Adverse association between diabetic retinopathy and cardiac structure and function

Association between Severity of Diabetic Retinopathy and Cardiac Function in Patients with Type 2 Diabetes

Background

The purpose of this research was to assess the relationship between the severity of diabetic retinopathy (DR) and indexes of left ventricle (LV) structure and function in type 2 diabetes mellitus (T2DM).

Methods

Retrospective analysis of 790 patients with T2DM and preserved LV ejection fraction. Retinopathy stages were classified as no DR, early nonproliferative DR, moderate to severe nonproliferative DR, or proliferative DR. The electrocardiogram was used to assess myocardial conduction function. Echocardiography was used to evaluate myocardial structure and function.

Results

Patients were divided into three groups based on the DR status: no DR group (NDR, n = 475), nonproliferative DR group (NPDR, n = 247), and proliferative DR group (PDR, n = 68). LV interventricular septal thickness (IVST) increased significantly with more severe retinopathy (NDR: 10.00 ± 1.09; NPDR: 10.42 ± 1.21; and PDR: 10.66 ± 1.58; P < 0.001). Multivariate logistic regression analysis showed that the significant correlation of IVST persisted between subjects with no retinopathy and proliferative DR (odds ratio = 1.35, P = 0.026). Indices of myocardial conduction function were assessed by electrocardiogram differences among groups of retinopathy (all P < 0.001). In multiple-adjusted linear regression analyses, the increasing degree of retinopathy was closely correlated with heart rate (β = 1.593, P = 0.027), PR interval (β = 4.666, P = 0.001), and QTc interval (β = 8.807, P = 0.005).

Conclusion

The proliferative DR was independently associated with worse cardiac structure and function by echocardiography. Furthermore, the severity of retinopathy significantly correlated with abnormalities of the electrocardiogram in patients with T2DM.

Left ventricular systolic dysfunction predicts long-term major microvascular complication outcomes in type 1 diabetes. The Pittsburgh Epidemiology of Diabetes Complications (EDC) study of childhood onset diabetes

OBJECTIVES

We aimed to assess association between abnormal LVEF, in the absence of coronary artery disease (CAD), and 25-year incidence of major outcomes of diabetes (MOD) in a cardiology substudy of the Pittsburgh Epidemiology of Diabetes Complications cohort of childhood-onset type 1 diabetes.

METHODS

115 normotensive type 1 diabetes individuals without known CAD, underwent a baseline exercise radionuclide ventriculography. Abnormal LVEF was defined as a resting ejection fraction <50% or a failure to increase ejection fraction with exercise by >5% (men) or a fall in ejection fraction with exercise (women). Cox proportional hazards models were used to predict the composite endpoint of MOD (first instance of major CAD, stroke, end-stage renal disease, blindness, amputation or diabetes-related death).

RESULTS

Mean baseline age was 28 and diabetes duration 19 years. In a mean follow-up of 19 years, 50 MOD events were identified. Allowing for established risk factors at baseline, abnormal LVEF (n = 22) independently predicted MOD incidence (HR = 2.12, 95% CI: 1.12-4.00, p = 0.022) but not major CAD (HR = 1.33, 95% CI: 0.53-3.33, p = 0.539).

CONCLUSIONS

An abnormal LVEF may identify diabetic cardiomyopathy and predict long term risk of MOD (but not CAD alone) in type 1 diabetes individuals, consistent with it reflecting microvascular disease.

Evaluation of the association between diabetic retinopathy and the incidence of atrial fibrillation: A nationwide population-based study

BACKGROUND

Atrial fibrillation (AF) is prevalent among type 2 diabetic patients. However, the association between diabetic retinopathy (DR) and AF is controversial.

METHODS

We included 40,500 patients with type 2 diabetes (≥40years, mean age 62±11years, 53% men) without AF from the Korean National Insurance Service-National Sample Cohort (2002-2007). Subjects were classified without DR (non-DR, n=30,178), with DR (DR, n=8920), and with proliferative DR (PDR, n=1402).

RESULTS

During a mean 5.9-year follow-up, 1261 (3.1%) patients were newly diagnosed as having AF (4.9, 6.0, and 8.3 per 1000 person-years in the non-DR, DR, and PDR groups, respectively). In multivariate Cox proportional hazard models, patients in the DR and PDR groups had a significantly higher risk of AF than those in the non-DR group (DR group: hazard ratio [HR] 1.14, 95% confidence interval [CI] 1.00-1.30; PDR group: HR 1.46, 95% CI 1.13-1.87); p for trend <0.001). The risk of AF increased in patients with DR and end-stage renal disease (ESRD) (HR 2.39, 95% CI 1.31-3.96, p<0.001) and in those with PDR and ESRD (HR 3.59, 95% CI 1.96-5.97, p<0.001) compared to those without DR and ESRD.

CONCLUSIONS

The presence and severity of DR was significantly associated with the incidence of AF. Also, the presence of ESRD had an impact on the incidence of AF in patients with DR.

Beyond type 2 diabetes, obesity and hypertension: an axis including sleep apnea, left ventricular hypertrophy, endothelial dysfunction, and aortic stiffness among Mexican Americans in Starr County, Texas

BACKGROUND

There is an increasing appreciation for a series of less traditional risk factors that should not be ignored when considering type 2 diabetes, obesity, hypertension, and cardiovascular disease. These include aortic stiffness, cardiac structure, impaired endothelial function and obstructive sleep apnea. They are associated to varying degrees with each disease categorization and with each other. It is not clear whether they represent additional complications, concomitants or antecedents of disease. Starr County, Texas, with its predominantly Mexican American population has been shown previously to bear a disproportionate burden of the major disease categories, but little is known about the distribution of these less traditional factors.

METHODS

Type 2 diabetes, obesity and hypertension frequencies were determined through a systematic survey of Starr County conducted from 2002 to 2006. Individuals from this examination and an enriched set with type 2 diabetes were re-examined from 2010 to 2014 including assessment of cardiac structure, sleep apnea, endothelial function and aortic stiffness. Individual and combined frequencies of these inter-related (i.e., axis) conditions were estimated and associations evaluated.

RESULTS

Household screening of 5230 individuals aged 20 years and above followed by direct physical assessment of 1610 identified 23.7 % of men and 26.7 % of women with type 2 diabetes, 46.2 and 49.5 % of men and women, respectively with obesity and 32.1 and 32.4 % with hypertension. Evaluation of pulse wave velocity, left ventricular mass, endothelial function and sleep apnea identified 22.3, 12.7, 48.6 and 45.2 % of men as having "at risk" values for each condition, respectively. Corresponding numbers in women were 16.0, 17.9, 23.6 and 28.8 %. Cumulatively, 88 % of the population has one or more of these while 50 % have three or more.

CONCLUSIONS

The full axis of conditions is high among Mexican Americans in Starr County, Texas. Individual and joint patterns suggest a genesis well before overt disease. Whether they are all mediated by common underlying factors or whether there exist multiple mechanisms remains to be seen.

Altered myocardial response in patients with diabetic retinopathy: an exercise echocardiography study

Background

Type 2 diabetes mellitus (T2DM) complicated by retinopathy is associated with altered left ventricular (LV) structure and resting myocardial dysfunction unlike T2DM without retinopathy. The myocardial response to stress has not been compared in patients with and without diabetic retinopathy. The aim of this retrospective study was to determine the relationship between retinopathy and myocardial function in patients with T2DM at rest and during exercise echocardiography.

Methods

134 patients with T2DM and no evidence of underlying coronary artery disease were recruited. All patients underwent retinal photography to screen for diabetic retinopathy, and resting and exercise echocardiography. Resting echocardiography was analyzed by conventional echocardiographic parameters and speckle tracking derived global longitudinal strain (GLS). Exercise echocardiography parameters included diastolic function reserve index (DFRI) and stress GLS.

Results

The mean age of participants was 60 years and 49 % were male. Diabetic retinopathy was identified in 43 patients (32 %). Resting echocardiography revealed that those with diabetic retinopathy had a higher prevalence of impaired diastolic function, higher E/E′ ratio (LV filling pressures) and impaired resting GLS compared with those without. Exercise echocardiography revealed that those with diabetic retinopathy also had more impaired DFRI and stress GLS. Multivariable analysis showed that the presence of diabetic retinopathy was independently associated with high resting E/E′, diastolic dysfunction grade, impaired resting GLS, low DFRI and impaired stress GLS.

Conclusions

In conclusion, the presence of diabetic retinopathy was independently associated with impaired resting myocardial function (diastolic and systolic function) and myocardial function during stress (evaluated by DFRI and stress GLS).

Electronic supplementary material

The online version of this article (doi:10.1186/s12933-015-0281-5) contains supplementary material, which is available to authorized users.

Relationship between increased left atrial volume and microvascular complications in patients with type 2 diabetes

AIMS

We assessed whether left atrial volume index (LAVI) was associated with the presence of microvascular complications in patients with type 2 diabetes, and whether this association was independent of hemodynamic and non-hemodynamic factors.

METHODS

We studied 157 consecutive outpatients with type 2 diabetes with no previous history of ischemic heart disease, chronic heart failure and valvular diseases. A transthoracic echocardiography and myocardial perfusion scintigraphy were performed in all participants. Presence of microvascular complications was also recorded.

RESULTS

Overall, 51 patients had decreased estimated glomerular filtration rate and/or abnormal albuminuria, 24 had diabetic retinopathy, 22 had lower-extremity sensory neuropathy, and 67 (42.7%) patients had one or more of these microvascular complications (i.e., combined endpoint). After stratifying patients by LAVI, those with LAVI ≥32 ml/m(2) had a greater prevalence of microvascular complication, lower left ventricular (LV) ejection fraction, higher LV mass index and higher E/e' ratio than those with LAVI <32 ml/m(2). Logistic regression analyses revealed that microvascular complications (singly or in combination) were associated with increased LAVI, independently of age, sex, diabetes duration, hemoglobin A1c, hypertension, LV-ejection fraction, LV mass index and the E/e' ratio.

CONCLUSIONS

These results indicate that microvascular diabetic complications are associated with increased LAVI in well-controlled type 2 diabetic patients with preserved systolic function and free from ischemic heart disease, independently of multiple potential confounders.

Low-grade inflammation and endothelial dysfunction explain the association between retinopathy and left ventricular ejection fraction in men: an 8-year follow-up of the Hoorn Study

PURPOSE

The aim of this study was to prospectively investigate the association of retinopathy with changes in left ventricular (LV) function.

METHODS

Within the Hoorn Study, a population-based cohort study of diabetes in The Netherlands, retinal photography and echocardiography were performed in the year 2000 (baseline) and 2008 (follow-up). Retinopathy was graded according to the Eurodiab classification and further defined as absent or present retinopathy. LV systolic and diastolic functions were assessed by LV ejection fraction (%), LV mass (g/m(2.7)) and left atrial (LA) volume indices and the ratio of LV inflow (E) and early diastolic lengthening (e') velocities. Linear regression analyses stratified for sex were completed to investigate associations of retinopathy with changes in LV function in participants with impaired glucose metabolism and type 2 diabetes.

RESULTS

One hundred forty-seven participants (58% men, mean age 66) were included in the study, of whom 13.6% were present with retinopathy at baseline. LV ejection fraction was similar among participants with and without retinopathy (60.2% versus 60.7%) at baseline. Eight years later, retinopathy was significantly associated with a lower LV ejection fraction (β -8.0 95% CI -15.37 to -0.68) in men, independent of risk factors. Microvascular endothelial dysfunction ([ED] β -4.87 95% CI -13.40 to 3.67) and low-grade inflammation ([LGI] β -5.30 95% CI -13.72 to 3.12) both diminished the association. No significant associations between retinopathy and other LV function parameters were observed.

CONCLUSION

Retinopathy was significantly associated with a lower LV ejection fraction in men but not in women. LGI and ED might explain the observed association.

Retinopathy and clinical outcomes in patients with type 2 diabetes mellitus, chronic kidney disease, and anemia

OBJECTIVE

Retinopathy is an established microvascular complication of type 2 diabetes mellitus (T2DM), but its independent relationship with macrovascular and other microvascular complications is less well defined across the spectrum of kidney disease in T2DM. We examined the prognostic value of retinopathy in assessing the risk of developing end-stage renal disease (ESRD), cardiovascular morbidity or death among patients in the Trial to Reduce cardiovascular Events with Aranesp Therapy (TREAT).

DESIGN

TREAT enrolled 4038 patients with T2DM, chronic kidney disease (CKD) and moderate anemia. Patients were grouped by baseline history of retinopathy. Proportional hazards regression models were utilized to assess the association between retinopathy and subsequent ESRD, cardiovascular morbidity or death over an average of 2.4 years.

RESULTS

Although younger, the 1895 (47%) patients with retinopathy had longer duration of diabetes, lower estimated glomerular filtration rate, more proteinuria, and more microvascular complications. In univariate analysis, retinopathy was associated with a higher rate of ESRD, but not with cardiovascular events or mortality. After adjustment, retinopathy was no longer statistically significant for the prediction of ESRD or any clinical endpoint.

CONCLUSIONS

In a large cohort of patients with T2DM, CKD, and anemia, retinopathy was common but not independently associated with a higher risk of renal or cardiovascular morbidity or death.

TRIAL REGISTRATION NUMBER

NCT00093015.

Normal limits in relation to age, body size and gender of two-dimensional echocardiographic aortic root dimensions in persons ≥15 years of age

Nomograms to predict normal aortic root diameter for body surface area (BSA) in broad ranges of age have been widely used but are limited by lack of consideration of gender effects, jumps in upper limits of aortic diameter among age strata, and data from older teenagers. Sinus of Valsalva diameter was measured by American Society of Echocardiography convention in normal-weight, nonhypertensive, nondiabetic subjects ≥15 years old without aortic valve disease from clinical or population-based samples. Analyses of covariance and linear regression with assessment of residuals identified determinants and developed predictive models for normal aortic root diameter. In 1,207 apparently normal subjects ≥15 years old (54% women), aortic root diameter was 2.1 to 4.3 cm. Aortic root diameter was strongly related to BSA and height (r = 0.48 for the 2 comparisons), age (r = 0.36), and male gender (+2.7 mm adjusted for BSA and age, p <0.001 for all comparisons). Multivariable equations using age, gender, and BSA or height predicted aortic diameter strongly (R = 0.674 for the 2 comparisons, p <0.001) with minimal relation of residuals to age or body size: for BSA 2.423 + (age [years] × 0.009) + (BSA [square meters] × 0.461) - (gender [1 = man, 2 = woman] × 0.267), SEE 0.261 cm; for height 1.519 + (age [years] × 0.010) + (height [centimeters] × 0.010) - (gender [1 = man, 2 = woman] × 0.247), SEE 0.215 cm. In conclusion, aortic root diameter is larger in men and increases with body size and age. Regression models incorporating body size, age, and gender are applicable to adolescents and adults without limitations of previous nomograms.

Prevalence and risk factors of diabetic retinopathy in subjects with suboptimal glycemic, blood pressure and lipid control. Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetic Study (SN-DREAMS, Report 33)

PURPOSE

To assess the rate of achieving optimal metabolic control among subjects with type 2 diabetes, to elucidate the influence of suboptimal control on diabetic retinopathy (DR) and to analyze the risk factors associated with DR in the subjects with suboptimal control.

MATERIAL AND METHODS

A population-based, cross-sectional study was conducted in south India. The study population consisted of 1414 subjects with type 2 diabetes. Optimal control of glycosylated hemoglobin (HbA1c), blood pressure (BP) and lipids was defined as: optimal HbA1c <7%, suboptimal HbA1c ≥ 7%; optimal BP ≤ 130/80 mm Hg, suboptimal BP >130/80 mm Hg; optimal low-density lipoprotein (LDL-C) <100 mg/dl, suboptimal LDL ≥ 100 mg/dl.

RESULTS

Of the subjects, 13.6% achieved combined optimal target levels for all metabolic parameters. When compared to subjects with optimal control, those with suboptimal control of HbA1c (trend P < 0.0001) and systolic blood pressure (SBP, trend P = 0.007) were more likely to have DR. Subjects having a combination of suboptimal glycemic and BP control (P < 0.0001 for SBP, P = 0.004 for diastolic blood pressure (DBP)), and suboptimal glycemic, BP and LDL control (P < 0.0001 for SBP, P = 0.017 for DBP), were more likely to have DR when compared to the subjects having optimal control of respective combinations. The factors associated with DR in the subjects with suboptimal control were younger age (P = 0.014 for BP, P = 0.016 for HbA1c), male gender (P = 0.035 for BP, P = 0.027 for HbA1c, P = 0.043 for LDL), presence of anemia (P = 0.021 for BP, P = 0.036 for HbA1c) and microalbuminuria (P < 0.0001 for both BP and HbA1c).

CONCLUSIONS

We found high prevalence of suboptimal metabolic control among subjects with type 2 diabetes. Suboptimal glycemic and SBP control, and their combination was the most detrimental for the development of DR.

Prevalence and risk factors for diabetic retinopathy: an Iranian eye study

PURPOSE

The aim of this study was to determine the prevalence of diabetic retinopathy among diabetic patients in Iran and its association with some predisposing factors.

METHODS

All diabetic patients who attended the diabetes clinic underwent ocular examination, including slit-lamp biomicroscopy. The blood pressure and blood biochemical parameters were then measured.

RESULTS

The prevalence of diabetic retinopathy among 1022 diabetic participants was 23.6% (241 cases). This study showed that there is a statistically significant relation between diabetic retinopathy and mean blood pressure, fasting blood sugar, blood urea nitrogen, and level of HbA1c. There was no difference in lipid profile between patients with and without retinopathy. The duration of diabetes was a predicting factor for retinopathy as well as presence of renal and cardiovascular diseases and fasting glucose >126 as independent variables.

CONCLUSIONS

The duration of diabetes was the most important risk factor for progression of retinopathy.

Association between Diabetic Retinopathy and Left Ventricular Dysfunction in Diabetic Patients with Unstable Angina

INTRODUCTION

Diabetes mellitus (DM) is associated with serious complications including macro- and microvascular problems such as diabetic retinopathy. Coronary involvement in diabetic patients is believed to be a consequence of microvascular complications. However, the available data are inconclusive and scarce. This study aimed to evaluate the probable association between diabetic retinopathy and left ventricular dysfunction in diabetic patients with unstable angina (UA).

METHODS

In this cross-sectional study, 200 diabetic patients with UA (100 cases with diabetic retinopathy and 100 cases without diabetic retinopathy) were enrolled in a teaching hospital. Left ventricular ejection fraction (LVEF) as well as the frequency of cases with left ventricular dysfunction (LVEF<50%) were compared between the two groups and different degrees of diabetic retinopathy (proliferative and non-proliferative).

RESULTS

Patients' demographic variables were comparable between the two groups. Mean diagnosis time of DM was significantly higher in the patients with diabetic retinopathy (8.40±6.60 vs. 3.81±3.58 years; P<0.001). Mean LVEF was significantly lower in the retinopathy group (50.50±6.91% vs. 53.07±4.87%; P=0.003). Frequency of cases with left ventricular dysfunction was significantly higher in the group with diabetic retinopathy (31% vs. 12%; P=0.001, OR=3.33, 95%CI: 1.58-7.14). The frequency of cases with left ventricular dysfunction was significantly yet independently higher in patients with proliferative vs. non-proliferative diabetic retinopathy.

CONCLUSION

Left ventricular dysfunction is more common in diabetic patients with unstable angina and diabetic retinopathy compared with their counterparts without diabetic retinopathy.

[Diabetic maculopathy and retinopathy. Functional and sociomedical significance]

OBJECTIVE

The incidence of diabetic microvascular complications is expected to increase by 20-50% in the coming years. Diabetic macular edema (DME) is already a leading cause of blindness in the working-age population in developed countries, and its impact is expected to increase dramatically.

METHODS

Recent literature on the epidemiology and impact of diabetic microangiopathy (maculopathy) on visual function was reviewed to provide a comprehensive overview of the functional and socioeconomic consequences of diabetic retinal microangiopathy and new therapeutic strategies.

RESULTS

The first changes indicating diabetic microangiopathy are detectable shortly after the development of hyperglycemia, and in the long term they induce severe organ damage. More resources are used for this condition's treatment than for the treatment of hyperglycemia, corresponding to an enormous sociomedical burden of disease. Early detection of increased retinal vascular permeability may help control treatment effects. The control of recognized risk factors for the development and progression of DME, namely hyperglycemia and hyperlipidemia, as well as of hypertension has remained the cornerstone of therapy and serves as the basis for preserving visual function.

CONCLUSIONS

Modern treatment options, begun early, may result in a remarkably delayed occurrence of irreversible diabetic microvascular pathologies, particularly diabetic retinopathy and maculopathy. Ophthalmological screening nowadays aims at earlier recognition of at-risk individuals to optimize the therapeutic strategy--that is, before visual impairment is imminent. Close interdisciplinary medical cooperation and implementation of new therapeutic options may provide the foundation for success in terms of maintaining visual function.

Estimating cardiovascular risk in patients with type 2 diabetes: a national multicenter study in Brazil

According to Brazilian National Data Survey diabetes is the fifth cause for hospitalization and is one of the ten major causes of mortality in this country.

AIMS

to stratify the estimated cardiovascular risk (eCVR) in a population of type 2 diabetics (T2DM) according to the Framingham prediction equations as well as to determine the association between eCVR with metabolic and clinical control of the disease.

METHODS

From 2000 to 2001 a cross-sectional multicenter study was conducted in 13 public out-patients diabetes/endocrinology clinics from 8 Brazilian cities. The 10-year risk of developing coronary heart disease (CHD) was estimated by the prediction equations described by Wilson et al (Circulation 1998). LDL equations were preferably used; when patients missed LDL data we used total cholesterol equations instead.

RESULTS

Data from 1382 patients (59.0% female) were analyzed. Median and inter-quartile range (IQ) of age and duration of diabetes were 57.4 (51-65) and 8.8 (3-13) years, respectively without differences according to the gender. Forty-two percent of these patients were overweight and 35.4% were obese (the prevalence of higher BMI and obesity in this T2DM group was significantly higher in women than in men; p < 0.001). The overall estimated eCVR in T2DM patients was 21.4 (13.5-31.3). The eCVR was high (> 20%) in 738 (53.4%), intermediate in 202 (14.6%) and low in 442 (32%) patients. Men [25.1(15.4-37.3)] showed a higher eCVR than women [18.8 (12.4-27.9) p < 0.001]. The most common risk factor was high LDL-cholesterol (80.8%), most frequently found in women than in men (p = 0.01). The median of risk factors present was three (2-4) without gender differences. Overall we observed that 60 (4.3%) of our patients had none, 154(11.1%) one, 310 (22.4%) two, 385 (27.9%) three, 300 (21.7%) four, 149 (10.5%) five and six, (2%) six risk factors. A higher eCVR was noted in overweight or obese patients (p = 0.01 for both groups). No association was found between eCVR with age or a specific type of diabetes treatment. A correlation was found between eCVR and duration of diabetes (p < 0.001), BMI (p < 0.001), creatinine (p < 0.001) and triglycerides levels (p < 0.001) but it was not found with HbA1c, fasting blood glucose and post-prandial glucose. A higher eCVR was observed in patients with retinopathy (p < 0.001) and a tendency in patients with microalbuminuria (p = 0.06).

CONCLUSION

our study showed that in this group of Brazilian T2DM the eCVR was correlated with the lipid profile and it was higher in patients with microvascular chronic complications. No correlation was found with glycemic control parameters. These data could explain the failure of intensive glycemic control programs aiming to reduce cardiovascular events observed in some studies.