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.

Treatment Adherence and Its Associated Factors in Patients with Type 2 Diabetes: Results from the Rio de Janeiro Type 2 Diabetes Cohort Study

OBJECTIVES

To investigate treatment adherence in patients with type 2 diabetes and to evaluate its associated factors.

METHODS

The Summary of Diabetes Self-Care Activities (SDSCA) questionnaire was used to assess treatment adherence. Good adherence was defined as ≥5 days a week in each SDSCA item. Pain, emotional, and physical domains of the SF-36 quality of life questionnaire and the Canadian Occupational Performance Measure (COPM) were also evaluated. Multivariable logistic regressions explored the independent correlates of good general adherence and of specific items of the SDSCA (diet, exercise, and medications).

RESULTS

Good adherence was 93.5% for medication use, 59.3% for foot care, 56.1% for blood glucose monitoring, 29.2% for diet, and 22.5% for exercise. Patients with general good adherence had lower BMI, better serum lipid profile, higher values of functional capacity, emotional and pain domains of SF-36, better occupational performance, and lower prevalence of pain or limitation in the upper and lower limbs than patients with worse adherence. The variables associated with good adherence were younger age, lower BMI, presence of macrovascular complications, better occupational performance and emotional domain of SF-36, and higher HDL cholesterol levels. The presence of pain/limitation in the upper limbs was associated with worse adherence. Good medication adherence was associated with longer diabetes duration, lower BMI, and lower HbA1c levels. Higher values of pain and emotional domains of the SF-36 and lower BMI were related to better exercise and diet adherence, while the presence of peripheral neuropathy and joint pain/limitation were associated with worse exercise adherence.

CONCLUSIONS

Emotional and physical performances are important determinants of good diabetic treatment adherence. Good adherence has beneficial impact on BMI, lipid, and glycemic control.

Pattern of 24-hour ambulatory blood pressure monitoring in type 2 diabetic patients with cardiovascular dysautonomy

The pathophysiological mechanisms linking cardiovascular dysautonomy to mortality are unclear. The aim of this study was to investigate the pattern of 24-h ambulatory blood pressure (BP) monitoring (ABPM) in diabetic patients with cardiovascular autonomic neuropathy (CAN). We evaluated 391 type 2 diabetic patients in a cross-sectional study. Five clinical tests of CAN were performed: heart-rate variation during deep breathing, the Valsalva maneuver, and standing, and BP variation during handgrip and standing. Patients were considered to have initial CAN if one heart-rate test was abnormal or two were borderline, and to have definite or severe CAN if at least two tests were abnormal. Differences between patients with and without CAN were assessed by bivariate tests and ANCOVA. Of the 391 patients, 230 (59%) presented clinical CAN, of whom 53 had definite or severe involvement. Patients with CAN were older, had diabetes of longer duration, and had an equal prevalence of hypertension but used more antihypertensive drugs than those without CAN. On ABPM, patients with definite or severe CAN had higher systolic BP (SBP) and pulse pressures (PP) than those without CAN, particularly in the nighttime (SBP: 128 +/- 18 vs. 117 +/- 16 mmHg, p = 0.007; PP: 58 +/- 13 vs. 50 +/- 11 mmHg, p = 0.003) and early morning (SBP: 140 +/- 18 vs. 131 +/- 17 mmHg, p = 0.05) after adjustment for potential confounders, as well as a higher prevalence of the systolic nondipping pattern (75.5% vs. 50.9%, p = 0.021). In conclusion, type 2 diabetic patients with more severe CAN have higher SBP and PP, especially during the nighttime and early morning, as well as a higher prevalence of nondipping status. This unfavorable 24-h ABPM pattern may contribute to the increased cardiovascular risk of diabetic patients with dysautonomy.

Prognostic significance of a reduced glomerular filtration rate and interaction with microalbuminuria in resistant hypertension: a cohort study

OBJECTIVE

The prognostic importance of a reduced glomerular filtration rate (GFR) is unsettled in resistant hypertension. The aim was to evaluate GFR and its interaction with microalbuminuria as prognostic predictors in resistant hypertensive patients.

METHODS

In a prospective study, 531 resistant hypertensive patients had albuminuria measured and GFR estimated by Cockroft-Gault (eGFRCG) and Modification of Diet in Renal Disease (MDRD; eGFRMDRD) equations. Primary endpoints were a composite of fatal and nonfatal cardiovascular events, all-cause and cardiovascular mortality. Multiple Cox regression assessed the associations between reduced GFR and endpoints, and interaction with microalbuminuria.

RESULTS

After a median follow-up of 4.9 years, 72 patients died, 42 from cardiovascular causes; and 96 cardiovascular events occurred. Decreasing grades of eGFRMDRD were predictors of the composite endpoint with hazard ratios of 2.1 [95% confidence interval (CI) 1.1-3.8], 2.2 (1.2-3.9) and 3.5 (1.4-8.7) for the subgroups with eGFR between 60-89, 30-59 and less than 30 mg/min per 1.73 m, respectively. A decreased eGFRCG was predictive of the composite endpoint only in the lowest GFR subgroup (hazard ratio 2.7, 95% CI 1.0-7.1). The lowest eGFR subgroups were also associated with all-cause mortality, regardless of the estimated equation used. The presence of both reduced eGFR and microalbuminuria significantly increased cardiovascular risk in relation to one or another isolated, with hazard ratios of 3.0 (1.7-5.3), 2.9 (1.5-5.5) and 4.6 (2.2-10.0), respectively for the composite endpoint, all-cause and cardiovascular mortality.

CONCLUSION

A reduced GFR, mainly estimated by the MDRD equation, is an independent predictor of increased cardiovascular morbidity and mortality in resistant hypertension. The combination of a reduced GFR and increased albuminuria identifies patients with a very high cardiovascular risk.

T-wave axis deviation as an independent predictor of mortality in chronic Chagas' disease

The T-wave axis shift has been reported to represent a general marker of ventricular repolarization abnormalities and a potential indicator of increased risk for cardiovascular mortality. We assessed the prognostic importance of the T-wave axis deviation for mortality rate in patients with chronic Chagas' disease. In a long-term follow-up prospective study, 738 adult outpatients in the chronic phase of Chagas' disease were enrolled. The frontal plane T-wave axis was estimated from 12-lead electrocardiograms obtained on admission and categorized as normal (15 degrees to 75 degrees ), borderline (75 degrees to 105 degrees or 15 degrees to -15 degrees ), and abnormal (>105 degrees or < -15 degrees ). Clinical and radiologic data, 2-dimensional echocardiographic data, and other electrocardiographic data were also recorded. Primary end points were all-cause, those related to Chagas' disease, and sudden cardiac deaths. Statistical analyses included Kaplan-Meier estimation of survival curves and multivariate Cox's proportional hazards models. During a follow-up of 58 +/- 39 months, 62 patients died, 54 from causes related to Chagas' disease and 40 due to sudden cardiac death. Kaplan-Meier survival curves showed that the 3 categories of T axis had significantly different prognoses. Multivariate Cox's survival analysis demonstrated that an abnormal T axis increases the risk of death threefold and sudden death nearly sixfold after adjustment for other covariates, including left ventricular systolic function and other electrocardiographic abnormalities. Borderline T-wave axis also indicated a worse prognosis, particularly in the subgroup of patients with abnormal baseline electrocardiograms. These results indicate that T-wave axis deviation is an easily quantified, strong, and independent mortality risk predictor in patients with chronic Chagas' disease.

Usefulness of the vibration perception thresholds measurement as a diagnostic method for diabetic peripheral neuropathy: Results from the Rio de Janeiro type 2 diabetes cohort study

AIMS

To investigate the associated factors with the vibration threshold perception (VPT) in patients with type 2 diabetes and to assess whether it is useful for detection of diabetic peripheral neuropathy (DPN).

METHODS

VPTs were measured with Vibration Sensory Analyzer (VSA-3000) in 426 diabetic patients. The diagnosis of DPN was based on Neuropathy Symptom Score and Neuropathy Disability Score (NDS). ROC curve analysis and multiple linear and logistic regressions were performed to investigate the associations between VPT and DPN.

RESULTS

Values of VPT were progressively higher according to NDS stages. Age, height, diabetes duration, and mean cumulative HbA1c exposure (partial correlation coefficients: 0.34; 0.27; 0.10; and 0.13; respectively) were the variables independently associated with VPT. Area under ROC curve of VPT for detection of DPN was 0.71 (95% CI: 0.66-0.75) and >8.9 μm was its best cut-off value. VPT, age, female sex, height, diabetes duration and mean HbA1c levels were the independent correlates of the presence of DPN. An increased VPT triplicate the likelihood of having DPN (OR: 3.24; 95% CI: 2.05-5.11).

CONCLUSIONS

VPT, measured by an automatic device, shares common correlates with DPN and is strongly associated with its presence. VPT testing may be useful as a screening tool for DPN assessment.

Efficacy of diacerein in reducing liver steatosis and fibrosis in patients with type 2 diabetes and non-alcoholic fatty liver disease: A randomized, placebo-controlled trial

The aim was to assess, in a randomized, double-blinded, placebo-controlled trial, the efficacy of diacerein, an anti-inflammatory drug, in improving liver fibrosis and steatosis in patients with type 2 diabetes and non-alcoholic fatty liver disease (NAFLD). Sixty-nine diabetic patients with NAFLD were randomized to 24-month treatment with placebo (35 patients) or diacerein 100 mg/day (34 patients). Liver stiffness and steatosis were assessed by transient elastography (Fibroscan®) at baseline, and 12 and 24 months of follow-up. The primary outcome was the difference in mean liver stiffness and steatosis changes during treatment. Adjusted differences in mean changes on intention-to-treat analyses were estimated by generalized repeated-measures mixed-effects regressions. Diacerein significantly reduced liver stiffness in contrast to placebo by 1.6 kPa (95% CI: -2.6 to -0.5 kPa; p = 0.003), whereas no significant difference in mean changes in liver steatosis was observed. The reduction in liver stiffness was already evident at the 12-month examination, and accentuated at the 24-month examination. Eight patients reduced liver fibrosis stage during treatment, seven of whom were in the diacerein group (p = 0.020). In conclusion, a 2-year treatment with diacerein significantly reduced liver fibrosis in diabetic patients with NAFLD.

Increased aortic stiffness predicts future development and progression of peripheral neuropathy in patients with type 2 diabetes: the Rio de Janeiro Type 2 Diabetes Cohort Study

AIMS/HYPOTHESIS

Diabetic peripheral neuropathy (DPN) is a chronic microvascular complication that is strongly associated with poor glycaemic control and also with a worse prognosis. We aimed to evaluate the predictors of the development and progression of DPN in a cohort of high-risk patients with type 2 diabetes.

METHODS

In a prospective study, 477 patients with type 2 diabetes were clinically assessed for the presence of DPN at baseline and after a median follow-up of 6.2 years (range 2-10 years). Clinical laboratory data were obtained at study entry and throughout the follow-up. Aortic stiffness was assessed by the carotid-femoral pulse wave velocity (cf-PWV) at baseline. Multivariate Poisson regression analysis was used to examine independent predictors of the development/progression of DPN.

RESULTS

At baseline, 135 patients (28%) had DPN, and during follow-up 97 patients (20%) had either a new development or a worsening of DPN. Patients who showed a development or progression of DPN were taller and had a longer duration of diabetes, a greater prevalence of other microvascular complications and hypertension, greater aortic stiffness and poorer glycaemic control than patients who did not have new or progressive neuropathy. After adjustments for the baseline prevalence of DPN, the patient's age and sex, and the time interval between DPN assessments; an increased aortic stiffness (cf-PWV >10 m/s) were predictive of new/progressive DPN (incidence rate ratio 2.04, 95% CI 1.28, 3.23; p = 0.002). Other independent predictors were the mean first-year HbA1c level (p = 0.05), nephropathy (p = 0.006), arterial hypertension (p = 0.06) and height (p = 0.03).

CONCLUSIONS/INTERPRETATION

Increased aortic stiffness at baseline predicts the future development or progression of peripheral neuropathy, independent of diabetic metabolic control, suggesting a physiopathological link between macrovascular and microvascular abnormalities in type 2 diabetes.

Prognostic impact of baseline and serial changes in electrocardiographic left ventricular hypertrophy in resistant hypertension

BACKGROUND

The prognostic value of electrocardiographic left ventricular hypertrophy (ECG-LVH) in resistant hypertension (RH) is unknown. The aim was to evaluate the importance of baseline and serial changes in ECG-LVH as predictors of cardiovascular morbidity and mortality in patients with RH.

METHODS

At baseline and during follow-up, 552 resistant hypertensive patients had 3 ECG-LVH criteria obtained: Sokolow-Lyon, Cornell voltage, and Cornell voltage-duration product. Primary end points were a composite of fatal and nonfatal cardiovascular events and all-cause and cardiovascular mortalities. Total strokes and coronary heart disease (CHD) events were secondary end points. Multiple Cox regression assessed the associations between time-varying ECG-LVH and subsequent end points.

RESULTS

After a median follow-up of 4.8 years, 70 patients died, 46 from cardiovascular causes; and 109 total cardiovascular events occurred, 46 strokes, and 44 CHD events. After adjustment for several cardiovascular risk factors, baseline Cornell voltage and product, but not Sokolow-Lyon voltage, were independent predictors of the composite end point and of all-cause and cardiovascular mortalities. Reductions of all ECG-LVH criteria were protective factors for the composite end point: a 1-SD (1.1 mV) reduction in Sokolow-Lyon voltage was associated with a 35% lower risk (95% CI 10%-53%) of cardiovascular events, whereas prevention or regression of Cornell product LVH criterion implied a 40% lower risk (95% CI 11%-60%). Baseline and serial changes in Sokolow-Lyon voltage were independent predictors of strokes, whereas Cornell voltage was predictive of CHD events.

CONCLUSIONS

Baseline and serial changes in ECG-LVH predict cardiovascular morbidity and mortality in RH patients. Antihypertensive treatment targeted at regression or prevention of ECG-LVH may improve prognosis.

Prognostic impact of liver fibrosis and steatosis by transient elastography for cardiovascular and mortality outcomes in individuals with nonalcoholic fatty liver disease and type 2 diabetes: the Rio de Janeiro Cohort Study

BACKGROUND

Liver stiffness measurement (LSM, which reflects fibrosis) and controlled attenuation parameter (CAP, which reflects steatosis), two parameters derived from hepatic transient elastography (TE), have scarcely been evaluated as predictors of cardiovascular complications and mortality in individuals with type 2 diabetes and nonalcoholic fatty liver disease (NAFLD).

METHODS

Four hundred type 2 diabetic patients with NAFLD had TE examination (by Fibroscan®) performed at baseline. Multivariate Cox analyses evaluated the associations between TE parameters and the occurrence of cardiovascular events (CVEs) and mortality. TE parameters were assessed as continuous variables and dichotomized at low/high values reflecting advanced liver fibrosis (LSM > 9.6 kPa) and severe steatosis (CAP > 296 or > 330 dB/m). Improvements in risk discrimination were assessed by C-statistic and by the relative Integrated Discrimination Improvement (IDI) index.

RESULTS

During a median follow-up of 5.5 years, 85 patients died (40 from cardiovascular causes), and 69 had a CVE. As continuous variables, an increasing LSM was a risk marker for total CVEs (hazard ratio [HR]: 1.05; 95% CI: 1.01-1.08) and all-cause mortality (HR: 1.04; 95% CI: 1.01-1.07); whereas an increasing CAP was a protective factor for both outcomes (HR: 0.93; 95% CI: 0.89-0.98; and HR: 0.92; 95% CI: 0.88-0.97; respectively). As dichotomized variables, a high LSM remained a risk marker of adverse outcomes (with HRs ranging from 2.5 to 3.0) and a high CAP was protective (with HRs from 0.3 to 0.5). The subgroup of individuals with low-LSM/high-CAP had the lowest risks while the opposite subgroup with high-LSM/low-CAP had the highest risks. Both LSM and CAP improved risk discrimination, with increases in C-statistics up to 0.037 and IDIs up to 52%.

CONCLUSIONS

Measured by hepatic TE, advanced liver fibrosis is a risk marker and severe steatosis is a protective factor for cardiovascular complications and mortality in individuals with type 2 diabetes and NAFLD.

Recent ventricular repolarization markers in resistant hypertension: are they different from the traditional QT interval?

BACKGROUND

Two electrocardiographic markers of ventricular repolarization abnormalities have been recently proposed: spatial T-wave axis deviation and T(peak)-T(end)-interval duration. The aim of this study was to evaluate these markers in patients with resistant hypertension, particularly their relationships with left ventricular mass (LVM) and geometric patterns, in comparison with the more traditional marker, the QTc interval.

METHODS

In a cross-sectional study, 810 resistant hypertensive patients were evaluated. Clinical, laboratory, electrocardiographic, 24-h blood pressures and echocardiographic variables were obtained. Maximum T(peak)-T(end)-interval duration (Tpe(max)) was considered prolonged if it was beyond the upper quartile value (120 ms), and the spatial T-wave axis on the frontal plane was considered abnormally deviated if >105 degrees or < 15 degrees . Statistical analysis involved bivariate tests, multivariate logistic regression and analysis of covariance.

RESULTS

Tpe(max)-interval prolongation, like QTc-interval prolongation, was found to be associated with body mass index, 24-h systolic blood pressure (SBP), indexed LVM, serum potassium, and heart rate. Abnormal T-axis deviation was associated with male gender, presence of coronary heart disease, serum creatinine, 24-h SBP, LVM, and serum potassium. All three repolarization parameters were shown to be associated with increased LVM, after adjustment for possible confounders. However, when included together into the same model, only abnormal T-axis and QTc-interval prolongation remained independently associated with LVM. All three parameters were also increased in patients with concentric hypertrophy geometric pattern.

CONCLUSIONS

Both the recently proposed repolarization parameters are associated with increased LVM and hypertrophy in patients with resistant hypertension, but only abnormal T-wave axis deviation appears to have distinct and additive relationships to the more classic marker, the QTc interval. Their prognostic values should be addressed in prospective studies .

QT-interval parameters are increased in systemic lupus erythematosus patients

Systemic lupus erythematosus (SLE) patients have increased cardiovascular morbidity and mortality. QT-interval parameters are presumed markers of cardiovascular risk and have not been previously evaluated in SLE. Standard 12-lead ECGs were obtained from 140 female SLE outpatients and 37 age and body mass index-matched controls. QT interval was measured in each lead and heart rate-corrected maximum QT-interval duration (QTcmax) and QT-interval dispersion (QTd) were calculated. Risk factors for cardiovascular disease and lupus clinical features, disease treatment, disease activity and damage index were recorded. SLE patients have increased QT-interval parameters when compared to controls (QTcmax: 427.91 +/- 31.53 ms(1/2) versus 410.05 +/- 15.45 ms(1/2), P < 0.001; QTd: 52.38 +/- 22.21 ms versus 37.12 +/- 12.88 ms, P < 0.001). These differences persisted after excluding those patients with arterial hypertension, diabetes and with ECG abnormalities (QTcmax: 419.90 +/- 28.78 ms(1/2) versus 409.15 +/- 15.85 ms(1/2), P = 0.041; QTd: 54.74 +/- 26.00 ms versus 37.96 +/- 13.05 ms, P = 0.001). Multivariate linear regression for factors associated with QTcmax selected the presence of electrocardiographic left ventricular hypertrophy (ECG-LVH) (P = 0.003), nonspecific ST-T-wave abnormalities (P = 0.022) and left atrial enlargement (P = 0.044). Multivariate associates with QTd were age (P = 0.018), ECG-LVH (P = 0.022) and ST-T abnormalities (P = 0.031). In conclusion, SLE patients have increased QT interval parameters when compared to controls. This prolongation may lead to an increased cardiovascular risk. This finding might be due to subclinical atherosclerotic cardiovascular disease.

Importance of the electrocardiographic strain pattern in patients with resistant hypertension

The electrocardiographic strain pattern is a marker of left ventricular hypertrophy and adverse cardiovascular prognosis. The objective of this study was to assess the factors associated with the presence of ECG strain in patients with resistant hypertension and, specifically, to evaluate the relationships between strain and left ventricular mass (LVM) and structure. In a cross-sectional design, 440 resistant hypertensive subjects were evaluated. Clinical, laboratory, electrocardiographic, 24-hour ambulatory blood pressures, and echocardiographic variables were obtained. Statistical analysis involved bivariate tests, analysis of covariance, and multivariate logistic regression. An ECG strain pattern was present in 101 patients (23%). Patients with strain were more frequently men with lower body mass index, had more target-organ damage, higher 24-hour blood pressure, higher serum creatinine and 24-hour microalbuminuria, and more prolonged QT interval duration than those without strain. After controlling for all covariates, the presence of strain remained associated with increased LVM and wall thicknesses, both in all patients and also in those with echocardiographic left ventricular hypertrophy. Furthermore, the presence of ECG strain was associated with increased LVM (P<0.001), higher 24-hour systolic blood pressure (P<0.001), prolonged maximum QTc-interval duration (P<0.001), lower waist circumference (P=0.009), male gender (P=0.011), physical inactivity (P=0.020), higher serum creatinine (P=0.031) and fasting glycemia (P=0.027), and the presence of coronary heart disease (P=0.001) and peripheral arterial disease (P=0.045). Thus, in resistant hypertension patients, the presence of ECG strain is independently associated with increased left ventricular wall thicknesses and mass and also with other potentially adverse factors. These relationships offer insight into the known association between strain and unfavorable cardiovascular prognosis.

Factors associated with carotid intima-media thickness and carotid plaques in type 2 diabetic patients

OBJECTIVE

Factors associated with carotid atherosclerosis are unclear in type 2 diabetic patients. The aim was to investigate the independent correlates of carotid intima-media thickness (IMT) and plaques in these individuals.

METHODS

In a cross-sectional study, we measured carotid IMT at three sites (common carotid, bifurcation and internal carotid artery) and the severity of extracranial carotid artery (ECCA) atherosclerosis by plaque score in 441 type 2 diabetic patients. Nontraditional cardiovascular risk factors [ambulatory blood pressures (BPs), aortic stiffness, C-reactive protein and ankle-brachial index) were obtained. Multivariate linear and logistic regressions assessed the independent correlates of carotid IMT and ECCA plaque score.

RESULTS

Patients with greater carotid IMT or plaque scores had worse clinical and laboratory profile than those with lower IMT and plaque scores, including higher BPs, aortic stiffness and prevalences of diabetic complications. On multivariate analysis, carotid IMT and plaques were mainly associated with older age, male sex, current-past smoking and ambulatory BPs, but not with clinic BPs. Night-time pulse pressure was the most important modifiable determinant of increased carotid IMT. No microvascular complication was independently associated with carotid atherosclerosis, except retinopathy for plaque score. Additionally, internal carotid IMT and plaque score were associated with ankle-brachial index in the subgroup of patients without macrovascular diseases.

CONCLUSION

In type 2 diabetic patients, older age, male sex, smoking status and ambulatory BPs, particularly night-time pulse pressure, were the main independent correlates of ultrasonographic carotid atherosclerosis. This finding reinforces the importance of ambulatory BP monitoring in type 2 diabetes management.

Prognostic importance of baseline and serial changes in microalbuminuria in patients with resistant hypertension

OBJECTIVE

The prognostic value of microalbuminuria is unsettled in resistant hypertension. The objective was to evaluate the importance of baseline and serial changes in albuminuria as predictors of cardiovascular morbidity and mortality in patients with resistant hypertension.

METHODS

531 resistant hypertensives had urinary albumin excretion rate (UAER) measured prospectively at baseline and at the 2nd year of follow-up. Primary endpoints were a composite of fatal and non-fatal cardiovascular events, all-cause and cardiovascular mortalities. Total strokes and coronary heart disease (CHD) events were secondary endpoints. Multiple Cox regression assessed the associations between UAER and endpoints.

RESULTS

After a median follow-up of 4.9 years, 72 patients died, 42 from cardiovascular causes; 96 cardiovascular events occurred, 42 strokes and 47 CHD events. After adjustment for several cardiovascular risk factors, baseline UAER, either analyzed as a continuous variable or dichotomized at different cut-off values, was an independent predictor of the composite endpoint, all-cause and cardiovascular mortality, strokes and CHD events. Each 10-fold increase in UAER implied a significant 1.6, 1.5, 2.0, 1.5 and 1.6-fold higher risk, respectively, for each of the above endpoints. Serial changes in microalbuminuria status during follow-up tended to parallel changes in cardiovascular risk, regression of microalbuminuria was associated with a 27% lower risk and development with a 65% higher risk of having a cardiovascular event.

CONCLUSIONS

Baseline albuminuria strongly predicts cardiovascular morbidity and mortality in resistant hypertensive patients and serial changes in microalbuminuria may translate into changes in risk. Microalbuminuria reduction may be a goal of anti-hypertensive treatment.

Serum biomarkers in type 2 diabetic patients with non-alcoholic steatohepatitis and advanced fibrosis

AIM

Advanced stages of non-alcoholic fatty liver disease (NAFLD) are highly prevalent in type 2 diabetes (T2DM), however, no diabetes-related or biochemical variable seems to be predictive of severity of NAFLD. The aim of this study was to investigate the association of several serum biomarkers with the more severe histopathological stages of NAFLD in T2DM.

METHODS

In a cross-sectional design, 84 T2DM patients with biopsy-proven NAFLD had adiponectin, tumor necrosis factor-α, transforming growth factor (TGF)-β1, interleukin (IL)-6, -8 and -10, and C-reactive protein measured. NAFLD severity was evaluated by two hepatopathologists according to the non-alcoholic steatohepatitis (NASH) Clinical Research Network scoring system. Independent associations of cytokines with NASH and advanced fibrosis were evaluated by multivariate logistic regressions.

RESULTS

Sixty-six patients (78.6%) had NASH, and 52 patients (61.9%) had advanced fibrosis considering the highest score between the two pathologists. Patients with NASH or with advanced fibrosis had equal cytokine levels to those without NASH or with absent/light fibrosis, except for a lower serum adiponectin (8.59 vs 12.77 μg/mL; P = 0.015) in patients with NASH and a lower TGF-β1 (170 vs 180 pg/mL; P = 0.026) in patients with advanced fibrosis. In multivariate analysis, lower adiponectin was independently associated with NASH (odds ratio = 7.7, 95% confidence interval = 1.5-39.9, P = 0.014, for the subgroup with adiponectin below the median value), whereas both lower adiponectin and lower TGF-β1 levels were associated with advanced fibrosis.

CONCLUSION

Low adiponectin and low TGF-β1 are associated with severest NAFLD stages in T2DM and may be a valuable tool to support liver biopsy indication in this setting.

Predictors of development and progression of microvascular complications in a cohort of Brazilian type 2 diabetic patients

AIMS

Microvascular complications are associated with increased mortality in diabetes. The objective of this study was to investigate the predictors of microvascular complication development and progression in a prospective study of Brazilian type 2 diabetic patients.

METHODS

A prospective follow-up study was carried out with 471 type 2 diabetic outpatients. Primary end points were the development or progression of retinopathy, peripheral neuropathy, and clinical nephropathy. Predictors were assessed for each individual microvascular complication and also as a composite outcome by Kaplan-Meier estimation of survival curves and by uni- and multivariate Cox analysis.

RESULTS

During a median follow-up of 57 months (range 2-84 months), 196 patients (41.6%) developed or had a progression in microvascular disease. Retinopathy occurred in 22.5%, nephropathy in 19.1%, and neuropathy in 15.5% of the patients. In Cox multivariate analysis, increased echocardiographic left ventricular mass (LVM) and longer diabetes duration were selected as predictors for all end points. Higher mean fasting glycemia was a predictor for retinopathy and neuropathy, lower serum high-density lipoprotein (HDL) cholesterol for neuropathy, and higher total cholesterol for nephropathy. Increased LVM [hazard ratio (HR): 1.39, 95% CI: 1.23-1.56], higher fasting glycemia (HR: 1.19, 95% CI: 1.04-1.36), and longer diabetes duration (HR: 1.28, 95% CI: 1.11-1.47) were the predictors of the composite end point.

CONCLUSIONS

Development and progression of microvascular complications in Brazilian type 2 diabetic patients are associated with worse hypertension and metabolic control. Additional studies are necessary to show if modification of these risk factors can reduce the burden of morbidity and mortality related to microvascular disease in type 2 diabetes.

Efficacy and Safety of Diacerein in Patients With Inadequately Controlled Type 2 Diabetes: A Randomized Controlled Trial

OBJECTIVE

To assess, in a randomized, double-blind, and placebo-controlled trial, the efficacy and safety of diacerein, an immune modulator anti-inflammatory drug, in improving glycemic control of patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Eighty-four patients with HbA1c between 7.5 and 9.5% (58-80 mmol/mol) were randomized to 48-week treatment with placebo (n = 41) or diacerein 100 mg/day (n = 43). The primary outcome was the difference in mean HbA1c changes during treatment. Secondary outcomes were other efficacy and safety measurements. A general linear regression with repeated measures, adjusted for age, sex, diabetes duration, and each baseline value, was used to estimate differences in mean changes. Both intention-to-treat (ITT) analysis and per-protocol analysis (excluding 10 patients who interrupted treatment) were performed.

RESULTS

Diacerein reduced HbA1c compared with placebo by 0.35% (3.8 mmol/mol; P = 0.038) in the ITT analysis and by 0.41% (4.5 mmol/mol; P = 0.023) in the per-protocol analysis. The peak of effect occurred at the 24th week of treatment (-0.61% [6.7 mmol/mol; P = 0.014] and -0.78% [8.5 mmol/mol; P = 0.005], respectively), but it attenuated toward nonsignificant differences at the 48th week. No significant effect of diacerein was observed in other efficacy and safety measures. Diarrhea occurred in 65% of patients receiving diacerein and caused treatment interruption in 16%. Seven patients in the diacerein group reduced insulin dosage, whereas 10 in the placebo group increased it; however, mild hypoglycemic events were equally observed.

CONCLUSIONS

Diacerein reduced mean HbA1c levels, with peak of effect at the 24th week of treatment. The drug was well tolerated and may be indicated as adjunct treatment in patients with type 2 diabetes, particularly in those with osteoarthritis.

A reduced heart rate variability is independently associated with a blunted nocturnal blood pressure fall in patients with resistant hypertension

BACKGROUND

A blunted nocturnal blood pressure (BP) fall is a marker of worse cardiovascular outcomes, and autonomic imbalance may be involved. The objective was to evaluate the associations between the nocturnal BP fall and heart rate variability (HRV) parameters in resistant hypertension.

DESIGN AND METHODS

In a cross-sectional analysis, 424 resistant hypertensive patients performed 24-h ambulatory BP and Holter monitoring, and 221 patients also performed polysomnography. Time-domain HRV parameters evaluated were the standard deviation of all normal RR intervals (SDNN), the standard deviation of the averaged normal RR intervals for all 5-min segments (SDANN), the root mean square of differences between adjacent R-R intervals (rMSSD) and the percentage of adjacent R-R intervals that varied by more than 50 ms (pNN50). Multivariate linear and logistic regressions assessed associations between the nocturnal BP fall and HRV parameters.

RESULTS

Two hundred and sixty-six patients (63%) presented a nondipping pattern. These patients had lower SDNN and SDANN than normal dipping patients, but equal rMSSD and pNN50. On multivariate analysis, after adjustments for several confounders, a reduced SDNN (<70 ms) implied a 2.9 to 3.4-fold [95% confidence interval (CI) 1.2-8.5] and a reduced SDANN (<50 ms) a 3.7 to 4.2-fold (95% CI 1.5-11.4) higher odds of having a nondipping pattern. Further adjustment for the presence and severity of obstructive sleep apnoea did not change the results.

CONCLUSION

Reduced SDNN and SDANN, two HRV parameters that mainly reflect sympathetic overactivity, were independently associated with a blunted nocturnal BP fall in resistant hypertension. These relationships offer insight into physiopathological mechanisms linking the circadian BP variability to cardiovascular outcomes.

Prognostic importance of visit-to-visit blood pressure variability for micro- and macrovascular outcomes in patients with type 2 diabetes: The Rio de Janeiro Type 2 Diabetes Cohort Study

BACKGROUND

The prognostic importance of an increased visit-to-visit blood pressure variability (BP-VVV) for the future development of micro- and macrovascular complications in type 2 diabetes has been scarcely investigated and is largely unsettled. We aimed to evaluate it in a prospective long-term follow-up study with 632 individuals with type 2 diabetes.

METHODS

BP-VVV parameters (systolic and diastolic standard deviations [SD] and variation coefficients) were measured during the first 24-months. Multivariate Cox analysis, adjusted for risk factors and mean BP levels, examined the associations between BP-VVV and the occurrence of microvascular (retinopathy, microalbuminuria, renal function deterioration, peripheral neuropathy) and macrovascular complications (total cardiovascular events [CVEs], major adverse CVEs [MACE] and cardiovascular and all-cause mortality). Improvement in risk discrimination was assessed by the C-statistic and integrated discrimination improvement (IDI) index.

RESULTS

Over a median follow-up of 11.3 years, 162 patients had a CVE (132 MACE), and 212 patients died (95 from cardiovascular diseases); 153 newly-developed or worsened diabetic retinopathy, 193 achieved the renal composite outcome (121 newly-developed microalbuminuria and 95 deteriorated renal function), and 171 newly-developed or worsened peripheral neuropathy. Systolic BP-VVV was an independent predictor of MACE (hazard ratio: 1.25, 95% CI 1.03-1.51 for a 1-SD increase in 24-month SD), but not of total CVEs, cardiovascular and all-cause mortality, and of any microvascular outcome. However, no BP-VVV parameter significantly improved cardiovascular risk discrimination (increase in C-statistic 0.001, relative IDI 0.9%).

CONCLUSIONS

Systolic BP-VVV was an independent predictor of MACE, but it did not improve cardiovascular risk stratification. The goal of anti-hypertensive treatment in patients with type 2 diabetes shall remain in controlling mean BP levels, not on decreasing their visit-to-visit variability.

Rate, pattern and factors related to damage in Brazilian systemic lupus erythematosus patients

The Systemic Lupus International Collaborating Clinics/American College of Rheumatology (ACR) Damage Index (SDI) is an accepted instrument to ascertain damage. It has been shown to vary among different SLE populations. The aim of this study was to assess SDI score, pattern and factors related to damage in Brazilian SLE outpatients. The SDI was obtained in 105 patients with a median age of 41 (5-95%, 19-61.7) years and a median SLE duration of 127 (17.6-345.9) months. Patients had a median SDI of 2 (0-8) and 81.9% had some damage (SDI > 0). Damage was associated with a higher number of ACR criteria for SLE in multivariate analysis (OR = 2.32, 95%CI = 1.23-4.37, P = 0.009). Antiphospholipid syndrome (APS) (OR = 9.82, 95%CI = 2.74-35.23, P < 0.001), methylprednisolone pulses (OR = 3.91, 95%CI = 1.19-12.81, P = 0.024), age (OR = 1.70, 95%CI = 1.02-1.13, P = 0.011) and prednisone use duration (OR = 1.01, 95%CI = 1.002-1.02, P = 0.020) were related to severe damage (SDI > or = 4). Hypertension was associated with renal, cardiac and atherosclerotic damage, as cyclophosphamide pulses were with premature menopause. In conclusion, damage was very frequent in Brazilian SLE patients, mainly due to skin involvement, compared to other SLE populations. The presence of APS was the major independent contributor to the development of severe damage. Arterial hypertension was identified as a common risk factor for renal, cardiac and atherosclerotic damage.

Prognostic importance of baseline and serial glycated hemoglobin levels in high-risk patients with type 2 diabetes: the Rio de Janeiro Type 2 Diabetes Cohort Study

The prognostic importance of baseline and serial glycated hemoglobin (HbA1c) changes for cardiovascular outcomes is still debated. We aimed to evaluate it in 620 high-risk individuals with type 2 diabetes (mean age 60.4 years, 37 % males, 55 % Caucasians). Patients had HbA1c levels measured at study entry and serially during follow-up. Primary end points were total cardiovascular events (CVEs), major CVEs (non-fatal myocardial infarctions and strokes plus cardiovascular deaths) and all-cause mortality. Cardiovascular and non-cardiovascular mortalities were secondary end points. HbA1c was evaluated either as a continuous variable and categorized at clinically relevant cutoffs. Multivariate Cox regressions assessed the associations with end points. After a median follow-up of 6.6 years, 125 total CVEs occurred (90 major CVEs), and 111 patients died (64 from cardiovascular diseases). After statistical adjustments for other cardiovascular risk factors, baseline and mean first-year HbA1c predicted all end points, except non-cardiovascular deaths; and hazard ratios tended to be higher for mean first year than for baseline HbA1c. Each 1 % (10.9 mmol/mol) increase in mean first-year HbA1c increased 27 % the risk of major CVEs occurrence (95 % CI 11-45 %). Updating HbA1c for values obtained beyond the second year of follow-up did not improve its predictive performance. The cardiovascular protection was observed until HbA1c values lower than 6.5 % (48 mmol/mol). Moreover, the magnitude of HbA1c reduction during the first year of follow-up was predictive of better cardiovascular outcomes, independent of baseline HbA1c levels. In conclusion, better glycemic control, especially during the first year of follow-up, is determinant of better cardiovascular outcomes in high-risk patients with type 2 diabetes, without any detectable lower threshold level of HbA1c.

Increasing aortic stiffness is predictive of advanced liver fibrosis in patients with type 2 diabetes: the Rio-T2DM cohort study

BACKGROUND & AIMS

Type 2 diabetes mellitus (T2DM) is a risk factor for cardiovascular disease (CVD) and advanced stages of non-alcoholic fatty liver disease (NAFLD). The aim was to evaluate the association between aortic stiffness, a preclinical CVD marker, with advanced liver fibrosis identified by transient elastography (TE) in T2DM outpatients with NAFLD.

METHODS

This longitudinal study included 291 T2DM patients with NAFLD detected by ultrasonography, who had two carotid-femoral pulse wave velocity (cf-PWV) measurements and a TE examination (Fibroscan(®) ) performed over a median follow-up of 7 years. Advanced liver fibrosis (corresponding to ≥ F3 stage) was considered as median values >7.9 kPa (M probe) or >7.2 kPa (XL probe). Increased aortic stiffness was defined as cf-PWV >10 m/s.

RESULTS

Eighty patients (27.5%) had advanced liver fibrosis. Overall, there was an increase in cf-PWV of 0.1 m/s/year (1% per year). Both a high aortic stiffness at the 2nd cf-PWV examination [odds ratios (OR): 3.0; 95% CI: 1.3-7.2; P = 0.011] and a serial increase in aortic stiffness (OR: 2.1; 95% CI: 1.0-4.3; P = 0.046) were associated with increased odds of having advanced liver fibrosis. Patients who presented either an increase in aortic stiffness or persisted with high values had significantly higher mean liver stiffness than those who either decreased aortic stiffness or persisted with normal cf-PWV values (mean difference: 2.1 kPa, 95% CI: 0.5-3.7 kPa, P = 0.012), after adjustments for anthropometric-demographic and clinical laboratory covariates.

CONCLUSIONS

In T2DM patients with NAFLD, a high or increasing aortic stiffness predicted development of advanced liver fibrosis on TE.

Prognostic value of ventricular repolarization prolongation in resistant hypertension: a prospective cohort study

OBJECTIVE

The prognostic value of prolonged ventricular repolarization in patients with resistant hypertension is unknown. The aim of this prospective study was to investigate the usefulness of electrocardiographic QT-interval parameters as predictors of cardiovascular morbidity and mortality.

METHODS

At baseline, 538 resistant hypertensive patients had five QT-interval components measured in standard 12-lead ECGs: maximum QRS, QTpeak, QTend, JT and Tpeak-to-end-interval durations. Primary endpoints were a composite of fatal and nonfatal cardiovascular events, all-cause and cardiovascular mortalities. Multiple Cox regression assessed the associations between QT-interval parameters and subsequent endpoints.

RESULTS

After a median follow-up of 4.8 years, 69 (12.8%) patients died, 46 from cardiovascular causes, and 107 (19.9%) fatal or nonfatal cardiovascular events occurred. After adjustment for several traditional risk factors, including 24-h ambulatory systolic blood pressure, an increment of 1 SD (35 ms) in QTcend-interval was associated with hazard ratios of 1.38 (1.15-1.67), 1.51 (1.16-1.98) and 1.30 (1.03-1.64), respectively, for the composite endpoint, cardiovascular mortality and all-cause mortality. Further adjustment for left ventricular hypertrophy attenuated the relative risks, but they remained significant for cardiovascular mortality (1.45, 1.07-1.97) and for the composite endpoint (1.35, 1.11-1.66). After full adjustment, a prolonged QTcend-interval (> or =460 ms) conferred a 1.7-fold (1.1-2.6) higher risk of having a future fatal or nonfatal cardiovascular event. No other QT-interval component added further prognostic information to QTcend-interval duration.

CONCLUSIONS

Prolonged ventricular repolarization is a risk marker for cardiovascular morbidity and mortality in patients with resistant hypertension, over and beyond traditional cardiovascular risk factors, including ambulatory blood pressure and left ventricular hypertrophy.

Prevalence and factors associated with dyslipoproteinemias in Brazilian systemic lupus erythematosus patients

To determine the prevalence of dyslipoproteinemias and their related factors in a Brazilian systemic lupus erythematosus (SLE) population, fasting lipids were measured in 185 female SLE outpatients. Age, BMI, smoking, post-menopausal status, presence of diabetes and hypertension, SLE duration, number of ARA criteria, drug treatment and disease activity (by SLEDAI) were registered. Statistics included uni and multivariate logistic regression. Eighty-nine patients (48.1%) had hypercholesterolemia, 55 (29.7%) had hypertriglyceridemia and 109 (58.9%) had either. On multivariate analysis, 24-h proteinuria (OR = 2.08, 95% CI: 1.11-3.88), BMI (OR = 1.08, 95% CI: 1.01-1.16) and post-menopausal status (OR = 2.48, 95% CI: 1.25-4.92) were associated with hypercholesterolemia. Disease activity was related to low HDL-cholesterol (OR = 2.59, 95% CI: 1.20-5.58) and, in pre-menopausal patients, also to hypertriglyceridemia (OR = 1.16, 95% CI: 1.03-1.30). Antimalarial use was protective for hypertriglyceridemia (OR = 0.44, 95% CI: 0.22-0.90). In conclusion, the increased prevalence of dyslipoproteinemias is due to proteinuria, obesity and SLE activity. Antimalarials have beneficial effect on lipid profile that may be due to reduction in disease activity.