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Movahed MR, Bahrami A, Manrique C, Hashemzadeh M. Strong independent association between third-degree AV-block and diabetes mellitus using a large database. Diabetes Res Clin Pract 2023; 205:110948. [PMID: 37832726 DOI: 10.1016/j.diabres.2023.110948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/27/2023] [Accepted: 10/10/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND Recent data suggests an association between DM and third-degree AV- Block. The goal of this study was to evaluate the independent association between diabetes and third-degree AV-Block using a very large database. METHOD We used ICD-9 Codes for DM and third-degree AV-block from the Nationwide Inpatient Sample (NIS) database. We randomly selected the 1992 and 2002 databases which are 10 years apart as two independent samples. We used uni- and multi-variate analysis to evaluate this association. RESULTS 1992 database contained a total of 6,195,744 patients. Diabetes occurred in (0.5 %) of patients with third-degree AV-block vs. (0.2 %) of the control (OR: 2.15, CI 2.06-2.25, p < 0.0001). 2002 database contained a total of 7,853,982 patients. Diabetes occurred in (0.4 %) of patients with third-degree AV-block vs. (0.2 %) of the control (OR: 1.86, CI: 1.80-1.93, p < 0.0001). Using Multivariate analysis adjusting for age, congestive heart failure, and coronary artery disease, DM remained independently associated with third-degree AV block in both databases. (for 1999: OR: 2.54, CI 2.51-2.57, p < 0.0001 and for 2002 OR: 1.56, CI 1.55-1.57, p < 0.0001). CONCLUSION DM is independently associated with third-degree AV-block with persistent association over a period of 10 years. The cause of this association warrants further investigation.
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Affiliation(s)
- Mohammad Reza Movahed
- University of Arizona College of Medicine, Tucson, AZ, United States; University of Arizona, College of Medicine, Phoenix, AZ, United States.
| | - Ashkan Bahrami
- University of Arizona College of Medicine, Tucson, AZ, United States
| | - Coraly Manrique
- University of Arizona College of Medicine, Tucson, AZ, United States
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Haxha S, Halili A, Malmborg M, Pedersen-Bjergaard U, Philbert BT, Lindhardt TB, Hoejberg S, Schjerning AM, Ruwald MH, Gislason GH, Torp-Pedersen C, Bang CN. Type 2 diabetes mellitus and higher rate of complete atrioventricular block: a Danish Nationwide Registry. Eur Heart J 2023; 44:752-761. [PMID: 36433808 DOI: 10.1093/eurheartj/ehac662] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 10/10/2022] [Accepted: 11/02/2022] [Indexed: 11/27/2022] Open
Abstract
AIMS The present study aimed to determine the association between Type 2 diabetes mellitus (T2DM) and third-degree (complete) atrioventricular block. METHODS AND RESULTS This nationwide nested case-control study included patients older than 18 years, diagnosed with third-degree atrioventricular block between 1 July 1995 and 31 December 2018. Data on medication, comorbidity, and outcomes were collected from Danish registries. Five controls, from the risk set of each case of third-degree atrioventricular block, were matched on age and sex to fit a Cox regression model with time-dependent exposure and time-dependent covariates. Subgroup analysis was conducted with Cox regression models for each subgroup. We located 25 995 cases with third-degree atrioventricular block that were matched with 130 004 controls. The mean age was 76 years and 62% were male. Cases had more T2DM (21% vs. 11%), hypertension (69% vs. 50%), atrial fibrillation (25% vs. 10%), heart failure (20% vs. 6.3%), and myocardial infarction (19% vs. 9.2%), compared with the control group. In Cox regression analysis, adjusting for comorbidities and atrioventricular nodal blocking agents, T2DM was significantly associated with third-degree atrioventricular block (hazard ratio: 1.63, 95% confidence interval: 1.57-1.69). The association remained in several subgroup analyses of diseases also suspected to be associated with third-degree atrioventricular block. There was a significant interaction with comorbidities of interest including hypertension, atrial fibrillation, heart failure, and myocardial infarction. CONCLUSION In this nationwide study, T2DM was associated with a higher rate of third-degree atrioventricular block compared with matched controls. The association remained independent of atrioventricular nodal blocking agents and other comorbidities known to be associated with third-degree atrioventricular block.
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Affiliation(s)
- Saranda Haxha
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark.,Department of Cardiology, North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark
| | - Andrim Halili
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark.,Department of Cardiology, North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark
| | - Morten Malmborg
- Danish Heart Foundation, Randersgade 60, 2100 Copenhagen, Denmark
| | - Ulrik Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark.,Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3b 33.5, 2200 Copenhagen, Denmark
| | - Berit T Philbert
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Tommi B Lindhardt
- Department of Cardiology, Herlev-Gentofte University Hospital, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Soeren Hoejberg
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Anne-Marie Schjerning
- Department of Cardiology, Zealand University Hospital, Sygehusvej 10, 4000 Roskilde, Denmark
| | - Martin H Ruwald
- Department of Cardiology, Herlev-Gentofte University Hospital, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Gunnar H Gislason
- Department of Cardiology, Herlev-Gentofte University Hospital, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark.,Faculty of Health and Medical Sciences, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, build. 24 Q, 1st floor 1353 Copenhagen, Denmark
| | - Casper N Bang
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
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3
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Counterregulatory responses to postprandial hypoglycemia after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2020; 17:55-63. [PMID: 33039341 DOI: 10.1016/j.soard.2020.08.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/25/2020] [Accepted: 08/30/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Postbariatric hypoglycemia (PBH) is a potentially serious complication after Roux-en-Y gastric bypass (RYGB), and impaired counterregulatory hormone responses have been suggested to contribute to the condition. OBJECTIVES We evaluated counterregulatory responses during postprandial hypoglycemia in individuals with PBH who underwent RYGB. SETTING University hospital. METHODS Eleven women with documented PBH who had RYGB underwent a baseline liquid mixed meal test (MMT) followed by 5 MMTs preceded by treatment with (1) acarbose 50 mg, (2) sitagliptin 100 mg, (3) verapamil 120 mg, (4) liraglutide 1.2 mg, and (5) pasireotide 300 μg. Blood was collected at fixed time intervals. Plasma and serum were analyzed for glucose, insulin, glucagon, epinephrine, norepinephrine, pancreatic polypeptide (PP), and cortisol. RESULTS During the baseline MMT, participants had nadir blood glucose concentrations of 3.3 ± .2 mmol/L. At the time of nadir glucose, there was a small but significant increase in plasma glucagon. Plasma epinephrine concentrations were not increased at nadir glucose but were significantly elevated by the end of the MMT. There were no changes in norepinephrine, PP, and cortisol concentrations in response to hypoglycemia. After treatment with sitagliptin, 8 individuals had glucose nadirs <3.2 mmol/L (versus 4 individuals at baseline), and significant increases in glucagon, PP, and cortisol responses were observed. CONCLUSIONS In response to postprandial hypoglycemia, individuals with PBH who underwent RYGB only had minor increases in counterregulatory hormones, while larger hormone responses occurred when glucose levels were lowered during treatment with sitagliptin. The glycemic threshold for counterregulatory activation could be altered in individuals with PBH, possibly explained by recurrent hypoglycemia.
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4
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Aberer F, Pferschy PN, Tripolt NJ, Sourij C, Obermayer AM, Prüller F, Novak E, Reitbauer P, Kojzar H, Prietl B, Kofler S, Brunner M, Svehlikova E, Stojakovic T, Scharnagl H, Oulhaj A, Aziz F, Riedl R, Sourij H. Hypoglycaemia leads to a delayed increase in platelet and coagulation activation markers in people with type 2 diabetes treated with metformin only: Results from a stepwise hypoglycaemic clamp study. Diabetes Obes Metab 2020; 22:212-221. [PMID: 31595635 PMCID: PMC6972619 DOI: 10.1111/dom.13889] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 09/11/2019] [Accepted: 09/27/2019] [Indexed: 12/13/2022]
Abstract
AIMS To investigate the effect of hypoglycaemia on platelet and coagulation activation in people with type 2 diabetes. MATERIALS AND METHODS This monocentric, open, single-arm, mechanistic trial included 14 people with established type 2 diabetes (four women, 10 men, age 55 ± 7 years, glycated haemoglobin concentration 51 ± 7 mmol/mol) receiving metformin monotherapy. A stepwise hyperinsulinaemic-hypoglycaemic clamp experiment (3.5 and 2.5 mmol/L, for 30 minutes respectively) was performed, aiming to investigate platelet and coagulation activity during predefined plateaus of hypoglycaemia, as well as 1 day and 7 days later. RESULTS While platelet activation assessed by light transmittance aggregometry did not significantly increase after the hypoglycaemic clamp procedure, the more sensitive flow cytometry-based measurement of platelet surface activation markers showed hypoglycaemia-induced activation 24 hours (PAC1pos CD62Ppos , PAC1pos CD63Ppos and PAC1pos CD62Ppos CD63pos ; P < .01) and 7 days after the hypoglycaemic clamp (P < .001 for PAC1pos CD63pos ; P < .01 for PAC1pos CD62Ppos and PAC1pos CD62Ppos CD63pos ) in comparison to baseline. Coagulation markers, such as fibrinogen, D-dimer, plasminogen activator inhibitor-1, von Willebrand factor activity and factor VIII, were also significantly increased, an effect that was most pronounced 24 hours after the hypoglycaemic clamp. CONCLUSION A single event of insulin-induced hypoglycaemia led to an increase in markers of platelet activation and coagulation in people with early stages of type 2 diabetes on metformin therapy. However, the activation occurred with a delay and was evident 24 hours and 7 days after the actual hypoglycaemic episode.
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Affiliation(s)
- Felix Aberer
- Division of Endocrinology and DiabetologyMedical University of GrazGrazAustria
| | - Peter N. Pferschy
- Division of Endocrinology and DiabetologyMedical University of GrazGrazAustria
- CBmed GmbH, Centre for Biomarker Research in MedicineGrazAustria
| | - Norbert J. Tripolt
- Division of Endocrinology and DiabetologyMedical University of GrazGrazAustria
| | - Caren Sourij
- Division of Endocrinology and DiabetologyMedical University of GrazGrazAustria
| | - Anna M Obermayer
- Division of Endocrinology and DiabetologyMedical University of GrazGrazAustria
- CBmed GmbH, Centre for Biomarker Research in MedicineGrazAustria
| | - Florian Prüller
- Medical University of Graz, Clinical Institute of Medical and Chemical Laboratory DiagnosticsGrazAustria
| | - Eva Novak
- Division of Endocrinology and DiabetologyMedical University of GrazGrazAustria
| | - Philipp Reitbauer
- Division of Endocrinology and DiabetologyMedical University of GrazGrazAustria
| | - Harald Kojzar
- Division of Endocrinology and DiabetologyMedical University of GrazGrazAustria
- CBmed GmbH, Centre for Biomarker Research in MedicineGrazAustria
| | - Barbara Prietl
- Division of Endocrinology and DiabetologyMedical University of GrazGrazAustria
- CBmed GmbH, Centre for Biomarker Research in MedicineGrazAustria
| | - Selina Kofler
- Division of Endocrinology and DiabetologyMedical University of GrazGrazAustria
- CBmed GmbH, Centre for Biomarker Research in MedicineGrazAustria
| | - Martina Brunner
- Division of Endocrinology and DiabetologyMedical University of GrazGrazAustria
| | - Eva Svehlikova
- Division of Endocrinology and DiabetologyMedical University of GrazGrazAustria
| | - Tatjana Stojakovic
- Medical University of Graz, Clinical Institute of Medical and Chemical Laboratory DiagnosticsGrazAustria
| | - Hubert Scharnagl
- Medical University of Graz, Clinical Institute of Medical and Chemical Laboratory DiagnosticsGrazAustria
| | - Abderrahim Oulhaj
- College of Medicine and Health SciencesUnited Arab Emirates University, Institute of Public HealthAl AinUAE
| | - Faisal Aziz
- Division of Endocrinology and DiabetologyMedical University of GrazGrazAustria
- CBmed GmbH, Centre for Biomarker Research in MedicineGrazAustria
| | - Regina Riedl
- Medical University of Graz, Institute for Medical Informatics, Statistics and DocumentationGrazAustria
| | - Harald Sourij
- Division of Endocrinology and DiabetologyMedical University of GrazGrazAustria
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Grisanti LA. Diabetes and Arrhythmias: Pathophysiology, Mechanisms and Therapeutic Outcomes. Front Physiol 2018; 9:1669. [PMID: 30534081 PMCID: PMC6275303 DOI: 10.3389/fphys.2018.01669] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 11/06/2018] [Indexed: 12/17/2022] Open
Abstract
The prevalence of diabetes is rapidly increasing and closely associated with cardiovascular morbidity and mortality. While the major cardiovascular complication associated with diabetes is coronary artery disease, it is becoming increasingly apparent that diabetes impacts the electrical conduction system in the heart, resulting in atrial fibrillation, and ventricular arrhythmias. The relationship between diabetes and arrhythmias is complex and multifactorial including autonomic dysfunction, atrial and ventricular remodeling and molecular alterations. This review will provide a comprehensive overview of the link between diabetes and arrhythmias with insight into the common molecular mechanisms, structural alterations and therapeutic outcomes.
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Affiliation(s)
- Laurel A Grisanti
- Department of Biomedical Sciences, College of Veterinary Medicine, University of Missouri, Columbia, MO, United States
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6
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Reno CM, VanderWeele J, Bayles J, Litvin M, Skinner A, Jordan A, Daphna-Iken D, Fisher SJ. Severe Hypoglycemia-Induced Fatal Cardiac Arrhythmias Are Augmented by Diabetes and Attenuated by Recurrent Hypoglycemia. Diabetes 2017; 66:3091-3097. [PMID: 28887311 PMCID: PMC5697941 DOI: 10.2337/db17-0306] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 08/31/2017] [Indexed: 01/12/2023]
Abstract
We previously demonstrated that insulin-mediated severe hypoglycemia induces lethal cardiac arrhythmias. However, whether chronic diabetes and insulin deficiency exacerbates, and whether recurrent antecedent hypoglycemia ameliorates, susceptibility to arrhythmias remains unknown. Thus, adult Sprague-Dawley rats were randomized into four groups: 1) nondiabetic (NONDIAB), 2) streptozotocin-induced insulin deficiency (STZ), 3) STZ with antecedent recurrent (3 days) hypoglycemia (∼40-45 mg/dL, 90 min) (STZ+RH), and 4) insulin-treated STZ (STZ+Ins). Following treatment protocols, all rats underwent hyperinsulinemic (0.2 units ⋅ kg-1 ⋅ min-1), severe hypoglycemic (10-15 mg/dL) clamps for 3 h with continuous electrocardiographic recordings. During matched nadirs of severe hypoglycemia, rats in the STZ+RH group required a 1.7-fold higher glucose infusion rate than those in the STZ group, consistent with the blunted epinephrine response. Second-degree heart block was increased 12- and 6.8-fold in the STZ and STZ+Ins groups, respectively, compared with the NONDIAB group, yet this decreased 5.4-fold in the STZ+RH group compared with the STZ group. Incidence of third-degree heart block in the STZ+RH group was 5.6%, 7.8-fold less than the incidence in the STZ group (44%). Mortality due to severe hypoglycemia was 5% in the STZ+RH group, 6.2-fold less than that in the STZ group (31%). In summary, severe hypoglycemia-induced cardiac arrhythmias were increased by insulin deficiency and diabetes and reduced by antecedent recurrent hypoglycemia. In this model, recurrent moderate hypoglycemia reduced fatal severe hypoglycemia-induced cardiac arrhythmias.
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Affiliation(s)
- Candace M Reno
- Division of Endocrinology, Metabolism, and Diabetes, Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Jennifer VanderWeele
- Division of Endocrinology, Metabolism, and Lipid Research, Department of Medicine, Washington University in St. Louis, St. Louis, MO
| | - Justin Bayles
- Division of Endocrinology, Metabolism, and Diabetes, Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Marina Litvin
- Division of Endocrinology, Metabolism, and Lipid Research, Department of Medicine, Washington University in St. Louis, St. Louis, MO
| | - Allie Skinner
- Division of Endocrinology, Metabolism, and Diabetes, Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Andrew Jordan
- Division of Endocrinology, Metabolism, and Diabetes, Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Dorit Daphna-Iken
- Division of Endocrinology, Metabolism, and Lipid Research, Department of Medicine, Washington University in St. Louis, St. Louis, MO
| | - Simon J Fisher
- Division of Endocrinology, Metabolism, and Diabetes, Department of Internal Medicine, University of Utah, Salt Lake City, UT
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Davis IC, Ahmadizadeh I, Randell J, Younk L, Davis SN. Understanding the impact of hypoglycemia on the cardiovascular system. Expert Rev Endocrinol Metab 2017; 12:21-33. [PMID: 29109754 PMCID: PMC5669378 DOI: 10.1080/17446651.2017.1275960] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Hypoglycemia occurs commonly in insulin requiring individuals with either Type 1 or Type 2 Diabetes. AREAS COVERED This article will review recent information on the pro-inflammatory and pro-atherothrombotic effects of hypoglycemia. Additionally, effects of hypoglycemia on arrhythmogenic potential and arterial endothelial dysfunction will be discussed. Effects of hypoglycemia on cardiovascular morbidity and mortality from large clinical studies in Type 1 and Type 2 DM will also be reviewed. EXPERT COMMENTARY The relative and absolute risk of severe hypoglycemia leading to death and serious adverse events in both cardiovascular and other organ systems has been highlighted following the publication of recent large clinical trials focused on glucose control and outcomes. It would be helpful if future studies could develop broader end points to include minor and moderate hypoglycemia as well as more robust methods for capturing hypoglycemia contemporaneously with adverse events. In addition, perhaps consideration of including hypoglycemia as a primary outcome, may help identify the possible cause and effect of hypoglycemia on cardiovascular morbidity and mortality.
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Affiliation(s)
- Ian Charles Davis
- University of Maryland School of Medicine, Baltimore, Maryland 21201-1544, United States
| | - Ida Ahmadizadeh
- University of Maryland School of Medicine, Baltimore, Maryland 21201-1544, United States
| | | | - Lisa Younk
- University of Maryland School of Medicine, Baltimore, Maryland 21201-1544, United States
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Tse G, Lai ETH, Tse V, Yeo JM. Molecular and Electrophysiological Mechanisms Underlying Cardiac Arrhythmogenesis in Diabetes Mellitus. J Diabetes Res 2016; 2016:2848759. [PMID: 27642609 PMCID: PMC5011530 DOI: 10.1155/2016/2848759] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 04/28/2016] [Indexed: 01/11/2023] Open
Abstract
Diabetes is a common endocrine disorder with an ever increasing prevalence globally, placing significant burdens on our healthcare systems. It is associated with significant cardiovascular morbidities. One of the mechanisms by which it causes death is increasing the risk of cardiac arrhythmias. The aim of this article is to review the cardiac (ion channel abnormalities, electrophysiological and structural remodelling) and extracardiac factors (neural pathway remodelling) responsible for cardiac arrhythmogenesis in diabetes. It is concluded by an outline of molecular targets for future antiarrhythmic therapy for the diabetic population.
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Affiliation(s)
- Gary Tse
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong
- *Gary Tse:
| | - Eric Tsz Him Lai
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong
| | - Vivian Tse
- Department of Physiology, McGill University, Montreal, QC, Canada H3G 1Y6
| | - Jie Ming Yeo
- School of Medicine, Imperial College London, London SW7 2AZ, UK
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9
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Kang MY. Blood electrolyte disturbances during severe hypoglycemia in Korean patients with type 2 diabetes. Korean J Intern Med 2015; 30:648-56. [PMID: 26354059 PMCID: PMC4578021 DOI: 10.3904/kjim.2015.30.5.648] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 12/26/2014] [Accepted: 04/05/2015] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS To investigate abnormalities in blood electrolyte levels during severe hypoglycemia in Korean patients with type 2 diabetes mellitus (T2DM) in a clinical setting. METHODS Blood electrolyte levels in adult T2DM patients during severe hypoglycemia were collected from January 1, 2008 to December 31, 2012. Patients who maintained normal serum creatinine and blood urea nitrogen levels were utilized in the study. Severe hypoglycemia was defined as a condition requiring medical assistance, such as administering carbohydrates when serum glucose levels less than 70 mg/dL were observed, in conjunction with other symptoms of hypoglycemia. RESULTS A total of 1,068 patients who visited the emergency room with severe hypoglycemia were screened, of which 219 patients were included in this study. The incidence of abnormal levels for any electrolyte was 47%. Hypokalemia (< 3.5 mmol/L) was the most common type of electrolyte disturbance observed at 21.9%. A decrease in serum potassium levels was associated with decreases in blood glucose levels (r = 0.151, p = 0.025). During severe hypoglycemia, median blood glucose levels, incidence of tachycardia (> 100 beats per minute) and severe hypertension (≥ 180/120 mmHg) were 30 mg/dL (range, 14 to 62) and 35 mg/dL (range, 10 to 69; p = 0.04), 18.8% and 7.2% (p = 0.02), and 20.8% and 10.2% (p = 0.05) in the hypokalemia and normokalemia groups, respectively. CONCLUSIONS During severe hypoglycemia, hypokalemia occurred in 21.9% of T2DM patients and was associated with tachycardia and severe hypertension. Therefore, the results suggest that severe hypoglycemia may increase cardiovascular events in T2DM.
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Affiliation(s)
- Mi Yeon Kang
- Correspondence to Mi Yeon Kang, M.D. Department of Internal Medicine, Saint Carollo Hospital, 221 Sungwang-ro, Suncheon 57931, Korea Tel: +82-61-720-2428 Fax: +82-61-720-6000 E-mail:
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10
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Hanefeld M, Duetting E, Bramlage P. Cardiac implications of hypoglycaemia in patients with diabetes - a systematic review. Cardiovasc Diabetol 2013; 12:135. [PMID: 24053606 PMCID: PMC3849493 DOI: 10.1186/1475-2840-12-135] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 09/16/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hypoglycaemia has been associated with increased cardiovascular (CV) risk and mortality in a number of recent multicentre trials, but the mechanistic links driving this association remain ill defined. This review aims to summarize the available data on how hypoglycaemia may affect CV risk in patients with diabetes. METHODS This was a systematic review of available mechanistic and clinical studies on the relationship between hypoglycaemia and cardiovascular risk. Study outcomes were compiled from relevant articles, and factors contributing to hypoglycaemia-mediated CVD and its complications are discussed. RESULTS Six recent comprehensive clinical trials have reinforced the critical importance of understanding the link between hypoglycaemia and the CV system. In addition, 88 studies have indicated that hypoglycaemia mechanistically contributes to CV risk by increasing thrombotic tendency, causing abnormal cardiac repolarization, inducing inflammation, and contributing to the development of atherosclerosis. These hypoglycaemia-associated risk factors are conducive to events such as unstable angina, non-fatal and fatal myocardial infarction, sudden death, and stroke in patients with diabetes. CONCLUSIONS Emerging data suggest that there is an impact of hypoglycaemia on CV function and mechanistic link is multifactorial. Further research will be needed to ascertain the full impact of hypoglycaemia on the CV system and its complications.
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Affiliation(s)
- Markolf Hanefeld
- Study Centre Professor Hanefeld, GWT, TU Dresden, Dresden, Germany.
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11
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Beom JW, Kim JM, Chung EJ, Kim JY, Ko SY, Na SD, Kim CH, Park G, Kang MY. Corrected QT Interval Prolongation during Severe Hypoglycemia without Hypokalemia in Patients with Type 2 Diabetes. Diabetes Metab J 2013; 37:190-5. [PMID: 23807922 PMCID: PMC3689016 DOI: 10.4093/dmj.2013.37.3.190] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 02/28/2013] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND To evaluate the effects of severe hypoglycemia without hypokalemia on the electrocardiogram in patients with type 2 diabetes in real-life conditions. METHODS Electrocardiograms of adult type 2 diabetic patients during the episodes of severe hypoglycemia and the recovered stage were obtained and analysed between October 1, 2011 and May 31, 2012. Patients who maintained the normal serum sodium and potassium levels during the episodes of severe hypoglycemia were only selected as the subjects of this study. Severe hypoglycemia was defined, in this study, as the condition requiring active medical assistance such as administering carbohydrate when serum glucose level was less than 60 mg/dL. RESULTS Nine type 2 diabetes patients (seven men, two women) were included in the study. The mean subject age was 73.2±7.7 years. The mean hemoglobin A1c level was 6.07%±1.19%. The median duration of diabetes was 10 years (range, 3.5 to 30 years). Corrected QT (QTc) intervals were significantly increased during the episodes of severe hypoglycemia compared to the recovered stage (447.6±18.2 ms vs. 417.2±30.6 ms; P<0.05). However, the morphology and the amplitude of the T waves were not changed and ST-segment elevation and/or depression were not found during the episodes of severe hypoglycemia. CONCLUSION In this study, QTc interval prolongation during the episodes of severe hypoglycemia was observed without hypokalemia. Therefore, the distinct alterations in cardiac repolarization during the episodes of severe hypoglycemia may not be associated with hypokalemia.
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Affiliation(s)
- Jae Won Beom
- Department of Internal Medicine, Saint Carollo Hospital, Suncheon, Korea
| | - Jung Min Kim
- Department of Internal Medicine, Saint Carollo Hospital, Suncheon, Korea
| | - Eun Joo Chung
- Department of Neurology, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Ju Yeong Kim
- Department of Internal Medicine, Saint Carollo Hospital, Suncheon, Korea
| | - Seung Yeong Ko
- Department of Internal Medicine, Saint Carollo Hospital, Suncheon, Korea
| | - Sang Don Na
- Department of Internal Medicine, Saint Carollo Hospital, Suncheon, Korea
| | - Cheol Hwan Kim
- Department of Internal Medicine, Saint Carollo Hospital, Suncheon, Korea
| | - Gun Park
- Department of Internal Medicine, Saint Carollo Hospital, Suncheon, Korea
| | - Mi Yeon Kang
- Department of Internal Medicine, Saint Carollo Hospital, Suncheon, Korea
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12
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Abstract
Hypoglycemia is a common finding in both daily clinical practice and acute care settings. The causes of severe hypoglycemia (SH) are multi-factorial and the major etiologies are iatrogenic, infectious diseases with sepsis and tumor or autoimmune diseases. With the advent of aggressive lowering of HbA1c values to achieve optimal glycemic control, patients are at increased risk of hypoglycemic episodes. Iatrogenic hypoglycemia can cause recurrent morbidity, sometime irreversible neurologic complications and even death, and further preclude maintenance of euglycemia over a lifetime of diabetes. Recent studies have shown that hypoglycemia is associated with adverse outcomes in many acute illnesses. In addition, hypoglycemia is associated with increased mortality among elderly and non-diabetic hospitalized patients. Clinicians should have high clinical suspicion of subtle symptoms of hypoglycemia and provide prompt treatment. Clinicians should know that hypoglycemia is associated with considerable adverse outcomes in many acute critical illnesses. In order to reduce hypoglycemia-associated morbidity and mortality, timely health education programs and close monitoring should be applied to those diabetic patients presenting to the Emergency Department with SH. ED disposition strategies should be further validated and justified to achieve balance between the benefits of euglycemia and the risks of SH. We discuss relevant issues regarding hypoglycemia in emergency and critical care settings.
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Affiliation(s)
- Shih-Hung Tsai
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yen-Yue Lin
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chin-Wang Hsu
- Department of Critical & Emergency Medicine, Cheng-Hsin General Hospital, Taipei, Taiwan
| | - Chien-Sheng Cheng
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Der-Ming Chu
- Peng-Hu Branch, Tri-Service General Hospital, National Defense Medical Center, Peng-Hu, Taiwan
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13
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Caduff A, Lutz HU, Heinemann L, Di Benedetto G, Talary MS, Theander S. Dynamics of blood electrolytes in repeated hyper- and/or hypoglycaemic events in patients with type 1 diabetes. Diabetologia 2011; 54:2678-89. [PMID: 21674178 DOI: 10.1007/s00125-011-2210-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Accepted: 05/09/2011] [Indexed: 01/12/2023]
Abstract
AIMS/HYPOTHESIS Electrolyte disturbances are well-known consequences of the diabetic pathology. However, less is known about the cumulative effects of repeated changes in glycaemia, a characteristic of diabetes, on the electrolyte balance. We therefore investigated the ionic profiles of patients with type 1 diabetes during consecutive hyper- and/or hypoglycaemic events using the glucose clamp. METHODS In protocol 1, two successive hyperglycaemic excursions to 18 mmol/l were induced; in protocol 2, a hypoglycaemic excursion (2.5 mmol/l) was followed by a hyperglycaemic excursion (12 mmol/l) and another hypoglycaemic episode (3.0 mmol/l). RESULTS Blood osmolarity increased during hyperglycaemia and was unaffected by hypoglycaemia. Hyperglycaemia induced decreases in plasma Na(+) Cl(-) and Ca(2+) concentrations and increases in K(+) concentrations. These changes were faithfully reproduced during a second hyperglycaemia. Hypoglycaemia provoked rapid and rapidly reversible increases in Na(+), Cl(-) and Ca(2+). In sharp contrast, K(+) levels displayed a rapid and substantial fall from which they did not fully recover even 2 h after the re-establishment of euglycaemia. A second hypoglycaemia caused an additional fall. CONCLUSIONS/INTERPRETATION Repeated hyperglycaemia events do not lead to any cumulative effects on blood electrolytes. However, repeated hypoglycaemias are cumulative with respect to K(+) levels due to a very slow recovery following hypoglycaemia. These results suggest that recurring hypoglycaemic events may lead to progressively lower K(+) levels despite rapid re-establishment of euglycaemia. This warrants close monitoring of plasma K(+) levels combined with continuous glucose monitoring particularly in patients under intensive insulin therapy who are subject to repeated hypoglycaemic episodes. TRIAL REGISTRATION Clinicaltrial.gov NCT01060917.
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Affiliation(s)
- A Caduff
- Solianis Monitoring AG, Leutschenbachstrasse 46, CH-8050 Zürich, Switzerland.
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14
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Christensen TF, Baekgaard M, Dideriksen JL, Steimle KL, Mogensen ML, Kildegaard J, Struijk JJ, Hejlesen OK. A physiological model of the effect of hypoglycemia on plasma potassium. J Diabetes Sci Technol 2009; 3:887-94. [PMID: 20144338 PMCID: PMC2769974 DOI: 10.1177/193229680900300436] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Adrenaline release and excess insulin during hypoglycemia stimulate the uptake of potassium from the bloodstream, causing low plasma potassium (hypokalemia). Hypokalemia has a profound effect on the heart and is associated with an increased risk of malignant cardiac arrhythmias. It is the aim of this study to develop a physiological model of potassium changes during hypoglycemia to better understand the effect of hypoglycemia on plasma potassium. METHOD Potassium counterregulation to hypokalemia was modeled as a linear function dependent on the absolute potassium level. An insulin-induced uptake of potassium was modeled using a negative exponential function, and an adrenaline-induced uptake of potassium was modeled as a linear function. Functional expressions for the three components were found using published data. RESULTS The performance of the model was evaluated by simulating plasma potassium from three published studies. Simulations were done using measured levels of adrenaline and insulin. The mean root mean squared error (RMSE) of simulating plasma potassium from the three studies was 0.09 mmol/liter, and the mean normalized RMSE was 14%. The mean difference between nadirs in simulated and measured potassium was 0.12 mmol/liter. CONCLUSIONS The presented model simulated plasma potassium with good accuracy in a wide range of clinical settings. The limited number of hypoglycemic episodes in the test set necessitates further tests to substantiate the ability of the model to simulate potassium during hypoglycemia. In conclusion, the model is a good first step toward better understanding of changes in plasma potassium during hypoglycemia.
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15
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Rothenbuhler A, Bibal CP, Le Fur S, Bougneres P. Effects of a controlled hypoglycaemia test on QTc in adolescents with Type 1 diabetes. Diabet Med 2008; 25:1483-5. [PMID: 19046250 DOI: 10.1111/j.1464-5491.2008.02599.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Our objective was to test the ventricular repolarization response to a controlled hypoglycaemia test in Type 1 diabetic adolescents, an age group at risk for 'dead in bed syndrome'. We measured QTc, blood glucose level, potassium, heart rate, blood pressure and urinary metanephrine levels in 16 Type 1 diabetic adolescents during an insulin clamp mimicking the transition from mild hyperglycaemia to hypoglycaemia. QTc increased in all patients by 146 +/- 44 ms (mean +/-sd) ranging from 70 to 230 ms. The longest QTc (630 ms) was recorded in the sibling of a diabetic patient found 'dead in bed'. Heart rate and urinary metanephrine levels correlated with QTc (r = 0.60 and 0.79, respectively; P = 0.02 and 0.003). QTc in euglycaemia showed no correlation with hypoglycaemia associated QTc prolongation. The prognostic value of the hypoglycaemia test for the risk of recurrent episodes of QTc prolongation should be evaluated in real-life conditions in large-scale studies of diabetic adolescents.
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Affiliation(s)
- A Rothenbuhler
- Department of Paediatric Endocrinology, University Paris Descartes, Hôpital Saint Vincent de Paul, AP-HP, Paris, France
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16
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Howarth FC, Qureshi MA. Effects of carbenoxolone on heart rhythm, contractility and intracellular calcium in streptozotocin-induced diabetic rat. Mol Cell Biochem 2006; 289:21-9. [PMID: 16583133 DOI: 10.1007/s11010-006-9143-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2005] [Accepted: 01/23/2006] [Indexed: 11/24/2022]
Abstract
Cardiac dysfunction is a frequently reported complication of clinical and experimental diabetes mellitus. Streptozotocin (STZ)-induced diabetes in rat is associated with a variety of cardiac defects including disturbances to heart rhythm and prolonged time-course of cardiac muscle contraction and/or relaxation. The effects of carbenoxolone (CBX), a selective gap junction inhibitor, on heart rhythm and contractility in STZ-induced diabetic rat have been investigated. Heart rate was significantly (P < 0.05) reduced in Langendorff perfused spontaneously beating diabetic rat heart (171+/-12 BPM) compared to age-matched controls (229+/- 9 BPM) and further reduced by 10(-5) M CBX in diabetic (20%) and in control (17%) hearts. Action potential durations (APDs), recorded on the epicardial surface of the left ventricle, were prolonged in paced (6 Hz) diabetic compared to control hearts. Perfusion of hearts with CBX caused further prolongation of APDs and to a greater extent in control compared to diabetic heart. Percentage prolongation at 70% from the peak of the action potential amplitude after CBX was 18% in diabetic compared to 48% in control heart. CBX had no significant effect on resting cell length or amplitude of ventricular myocyte shortening in diabetic or control rats. However, resting fura-2 ratio (indicator for intracellular Ca(2+) concentration) and amplitude of the Ca(2+) transient were significantly (P < 0.05) reduced by CBX in diabetic rats but not in controls. In conclusion the larger effects of CBX on APD in control ventricle and the normalizing effects of CBX on intracellular Ca(2+) in ventricular myocytes from diabetic rat suggest that there may be alterations in gap junction electrophysiology in STZ-induced diabetic rat heart.
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Affiliation(s)
- F C Howarth
- Department of Physiology, Faculty of Medicine & Health Sciences, United Arab Emirates University, P.O. Box 17666, Al Ain, U.A.E.
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