1
|
Mi J, Han X, Cao M, Pan Z, Guo J, Huang D, Sun W, Liu Y, Xue T, Guan T. The Association Between Urbanization and Electrocardiogram Abnormalities in China: a Nationwide Longitudinal Study. J Urban Health 2024; 101:109-119. [PMID: 38216823 PMCID: PMC10897075 DOI: 10.1007/s11524-023-00816-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 01/14/2024]
Abstract
The health effects of urbanization are controversial. The association between urbanization and reversible subclinical risks of cardiovascular diseases (e.g., electrocardiogram (ECG) abnormalities) has rarely been studied. This study aimed to assess the association between urbanization and ECG abnormalities in China based on the China National Stroke Screening Survey (CNSSS). We used changes in the satellite-measured impervious surfaces rate and nighttime light data to assess the level of urbanization. Every interquartile increment in the impervious surfaces rate or nighttime light was related to a decreased risk of ECG abnormalities, with odds ratios of 0.894 (95% CI, 0.869-0.920) or 0.809 (95% CI, 0.772-0.847), respectively. And we observed a U-shaped nonlinear exposure-response relationship curve between the impervious surfaces rate and ECG abnormalities. In conclusion, the current average level of urbanization among the studied Chinese adults remains a beneficial factor for reducing cardiovascular risks.
Collapse
Affiliation(s)
- Jiarun Mi
- School of Health Policy and Management, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Xueyan Han
- School of Health Policy and Management, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Man Cao
- School of Health Policy and Management, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Zhaoyang Pan
- School of Health Policy and Management, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Jian Guo
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
- Medical Research Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Dengmin Huang
- School of Health Policy and Management, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Wei Sun
- School of Health Policy and Management, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Yuanli Liu
- School of Health Policy and Management, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Tao Xue
- Institute of Reproductive and Child Health, National Health Commission Key Laboratory of Reproductive Health/Department of Epidemiology and Biostatistics, Ministry of Education Key Laboratory of Epidemiology of Major Diseases (PKU), School of Public Health, Peking University Health Science Centre, Beijing, 100191, China.
- State Environmental Protection Key Laboratory of Atmospheric Exposure, and Health Risk Management and Center for Environment and Health, Peking University, Beijing, 100871, China.
- Advanced Institute of Information Technology, Peking University, Hangzhou, 311215, China.
| | - Tianjia Guan
- School of Health Policy and Management, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
| |
Collapse
|
2
|
Ahmad A, Lim LL, Morieri ML, Tam CHT, Cheng F, Chikowore T, Dudenhöffer-Pfeifer M, Fitipaldi H, Huang C, Kanbour S, Sarkar S, Koivula RW, Motala AA, Tye SC, Yu G, Zhang Y, Provenzano M, Sherifali D, de Souza RJ, Tobias DK, Gomez MF, Ma RCW, Mathioudakis N. Precision prognostics for cardiovascular disease in Type 2 diabetes: a systematic review and meta-analysis. COMMUNICATIONS MEDICINE 2024; 4:11. [PMID: 38253823 PMCID: PMC10803333 DOI: 10.1038/s43856-023-00429-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 12/14/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Precision medicine has the potential to improve cardiovascular disease (CVD) risk prediction in individuals with Type 2 diabetes (T2D). METHODS We conducted a systematic review and meta-analysis of longitudinal studies to identify potentially novel prognostic factors that may improve CVD risk prediction in T2D. Out of 9380 studies identified, 416 studies met inclusion criteria. Outcomes were reported for 321 biomarker studies, 48 genetic marker studies, and 47 risk score/model studies. RESULTS Out of all evaluated biomarkers, only 13 showed improvement in prediction performance. Results of pooled meta-analyses, non-pooled analyses, and assessments of improvement in prediction performance and risk of bias, yielded the highest predictive utility for N-terminal pro b-type natriuretic peptide (NT-proBNP) (high-evidence), troponin-T (TnT) (moderate-evidence), triglyceride-glucose (TyG) index (moderate-evidence), Genetic Risk Score for Coronary Heart Disease (GRS-CHD) (moderate-evidence); moderate predictive utility for coronary computed tomography angiography (low-evidence), single-photon emission computed tomography (low-evidence), pulse wave velocity (moderate-evidence); and low predictive utility for C-reactive protein (moderate-evidence), coronary artery calcium score (low-evidence), galectin-3 (low-evidence), troponin-I (low-evidence), carotid plaque (low-evidence), and growth differentiation factor-15 (low-evidence). Risk scores showed modest discrimination, with lower performance in populations different from the original development cohort. CONCLUSIONS Despite high interest in this topic, very few studies conducted rigorous analyses to demonstrate incremental predictive utility beyond established CVD risk factors for T2D. The most promising markers identified were NT-proBNP, TnT, TyG and GRS-CHD, with the highest strength of evidence for NT-proBNP. Further research is needed to determine their clinical utility in risk stratification and management of CVD in T2D.
Collapse
Affiliation(s)
- Abrar Ahmad
- Department of Clinical Sciences, Lund University Diabetes Centre, Lund University, Malmö, Sweden
| | - Lee-Ling Lim
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
- Asia Diabetes Foundation, Hong Kong SAR, China
| | - Mario Luca Morieri
- Metabolic Disease Unit, University Hospital of Padova, Padova, Italy
- Department of Medicine, University of Padova, Padova, Italy
| | - Claudia Ha-Ting Tam
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
- Laboratory for Molecular Epidemiology in Diabetes, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Feifei Cheng
- Health Management Center, The Second Affiliated Hospital of Chongqing Medical University, Chongqing Medical University, Chongqing, China
| | - Tinashe Chikowore
- MRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Sydney Brenner Institute for Molecular Bioscience, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Hugo Fitipaldi
- Department of Clinical Sciences, Lund University Diabetes Centre, Lund University, Malmö, Sweden
| | - Chuiguo Huang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
- Laboratory for Molecular Epidemiology in Diabetes, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong SAR, China
| | | | - Sudipa Sarkar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Robert Wilhelm Koivula
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, United Kingdom
| | - Ayesha A Motala
- Department of Diabetes and Endocrinology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Sok Cin Tye
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, the Netherlands
- Sections on Genetics and Epidemiology, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Gechang Yu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
- Laboratory for Molecular Epidemiology in Diabetes, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yingchai Zhang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
- Laboratory for Molecular Epidemiology in Diabetes, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Michele Provenzano
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Diana Sherifali
- Heather M. Arthur Population Health Research Institute, McMaster University, Ontario, Canada
| | - Russell J de Souza
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton Health Sciences Corporation, Hamilton, Ontario, Canada
| | | | - Maria F Gomez
- Department of Clinical Sciences, Lund University Diabetes Centre, Lund University, Malmö, Sweden.
- Faculty of Health, Aarhus University, Aarhus, Denmark.
| | - Ronald C W Ma
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China.
- Laboratory for Molecular Epidemiology in Diabetes, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China.
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong SAR, China.
| | - Nestoras Mathioudakis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| |
Collapse
|
3
|
Ahmad A, Lim LL, Morieri ML, Tam CHT, Cheng F, Chikowore T, Dudenhöffer-Pfeifer M, Fitipaldi H, Huang C, Kanbour S, Sarkar S, Koivula RW, Motala AA, Tye SC, Yu G, Zhang Y, Provenzano M, Sherifali D, de Souza R, Tobias DK, Gomez MF, Ma RCW, Mathioudakis NN. Precision Prognostics for Cardiovascular Disease in Type 2 Diabetes: A Systematic Review and Meta-analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.26.23289177. [PMID: 37162891 PMCID: PMC10168509 DOI: 10.1101/2023.04.26.23289177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Background Precision medicine has the potential to improve cardiovascular disease (CVD) risk prediction in individuals with type 2 diabetes (T2D). Methods We conducted a systematic review and meta-analysis of longitudinal studies to identify potentially novel prognostic factors that may improve CVD risk prediction in T2D. Out of 9380 studies identified, 416 studies met inclusion criteria. Outcomes were reported for 321 biomarker studies, 48 genetic marker studies, and 47 risk score/model studies. Results Out of all evaluated biomarkers, only 13 showed improvement in prediction performance. Results of pooled meta-analyses, non-pooled analyses, and assessments of improvement in prediction performance and risk of bias, yielded the highest predictive utility for N-terminal pro b-type natriuretic peptide (NT-proBNP) (high-evidence), troponin-T (TnT) (moderate-evidence), triglyceride-glucose (TyG) index (moderate-evidence), Genetic Risk Score for Coronary Heart Disease (GRS-CHD) (moderate-evidence); moderate predictive utility for coronary computed tomography angiography (low-evidence), single-photon emission computed tomography (low-evidence), pulse wave velocity (moderate-evidence); and low predictive utility for C-reactive protein (moderate-evidence), coronary artery calcium score (low-evidence), galectin-3 (low-evidence), troponin-I (low-evidence), carotid plaque (low-evidence), and growth differentiation factor-15 (low-evidence). Risk scores showed modest discrimination, with lower performance in populations different from the original development cohort. Conclusions Despite high interest in this topic, very few studies conducted rigorous analyses to demonstrate incremental predictive utility beyond established CVD risk factors for T2D. The most promising markers identified were NT-proBNP, TnT, TyG and GRS-CHD, with the highest strength of evidence for NT-proBNP. Further research is needed to determine their clinical utility in risk stratification and management of CVD in T2D.
Collapse
|
4
|
Harms PP, Elders PPJM, Femke R, Lissenberg-Witte BI, Tan HL, Beulens JWJ, Nijpels G, van der Heijden AA. Longitudinal association of ECG abnormalities with major adverse cardiac events in people with type 2 diabetes: The Hoorn Diabetes Care System cohort. Eur J Prev Cardiol 2023:6982519. [PMID: 36625405 DOI: 10.1093/eurjpc/zwac314] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 12/15/2022] [Accepted: 12/27/2022] [Indexed: 01/11/2023]
Abstract
AIMS To investigate the association of (changes in) ECG abnormalities with incident major adverse cardiac events (MACE) in people with type 2 diabetes (T2D) without pre-existing cardiovascular disease (CVD). METHODS A prospective longitudinal study of 11,993 people with T2D without known CVD from the Hoorn Diabetes Care System cohort. Annually repeated measurements (1998-2018), included cardiovascular risk factors, over 70,000 ECGs, and self-reported cardiovascular events. ECG abnormalities were classified according to the Minnesota Classification as prolonged PR duration, prolonged QRS duration, left QRS-axis, QS pattern, ST-segment/T-wave abnormalities, or tall R-wave. The association of ECG abnormalities with MACEs was assessed using time-dependent Cox-regression models, adjusted for time-varying cardiovascular risk factors and medication use (Hazzard Ratios with 95%CIs). RESULTS During a median follow-up of 6.6 (IQR, 3.1-10.7) years, 5445 (45.4%) of the participants had an ECG abnormality (prevalent or incident) at any of the median 6 (IQR, 3-10) annual ECG recordings, and 905 people (7.5%) had a MACE (529 CHD, 250 HF, 126 SCA). After adjustment, most ECG abnormalities were associated with HF: prolonged QRS duration (HR, 4.01 (95%CI, 2.67-6.03)), QS pattern (2.68 (0.85-8.49)), ST-segment/T-wave abnormalities (4.26 (2.67-6.80)), and tall R-wave (2.23 (1.33-3.76)). Only QS pattern (2.69 (1.20-6.03)), and ST-segment/T-wave abnormalities (2.11 (1.48-3.02)) were associated with CHD. These associations were robust across age, sex, hypertension, or estimated CVD risk subgroups. CONCLUSION In people with T2D without pre-existing cardiovascular disease, ECG abnormalities related to decelerated conduction, ischemia and hypertrophy are predominantly early signs of emerging HF, while only abnormalities related to ischemic disorders are signs of CHD.
Collapse
Affiliation(s)
- Peter P Harms
- Amsterdam UMC location Vrije Universiteit Amsterdam, General Practice Medicine, Boelelaan 1117, Amsterdam, The Netherlands.,Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Petra P J M Elders
- Amsterdam UMC location Vrije Universiteit Amsterdam, General Practice Medicine, Boelelaan 1117, Amsterdam, The Netherlands.,Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Rutters Femke
- Amsterdam UMC location Vrije Universiteit Amsterdam, Epidemiology and Data Science, Boelelaan 1117, Amsterdam, The Netherlands.,Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Birgit I Lissenberg-Witte
- Amsterdam UMC location Vrije Universiteit Amsterdam, Epidemiology and Data Science, Boelelaan 1117, Amsterdam, The Netherlands
| | - Hanno L Tan
- Amsterdam UMC location University of Amsterdam, Clinical and Experimental Cardiology, Meibergdreef 9, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences research institute, Amsterdam, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands
| | - Joline W J Beulens
- Amsterdam UMC location Vrije Universiteit Amsterdam, Epidemiology and Data Science, Boelelaan 1117, Amsterdam, The Netherlands.,Amsterdam Public Health research institute, Amsterdam, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Giel Nijpels
- Amsterdam UMC location Vrije Universiteit Amsterdam, General Practice Medicine, Boelelaan 1117, Amsterdam, The Netherlands.,Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Amber A van der Heijden
- Amsterdam UMC location Vrije Universiteit Amsterdam, General Practice Medicine, Boelelaan 1117, Amsterdam, The Netherlands.,Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | | |
Collapse
|
5
|
Park S, Yum Y, Cha JJ, Joo HJ, Park JH, Hong SJ, Yu CW, Lim DS. Prevalence and Clinical Impact of Electrocardiographic Abnormalities in Patients with Chronic Kidney Disease. J Clin Med 2022; 11:jcm11185414. [PMID: 36143060 PMCID: PMC9506179 DOI: 10.3390/jcm11185414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/09/2022] [Accepted: 09/10/2022] [Indexed: 11/16/2022] Open
Abstract
Chronic kidney disease (CKD) is a strong risk factor for cardiovascular disease. An electrocardiogram (ECG) is a basic test for screening cardiovascular disease. However, the impact of ECG abnormalities on cardiovascular prognosis in patients with CKD is largely unknown. A total of 2442 patients with CKD (stages 3−5) who underwent ECG between 2013 and 2015 were selected from the electronic health record database of the Korea University Anam Hospital. ECG abnormalities were defined using the Minnesota classification. The five-year major adverse cerebrocardiovascular event (MACCE), the composite of death, myocardial infarction (MI), and stroke were analyzed. The five-year incidences for MACCE were 27.7%, 20.8%, and 17.2% in patients with no, minor, and major ECG abnormality (p < 0.01). Kaplan−Meier curves also showed the highest incidence of MI, death, and MACCE in patients with major ECG abnormality. Multivariable Cox regression analysis revealed age, sex, diabetes, CKD stage, hsCRP, antipsychotic use, and major ECG abnormality as independent risk predictors for MACCE (adjusted HR of major ECG abnormality: 1.39, 95% CI: 1.09−1.76, p < 01). Among the detailed ECG diagnoses, sinus tachycardia, myocardial ischemia, atrial premature complex, and right axis deviation were proposed as important ECG diagnoses. The accuracy of cardiovascular risk stratification was improved when the ECG results were added to the conventional SCORE model (net reclassification index 0.07). ECG helps to predict future cerebrocardiovascular events in CKD patients. ECG diagnosis can be useful for cardiovascular risk evaluation in CKD patients when applied in addition to the conventional risk stratification model.
Collapse
Affiliation(s)
- Sejun Park
- Department of Internal Medicine, Korea University Anam Hospital, Seoul 02841, Korea
| | - Yunjin Yum
- Department of Biostatistics, Korea University College of Medicine, Seoul 02841, Korea
| | - Jung-Joon Cha
- Department of Internal Medicine, Division of Cardiology, Korea University Anam Hospital, Seoul 02841, Korea
| | - Hyung Joon Joo
- Department of Internal Medicine, Division of Cardiology, Korea University Anam Hospital, Seoul 02841, Korea
- Department of Medical Informatics, Korea University College of Medicine, Seoul 02841, Korea
- Research Institute for Medical Bigdata Science, College of Medicine, Korea University, Seoul 02708, Korea
- Correspondence: ; Tel.: +82-2-920-6411
| | - Jae Hyoung Park
- Department of Internal Medicine, Division of Cardiology, Korea University Anam Hospital, Seoul 02841, Korea
| | - Soon Jun Hong
- Department of Internal Medicine, Division of Cardiology, Korea University Anam Hospital, Seoul 02841, Korea
| | - Cheol Woong Yu
- Department of Internal Medicine, Division of Cardiology, Korea University Anam Hospital, Seoul 02841, Korea
| | - Do-Sun Lim
- Department of Internal Medicine, Division of Cardiology, Korea University Anam Hospital, Seoul 02841, Korea
| |
Collapse
|
6
|
Busch N, Jensen MT, Goetze JP, Schou M, Biering-Sørensen T, Fritz-Hansen T, Andersen HU, Vilsbøll T, Rossing P, Jørgensen PG. Prognostic and comparative performance of cardiovascular risk markers in patients with type 2 diabetes. J Diabetes 2021; 13:754-763. [PMID: 33656260 DOI: 10.1111/1753-0407.13172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/09/2021] [Accepted: 02/21/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Diagnostic tests including echocardiography, albuminuria, electrocardiogram (ECG), high-sensitivity troponin I (hs-TnI), and N-terminal prohormone brain natriuretic peptide (NT-proBNP) have been suggested as cardiovascular (CV) risk predictors in type 2 diabetes. We studied the separate and combined prognostic yield of these risk markers. METHODS In all, 1030 patients with type 2 diabetes were recruited from specialized clinics in this prospective cohort study. Full echocardiographic evaluation was feasible in 886 patients in sinus rhythm with adequate image quality. ECG was performed in 998 patients. Albuminuria was measured in 1009 and NT-proBNP/hs-TnI in 933 patients. The end point was a composite of CV events. RESULTS The median follow-up was 4.7 years (interquartile range: 4.0-5.3), and 174 patients experienced a CV disease event. All considered markers, except hs-TnI, were significantly (P < .001) associated with the outcome: abnormal echocardiogram (hazard ratio 2.40 [1.70-3.39]), albuminuria 2.01 (1.47-2.76), abnormal ECG (2.27 [1.66-3.08]), high NT-proBNP (>150 pg/mL) 3.05 (2.11-4.40), and hs-TnI 1.12 (0.79-1.59). After adjusting for clinical variables, all remained significantly associated with the end point. However, after adjusting for each other, only NT-proBNP >150 pg/mL remained significantly associated with the end point (2.07 [1.28-3.34], P < .001). Measured by C-statistics, model performance was highest with log2 (NT-proBNP) (0.70 [0.65-0.75]) and similar to clinical variables alone (0.71 [0.67-0.76]). Combining all risk markers only resulted in a very limited increase in C-statistics (0.69 [0.64-0.74]). CONCLUSIONS This study identified NT-proBNP over echocardiography, ECG, and albuminuria in risk prediction in patients with type 2 diabetes. The diagnostic yield in considering more than one risk marker was limited in this population.
Collapse
Affiliation(s)
- Nikolaj Busch
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Magnus T Jensen
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jens P Goetze
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Fritz-Hansen
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | - Tina Vilsbøll
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Peter G Jørgensen
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
7
|
Harms PP, van der Heijden AA, Rutters F, Tan HL, Beulens JWJ, Nijpels G, Elders P. Prevalence of ECG abnormalities in people with type 2 diabetes: The Hoorn Diabetes Care System cohort. J Diabetes Complications 2021; 35:107810. [PMID: 33280986 DOI: 10.1016/j.jdiacomp.2020.107810] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/26/2020] [Accepted: 11/01/2020] [Indexed: 10/22/2022]
Abstract
AIMS The American Diabetes Association, and the joint European Society of Cardiology and European Association for the Study of Diabetes guidelines recommend a resting ECG in people with type 2 diabetes with hypertension or suspected cardiovascular disease (CVD). However, knowledge on the prevalence of ECG abnormalities is incomplete. We aimed to analyse the prevalence of ECG abnormalities and their cross-sectional associations with cardiovascular risk factors in people with type 2 diabetes. METHODS We used data of the Diabetes Care System cohort obtained in 2018. ECG abnormalities were defined using the Minnesota Classification and categorised into types of abnormalities. The prevalence was calculated for the total population (n = 8068) and the subgroup of people without a history of CVD (n = 6494). Logistic regression models were used to asses cross-sectional associations. RESULTS Approximately one-third of the total population had minor (16.0%) or major (13.1%) ECG abnormalities. Of the participants without a CVD history, approximately one-quarter had minor (14.9%) or major (9.1%) ECG abnormalities, and for those with hypertension or very high CVD risk, the prevalence was 27.5% and 39.6%, respectively. ECG abnormalities were significantly and consistently associated with established CVD risk factors. CONCLUSIONS Resting ECG abnormalities are common in all people with type 2 diabetes (29.1%), including those without a history of CVD (24.0%), and their prevalence is related to traditional cardiovascular risk factors such as older age, male sex, hypertension, lower HDL cholesterol, higher BMI, and smoking behaviour.
Collapse
Affiliation(s)
- Peter P Harms
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of General Practice Medicine, Amsterdam Public Health Research Institute, De Boelelaan 1117, Amsterdam, the Netherlands.
| | - Amber A van der Heijden
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of General Practice Medicine, Amsterdam Public Health Research Institute, De Boelelaan 1117, Amsterdam, the Netherlands
| | - Femke Rutters
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, De Boelelaan 1117, Amsterdam, the Netherlands
| | - Hanno L Tan
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Experimental and Clinical Cardiology, Amsterdam Cardiovascular Sciences Research Institute, Meibergdreef 9, Amsterdam, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands
| | - Joline W J Beulens
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, De Boelelaan 1117, Amsterdam, the Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Giel Nijpels
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of General Practice Medicine, Amsterdam Public Health Research Institute, De Boelelaan 1117, Amsterdam, the Netherlands
| | - Petra Elders
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of General Practice Medicine, Amsterdam Public Health Research Institute, De Boelelaan 1117, Amsterdam, the Netherlands
| |
Collapse
|
8
|
Ioannou A, Papageorgiou N, Singer D, Missouris CG. Registry report of the prevalence of ECG abnormalities and their relation to patient characteristics in an asymptomatic population. QJM 2018; 111:875-879. [PMID: 30239921 DOI: 10.1093/qjmed/hcy212] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Cardiovascular disease is the leading cause of morbidity and mortality in developed countries. Many patients do not experience symptoms before a first major cardiovascular event. Resting electrocardiogram (ECG) may help identify asymptomatic individuals with a high risk of cardiovascular disease. OBJECTIVE We sought to determine the prevalence of ECG abnormalities in an apparently symptom-free adult population within a prospective registry. METHODS The registry consisted of 4739 consecutive apparently healthy individuals [age 62.8 ± 6.2 (SD) years; 54% female], referred by their General Practitioners between 2009 and 2013. Patient demographics, and clinical data were obtained, alongside blood tests and a resting ECG. RESULTS ECG abnormalities were present in 1509 (31.8%) subjects and were commoner with increasing age (F = 0.161, p = 0.01), systolic (F = 0.134, p = 0.01) and diastolic (F = 0.44, p = 0.01) blood pressure and waist circumference (F = 0.53, p = 0.01). Left ventricular hypertrophy (LVH) was the most common abnormality (n = 281) and was positively associated with systolic (F = 0.12, p = 0.01) and diastolic blood pressure (F = 0.99, p = 0.01) and male gender (X2 = 60.5, p < 0.01). All ECG abnormalities (except for LVH) were associated with an increasing age, while right bundle branch block (F = 0.041, p = 0.01) and atrial fibrillation (n = 29; F = 0.036, p = 0.05) were associated with the presence of diabetes mellitus (n = 211). Only left bundle branch block (n = 50) was associated with angina (F = 0.05, p = 0.01). CONCLUSIONS Unrecognized cardiac abnormalities are common in middle-aged men and women with no overt symptoms. ECG offers the potential to identify these abnormalities and provide earlier intervention and treatment, and possibly improve cardiovascular outcome.
Collapse
Affiliation(s)
- A Ioannou
- Department of Cardiology, Royal Free Hospital, London, UK
| | - N Papageorgiou
- Department of Cardiology, St. Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - D Singer
- Department of Internal Medicine, Office of Global Health, Yale University School of Medicine, New Haven, Connecticut, USA
| | - C G Missouris
- Department of Cardiology, Wexham Park Hospital, Frimley Health NHS Trust, Slough, UK
- Medical School, University of Cyprus, Nicosia, Cyprus
| |
Collapse
|
9
|
Gori M, Canova P, Calabrese A, Cioffi G, Trevisan R, De Maria R, Grosu A, Iacovoni A, Fontana A, Ferrari P, Greene SJ, Gheorghiade M, Parati G, Gavazzi A, Senni M. Strategy to identify subjects with diabetes mellitus more suitable for selective echocardiographic screening: The DAVID-Berg study. Int J Cardiol 2017; 248:414-420. [PMID: 28709699 DOI: 10.1016/j.ijcard.2017.06.101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 06/15/2017] [Accepted: 06/26/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Despite the burden of pre-clinical heart failure (HF) among diabetes mellitus (DM) patients, routine screening echocardiography is not currently recommended. We prospectively assessed risk prediction for HF/death of a screening strategy combining clinical data, electrocardiogram, NTproBNP, and echocardiogram, aiming to identify DM patients more suitable for selective echocardiography. METHODS Among 4047 screened subjects aged≥55/≤80years, the DAVID-Berg Study prospectively enrolled 623 outpatients with DM, or hypertension, or known cardiovascular disease but with no HF history/symptoms. The present analysis focuses on data obtained during a longitudinal follow-up of the 219 patients with DM. RESULTS Mean age was 68years, 61% were men, and median DM duration was 4.9years. During a median follow-up of 5.2years, 50 subjects developed HF or died. A predictive model using clinical data demonstrated moderate predictive power, which significantly improved by adding electrocardiogram (C-statistic 0.75 versus 0.70; p<0.05), but not NTproBNP (C-statistic 0.72, p=0.20). Subjects with normal clinical variables or abnormal clinical variables but normal electrocardiogram had low events rate (1.3 versus 2.4events/100-person-years, p=NS). Conversely, subjects with both clinical and electrocardiogram abnormalities (47%) carried higher risk (9.0events/100-person-years, p<0.001). The predictive power for mortality/HF development increased when echocardiography was added (13.6events/100-person-years, C-statistic 0.80, p<0.05). CONCLUSIONS Our prospective study found that a selective echocardiographic screening strategy guided by abnormal clinical/electrocardiogram data can reliably identify DM subjects at higher risk for incident HF and death. This screening approach may hold promise in guiding HF prevention efforts among DM patients.
Collapse
Affiliation(s)
- Mauro Gori
- CardioVascular Department, Ospedale Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Paolo Canova
- CardioVascular Department, Ospedale Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Alice Calabrese
- CardioVascular Department, Ospedale Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Giovanni Cioffi
- Department of Cardiology, Villa Bianca Hospital, Trento, Italy
| | - Roberto Trevisan
- Diabetology Unit, Ospedale Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Renata De Maria
- CNR Institute of Clinical Physiology, CardioThoracic and Vascular Department, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Aurelia Grosu
- CardioVascular Department, Ospedale Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Attilio Iacovoni
- CardioVascular Department, Ospedale Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Alessandra Fontana
- CardioVascular Department, Ospedale Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Paola Ferrari
- CardioVascular Department, Ospedale Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Stephen J Greene
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Mihai Gheorghiade
- Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, St. Luke Hospital, Istituto Auxologico Italiano, Milan and Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Antonello Gavazzi
- FROM Research Foundation, Ospedale Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Michele Senni
- CardioVascular Department, Ospedale Papa Giovanni XXIII Hospital, Bergamo, Italy.
| |
Collapse
|
10
|
Dobre M, Brateanu A, Rashidi A, Rahman M. Electrocardiogram abnormalities and cardiovascular mortality in elderly patients with CKD. Clin J Am Soc Nephrol 2012; 7:949-56. [PMID: 22461533 DOI: 10.2215/cjn.07440711] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Cardiovascular disease is the most common cause of death in CKD. This study evaluated whether electrocardiogram (ECG) abnormalities are predictors of cardiovascular death in CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Cardiovascular Health Study limited database (1989-2005) was used to identify a cohort with CKD at baseline (estimated GFR < 60 mL/min per 1.73 m(2)). The patients were categorized as having major, minor, or no ECG abnormalities. Rates of adjudicated cardiovascular events and mortality were compared among the groups using proportional hazards regression models. RESULTS A total of 1192 participants had CKD at baseline; mean age ± SD was 74.7±6.2 years. Of these patients, 452 (38.8%) had major, 346 (29.7%) had minor, and 367 (31.5%) had no ECG abnormalities. Participants with estimated GFR < 60 mL/min per 1.73 m(2) were more likely to have ECG abnormalities at baseline (adjusted prevalence odds ratio, 1.23 [95% confidence interval (CI), 1.06-1.43]) than those with GFR ≥ 60 mL/min per 1.73 m(2). During mean follow-up of 10.3±3.8 years, 814 (68.3%) participants died. Compared with participants without ECG abnormalities, participants with major abnormalities had the highest risk for cardiovascular events and death; adjusted hazard ratios were 2.15 (95% CI, 1.56-2.98) and 2.27 (95% CI, 1.56-3.30), respectively. For minor ECG abnormalities, hazard ratios were 1.24 (95% CI, 0.91-1.70) and 1.48 (95% CI, 1.00-2.18), respectively. CONCLUSIONS In patients with CKD, major ECG abnormalities are frequently present and predict a significantly higher risk for death and adverse cardiovascular outcomes.
Collapse
Affiliation(s)
- Mirela Dobre
- Division of Nephrology and Hypertension, Case Western Reserve University, Cleveland, Ohio, USA.
| | | | | | | |
Collapse
|
11
|
Xiang YL, He L, Xiao J, Xia S, Deng SB, Xiu Y, She Q. Effect of trimetazidine treatment on the transient outward potassium current of the left ventricular myocytes of rats with streptozotocin-induced type 1 diabetes mellitus. Braz J Med Biol Res 2012; 45:205-11. [PMID: 22331134 PMCID: PMC3854190 DOI: 10.1590/s0100-879x2012007500019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2011] [Accepted: 02/06/2012] [Indexed: 02/22/2023] Open
Abstract
Cardiovascular complications are a leading cause of mortality in patients with diabetes mellitus (DM). The present study was designed to investigate the effects of trimetazidine (TMZ), an anti-angina drug, on transient outward potassium current (Ito) remodeling in ventricular myocytes and the plasma contents of free fatty acid (FFA) and glucose in DM. Sprague-Dawley rats, 8 weeks old and weighing 200-250 g, were randomly divided into three groups of 20 animals each. The control group was injected with vehicle (1 mM citrate buffer), the DM group was injected with 65 mg/kg streptozotocin (STZ) for induction of type 1 DM, and the DM+TMZ group was injected with the same dose of STZ followed by a 4-week treatment with TMZ (60 mg·kg−1·day−1). All animals were then euthanized and their hearts excised and subjected to electrophysiological measurements or gene expression analyses. TMZ exposure significantly reversed the increased plasma FFA level in diabetic rats, but failed to change the plasma glucose level. The amplitude of Ito was significantly decreased in left ventricular myocytes from diabetic rats relative to control animals (6.25 ± 1.45 vs 20.72 ± 2.93 pA/pF at +40 mV). The DM-associated Ito reduction was attenuated by TMZ. Moreover, TMZ treatment reversed the increased expression of the channel-forming alpha subunit Kv1.4 and the decreased expression of Kv4.2 and Kv4.3 in diabetic rat hearts. These data demonstrate that TMZ can normalize, or partially normalize, the increased plasma FFA content, the reduced Ito of ventricular myocytes, and the altered expression Kv1.4, Kv4.2, and Kv4.3 in type 1 DM.
Collapse
Affiliation(s)
- Yu-luan Xiang
- Department of Cardiology, the Second Affiliated Hospital, Chongqing Medical University, 76 Linjiang Road, Chongqing, China
| | | | | | | | | | | | | |
Collapse
|
12
|
Coronary heart disease and cardiac conduction abnormalities in persons with psychotic disorders in a general population. Psychiatry Res 2010; 175:126-32. [PMID: 19926142 DOI: 10.1016/j.psychres.2008.07.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Revised: 06/26/2008] [Accepted: 07/31/2008] [Indexed: 11/21/2022]
Abstract
We investigated the prevalence of coronary heart disease (CHD) and myocardial infarction (MI) in persons with DSM-IV psychotic disorders. We also examined cardiac conduction abnormalities, and the role of antipsychotic medication in them. The study was based on a nationally representative survey of 8028 persons aged 30 years or over from Finland. Diagnoses of CHD and MI were based on electrocardiographic findings, health examination, and register information. QTc was calculated using the Bazett formula, and Minnesota classification was used for conduction abnormalities. We found that large Q-waves suggesting past MI were significantly more frequent in persons with schizophrenia, while the prevalence of CHD in persons with psychotic disorders did not differ significantly from the remaining study sample. Prevalence of prolonged QTc interval was significantly increased in persons with schizophrenia and in users of typical antipsychotics. However, low-potency antipsychotic use but not diagnosis of schizophrenia remained an independent predictor of prolonged QTc interval in a logistic regression. Low-potency antipsychotic use was associated with ventricular conduction defects, and high-potency antipsychotic use with premature beats. Symptoms and signs of CHD should be actively monitored patients with schizophrenia, and the electrocardiogram should be monitored for all types of changes in persons receiving antipsychotic medication.
Collapse
|
13
|
Haluska BA, Chan L, Jeffriess L, Shaw AA, Shaw J, Marwick TH. Correlates of preclinical cardiovascular disease in Indigenous and Non-Indigenous Australians: a case control study. Cardiovasc Ultrasound 2008; 6:36. [PMID: 18627637 PMCID: PMC2500007 DOI: 10.1186/1476-7120-6-36] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2008] [Accepted: 07/16/2008] [Indexed: 12/04/2022] Open
Abstract
Background The high frequency of premature death from cardiovascular disease in indigenous Australians is often attributed to the high prevalence of risk factors, especially type II diabetes mellitus (DM). We evaluated the relationship of ethnicity to atherosclerotic burden, as evidenced by carotid intima-media thickness (IMT), independent of risk factor status. Methods We studied 227 subjects (147 men; 50 ± 13 y): 119 indigenous subjects with (IDM, n = 54), and without DM (InDM, n = 65), 108 Caucasian subjects with (CDM, n = 52), and without DM (CnDM, n = 56). IMT was measured according to standard methods and compared with clinical data and cardiovascular risk factors. Results In subjects both with and without DM, IMT was significantly greater in indigenous subjects. There were no significant differences in gender, body mass index (BMI), systolic blood pressure (SBP), or diastolic blood pressure (DBP) between any of the groups, and subjects with DM showed no difference in plasma HbA1c. Cardiovascular risk factors were significantly more prevalent in indigenous subjects. Nonetheless, ethnicity (β = -0.34; p < 0.0001), age (β = 0.48; p < 0.0001), and smoking (β = 0.13; p < 0.007) were independent predictors of IMT in multiple linear regression models. Conclusion Ethnicity appears to be an independent correlate of preclinical cardiovascular disease, even after correction for the high prevalence of cardiovascular risk factors in indigenous Australians. Standard approaches to control currently known risk factors are vital to reduce the burden of cardiovascular disease, but in themselves may be insufficient to fully address the high prevalence in this population.
Collapse
Affiliation(s)
- Brian A Haluska
- School of Medicine, University of Queensland, Brisbane, Australia.
| | | | | | | | | | | |
Collapse
|
14
|
Kim NH, Pavkov ME, Looker HC, Nelson RG, Bennett PH, Hanson RL, Curtis JM, Sievers ML, Knowler WC. Plasma glucose regulation and mortality in pima Indians. Diabetes Care 2008; 31:488-92. [PMID: 18071000 DOI: 10.2337/dc07-1850] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate whether impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT) are associated with increased risk of mortality and prevalent ischemic heart disease (IHD) and to analyze if the increased risk of death is dependent on subsequent development of diabetes in Pima Indians. RESEARCH DESIGN AND METHODS A total of 2,993 Pima Indians aged >or=35 years were included. Prevalent IHD, defined by major ischemic electrocardiogram changes, was evaluated according to the following glucose/diabetes categories: normal glucose regulation (NGR), IFG and/or IGT, and diabetic groups by duration. During a median follow-up of 10.4 years, 780 subjects died from natural causes and 156 of these died from IHD. Mortality was analyzed according to the same glucose/diabetes categories at baseline and then as time-dependent variables. RESULTS Only subjects with diabetes >or=15 years of duration have a higher prevalence of IHD (odds ratio 1.9 [95% CI 1.4-2.5]) relative to NGR. In baseline and time-dependent models, age- and sex-adjusted death rates from natural causes and from IHD were similar among the nondiabetic groups. Among diabetic subjects, natural mortality was higher in those with >or=15 years diabetes duration (death rate ratio [DRR] relative to NGR = 2.6 [95% CI 2.1-3.3]). IHD mortality was higher in subjects with long diabetes duration (DRR for diabetes 10-15 years = 3.8 [1.5-9.5]; DRR for diabetes >or=15 years = 8.6 [3.8-19.4]) in the time-dependent model. CONCLUSIONS Natural and IHD mortality are not increased in Pima Indians with IFG and/or IGT. Only after the onset of diabetes do the rates of these events increase relative to NGR.
Collapse
Affiliation(s)
- Nan Hee Kim
- Diabetes Epidemiology and Clinical Research Section, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, Arizona 85014-4972, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
15
|
de Santiago A, García-Lledó A, Ramos E, Catalina Santiago. Valor pronóstico del electrocardiograma en pacientes con diabetes tipo 2 sin enfermedad cardiovascular conocida. Rev Esp Cardiol 2007; 60:1035-41. [DOI: 10.1157/13111235] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
16
|
Association Between Sonographic Fatty Liver and Ischemic Electrocardiogram Among Non-obese Taiwanese Male Adults. J Med Ultrasound 2006. [DOI: 10.1016/s0929-6441(09)60092-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|