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Castelblanco E, Granado-Casas M, Hernández M, Pinyol M, Correig E, Julve J, Rojo-López MI, Alonso N, Avogaro A, Ortega E, Mauricio D. Diabetic retinopathy predicts cardiovascular disease independently of subclinical atherosclerosis in individuals with type 2 diabetes: A prospective cohort study. Front Cardiovasc Med 2022; 9:945421. [PMID: 36407461 PMCID: PMC9668891 DOI: 10.3389/fcvm.2022.945421] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 10/19/2022] [Indexed: 01/29/2024] Open
Abstract
BACKGROUND Diabetic retinopathy (DR) and preclinical atherosclerosis are associated with higher cardiovascular risk. However, no studies have investigated the predictive role of DR and preclinical atherosclerosis jointly on cardiovascular events in subjects with type 2 diabetes (T2D). We aimed to assess the contribution of DR and subclinical atherosclerosis on the risk of adverse cardiovascular events in subjects with T2D without previous cardiovascular disease (CVD). METHODS We included two prospective cohorts of subjects with T2D from the same geographical area. Assessment of subclinical atherosclerosis was performed by carotid ultrasound. An ophthalmologist classified DR according to standard criteria. Cardiovascular outcomes considered for analysis were the following: ischemic heart disease, stroke, heart failure, peripheral artery disease, revascularization procedures, and cardiovascular mortality. Bivariable and multivariable predictive models were performed. RESULTS From a total of 374 subjects with T2D 44 developed cardiovascular events during the 7.1 years of follow-up. Diabetes duration, total cholesterol, and glycated hemoglobin (HbA1c) at baseline were higher in subjects who developed cardiovascular outcomes (p < 0.001, p = 0.026, and p = 0.040, respectively). Compared with subjects without events, those developing cardiovascular events had higher prevalence of retinopathy (65.9% vs. 38.8%, p = 0.001; respectively) and more than mild retinopathy (43.2% vs. 31.8%, p = 0.002; respectively). Furthermore, all-cause mortality was higher in subjects with MACE than those without events (13.6% vs. 3.3%, p = 0.009; respectively). The multivariable analyses showed that HbA1c and the presence of DR at baseline were predictive of cardiovascular outcomes (p = 0.045 and p = 0.023, respectively). However, the burden of subclinical atherosclerosis was not (p = 0.783 and p = 0.071, respectively). CONCLUSION DR is a strong predictor of cardiovascular events in T2D individuals at primary CVD prevention, even after accounting for the presence of preclinical carotid atherosclerosis. These results may help to individualize CVD prevention strategies in T2D.
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Affiliation(s)
- Esmeralda Castelblanco
- Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
- DAP-Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut Jordi Gol i Gurina, Barcelona, Spain
| | - Minerva Granado-Casas
- Center for Biomedical Research on Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III, Barcelona, Spain
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu i Sant Pau and Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
| | - Marta Hernández
- Lleida Institute for Biomedical Research Dr. Pifarré Foundation IRBLleida, University of Lleida, Lleida, Spain
- Department of Endocrinology and Nutrition, University Hospital Arnau de Vilanova, Lleida, Spain
| | - Montserrat Pinyol
- Consorcio de Atención Primaria del Eixample (CAPSE), Grup Transversal de Recerca en Atenció Primària, Institut d’Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Eudald Correig
- Department of Biostatistics, Universitat Rovira i Virgili, Reus, Spain
| | - Josep Julve
- Center for Biomedical Research on Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III, Barcelona, Spain
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu i Sant Pau and Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
| | - Marina Idalia Rojo-López
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu i Sant Pau and Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
| | - Núria Alonso
- Center for Biomedical Research on Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III, Barcelona, Spain
- Department of Endocrinology and Nutrition, Germans Trias i Pujol Hospital and Research Institute, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Angelo Avogaro
- Department of Medicine, Università di Padova, Padua, Italy
| | - Emilio Ortega
- Diabetes Unit, Department of Endocrinology and Nutrition, Hospital Clínic de Barcelona, Barcelona, Spain
- Center for Biomedical Research on Pathophysiology of Obesity and Nutrition (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Didac Mauricio
- Center for Biomedical Research on Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III, Barcelona, Spain
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu i Sant Pau and Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
- Faculty of Medicine, University of Vic (UVic-UCC), Barcelona, Spain
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Eid M, Mounir A, El Etriby S, Al Taher A, Ezzat MAW. Diabetic Retinopathy as a Predictor of Angiographic Coronary Atherosclerosis Severity in Patients with Type 2 Diabetes Mellitus. Diabetes Metab Syndr Obes 2022; 15:1485-1494. [PMID: 35591908 PMCID: PMC9113458 DOI: 10.2147/dmso.s363406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 04/30/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Diabetic retinopathy (DR) is one of the most prevalent consequences of diabetes mellitus (DM). Much emphasis has been focused on the link between DR and cardiovascular disorders in patients with type 2 diabetes (T2DM). However, there is little information about the relation between the degree of DR and coronary atherosclerosis severity in Egyptian patients. AIM To assess the correlation between the degree of DR and the coronary atherosclerosis severity in T2DM. PATIENTS AND METHODS This work included 140 diabetic patients with T2DM who underwent diagnostic coronary angiography because of suspected coronary artery disease (CAD). All participants were evaluated by history, fundus assessment, laboratory tests (lipid profile and glycated hemoglobin [HbA1c]), and selective coronary angiography. The severity of coronary artery lesion was detected by Gensini score and vessel score. RESULTS Patients with DR had a significantly higher Gensini score (67.86± 44.56 versus 5.93± 9.02, P < 0.001) and a vessel score (2.29± 0.86 versus 0.50± 0.66, P < 0.001). There was a significant relation between the degree of DR, Gensini score (P < 0.001), and vessel score (P < 0.001), as both scores increased according to the severity of DR. The presence and degree of retinopathy were the only independent factors linked to the severity score in multivariate linear regression analyses (P < 0.001). CONCLUSION The presence and degree of DR are independent predictors of severe coronary atherosclerosis. Therefore, when evaluating whether a patient with T2DM is at high risk for CAD, the DR degree should be taken into consideration.
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Affiliation(s)
- Mohamed Eid
- Department of Internal Medicine, Sohag University Hospital, Sohag University, Sohag, Egypt
| | - Amr Mounir
- Department of Ophthalmology, Sohag Faculty of Medicine, Sohag University, Sohag, Egypt
- Correspondence: Amr Mounir, Email
| | - Shehab El Etriby
- Department of Cardiology, Ain Shams Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ali Al Taher
- Department of Internal Medicine, Sohag University Hospital, Sohag University, Sohag, Egypt
| | - Mohamed A W Ezzat
- Department of Internal Medicine, Sohag University Hospital, Sohag University, Sohag, Egypt
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Gan J, Zheng Y, Yu Q, Zhang Y, Xie W, Shi Y, Yu N, Yan Y, Lin Z, Yang H. Serum Lipocalin-2 Levels Are Increased and Independently Associated With Early-Stage Renal Damage and Carotid Atherosclerotic Plaque in Patients With T2DM. Front Endocrinol (Lausanne) 2022; 13:855616. [PMID: 35547005 PMCID: PMC9081837 DOI: 10.3389/fendo.2022.855616] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 03/15/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Diabetic nephropathy (DN), one of the major complications of diabetes mellitus, is the major cause of end-stage renal failure that finally increases the risk of cardiovascular disease and mortality. The aim of this study is to explore the relationship between serum lipocalin-2 (LCN-2) levels and DN and carotid atherosclerotic plaque (CAP) in patients with type 2 diabetes mellitus (T2DM). METHODS We have performed a prospective study of 749 T2DM patients with or without DN. Blood samples were collected and used to test serum LCN-2 levels, renal function, as well as biochemical parameters. CAP in these subjects was determined by ultrasonography. RESULTS In these 749 subjects with T2DM, an increased morbidity of CAP was observed in T2DM patients with DN as compared with those without this complication (P < 0.05). Interestingly, serum LCN-2 levels were significantly increased in T2DM patients with DN or CAP compared with T2DM alone [97.71 (71.49-130.13) vs. 77.29 (58.83-115.05) ng/ml, P < 0.001]. In addition, serum LCN-2 levels in T2DM patients with DN and CAP were significantly higher than that of T2DM patients with DN or CAP [131.37 (101.43-182.04) vs. 97.71(71.49-130.13) ng/ml, P < 0.001]. Furthermore, serum LCN-2 levels were positively correlated with hemoglobin A1c, systolic blood pressure, hypertension, CAP, and DN, as well as renal function factors including uric acid, creatinine, the estimated glomerular filtration rate, and urinary albumin-to-creatinine ratio, respectively (P < 0.05), but negatively correlated with HDL-c (P < 0.05). The multinomial logistic regression analysis showed that serum LCN-2 was independently associated with DN and CAP in patients with T2DM after the adjustment for risk factors (P < 0.001). CONCLUSIONS Early-stage renal damage is a risk factor associated with the incidence of CAP in patients with T2DM. Serum LCN-2 is significantly increased and associated with early-stage renal damage and the incidence of CAP in patients with T2DM.
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Affiliation(s)
- Jing Gan
- The 2nd Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yu Zheng
- The 2nd Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Qiongli Yu
- School of Pharmaceutical College, Wenzhou Medical University, Wenzhou, China
| | - Yingchao Zhang
- School of Pharmaceutical College, Wenzhou Medical University, Wenzhou, China
| | - Wei Xie
- School of Pharmaceutical College, Wenzhou Medical University, Wenzhou, China
| | - Yaru Shi
- School of Pharmaceutical College, Wenzhou Medical University, Wenzhou, China
| | - Ning Yu
- School of Pharmaceutical College, Wenzhou Medical University, Wenzhou, China
| | - Yu Yan
- The 2nd Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhuofeng Lin
- School of Pharmaceutical College, Wenzhou Medical University, Wenzhou, China
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Laboratory Animal Center of Wenzhou Medical University, Wenzhou, China
- *Correspondence: Zhuofeng Lin, ; Hong Yang,
| | - Hong Yang
- The 3rd Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- *Correspondence: Zhuofeng Lin, ; Hong Yang,
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Lee JH, Kim YA, Lee Y, Bang WD, Seo JH. Association between interarm blood pressure differences and diabetic retinopathy in patients with type 2 diabetes. Diab Vasc Dis Res 2020; 17:1479164120945910. [PMID: 32746630 PMCID: PMC7510376 DOI: 10.1177/1479164120945910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The effect of interarm blood pressure difference on the development of diabetic retinopathy, proteinuria and chronic kidney disease remains unknown. We investigated to determine the impact of interarm blood pressure difference on the prevalence of diabetic retinopathy, proteinuria and chronic kidney disease in patients with type 2 diabetes. METHODS The study included 563 patients with diabetes, who were evaluated with a simultaneous bilateral blood pressure measurement. The cutoff values for interarm blood pressure difference were 5, 10 and 15 mmHg. Logistic regression analysis was used to explore the relation between interarm blood pressure difference and diabetic retinopathy, proteinuria and chronic kidney disease. RESULTS Diabetic patients with systolic interarm blood pressure difference ⩾5, ⩾10 and ⩾15 mmHg showed an increased risk of diabetic retinopathy [adjusted odds ratio = 1.48 (95% confidence interval = 1.01-2.18), odds ratio = 1.80 (95% confidence interval = 0.99-3.22), odds ratio = 2.29 (95% confidence interval = 1.00-5.23)] after adjustment. There were significant associations between interarm blood pressure difference ⩾5 and ⩾10 mmHg and proteinuria [odds ratio = 1.68 (95% confidence interval = 1.15-2.44), 1.89 (95% confidence interval = 1.05-3.37)]. CONCLUSION The association between interarm blood pressure difference and the presence of diabetic retinopathy emerged even for systolic interarm blood pressure difference ⩾5 mmHg without interaction of systolic blood pressure. Systolic interarm blood pressure difference should be considered a surrogate marker for vascular complication in patients with type 2 diabetes.
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Affiliation(s)
- Ji Hyun Lee
- Division of Endocrinology, Department of
Internal Medicine, Veterans Health Service Medical Center, Seoul, Republic of
Korea
| | - Ye An Kim
- Division of Endocrinology, Department of
Internal Medicine, Veterans Health Service Medical Center, Seoul, Republic of
Korea
| | - Young Lee
- Veterans Medical Research Institute,
Veterans Health Service Medical Center, Seoul, Republic of Korea
| | - Woo-Dae Bang
- Division of Cardiology, Department of
Internal Medicine, University of Ulsan College of Medicine, Gangneung Asan Hospital,
Gangneung, Republic of Korea
| | - Je Hyun Seo
- Veterans Medical Research Institute,
Veterans Health Service Medical Center, Seoul, Republic of Korea
- Je Hyun Seo, Veterans Medical Research
Institute, Veterans Health Service Medical Center, Jinhwangdo-ro 61-gil 53,
Gangdong-gu, Seoul 05368, Republic of Korea.
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Drinkwater JJ, Davis TME, Davis WA. The relationship between carotid disease and retinopathy in diabetes: a systematic review. Cardiovasc Diabetol 2020; 19:54. [PMID: 32375803 PMCID: PMC7201797 DOI: 10.1186/s12933-020-01023-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 04/25/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Since studies of the relationship between carotid disease and diabetic retinopathy (DR) have shown apparent inconsistencies, the aim of this study was to conduct a systematic review of available published data. METHODS Electronic databases were searched independently by two reviewers, according to an iterative protocol, for relevant articles. The search term used was "diabetes AND (carotid disease OR intima-media OR carotid plaque OR carotid stenosis OR carotid arterial disease OR carotid artery disease OR carotid atherosclerosis) AND (retinopathy OR diabetic retinopathy)". RESULTS From 477 publications, 14 studies were included. There were differences in the variables used as markers of carotid disease and DR across the included studies. Ten studies used carotid disease as the dependent variable, and the remainder used DR. All but one study involved cross-sectional data. Most studies reported a statistically significant association between at least one parameter of carotid disease as assessed by ultrasound and DR presence or severity. Only four studies reported no significant association. A common limitation was the use of convenience participant sampling. CONCLUSIONS There appears to be an increased likelihood of DR when there is ultrasonographic evidence of carotid disease, and vice versa. The available studies suggest that there may be a direct relationship between DR and carotid macrovascular disease and/or that these complications co-exist due to shared risk factors. If carotid disease is detected, retinal assessment should be performed. If DR is identified, intensive cardiovascular disease risk management should be considered. Additional longitudinal studies are needed to assess the directionality of the association.
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Affiliation(s)
- Jocelyn J Drinkwater
- Medical School, The University of Western Australia, Fremantle Hospital, P. O. Box 480, Fremantle, WA, 6959, Australia
| | - Timothy M E Davis
- Medical School, The University of Western Australia, Fremantle Hospital, P. O. Box 480, Fremantle, WA, 6959, Australia.
| | - Wendy A Davis
- Medical School, The University of Western Australia, Fremantle Hospital, P. O. Box 480, Fremantle, WA, 6959, Australia
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Pearce I, Simó R, Lövestam‐Adrian M, Wong DT, Evans M. Association between diabetic eye disease and other complications of diabetes: Implications for care. A systematic review. Diabetes Obes Metab 2019; 21:467-478. [PMID: 30280465 PMCID: PMC6667892 DOI: 10.1111/dom.13550] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/12/2018] [Accepted: 09/25/2018] [Indexed: 02/06/2023]
Abstract
The aim of this systematic review was to examine the associations between diabetic retinopathy (DR) and the common micro- and macrovascular complications of diabetes mellitus, and how these could potentially affect clinical practice. A structured search of the PubMed database identified studies of patients with diabetes that assessed the presence or development of DR in conjunction with other vascular complications of diabetes. From 70 included studies, we found that DR is consistently associated with other complications of diabetes, with the severity of DR linked to a higher risk of the presence of, or of developing, other micro- and macrovascular complications. In particular, DR increases the likelihood of having or developing nephropathy and is also a strong predictor of stroke and cardiovascular disease, and progression of DR significantly increases this risk. Proliferative DR is a strong risk factor for peripheral arterial disease, which carries a risk of lower extremity ulceration and amputation. Additionally, our findings suggest that a patient with DR has an overall worse prognosis than a patient without DR. In conclusion, this analysis highlights the need for a coordinated and collaborative approach to patient management. Given the widespread use of DR screening programmes that can be performed outside of an ophthalmology office, and the overall cost-effectiveness of DR screening, the presence and severity of DR can be a means of identifying patients at increased risk for micro- and macrovascular complications, enabling earlier detection, referral and intervention with the aim of reducing morbidity and mortality among patients with diabetes. Healthcare professionals involved in the management of diabetes should encourage regular DR screening.
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Affiliation(s)
- Ian Pearce
- St Paul's Eye UnitRoyal Liverpool University HospitalLiverpoolUK
| | - Rafael Simó
- Vall d'Hebron Research Institute (VHIR) and Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM)BarcelonaSpain
| | | | - David T. Wong
- St. Michael's Hospital, University of TorontoTorontoCanada
| | - Marc Evans
- University Hospital Llandough, LlandoughWalesUK
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Hjelmgren O, Strömberg U, Gellerman K, Thurin A, Zetterberg M, Bergström G. Does retinopathy predict stroke recurrence in type 2 diabetes patients: A retrospective study? PLoS One 2019; 14:e0210832. [PMID: 30653584 PMCID: PMC6336303 DOI: 10.1371/journal.pone.0210832] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 01/02/2019] [Indexed: 01/14/2023] Open
Abstract
AIMS To study if retinopathy increases the risk of stroke recurrence in stroke patients with type 2 diabetes. Also, to study if stroke patients with type 2 diabetes have an increased risk of stroke recurrence compared to non-diabetics and if stroke patients with type 2 diabetes, regardless of retinopathy, have a higher incidence of carotid stenosis. Also, to study if stroke patients with type 2 diabetes retinopathy have increased incidence of carotid stenosis. METHODS We included 445 patients with type 2 diabetes mellitus and a matched control group of 445 patients without diabetes, who had all suffered their first stroke or TIA. Information on retinopathy, risk factors and stroke recurrence were obtained from registers and medical records. RESULTS Retinopathy did not increase the risk of stroke recurrence in diabetes patients, HR 0.89 (0.51-1.53), p = 0.67. The risk of stroke recurrence was not increased in diabetics compared to non-diabetes. Diabetes patients had an increased prevalence of carotid stenosis compared to non-diabetics, 1.69 (1.15-2.48), p = 0.008. The prevalence of carotid stenosis in diabetics with retinopathy was not increased compared to diabetics without retinopathy. CONCLUSION Retinopathy is not a predictor of stroke recurrence or carotid stenosis in type 2 diabetes patients.
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Affiliation(s)
- Ola Hjelmgren
- The Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- * E-mail:
| | - Ulf Strömberg
- Health Metrics Unit, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Karl Gellerman
- The Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Anders Thurin
- Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Madeleine Zetterberg
- Department of Clinical Neuroscience and Rehabilitation/Ophthalmology, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Göran Bergström
- The Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Cardoso CRL, Salles GC, Leite NC, Salles GF. Prognostic impact of carotid intima-media thickness and carotid plaques on the development of micro- and macrovascular complications in individuals with type 2 diabetes: the Rio de Janeiro type 2 diabetes cohort study. Cardiovasc Diabetol 2019; 18:2. [PMID: 30630491 PMCID: PMC6327523 DOI: 10.1186/s12933-019-0809-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 01/03/2019] [Indexed: 12/18/2022] Open
Abstract
Background The prognostic importance of carotid atherosclerosis in individuals with diabetes is unsettled. We aimed to evaluate the relationships between parameters of carotid atherosclerosis and the future occurrence of micro- and cardiovascular complications in individuals with type 2 diabetes. Methods Ultrasonographic parameters of carotid atherosclerosis, intima-media thickness (CIMT) and plaques, were measured at baseline in 478 participants who were followed-up for a median of 10.8 years. Multivariate Cox analysis was used to examine the associations between carotid parameters and the occurrence of microvascular (retinopathy, renal, and peripheral neuropathy) and cardiovascular complications (total cardiovascular events [CVEs] and cardiovascular mortality), and all-cause mortality. The improvement in risk stratification was assessed by using the C-statistic and the integrated discrimination improvement (IDI) index. Results During follow-up, 116 individuals had a CVE and 115 individuals died (56 from cardiovascular diseases); 131 newly-developed or worsened diabetic retinopathy, 156 achieved the renal composite outcome (94 newly developed microalbuminuria and 78 deteriorated renal function), and 83 newly-developed or worsened peripheral neuropathy. CIMT, either analysed as a continuous or as a categorical variable, and presence of plaques predicted CVEs occurrence and renal outcomes, but not mortality or other microvascular complications. Individuals with an increased CIMT and plaques had a 1.5- to 1.8-fold increased risk of CVEs and a 1.6-fold higher risk of renal outcome. CIMT and plaques modestly improved cardiovascular risk discrimination over classic risk factors, with IDIs ranging from 7.8 to 8.4%; but more markedly improved renal risk discrimination, with IDIs from 14.8 to 18.5%. Conclusions Carotid atherosclerosis parameters predicted cardiovascular and renal outcomes, and improved renal risk stratification. Ultrasonographic carotid imaging may be useful in type 2 diabetes management.
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Affiliation(s)
- Claudia R L Cardoso
- Department of Internal Medicine, School of Medicine, University Hospital Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Rodolpho Rocco, 255, Cidade Universitária, Rio de Janeiro, CEP 21941-913, Brazil
| | - Guilherme C Salles
- Civil Engineering Program, COPPE, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Nathalie C Leite
- Department of Internal Medicine, School of Medicine, University Hospital Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Rodolpho Rocco, 255, Cidade Universitária, Rio de Janeiro, CEP 21941-913, Brazil
| | - Gil F Salles
- Department of Internal Medicine, School of Medicine, University Hospital Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Rodolpho Rocco, 255, Cidade Universitária, Rio de Janeiro, CEP 21941-913, Brazil.
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Simó R, Bañeras J, Hernández C, Rodríguez-Palomares J, Valente F, Gutierrez L, González-Alujas T, Ferreira I, Aguadé-Bruix S, Montaner J, Seron D, Genescà J, Boixadera A, García-Arumí J, Planas A, Simó-Servat O, García-Dorado D. Diabetic retinopathy as an independent predictor of subclinical cardiovascular disease: baseline results of the PRECISED study. BMJ Open Diabetes Res Care 2019; 7:e000845. [PMID: 31908800 PMCID: PMC6936469 DOI: 10.1136/bmjdrc-2019-000845] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 11/01/2019] [Accepted: 11/11/2019] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE Detection of subclinical cardiovascular disease (CVD) has significant impact on the management of type 2 diabetes. We examined whether the assessment of diabetic retinopathy (DR) is useful for identifying patients at a higher risk of having silent CVD. RESEARCH DESIGN AND METHODS Prospective case-control study comprising 200 type 2 diabetic subjects without history of clinical CVD and 60 age-matched non-diabetic subjects. The presence of subclinical CVD was examined using two parameters: (1) calcium coronary score (CACs); (2) composite of CACs >400 UA, carotid plaque ≥3 mm, carotid intima-media thickness ratio >1, or the presence of ECG changes suggestive of previous asymptomatic myocardial infarction. In addition, coronary angio-CT was performed. DR was assessed by slit-lamp biomicroscopy and retinography. RESULTS Type 2 diabetic subjects presented higher CACs than non-diabetic control subjects (p<0.01). Age, male gender, and the presence of DR were independently related to CACs >400 (area under the receiver operating characteristic curve (AUROC) 0.76). In addition, an inverse relationship was observed between the degree of DR and CACs <10 AU. The variables independently associated with the composite measurement of subclinical CVD were age, diabetes duration, the glomerular filtration rate, microalbuminuria, and the presence of DR (AUROC 0.71). In addition, a relationship (p<0.01) was observed between the presence and degree of DR and coronary stenosis. CONCLUSIONS The presence and degree of DR is independently associated with subclinical CVD in type 2 diabetic patients. Our results lead us to propose a rationalized screening for coronary artery disease in type 2 diabetes based on prioritizing patients with DR, particularly those with moderate-severe degree.
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Affiliation(s)
- Rafael Simó
- Diabetes and Metabolism Research Unit, Endocrinology Department, Vall d'Hebron Research Unit, Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
- CIBERDEM, ISCIII, Madrid, Spain
| | - Jordi Bañeras
- Cardiology Research Group, Cardiology Department, Vall d'Hebron Research Institute, Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
- CIBER CV, ISCIII, Madrid, Spain
| | - Cristina Hernández
- Diabetes and Metabolism Research Unit, Endocrinology Department, Vall d'Hebron Research Unit, Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
- CIBERDEM, ISCIII, Madrid, Spain
| | - José Rodríguez-Palomares
- Cardiology Research Group, Cardiology Department, Vall d'Hebron Research Institute, Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
- CIBER CV, ISCIII, Madrid, Spain
| | - Filipa Valente
- Cardiology Research Group, Cardiology Department, Vall d'Hebron Research Institute, Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
- CIBER CV, ISCIII, Madrid, Spain
| | - Laura Gutierrez
- Cardiology Research Group, Cardiology Department, Vall d'Hebron Research Institute, Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
- CIBER CV, ISCIII, Madrid, Spain
| | - Teresa González-Alujas
- Cardiology Research Group, Cardiology Department, Vall d'Hebron Research Institute, Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
- CIBER CV, ISCIII, Madrid, Spain
| | - Ignacio Ferreira
- Cardiology Research Group, Cardiology Department, Vall d'Hebron Research Institute, Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
- CIBER CV, ISCIII, Madrid, Spain
| | - Santiago Aguadé-Bruix
- Medical and Metabolic Research Area, Nuclear Medicine, Vall d'Hebron Research Institute, Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Research Institute, Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Daniel Seron
- Nephrology Department, Vall d'Hebron Research Institute, Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
- REDinREN, ISCIII, Madrid, Spain
| | - Joan Genescà
- Liver Unit, Department of Medicine, Vall d'Hebron Research Institute, Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
- CIBEREHD, ISCIII, Madrid, Spain
| | - Anna Boixadera
- Ophthalmology Department, Vall d'Hebron Research Institute, Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - José García-Arumí
- Ophthalmology Department, Vall d'Hebron Research Institute, Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Alejandra Planas
- Diabetes and Metabolism Research Unit, Endocrinology Department, Vall d'Hebron Research Unit, Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Olga Simó-Servat
- Diabetes and Metabolism Research Unit, Endocrinology Department, Vall d'Hebron Research Unit, Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
- CIBERDEM, ISCIII, Madrid, Spain
| | - David García-Dorado
- Cardiology Research Group, Cardiology Department, Vall d'Hebron Research Institute, Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
- CIBER CV, ISCIII, Madrid, Spain
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10
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Lovshin JA, Bjornstad P, Lovblom LE, Bai JW, Lytvyn Y, Boulet G, Farooqi MA, Santiago S, Orszag A, Scarr D, Weisman A, Keenan HA, Brent MH, Paul N, Bril V, Perkins BA, Cherney DZI. Atherosclerosis and Microvascular Complications: Results From the Canadian Study of Longevity in Type 1 Diabetes. Diabetes Care 2018; 41:2570-2578. [PMID: 30275283 PMCID: PMC6245210 DOI: 10.2337/dc18-1236] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 09/02/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Type 1 diabetes carries a significant risk for cardiovascular mortality, but it is unclear how atherosclerosis associates with microvascular complications. We aimed to determine the relationships between atherosclerotic burden and neuropathy, retinopathy, and diabetic kidney disease (DKD) in adults with a ≥50-year history of type 1 diabetes. RESEARCH DESIGN AND METHODS Adults with type 1 diabetes (n = 69) underwent coronary artery calcification (CAC) volume scoring by wide-volume computerized tomography. Microvascular complications were graded as follows: neuropathy by clinical assessment, electrophysiology, vibration and cooling detection thresholds, heart rate variability, and corneal confocal microscopy; retinopathy by ultra-wide-field retinal imaging; and DKD by renal hemodynamic function measured by inulin and para-aminohippurate clearance at baseline and after intravenous infusion of angiotensin II. The cohort was dichotomized to high (≥300 Agatston units [AU]) or low (<300 AU) CAC and was stratified by diabetes status. A comparator group without diabetes (n = 73) matched for age and sex also underwent all study procedures except for retinal imaging. RESULTS CAC scores were higher in participants with type 1 diabetes (median Agatston score 1,000 [interquartile range = 222, 2,373] AU vs. 1 [0.75] AU in comparators, P < 0.001). In participants with type 1 diabetes, high CAC scores associated with markers of neuropathy and retinopathy, but not with DKD, or renal hemodynamic function at baseline or in response to angiotensin II. CONCLUSIONS The presence of high CAC in adults with longstanding type 1 diabetes was associated with large nerve fiber neuropathy and retinopathy but not with renal hemodynamic function, suggesting that neuropathy, retinopathy, and macrovascular calcification share common risk factors.
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Affiliation(s)
- Julie A Lovshin
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada .,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Petter Bjornstad
- Division of Endocrinology, Department of Pediatrics, University of Colorado, Aurora, CO.,Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Leif E Lovblom
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Johnny-Wei Bai
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Yuliya Lytvyn
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Geneviève Boulet
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Mohammed A Farooqi
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Sam Santiago
- Joint Department of Medical Imaging, Division of Cardiothoracic Radiology, University Health Network, Toronto, Ontario, Canada
| | - Andrej Orszag
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Daniel Scarr
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Alanna Weisman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | | | - Michael H Brent
- Department of Ophthalmology and Vision Sciences, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Narinder Paul
- Joint Department of Medical Imaging, Division of Cardiothoracic Radiology, University Health Network, Toronto, Ontario, Canada
| | - Vera Bril
- The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Krembil Neuroscience Centre, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Bruce A Perkins
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - David Z I Cherney
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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11
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Bian L, Xia L, Wang Y, Jiang J, Zhang Y, Li D, Li W, He Y. Risk Factors of Subclinical Atherosclerosis and Plaque Burden in High Risk Individuals: Results From a Community-Based Study. Front Physiol 2018; 9:739. [PMID: 29988372 PMCID: PMC6023999 DOI: 10.3389/fphys.2018.00739] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 05/28/2018] [Indexed: 12/16/2022] Open
Abstract
China is going through major change and the incidence of first-ever stroke has increased dramatically. In this study, we aim to determine the ultrasound characteristics of carotid intima-media thickness (CIMT) and carotid plaques (CP) in the Chinese community-based population with high risk of stroke. 1009 stroke-free participants from Datun community were classified at high risk of stroke and included in this cross-sectional study. We performed B-mode carotid ultrasound imaging in all of the study subjects to measure the CIMT in the common carotid artery (CCA) far wall and CP in the CCA, bifurcation and internal carotid artery. Stepwise logistic regression analyses were used to determine factors associated with elevated CIMT and subclinical atherosclerosis, as well as plaque burden (≥2 plaques). Our results showed that traditional risk factors including aging, hypertension, current smoking and the level of high density lipoprotein cholesterol are associated with subclinical atherosclerosis and plaque burden in high-risk community residents. To improve primary prevention in this population, we may consider intense blood pressure and lipid management, and smoking cessation.
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Affiliation(s)
- Lianduo Bian
- Department of General Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lili Xia
- Editorial Office of Hepatobiliary and Pancreatic Diseases International, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Department of Epidemiology and Biostatics, School of Public Health, Capital Medical University, Beijing, China
| | - Yixin Wang
- Department of General Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jiajia Jiang
- Department of Epidemiology and Biostatics, School of Public Health, Capital Medical University, Beijing, China
| | - Yonghui Zhang
- Department of General Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dongxue Li
- Department of Epidemiology and Biostatics, School of Public Health, Capital Medical University, Beijing, China
| | - Wei Li
- Department of Epidemiology and Biostatics, School of Public Health, Capital Medical University, Beijing, China
| | - Yan He
- Department of Epidemiology and Biostatics, School of Public Health, Capital Medical University, Beijing, China
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12
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Carbonell M, Castelblanco E, Valldeperas X, Betriu À, Traveset A, Granado-Casas M, Hernández M, Vázquez F, Martín M, Rubinat E, Lecube A, Franch-Nadal J, Fernández E, Puig-Domingo M, Avogaro A, Alonso N, Mauricio D. Diabetic retinopathy is associated with the presence and burden of subclinical carotid atherosclerosis in type 1 diabetes. Cardiovasc Diabetol 2018; 17:66. [PMID: 29728117 PMCID: PMC5935933 DOI: 10.1186/s12933-018-0706-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 04/18/2018] [Indexed: 02/07/2023] Open
Abstract
Background Cardiovascular (CV) disease due to atherosclerosis is a major cause of morbidity and mortality in adult patients with diabetes, either type 1 or type 2 diabetes. The aim of the study was to assess the association of the frequency and the burden of subclinical carotid atherosclerotic disease in patients with type 1 diabetes according to the presence and severity of diabetic retinopathy (DR). Methods A cross-sectional study was conducted in 340 patients with type 1 diabetes (41.5% with DR), and in 304 non-diabetic individuals. All participants were free from previous CV disease and chronic kidney disease (CKD). B-mode carotid ultrasound imaging was performed in all the study subjects. Patients with type 1 diabetes underwent a full eye examination, and DR patients were divided into two groups: mild disease and advanced disease. Results In the group of patients with type 1 diabetes, the percentage of patients with carotid plaques was higher in those with DR compared with those without DR (44.7% vs. 24.1%, p < 0.001). Patients with DR also presented a higher incidence of ≥ 2 carotid plaques (25.5% vs. 11.1%, p < 0.001). Apart from other traditional cardiovascular risk factors, the presence of advanced stages of DR was independently associated with the presence (p = 0.044) and the burden (≥ 2 carotid plaques; p = 0.009) of subclinical carotid atherosclerosis. Conclusions In patients with type 1 diabetes without previous CV disease or established CKD, the presence of advanced stages of DR is associated with a higher atherosclerotic burden in the carotid arteries. The presence of DR identifies patients at risk for carotid atherosclerotic disease. Electronic supplementary material The online version of this article (10.1186/s12933-018-0706-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marc Carbonell
- Department of Ophthalmology, University Hospital Germans Trias i Pujol, Badalona, Spain.,Department of Medicine, Barcelona Autonomous University (UAB), Barcelona, Spain.,Department of Surgery, Barcelona Autonomous University (UAB), Barcelona, Spain
| | - Esmeralda Castelblanco
- Department of Endocrinology and Nutrition, University Hospital and Health Science Research Institute Germans Trias i Pujol, Carretera Canyet S/N, 08916, Badalona, Spain.,Center for Biomedical Research on Diabetes and Associated Metabolic Diseases (CIBERDEM), Barcelona, Spain
| | - Xavier Valldeperas
- Department of Ophthalmology, University Hospital Germans Trias i Pujol, Badalona, Spain.,Department of Medicine, Barcelona Autonomous University (UAB), Barcelona, Spain.,Department of Surgery, Barcelona Autonomous University (UAB), Barcelona, Spain
| | - Àngels Betriu
- Biomedical Research Institute of Lleida, Lleida, Spain
| | - Alícia Traveset
- Department of Ophthalmology, University Hospital Arnau de Vilanova, Lleida, Spain
| | - Minerva Granado-Casas
- Department of Endocrinology and Nutrition, University Hospital and Health Science Research Institute Germans Trias i Pujol, Carretera Canyet S/N, 08916, Badalona, Spain.,Biomedical Research Institute of Lleida, Lleida, Spain
| | - Marta Hernández
- Biomedical Research Institute of Lleida, Lleida, Spain.,Department of Endocrinology and Nutrition, University Hospital Arnau de Vilanova, Lleida, Spain
| | - Federico Vázquez
- Department of Endocrinology and Nutrition, University Hospital and Health Science Research Institute Germans Trias i Pujol, Carretera Canyet S/N, 08916, Badalona, Spain
| | - Mariona Martín
- Department of Endocrinology and Nutrition, University Hospital and Health Science Research Institute Germans Trias i Pujol, Carretera Canyet S/N, 08916, Badalona, Spain
| | | | - Albert Lecube
- Biomedical Research Institute of Lleida, Lleida, Spain.,Department of Endocrinology and Nutrition, University Hospital Arnau de Vilanova, Lleida, Spain
| | - Josep Franch-Nadal
- Center for Biomedical Research on Diabetes and Associated Metabolic Diseases (CIBERDEM), Barcelona, Spain.,Primary Health Care Center Raval Sud, Gerència d'Atenció Primaria, Institut Català de la Salut, Barcelona, Spain
| | | | - Manel Puig-Domingo
- Department of Endocrinology and Nutrition, University Hospital and Health Science Research Institute Germans Trias i Pujol, Carretera Canyet S/N, 08916, Badalona, Spain.,Center for Biomedical Research on Diabetes and Associated Metabolic Diseases (CIBERDEM), Barcelona, Spain.,Department of Medicine, Barcelona Autonomous University (UAB), Barcelona, Spain
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Padua, Italy
| | - Núria Alonso
- Department of Endocrinology and Nutrition, University Hospital and Health Science Research Institute Germans Trias i Pujol, Carretera Canyet S/N, 08916, Badalona, Spain. .,Center for Biomedical Research on Diabetes and Associated Metabolic Diseases (CIBERDEM), Barcelona, Spain. .,Biomedical Research Institute of Lleida, Lleida, Spain. .,Department of Medicine, Barcelona Autonomous University (UAB), Barcelona, Spain.
| | - Dídac Mauricio
- Department of Endocrinology and Nutrition, University Hospital and Health Science Research Institute Germans Trias i Pujol, Carretera Canyet S/N, 08916, Badalona, Spain. .,Center for Biomedical Research on Diabetes and Associated Metabolic Diseases (CIBERDEM), Barcelona, Spain. .,Biomedical Research Institute of Lleida, Lleida, Spain. .,Department of Medicine, Barcelona Autonomous University (UAB), Barcelona, Spain.
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13
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Lee MY, Hsiao PJ, Huang JC, Hsu WH, Chen SC, Chang JM, Shin SJ. Abnormally Low or High Ankle-Brachial Index Is Associated With the Development of Diabetic Retinopathy in Type 2 Diabetes Mellitus. Sci Rep 2018; 8:441. [PMID: 29323191 PMCID: PMC5765125 DOI: 10.1038/s41598-017-18882-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 12/19/2017] [Indexed: 01/09/2023] Open
Abstract
Although some studies have reported an association between peripheral artery disease (PAD) and diabetic retinopathy (DR) in patients with diabetes, whether or not a causal relationship exists is unknown. The aim of this study was to investigate whether PAD, as indicated by an abnormally low or high ankle-brachial index (ABI), is associated with the development of DR in patients with type 2 diabetes mellitus (DM) without DR. We enrolled 414 (221 men and 193 women) patients with type 2 DM who underwent ABI measurements at our outpatient clinic. PAD was defined as an abnormally low (<0.9) or high (≥1.3) ABI in either leg, and DR was defined as being non-proliferative or proliferative. Of the enrolled patients, 69 (16.7%) had an ABI <0.9 or ≥1.3. The median follow-up period was 23 (15–40) months, during which 74 (17.9%) patients developed DR. In multivariate analysis, an ABI <0.9 or ≥1.3 was independently associated with the development of DR (vs. ABI ≥0.9 to <1.3; hazard ratio, 2.186; 95% confidence interval, 1.261 to 3.789; p = 0.005). An abnormal ABI was associated with the development of DR in our patients with type 2 DM without DR.
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Affiliation(s)
- Mei-Yueh Lee
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pi-Jung Hsiao
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jiun-Chi Huang
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Hao Hsu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Szu-Chia Chen
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan. .,Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan. .,Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan. .,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Jer-Ming Chang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shyi-Jang Shin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan. .,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan. .,Center for Lipid and Glycomedicine Research, Kaohsiung Medical University, Kaohsiung, Taiwan.
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14
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Jiang X, Zhao X, Chen R, Jiang Q, Zhou B. Plasma soluble CD36, carotid intima-media thickness and cognitive function in patients with type 2 diabetes. Arch Med Sci 2017; 13:1031-1039. [PMID: 28883843 PMCID: PMC5575210 DOI: 10.5114/aoms.2016.60821] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 11/07/2015] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Diabetes and atherosclerosis are both risk factors of cognitive deficits. Scavenger receptor CD36 is associated with increasing risk of diabetes and atherosclerosis, and may play a role in cognitive deficits. The aim of this study is to determine the correlations of plasma soluble CD36 concentrations with carotid intima-media thickness (IMT) and cognitive function in patients with type 2 diabetes. MATERIAL AND METHODS We determined the levels of soluble CD36 (sCD36), blood lipids, fasting blood glucose, glycosylated hemoglobin, carotid atherosclerosis as IMT, cognitive function by the Montreal Cognitive Assessment (MoCA) scoring system, and other clinical characteristics in 357 patients with type 2 diabetes. RESULTS Diabetic patients with the lowest quartile of IMT (Q1) had lower sCD36 concentrations (ANOVA, ptrend < 0.05) and higher MoCA scores than upper ones (Q2-Q4) (ptrend < 0.05), and those with the highest quartile of sCD36(Q4) had higher FBG, LDL-C and carotid IMT than lower ones (Q1-Q3) (ptrend < 0.05 for all). Plasma log10(sCD36) was significantly correlated with carotid IMT (r = 0.202, p < 0.001) after adjustment for age, gender, and education level. Carotid IMT was significantly associated with MoCA scores (r = 0.284, p < 0.001) after adjustment for, age, gender, education level, duration of DM and hypertension. There were no correlations between sCD36 and MoCA scores (r = -0.038, p = 0.470). CONCLUSIONS Our study shows that sCD36 is associated with carotid IMT, and carotid IMT is inversely correlated with cognitive function in type 2 diabetic patients. Nevertheless, no cross-sectional association between sCD36 and MoCA scores was detected in this study.
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Affiliation(s)
- Xiaozhen Jiang
- Department of Endocrinology, Shanghai Pudong New Area People’s Hospital, Shanghai, China
| | - Xiaohui Zhao
- Department of Neurology, Shanghai Pudong New Area People’s Hospital, Shanghai, China
| | - Ruihua Chen
- Department of Endocrinology, Shanghai Pudong New Area People’s Hospital, Shanghai, China
| | - Quan Jiang
- Department of Ultrasonography, Shanghai Pudong New Area People’s Hospital, Shanghai, China
| | - Bin Zhou
- Department of Endocrinology, Shanghai Pudong New Area People’s Hospital, Shanghai, China
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15
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Abnormally Low or High Ankle-Brachial Index Is Associated with Proliferative Diabetic Retinopathy in Type 2 Diabetic Mellitus Patients. PLoS One 2015; 10:e0134718. [PMID: 26230390 PMCID: PMC4521755 DOI: 10.1371/journal.pone.0134718] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 07/02/2015] [Indexed: 01/06/2023] Open
Abstract
Although some studies have reported that low ankle-brachial index (ABI) is associated with diabetic retinopathy (DR) in diabetic patients, it remains controversial as to which stage of DR. The aim of this study is to assess whether peripheral artery disease (PAD), indicated by abnormally low or high ABI, is associated with different stages of DR in patients with type 2 diabetes mellitus (DM), and further evaluate the risk factors. A total of 2001 (858 men and 1143 women) patients with type 2 DM who underwent ABI measurement in an outpatient clinic were enrolled. PAD was defined as ABI < 0.9 or ≧ 1.3 in either leg. DR was classified as non-DR, nonproliferative DR and proliferative DR stages. The clinical data were analyzed and the risk factors for abnormal ABI were determined by multivariate logistic regression analysis. The prevalence of ABI < 0.9 or ≧ 1.3 was 3.0%. Multivariate forward logistic regression analysis identified proliferative DR (vs. non-DR) was associated with abnormal ABI (odds ratio, 1.718; 95% confidence interval, 1.152 to 2.562; p = 0.008), but nonproliferative DR was not. Furthermore, the presence of coronary artery disease, cerebrovascular disease, declining renal function and patients without diuretics use were associated with abnormal ABI in patients with proliferative DR. Our study in patients of type 2 DM demonstrated that PAD was associated with proliferative DR. We emphasize the recommendation of performing the ABI test in this population at risk.
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16
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Alonso N, Traveset A, Rubinat E, Ortega E, Alcubierre N, Sanahuja J, Hernández M, Betriu A, Jurjo C, Fernández E, Mauricio D. Type 2 diabetes-associated carotid plaque burden is increased in patients with retinopathy compared to those without retinopathy. Cardiovasc Diabetol 2015; 14:33. [PMID: 25856787 PMCID: PMC4389661 DOI: 10.1186/s12933-015-0196-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 02/27/2015] [Indexed: 12/13/2022] Open
Abstract
Background Cardiovascular disease (CVD) is the leading cause of mortality among subjects with type 2 diabetes (T2D), and diabetic retinopathy (DR) has been associated with an increased risk for CVD. The present study was designed to test the concept that T2D patients with DR, but without previous cardiovascular (CV) events and with normal renal function, have an increased atherosclerotic burden compared with patients without DR. Methods A cross-sectional study was performed using patients with normal renal function (estimated glomerular filtration rate (eGFR) >60 ml/min) and without previous CV events. A total of 312 patients (men, 51%; mean age, 57 yrs; age range 40–75 yrs) were included in the study; 153 (49%) of the patients had DR. B-mode carotid ultrasound imaging was performed for all of the study subjects to measure the carotid intima-media thickness (cIMT) and carotid plaques in the common carotid artery (CCA), bifurcation and internal carotid artery (ICA). Results The percentage of carotid plaques in T2D patients with DR was higher than in T2D patients without DR (68% vs. 52.2%, p = 0.0045), and patients with DR had a higher prevalence of ≥2 carotid plaques (44.4% vs. 21.4%; p < 0.0001). No differences were observed in the cIMT measured at different carotid regions between the patients with or without DR. Using multivariate logistic regression (adjustment for major risk factors for atherosclerosis), DR was independently associated with mean-internal cIMT (p = 0.0176), with the presence of carotid plaques (p = 0.0366) and with carotid plaque burden (≥2 plaques; p < 0.0001). Conclusions The present study shows that DR in T2D patients without CVD and with normal renal function is associated with a higher atherosclerotic burden (presence and number of plaques) in the carotid arteries. These patients may be at a higher risk for future CV events; therefore, an ultrasound examination of the carotid arteries should be considered in patients with DR for more careful and individualised CV assessment and follow-up.
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Affiliation(s)
- Núria Alonso
- Department of Endocrinology and Nutrition, Health Sciences Research Institute and University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Alicia Traveset
- Department of Ophthalmology, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Esther Rubinat
- Department of Endocrinology and Nutrition, Hospital Universitari Arnau de Vilanova, Lleida, Spain.,Institut de Recerca Biomedica de Lleida, University of Lleida, Lleida, Spain
| | - Emilio Ortega
- Department of Endocrinology and Nutrition, Institut d'Investigacions Biomediques August Pi Suñer, CIBER de Diabetes y Enfermedades Metabólicas asociadas, Hospital Clinic, 08036, Barcelona, Spain
| | - Nuria Alcubierre
- Institut de Recerca Biomedica de Lleida, University of Lleida, Lleida, Spain
| | - Jordi Sanahuja
- Department of Neurology, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Marta Hernández
- Department of Endocrinology and Nutrition, Hospital Universitari Arnau de Vilanova, Lleida, Spain.,Unitat de Detecció i Tractament de Malalties Aterotrombòtiques, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Angels Betriu
- Unitat de Detecció i Tractament de Malalties Aterotrombòtiques, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Carmen Jurjo
- Department of Ophthalmology, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Elvira Fernández
- Unitat de Detecció i Tractament de Malalties Aterotrombòtiques, Hospital Universitari Arnau de Vilanova, Lleida, Spain.,Department of Nephrology, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Didac Mauricio
- Department of Endocrinology and Nutrition, Health Sciences Research Institute and University Hospital Germans Trias i Pujol, Badalona, Spain.
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17
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Kim DH, Grodstein F, Newman AB, Chaves PHM, Odden MC, Klein R, Sarnak MJ, Patel KV, Lipsitz LA. Prognostic implications of microvascular and macrovascular abnormalities in older adults: cardiovascular health study. J Gerontol A Biol Sci Med Sci 2014; 69:1495-502. [PMID: 24864308 DOI: 10.1093/gerona/glu074] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Microvascular and macrovascular abnormalities are frequently found on noninvasive tests performed in older adults. Their prognostic implications on disability and life expectancy have not been collectively assessed. METHODS This prospective study included 2,452 adults (mean age: 79.5 years) with available measures of microvascular (brain, retina, kidney) and macrovascular abnormalities (brain, carotid, coronary, peripheral artery) in the Cardiovascular Health Study. The burden of microvascular and macrovascular abnormalities was examined in relation to total, activity-of-daily-living disability-free, and severe disability-free life expectancies in the next 10 years (1999-2009). RESULTS At 75 years, individuals with low burden of both abnormalities lived, on average, 8.71 years (95% confidence interval: 8.29, 9.12) of which 7.67 years (7.16, 8.17) were without disability. In comparison, individuals with high burden of both abnormalities had shortest total life expectancy (6.95 years [6.52, 7.37]; p < .001) and disability-free life expectancy (5.60 years [5.10, 6.11]; p < .001). Although total life expectancy was similarly reduced for those with high burden of either type of abnormalities (microvascular: 7.96 years [7.50, 8.42] vs macrovascular: 8.25 years [7.80, 8.70]; p = .10), microvascular abnormalities seemed to have larger impact than macrovascular abnormalities on disability-free life expectancy (6.45 years [5.90, 6.99] vs 6.96 years [6.43, 7.48]; p = .016). These results were consistent for severe disability-free life expectancy and in individuals without clinical cardiovascular disease. CONCLUSIONS Considering both microvascular and macrovascular abnormalities from multiple noninvasive tests may provide additional prognostic information on how older adults spend their remaining life. Optimal clinical use of this information remains to be determined.
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Affiliation(s)
- Dae Hyun Kim
- Division of Gerontology, Beth Israel Deaconess Medical Center, Institute for Aging Research, Hebrew SeniorLife, and
| | - Francine Grodstein
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Anne B Newman
- Department of Epidemiology, University of Pittsburgh, Pennsylvania
| | - Paulo H M Chaves
- Benjamin Leon Center for Geriatric Research and Education, Herbert Wertheim College of Medicine, Florida International University, Miami
| | - Michelle C Odden
- School of Biological and Population Health Sciences, Oregon State University, Corvallis
| | - Ronald Klein
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison
| | - Mark J Sarnak
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Kushang V Patel
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
| | - Lewis A Lipsitz
- Division of Gerontology, Beth Israel Deaconess Medical Center, Institute for Aging Research, Hebrew SeniorLife, and
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Jung CH, Baek AR, Kim KJ, Kim BY, Kim CH, Kang SK, Mok JO. Association between Cardiac Autonomic Neuropathy, Diabetic Retinopathy and Carotid Atherosclerosis in Patients with Type 2 Diabetes. Endocrinol Metab (Seoul) 2013; 28:309-19. [PMID: 24396696 PMCID: PMC3871040 DOI: 10.3803/enm.2013.28.4.309] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 07/10/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND It is not clear whether microangiopathies are associated with subclinical atherosclerosis in type 2 diabetes mellitus (T2DM). We investigated the relation of cardiac autonomic neuropathy (CAN) and other microangiopathies with carotid atherosclerosis in T2DM. METHODS A total of 131 patients with T2DM were stratified by mean carotid intima-media thickness (CIMT) ≥ or <1.0 mm and the number of carotid plaques. CAN was assessed by the five standard cardiovascular reflex tests according to the Ewing's protocol. CAN was defined as the presence of at least two abnormal tests or an autonomic neuropathy points ≥2. Diabetic microangiopathies were assessed. RESULTS Patients with CAN comprised 77% of the group with mean CIMT ≥1.0 mm, while they were 29% of the group with CIMT <1.0 mm (P=0.016). Patients with diabetic retinopathy (DR) comprised 68% of the group with CIMT ≥1.0 mm, while they were 28% of the group without CIMT thickening (P=0.003). Patients with CAN comprised 51% of the group with ≥2 carotid plaques, while they were 23% of the group with ≤1 carotid plaque (P=0.014). In multivariable adjusted logistic regression analysis, the patients who presented with CAN showed an odds ratio [OR] of 8.6 (95% confidence interval [CI], 1.6 to 44.8) for CIMT thickening and an OR of 2.9 (95% CI, 1.1 to 7.5) for carotid plaques. Furthermore, patients with DR were 3.8 times (95% CI, 1.4 to 10.2) more likely to have CIMT thickening. CONCLUSION These results suggest that CAN is associated with carotid atherosclerosis, represented as CIMT and plaques, independent of the traditional cardiovascular risk factors in T2DM. CAN or DR may be a determinant of subclinical atherosclerosis in T2DM.
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Affiliation(s)
- Chan-Hee Jung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Ae-Rin Baek
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Kyu-Jin Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Bo-Yeon Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Chul-Hee Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Sung-Koo Kang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Ji-Oh Mok
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
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19
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Yun YW, Shin MH, Lee YH, Rhee JA, Choi JS. Arterial stiffness is associated with diabetic retinopathy in Korean type 2 diabetic patients. J Prev Med Public Health 2012; 44:260-6. [PMID: 22143176 PMCID: PMC3249265 DOI: 10.3961/jpmph.2011.44.6.260] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives We evaluated the association between common carotid artery intima-media thickness (CCA-IMT), brachial-ankle pulse wave velocity (baPWV), carotid plaque, and peripheral arterial disease (PAD) as indicators of macroangiopathy and diabetic retinopathy as an indicator of microangiopathy in type 2 diabetic patients. Methods We analyzed 605 type 2 diabetic patients registered at a public health center in Korea. Following overnight fasting, venous blood and urine samples were collected and analyzed. The CCA-IMT, levels of carotid plaque, baPWV, and ankle-brachial index (ABI) of the subjects were assessed. We used non-mydriatic fundus photography to diagnose diabetic retinopathy. Multiple logistic regression analyses were used to evaluate the association between macroangiopathy and diabetic retinopathy. CCA-IMT and baPWV were divided into tertiles: CCA-IMT, 0.39 to 0.65 mm, 0.66 to 0.78 mm, and 0.79 to 1.30 mm; baPWV, 9.9 to 15.8 m/s, 15.9 to 18.9 m/s, and 19.0 to 38.0 m/s. Results The association between baPWV and diabetic retinopathy remained significant after adjustment, with an increasing odds ratio (OR) in the second tertile (OR, 2.41; 95% confidence interval [CI], 1.27 to 4.55) and the third tertile (OR, 4.63; 95% CI, 2.33 to 9.21). No significant differences were observed in carotid plaque, PAD, and each tertile of CCA-IMT. Conclusions BaPWV was associated with diabetic retinopathy, while CCA-IMT, carotid plaque, and PAD were not. This study suggests that the association between macroangiopathy and microangiopathy may be attributable to functional processes rather than structural processes within the vascular system.
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Affiliation(s)
- Yong Woon Yun
- Department of Preventive Medicine, Chonnam National University Medical School, Gwangju, Korea
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Sibal L, Agarwal SC, Home PD. Carotid intima-media thickness as a surrogate marker of cardiovascular disease in diabetes. Diabetes Metab Syndr Obes 2011; 4:23-34. [PMID: 21448319 PMCID: PMC3064409 DOI: 10.2147/dmso.s8540] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Diabetes mellitus is associated with a high risk of cardiovascular disease. Carotid intima-media thickness (CIMT) is increasingly used as a surrogate marker for atherosclerosis. Its use relies on its ability to predict future clinical cardiovascular end points. METHODS This review examines the evidence linking CIMT as a surrogate marker of vascular complications in people with type 1 and type 2 diabetes. We have also reviewed the various treatment strategies which have been shown to influence CIMT. CONCLUSIONS CIMT measurement is an effective, noninvasive tool which can assist in identifying people with diabetes who are at higher risk of developing microvascular and macrovascular complications. It may also help to evaluate the effectiveness of various treatment strategies used to treat people with diabetes.
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Affiliation(s)
- Latika Sibal
- Wolfson Diabetes and Endocrine Clinic, Addenbrooke’s Hospital, Cambridge, UK
- Correspondence: Latika Sibal, Wolfson Diabetes and Endocrine Clinic, Institue of Metabolic Science, Box 281, Addenbrooke’s Hospital, Hill’s Road, Cambridge CB2 0QQ, UK, Tel +44 7766445165, Email
| | - Sharad C Agarwal
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Philip D Home
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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