evaluate the relationships between parameters of carotid atherosclerosis and the future occurrence of micro- and cardiovascular complications in individuals with type 2 diabetes.

METHODS

Ultrasonographic parameters of carotid atherosclerosis, intima-media thickness (CIMT) and plaques, were measured at baseline in 478 participants who were followed-up for a median of 10.8 years. Multivariate Cox analysis was used to examine the associations between carotid parameters and the occurrence of microvascular (retinopathy, renal, and peripheral neuropathy) and cardiovascular complications (total cardiovascular events [CVEs] and cardiovascular mortality), and all-cause mortality. The improvement in risk stratification was assessed by using the C-statistic and the integrated discrimination improvement (IDI) index.

RESULTS

During follow-up, 116 individuals had a CVE and 115 individuals died (56 from cardiovascular diseases); 131 newly-developed or worsened diabetic retinopathy, 156 achieved the renal composite outcome (94 newly developed microalbuminuria and 78 deteriorated renal function), and 83 newly-developed or worsened peripheral neuropathy. CIMT, either analysed as a continuous or as a categorical variable, and presence of plaques predicted CVEs occurrence and renal outcomes, but not mortality or other microvascular complications. Individuals with an increased CIMT and plaques had a 1.5- to 1.8-fold increased risk of CVEs and a 1.6-fold higher risk of renal outcome. CIMT and plaques modestly improved cardiovascular risk discrimination over classic risk factors, with IDIs ranging from 7.8 to 8.4%; but more markedly improved renal risk discrimination, with IDIs from 14.8 to 18.5%.

CONCLUSIONS

Carotid atherosclerosis parameters predicted cardiovascular and renal outcomes, and improved renal risk stratification. Ultrasonographic carotid imaging may be useful in type 2 diabetes management.

Prognostic impact of the ambulatory arterial stiffness index in resistant hypertension

OBJECTIVE

The ambulatory arterial stiffness index (AASI), derived from ambulatory blood pressure (BP) monitoring recordings, is an indirect marker of arterial stiffness and a potential predictor of cardiovascular risk. Resistant hypertension is defined as uncontrolled office BP despite the use of at least three antihypertensive drugs. The aim of this prospective study was to investigate the AASI prognostic value in patients with resistant hypertension.

METHODS

At baseline, 547 patients underwent clinical-laboratory, and 24-h ambulatory BP monitoring examinations. AASI was defined as 1 minus the regression slope of DBP on SBP, and was calculated by standard and symmetric regression. Primary endpoints were a composite of fatal and nonfatal cardiovascular events and all-cause and cardiovascular mortalities. Multiple Cox regression was used to assess associations between AASI and subsequent endpoints.

RESULTS

After median follow-up of 4.8 years, 101 patients (18.4%) reached the primary endpoint, and 65 all-cause deaths (11.9%) occurred (45 from cardiovascular causes). 24-h AASI was the best independent predictor of composite endpoint (hazard ratio 1.46, 95% confidence interval 1.12-1.92, for increments of 1-SD = 0.14), whereas cardiovascular mortality was best predicted by night-time AASI (hazard ratio 1.73, 95% confidence interval 1.13-2.65), after adjustments for cardiovascular risk factors, including mean ambulatory BPs and nocturnal BP reduction. Symmetric AASI was not superior to standard AASI. In sensitivity analysis, 24-h AASI was a better predictor of cardiovascular outcomes in women, in younger individuals, and in nondiabetic individuals.

CONCLUSION

AASI is a predictor of cardiovascular morbidity and mortality in resistant hypertension, over and beyond traditional risk factors and other ambulatory BP monitoring parameters.

Long-term thalidomide use in refractory cutaneous lesions of lupus erythematosus: a 65 series of Brazilian patients

Thalidomide has been reported as efficacious in refractory cutaneous lupus erythematosus (LE). The most fearful side-effects are teratogenicity and neuropathy. We reported clinical efficacy of long-term low-dose use of thalidomide in 65 patients with LE, emphasizing the prevalence of adverse effects, especially of neuropathy and its related factors. Data obtained from medical records included age, sex, disease duration, and the presence of diagnostic criteria for systemic lupus erythematosus (SLE), the extent and activity of cutaneous lesions and previous treatments. Sixty-three patients (98.9%) presented complete or partial improvement with thalidomide therapy. Drowsiness occurred in 50 patients (77%). Twenty-eight patients (43.2%) presented neuropathy symptoms. Nerve conduction studies were done in 21 (75%) of them and were abnormal in 12 (57%). With the interruption of thalidomide, 24 (82.5%) had complete or partial improvement of neuropathy symptoms and 23 (82%) of them had cutaneous relapse. There were no significant differences between those who developed or not neuropathy in treatment duration, age, total dose and systemic versus cutaneous LE. In conclusion, thalidomide can be used in refractory cutaneous LE with great efficacy and relative security. Controlled studies with schemes with lower doses or intermittent usage or alternative drugs are wanted to reduce the burden of cutaneous morbidity of lupus erythematosus.

NAFLD and Increased Aortic Stiffness: Parallel or Common Physiopathological Mechanisms?

Non-alcoholic fatty liver disease (NAFLD) has become the leading cause of chronic liver diseases worldwide. Liver inflammation and fibrosis related to NAFLD contribute to disease progression and increasing liver-related mortality and morbidity. Increasing data suggest that NAFLD may be linked to atherosclerotic vascular disease independent of other established cardiovascular risk factors. Central arterial stiffness has been recognized as a measure of cumulative cardiovascular risk marker load, and the measure of carotid-femoral pulse wave velocity (cf-PWV) is regarded as the gold standard assessment of aortic stiffness. It has been shown that increased aortic stiffness predicts cardiovascular morbidity and mortality in several clinical settings, including type 2 diabetes mellitus, a well-known condition associated with advanced stages of NAFLD. Furthermore, recently-published studies reported a strong association between NAFLD and increased arterial stiffness, suggesting a possible link in the pathogenesis of atherosclerosis and NAFLD. We sought to review the published data on the associations between NAFLD and aortic stiffness, in order to better understand the interplay between these two conditions and identify possible common physiopathological mechanisms.

A blunted decrease in nocturnal blood pressure is independently associated with increased aortic stiffness in patients with resistant hypertension

Increased arterial stiffness may be causally related to resistant hypertension. Our objective was to investigate the variables, particularly those derived from ambulatory blood pressure (BP) monitoring (ABPM), associated with increased aortic stiffness in resistant hypertensives. In a cross-sectional study, 600 resistant hypertensive patients without peripheral arterial disease were evaluated. Arterial stiffness was assessed by aortic pulse wave velocity (PWV), and was considered increased if >12 m s(-1). Statistical analyses included multiple linear and logistic regressions to assess the independent correlates of increased aortic stiffness. One hundred and sixty-eight patients (28%) had aortic PWV >12 m s(-1). Patients with increased PWV were older and had a higher prevalence of cardiovascular risk factors than did those patients with low PWV. On ABPM, patients with elevated PWV had higher daytime and night time systolic BP (SBP) and pulse pressures (PP), less nocturnal decrease in SBP and a higher prevalence of non-dipping pattern. On multiple linear regression, the independently associated variables with aortic PWV were age (P<0.001), 24-h PP (P<0.001), high-density lipoprotein (HDL)-cholesterol (P<0.001), microalbuminuria (P<0.001), fasting glycemia (P=0.001) and a decrease in nocturnal SBP (P=0.002). Multivariate logistic regression confirmed these results, with the non-dipping patients having a 72% higher likelihood of presenting with increased aortic stiffness (95% confidence interval: 1.12-2.65, P=0.013). This association was observed in both the reduced and reverted dipping patterns, but not in the extreme dipping pattern. In conclusion, a blunted nocturnal decrease in BP is independently associated with increased aortic stiffness in resistant hypertensive patients. Other independent correlates are older age, diabetes, microalbuminuria, low HDL-cholesterol and a widened 24-h PP.

Mortality and predictors of mortality in a cohort of Brazilian type 2 diabetic patients

OBJECTIVE

To investigate mortality rates and predictors of mortality in Brazilian type 2 diabetic patients.

RESEARCH DESIGN AND METHODS

A prospective follow-up study was carried out with 471 type 2 diabetic outpatients. Primary end points were all-cause, diabetes-related, and cardiovascular deaths. Excess mortality in this cohort was evaluated by calculating standardized mortality ratios (SMRs) in relation to those of the Rio de Janeiro population. Predictors of mortality were assessed by Kaplan-Meier survival curves and by uni- and multivariate Cox survival analyses.

RESULTS

During a median follow-up of 57 months (range 2-84 months), 121 (25.7%) patients died, 91 (75.2%) from diabetes-related causes and 44 (36.4%) from cardiovascular diseases. After adjusting for age and sex, the all-cause SMR was 3.36 (95% confidence interval [CI] 2.81-4.02) and the cardiovascular SMR was 3.28 (CI 2.44-4.41). In the Cox multivariate analysis, the predictors of mortality were older age, increased 24-h proteinuria, preexisting vascular disease, presence of frequent ventricular premature contractions and prolonged maximum heart rate-corrected QT interval on baseline electrocardiogram, and decreased serum HDL cholesterol. The use of beta-blockers was a protective factor. In Kaplan-Meier curves, these variables were capable of distinguishing subgroups of patients with significantly different prognoses.

CONCLUSIONS

Brazilian type 2 diabetic patients had a more than threefold excess mortality than the general population, largely because of increased cardiovascular mortality risk. Several clinical, laboratory, and electrocardiographic predictors of mortality were identified that could possibly be modified to decrease the mortality burden of type 2 diabetes in Brazil.

Aortic Stiffness as a Surrogate Endpoint to Micro- and Macrovascular Complications in Patients with Type 2 Diabetes

Increased aortic stiffness has been recognized as a predictor of adverse cardiovascular outcomes in some clinical conditions, such as in patients with arterial hypertension and end-stage renal disease, in population-based samples and, more recently, in type 2 diabetic patients. Patients with type 2 diabetes have higher aortic stiffness than non-diabetic individuals, and increased aortic stiffness has been correlated to the presence of micro- and macrovascular chronic diabetic complications. We aimed to review the current knowledge on the relationships between aortic stiffness and diabetic complications, their possible underlying physiopathological mechanisms, and their potential applications to clinical type 2 diabetes management.

Clinical determinants of increased QT dispersion in patients with diabetes mellitus

AIMS

To compare QT dispersion measurements in diabetic patients to control subjects and assess any associations between QT dispersion and diabetic clinical characteristics.

METHODS

A total of 512 diabetics and 50 age and gender matched controls were studied. QT interval was measured manually in 12-lead conventional electrocardiograms, and QT dispersion (QTd), heart rate-corrected QT dispersion (QTcd), number of leads-adjusted QT dispersion (adjuQTd) and adjacent QT dispersion (adjaQTd) were calculated. Demographic, clinical, laboratory and electrocardiographic data were recorded.

RESULTS

Diabetics showed increased QT dispersion compared to controls (QTd: P<0.001, QTcd: P<0.001, adjuQTd: P<0.001), even those with recent diagnosis (less than 2 years) and without arterial hypertension, ECG abnormalities or chronic degenerative complications (QTd: P=0.01, QTcd: P<0.001, adjuQTd: P=0.04). Left ventricular hypertrophy (QTd: P<0.001, QTcd: P<0.001, adjuQTd: P<0.001, adjaQTd: P<0.001) and conduction disturbances (QTd: P=0.002, QTcd: P=0.003, adjuQTd: P=0.003) were the electrocardiographic findings associated with increased QT dispersion in bivariate analysis. Clinical variables were the presence of arterial hypertension (QTd: P=0.004, QTcd: P=0.01, adjuQTd: P<0.001), even without left ventricular hypertrophy (QTd: P=0.01, QTcd: P=0.03, adjuQTd: P=0.003), and the presence of diabetic cardiovascular complications (QTd: P=0.02, QTcd: P=0.01, adjuQTd: P=0.008, adjaQTd: P=0.03). No association between QT dispersion and the presence of diabetic microvascular complications, glycaemic control, age and gender, or cardiovascular drugs was observed. Multivariate regressive statistical analysis confirmed the associations noted in bivariate analysis.

CONCLUSIONS

Diabetic patients have increased QT dispersion compared to non-diabetics even those without arterial hypertension and cardiovascular complications and with recent diagnosis. The presence of arterial hypertension, diabetic cardiovascular complications and electrocardiographic abnormalities of left ventricular hypertrophy and conduction disturbances were associated to increased QT dispersion in diabetes mellitus.

Prognostic impact of clinic and ambulatory blood pressure components in high-risk type 2 diabetic patients: the Rio de Janeiro Type 2 Diabetes Cohort Study

BACKGROUND

The prognostic importance of tight clinic blood pressure (BP) control is controversial in diabetic patients. The objective was to investigate the prognostic impact of clinic and ambulatory BPs for cardiovascular morbidity and mortality in type 2 diabetes.

METHODS

In a prospective cohort study, 565 type 2 diabetic patients had clinical, laboratory and ambulatory BP monitoring (ABPM) data obtained at baseline and during follow-up. The primary endpoints were a composite of fatal and nonfatal cardiovascular events and all-cause mortality. Multivariable Cox survival and splines regression analyses assessed associations between each BP component [SBP, DBP and pulse pressure (PP)] and the endpoints.

RESULTS

After a median follow-up of 5.75 years, 88 total cardiovascular events and 70 all-cause deaths occurred. After adjustments for cardiovascular risk factors, clinic SBP and DBPs were predictive of the composite endpoint but not of all-cause mortality, whereas all ambulatory BP components were predictors of both endpoints. Ambulatory systolic and PPs were the strongest predictors and achieved ambulatory BPs during follow-up improved risk prediction in relation to baseline values. When categorized at clinically relevant cut-off values, risk began only at clinic BPs at least 140/90 mmHg, whereas for ambulatory BPs it began at lower values (≥120/75 mmHg for the 24-h period).

CONCLUSION

ABPM provides more valuable information regarding cardiovascular risk stratification than office BPs and should be performed, if possible, in every high-risk type 2 diabetic patient. Achieved 24-h ambulatory BPs less than 120/75 mmHg are associated with significant cardiovascular protection and, if confirmed by other studies, may be considered as BP treatment targets.