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Dun Y, Wu S, Cui N, Thomas RJ, Olson TP, Zhou N, Li Q, Liu S. Screening for Asymptomatic Coronary Artery Disease via Exercise Stress Testing in Patients With Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2021; 8:770648. [PMID: 34790709 PMCID: PMC8591186 DOI: 10.3389/fcvm.2021.770648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 10/08/2021] [Indexed: 11/15/2022] Open
Abstract
Objectives: This meta-analysis aims to investigate the diagnostic value of exercise stress testing (EST) for asymptomatic coronary artery disease (CAD) among patients with type 2 diabetes mellitus (T2DM) and to ascertain the influence of different variables on the sensitivity and specificity of EST. Background: Asymptomatic CAD occurs in >1 in five diabetes mellitus patients, and it is associated with an increased risk of complications. Methods for screening asymptomatic CAD in T2DM patients are still not unified. Methods: MEDLINE (via Ovid), Embase (via Ovid), Cochrane Library, SCOPUS, PubMed, Ovid, EBSCO ASP, and Web of Science were systematically searched on June 8 and 9, 2021, for diagnostic cohort and case-control studies. We included studies that used EST to screen for CAD in asymptomatic patients with T2DM, and that used coronary angiography to diagnose CAD and had reported the basic diagnostic indicators. The Quality Assessment of Diagnostic Accuracy Studies 2 tool was used to assess study quality. The combined effect sizes were calculated by overall analysis and multiple variable effects were explored by regression analysis and subgroup analysis. Results: Nine groups of data from eight diagnostic cohort studies, totaling 515 participants, were included. Included studies showed a low risk of bias in most items, except for flow and timing. The combined sensitivity and specificity of EST for asymptomatic CAD in patients with T2DM were 55 (48 to 61%) and 66 (61 to 70%), respectively. When non-diagnostic tests were excluded, sensitivity increased to 73 (56 to 88%). The proportion receiving angiography also significantly affected sensitivity. No significant difference was found in the duration of diabetes or other additional risk factors. Conclusions: EST is a tool of moderate sensitivity and specificity to be used for the initial screening of asymptomatic CAD in T2DM. It has the advantage of being non-invasive, relatively inexpensive, easily available in most settings, and has no radiation associated with its use. Additional research with higher quality studies in which tests that are non-diagnostic are included and flow and timing is described clearly, will be important to further our understanding of EST for asymptomatic CAD detection in patients with T2DM. Systematic review registration: PROSPERO CRD42021259555.
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Affiliation(s)
- Yaoshan Dun
- Division of Cardiac Rehabilitation, Department of Physical Medicine & Rehabilitation, Xiangya Hospital of Central South University, Changsha, China
- National Clinical Research Centre for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, China
- Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Shaoping Wu
- Division of Cardiac Rehabilitation, Department of Physical Medicine & Rehabilitation, Xiangya Hospital of Central South University, Changsha, China
| | - Ni Cui
- Division of Cardiac Rehabilitation, Department of Physical Medicine & Rehabilitation, Xiangya Hospital of Central South University, Changsha, China
| | - Randal J. Thomas
- Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Thomas P. Olson
- Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Nanjiang Zhou
- Division of Cardiac Rehabilitation, Department of Physical Medicine & Rehabilitation, Xiangya Hospital of Central South University, Changsha, China
| | - Qiuxia Li
- Division of Cardiac Rehabilitation, Department of Physical Medicine & Rehabilitation, Xiangya Hospital of Central South University, Changsha, China
| | - Suixin Liu
- Division of Cardiac Rehabilitation, Department of Physical Medicine & Rehabilitation, Xiangya Hospital of Central South University, Changsha, China
- National Clinical Research Centre for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, China
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Knapper JT, Raval Z, Harinstein ME, Friedewald JJ, Skaro AI, Abecassis MI, Ali ZA, Gheorghiade M, Flaherty JD. Assessment and management of coronary artery disease in kidney and pancreas transplant candidates. J Cardiovasc Med (Hagerstown) 2019; 20:51-58. [DOI: 10.2459/jcm.0000000000000742] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Heier M, Ofstad AP, Borja MS, Brunborg C, Endresen K, Gullestad L, Birkeland KI, Johansen OE, Oda MN. High-density lipoprotein function is associated with atherosclerotic burden and cardiovascular outcomes in type 2 diabetes. Atherosclerosis 2018; 282:183-187. [PMID: 30017177 DOI: 10.1016/j.atherosclerosis.2018.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 07/05/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND AIMS Measures of HDL function are emerging tools for assessing cardiovascular disease (CVD) event risk. HDL-apoA-I exchange (HAE) reflects HDL capacity for reverse cholesterol transport. METHODS HAE was measured in 93 participants with type 2 diabetes (T2D) and at least one additional CVD risk factor in the Asker and Bærum Cardiovascular Diabetes study. At baseline and after seven years, the atherosclerotic burden was assessed by invasive coronary angiography. Major CVD events were registered throughout the study. RESULTS Linear regression analysis demonstrated a significant inverse association between HAE and atherosclerotic burden. Cox proportional hazard regression analysis showed a significant association between HAE and a composite of major CVD events when controlling for waist-hip ratio, HR = 0.89, 95% CI = 0.80-1.00 and p=0.040. CONCLUSIONS Despite the relatively small size of the study population and the limited number of CVD events, these findings suggest that HAE provides valuable information in determining CVD risk.
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Affiliation(s)
- Martin Heier
- Children's Hospital Oakland Research Institute, 5700 Martin Luther King Jr Way, Oakland, CA, 94609, USA; Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Anne Pernille Ofstad
- Vestre Viken HF, Bærum Hospital, Department of Medical Research, Gjettum, Norway
| | - Mark S Borja
- Children's Hospital Oakland Research Institute, 5700 Martin Luther King Jr Way, Oakland, CA, 94609, USA
| | - Cathrine Brunborg
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Knut Endresen
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Lars Gullestad
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Kåre I Birkeland
- Department of Transplantation Medicine, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Odd Erik Johansen
- Vestre Viken HF, Bærum Hospital, Department of Medical Research, Gjettum, Norway
| | - Michael N Oda
- Children's Hospital Oakland Research Institute, 5700 Martin Luther King Jr Way, Oakland, CA, 94609, USA
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Chen L, Wei B, Xu L, Wu Y. The association of inflammatory markers and periodontal indexes with the risk of coronary heart disease in Chinese patients with type 2 diabetes mellitus. Diabetes Res Clin Pract 2018; 135:37-44. [PMID: 29111278 DOI: 10.1016/j.diabres.2017.10.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 09/29/2017] [Accepted: 10/11/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVES The present study was designed to investigate the association of four inflammatory markers and five periodontal indexes with the risk of coronary heart disease (CHD) in 131 patients with type 2 diabetes mellitus (T2DM). METHODS All subjects were inpatients, including 63 T2DM patients with comorbid CHD ("cases") and 68 T2DM patients without CHD ("controls"). The diagnosis of CHD is based on coronary angiography. RESULTS Peripheral blood concentrations of high sensitivity C-reactive protein (hs-CRP) (11.51 vs. 10.39 mg/L), leptin (24.60 vs. 21.22 ng/L) and visfatin (65.92 vs. 57.62 ng/L) were significantly higher in cases than in controls (P = .033, 0.041 and 0.041, respectively). The levels of three periodontal indexes - probing pocket depth, attachment loss (AL) and sulcus bleeding index, were significantly higher in cases than in controls, especially for periodontal AL (3.60 mm vs. 3.29 mm, P = .002). A Forward logistic regression was performed for selection, and specifically hs-CRP, leptin, visfatin and periodontal AL were found to be associated with the significant risk of CHD (odds ratio: 1.16, 1.07, 1.03 and 2.04; P = .025, .022, .022 and .010, respectively). Importantly, the benefits of inflammatory markers and periodontal indexes over basic risk factors were significant (likelihood ratio test) and obvious (decision curve analysis). A nomogram was delineated based on significant variables, and it had good accuracy (C-index: 0.801, P < .001). CONCLUSIONS Our findings support the significant contribution of inflammatory markers and periodontal indexes to the pathogenesis of CHD in T2DM. Specifically, hs-CRP, leptin, visfatin and periodontal AL were identified as significant contributors.
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Affiliation(s)
- Ling Chen
- Department of Stomatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China; Teaching and Research Section of Stomatology, The First Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China
| | - Bin Wei
- Department of Stomatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China; Teaching and Research Section of Stomatology, The First Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China
| | - Liang Xu
- Department of Stomatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China; Teaching and Research Section of Stomatology, The First Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China
| | - Yun Wu
- Department of Stomatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China; Teaching and Research Section of Stomatology, The First Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China.
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Ofstad AP, Ulimoen GR, Orvik E, Birkeland KI, Gullestad LL, Fagerland MW, Johansen OE. Long-term follow-up of a hospital-based, multi-intervention programme in type 2 diabetes mellitus: impact on cardiovascular events and death. J Int Med Res 2017. [PMID: 28627980 PMCID: PMC5718720 DOI: 10.1177/0300060517707674] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Objective To report the long-term impact on cardiovascular (CV) outcomes and mortality of a 2-year hospital-based multi-interventional care programme as compared with general practitioner (GP)-provided standard care. Methods Patients with type 2 diabetes with ≥ 1 additional CV risk factor were randomized to 2 years of specialist-based, multi-intervention comprising lifestyle modification and specific pharmacological treatment, or GP-based standard care. After the 2-year intervention period, all participants returned to pre-study care, but were followed up for CV outcomes and mortality. The primary outcome was time to any first severe CV event or death. Results A total of 120 patients (31 women) were enrolled in the study. During the mean ± SD observational period of 8.7 ± 2.0 years, 27 patients (16 and 11 in the multi-intervention and standard care groups, respectively) experienced at least one primary outcome event, with a hazard ratio (HR) if allocated to the multi-intervention group of 1.73 (95% confidence interval (CI) 0.80, 3.75). The HR for total mortality was 1.82 (95% CI 0.66, 5.01). Conclusions Hospital-based multi-intervention in patients with type 2 diabetes mellitus improved long-term glycaemic control, but failed to reduce CV outcomes and deaths. Clinical trials.gov id: NCT00133718.
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Affiliation(s)
- Anne Pernille Ofstad
- 1 Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Drammen, Norway
| | | | - Elsa Orvik
- 1 Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Drammen, Norway
| | - Kåre Inge Birkeland
- 3 Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.,6 Institue for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Lars L Gullestad
- 4 Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Morten Wang Fagerland
- 5 Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Odd Erik Johansen
- 1 Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Drammen, Norway
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Ulimoen GR, Ofstad AP, Endresen K, Gullestad L, Johansen OE, Borthne A. Low-dose CT coronary angiography for assessment of coronary artery disease in patients with type 2 diabetes--a cross-sectional study. BMC Cardiovasc Disord 2015; 15:147. [PMID: 26573616 PMCID: PMC4647633 DOI: 10.1186/s12872-015-0143-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 11/06/2015] [Indexed: 11/22/2022] Open
Abstract
Background Silent coronary artery disease (CAD) is prevalent in type 2 diabetes mellitus (T2DM). Although coronary computed tomography angiography (CCTA) over recent years has emerged a useful tool for assessing and diagnosing CAD it’s role and applicability for patients with T2DM is still unclarified, in particular in asymptomatic patients. We aimed to assess the role of CCTA in detecting and characterizing CAD in patients with T2DM without cardiac symptoms when compared to gold standard invasive coronary angiography (ICA). Methods This was a cross-sectional analysis of patients with T2DM without symptomatic CAD enrolled in the Asker and Baerum Cardiovascular Diabetes Study who, following clinical examination and laboratory assessment, underwent subsequently CCTA and ICA. Results In total 48 Caucasian patients with T2DM (36 men, age 64.0 ± 7.3 years, diabetes duration 14.6 ± 6.4 years, HbA1c 7.4 ± 1.1 %, BMI 29.6 ± 4.3 kg/m2) consented to, and underwent, both procedures (CCTA and ICA). The population was at intermediate cardiovascular risk (mean coronary artery calcium score 269, 75 % treated with antihypertensive therapy). ICA identified a prevalence of silent CAD at 17 % whereas CCTA 35 %. CCTA had a high sensitivity (100 %) and a high negative predictive value (100 %) for detection of patients with CAD when compared to ICA, but the positive predictive value was low (47 %). Conclusions Low-dose CCTA is a reliable method for detection and exclusion of significant CAD in T2DM and thus may be a useful tool for the clinicians. However, a low positive predictive value may limit its usefulness as a screening tool for all CAD asymptomatic patients with T2DM. Further studies should assess the applicability for risk assessment beyond the evaluation of the vascular bed.
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Affiliation(s)
- Geir Reinvik Ulimoen
- Department of Radiology, Akershus University Hospital, PB 1000, 1478, Lorenskog, Norway.
| | - Anne Pernille Ofstad
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, 3004, Drammen, Norway.
| | - Knut Endresen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, 0372, Oslo, Norway.
| | - Lars Gullestad
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, 0372, Oslo, Norway. .,University of Oslo, Oslo, Norway.
| | - Odd Erik Johansen
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, 3004, Drammen, Norway.
| | - Arne Borthne
- Department of Radiology, Akershus University Hospital, PB 1000, 1478, Lorenskog, Norway. .,University of Oslo, Oslo, Norway.
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7
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Ofstad AP, Urheim S, Dalen H, Orvik E, Birkeland KI, Gullestad L, W Fagerland M, Johansen OE, Aakhus S. Identification of a definite diabetic cardiomyopathy in type 2 diabetes by comprehensive echocardiographic evaluation: A cross-sectional comparison with non-diabetic weight-matched controls. J Diabetes 2015; 7:779-90. [PMID: 25350248 DOI: 10.1111/1753-0407.12239] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 09/11/2014] [Accepted: 10/07/2014] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Subclinical left ventricular (LV) dysfunction is prevalent in type 2 diabetes (T2DM). As obesity has been proposed as one causal factor in the disease process, this could bias the reported prevalences. We wanted to characterize echocardiographic LV dysfunction in obese T2DM subjects as compared to non-diabetic obese controls. METHODS One hundred patients with T2DM without clinical signs of heart failure (29% females, mean ± SD age 58.4 ± 10.5 years, body mass index (BMI) 30.1 ± 5.5 kg/m(2), blood pressure (BP) 141 ± 18/83 ± 9 mmHg) and 100 non-diabetic controls (29% females) matched for age (58.6 ± 10.5 years), BMI (29.8 ± 4.0 kg/m(2) and systolic BP (140 ± 14 mmHg) underwent echocardiography and color tissue Doppler imaging (TDI). Diastolic function was evaluated with conventional Doppler recordings and early (e') and late (a') myocardial velocities. The ratio between early transmitral filling (E) and the corresponding myocardial tissue velocity (e') served as an index of LV filling pressure. RESULTS T2DM patients had more concentric hypertrophy with a relative wall thickness of 0.42 ± 0.07 vs controls 0.38 ± 0.07, P < 0.001. The T2DM group had signs of diastolic dysfunction with lower E/A ratio (0.91 ± 0.27 vs. 1.12 ± 0.38, P < 0.001), deceleration time (195 ± 49 vs 242 ± 72 ms, P < 0.001), e' (5.7 ± 2.0 vs. 6.6 ± 1.8 cm/s, P = 0.001), and a' (6.5 ± 2.0 vs. 7.6 ± 1.5 cm/s, P < 0.001) compared to the controls, and higher E/e' (13.3 ± 4.7 vs. 11.1 ± 3.5, P < 0.001). Thus, there were indications of pseudo normalization and increased filling pressure in the T2DM group, whereas the controls had evidence for relaxation abnormalities without elevated filling pressure. CONCLUSION Compared to a non-diabetic obese group, more advanced subclinical impairment of diastolic function was seen in T2DM.
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MESH Headings
- Aged
- Body Mass Index
- Case-Control Studies
- Confounding Factors, Epidemiologic
- Cross-Sectional Studies
- Diabetes Mellitus, Type 2/complications
- Diabetes Mellitus, Type 2/diagnosis
- Diabetic Cardiomyopathies/diagnostic imaging
- Diabetic Cardiomyopathies/etiology
- Diabetic Cardiomyopathies/physiopathology
- Diastole
- Echocardiography, Doppler, Color
- Female
- Humans
- Hypertrophy, Left Ventricular/diagnostic imaging
- Hypertrophy, Left Ventricular/etiology
- Hypertrophy, Left Ventricular/physiopathology
- Logistic Models
- Male
- Middle Aged
- Multivariate Analysis
- Obesity/complications
- Obesity/diagnosis
- Odds Ratio
- Predictive Value of Tests
- Risk Factors
- Systole
- Ventricular Dysfunction, Left/diagnostic imaging
- Ventricular Dysfunction, Left/etiology
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Function, Left
- Ventricular Pressure
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Affiliation(s)
- Anne Pernille Ofstad
- Department of Medical Research, Baerum Hospital, Vestre Viken Hospital Trust, Baerum, Norway
| | - Stig Urheim
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Håvard Dalen
- MI Lab and Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Medicine, Levanger Hospital, Nord-Trøndelag Health Trust, Levanger, Norway
| | - Elsa Orvik
- Department of Medical Research, Baerum Hospital, Vestre Viken Hospital Trust, Baerum, Norway
| | - Kåre I Birkeland
- Department of Endocrinology, Morbid Obesity and Preventive Disease, Oslo University Hospital Aker, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Lars Gullestad
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- K.G. Jebsen Cardiac Research Centre and Center for Heart Failure Research, Oslo Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Morten W Fagerland
- Unit of Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - Odd Erik Johansen
- Department of Medical Research, Baerum Hospital, Vestre Viken Hospital Trust, Baerum, Norway
| | - Svend Aakhus
- MI Lab and Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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Johansen OE. Interpretation of cardiovascular outcome trials in type 2 diabetes needs a multiaxial approach. World J Diabetes 2015; 6:1092-6. [PMID: 26265995 PMCID: PMC4530322 DOI: 10.4239/wjd.v6.i9.1092] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 06/25/2015] [Accepted: 07/21/2015] [Indexed: 02/05/2023] Open
Abstract
In cardiovascular (CV) diabetology a "one-size fits-all" approach needs caution as vasculopathy and CV manifestations in patients with type 2 diabetes (T2D) with short disease duration are different as compared to those with longer duration. This is of relevance when interpreting results of CV outcome trials as responses to any intervention aimed to reduce CV risk might be different in patients with established vasculopathy as compared to those without, where also the duration of the intervention may play a role. Additionally, the mode-of-action of the intervention and its assumed time to peak CV risk modulation need to be taken into account: an intervention with possibly immediate effects, like on blood pressure or other direct functional dynamic parameters such as endothelial function or renal hemodynamics, could likely provide a meaningful impact on CV outcomes over a shorter time span than interventions that primarily target pathways that work on atherosclerotic processes, organ-remodelling, or vessel integrity. We are now faced with CV outcome results to interpret from a plethora of outcomes trials in T2D, some of which are testing the CV risk modulation predominantly beyond glucose lowering, e.g., as is the case for several trials testing the newer therapy classes di-peptidyl peptidase-4 inhibitors, glucagon-like protein-1 receptor analogues and sodium glucose co-transporter-2 inhibitors, and this paper reviews the data that support a call for a multiaxial approach to interpret these results.
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Ofstad AP, Johansen OE, Gullestad L, Birkeland KI, Orvik E, Fagerland MW, Urheim S, Aakhus S. Neutral impact on systolic and diastolic cardiac function of 2 years of intensified multi-intervention in type 2 diabetes: the randomized controlled Asker and Bærum Cardiovascular Diabetes (ABCD) study. Am Heart J 2014; 168:280-288.e2. [PMID: 25173538 DOI: 10.1016/j.ahj.2014.03.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 03/19/2014] [Indexed: 01/21/2023]
Abstract
BACKGROUND Patients with type 2 diabetes (T2D) are prone to develop preclinical myocardial dysfunction, but no single strategy to prevent progression to heart failure has been established. We aimed to assess whether intensified global cardiovascular (CV) risk factor control would improve left ventricular (LV) systolic and diastolic function as compared with standard of care. METHODS A total of 100 patients with ≥1 CV risk factor (29% female, mean ± SD age 58 ± 10 years, LV ejection fraction 63 ± 8%, 16% with LV diastolic dysfunction) were randomized to 2 years of intensified CV risk multi-intervention (INT, n = 50) or standard care (STAND, n = 50). Echocardiography, including tissue Doppler imaging, and maximum exercise test were performed at baseline and study end. Multi-intervention comprised lifestyle intervention and pharmacologic treatment to reach strict prespecified CV risk factor goals, whereas STAND group received current guideline care. RESULTS Greater reductions were observed for hemoglobin A1c and total cholesterol in the INT group (P < .001 and P = .021, respectively), whereas blood pressure reduction was similar. Work capacity increased in INT and decreased in STAND (P = .014). There was no significant between-group difference in the change in any of the echocardiographic parameters. CONCLUSIONS Two years of intensified multi-intervention in patients with T2D improved work capacity and glycemic and lipid control and had no significant benefit or harm on resting cardiac function.
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Ofstad AP, Gullestad L, Orvik E, Aakhus S, Endresen K, Ueland T, Aukrust P, Fagerland MW, Birkeland KI, Johansen OE. Interleukin-6 and activin A are independently associated with cardiovascular events and mortality in type 2 diabetes: the prospective Asker and Bærum Cardiovascular Diabetes (ABCD) cohort study. Cardiovasc Diabetol 2013; 12:126. [PMID: 23987834 PMCID: PMC3766106 DOI: 10.1186/1475-2840-12-126] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Accepted: 08/26/2013] [Indexed: 01/29/2023] Open
Abstract
Background Novel and robust cardiovascular (CV) markers are needed to improve CV morbidity and mortality risk prediction in type 2 diabetes (T2D). We assessed the long term predictive value of 4 novel CV risk markers for major CV events and mortality. Methods We included patients with T2D who had cytokines (interleukin [IL]-6 and activin A [actA]), a maximum stress ECG test (evaluated by the normalization pattern in early recovery phase) and echocardiography (evaluated by a measure of the left ventricular filling pressure - E/Em) assessed at baseline. The primary endpoint was time to first of any of the following events: myocardial infarction, stroke, hospitalization for unstable angina pectoris and death. All outcomes were adjudicated by independent experts. We used Cox proportional hazard modeling, Harrell C-statistic and the net reclassification improvement (NRI) to assess the additional value beyond conventional markers (age, gender, prior CV disease, HDL, creatinine, diastolic BP, microalbuminuria). Results At baseline the study cohort (n = 135, mean age/diabetes duration/HbA1c: 59 yrs/7 yrs/7.6% [59 mmol/mol], 26% females) had moderate elevated CV risk (42% microalbuminuria, mean Framingham 10 year CV-risk 9.6%). During 8.6 yrs/1153.7 person years, 26 patients experienced 36 events. All 4 novel risk markers were significantly associated with increased risk of the primary endpoint, however, only IL-6 and actA improved C-statistic and NRI (+0.119/43.2%, +0.065/20.3% respectively) compared with the conventional CV risk factors. Conclusions IL-6 and actA may provide prognostic information on CV events and mortality in T2D beyond conventional CV risk factors. Trial registration ClinicalTrials.gov:
NCT00133718
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Affiliation(s)
- Anne Pernille Ofstad
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, N-1309 Rud, Bærum, Norway.
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Ueland T, Aukrust P, Aakhus S, Smith C, Endresen K, Birkeland KI, Gullestad L, Johansen OE. Activin A and cardiovascular disease in type 2 diabetes mellitus. Diab Vasc Dis Res 2012; 9:234-7. [PMID: 22234949 DOI: 10.1177/1479164111431171] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Silent coronary artery disease is a frequent complication of type 2 diabetes (T2DM). Based on its multiple roles in inflammation, atherogenesis and glucose homeostasis, we hypothesised that activin A could be related to coronary atherosclerosis in T2DM. METHODS Activin A and follistatin were measured in 102 patients with T2DM and 20 age- and sex-matched healthy controls. Coronary angiography was performed in a sub-population of patients and associations with activin A were examined using multiple linear regression. RESULTS Serum activin A and the activin A/follistatin ratio were increased in patients with T2DM and coronary artery disease (CAD) compared with healthy volunteers and the elevated activin A was associated with the severity of coronary atherosclerotic burden as determined by the proportion of ≥2 vessel disease (p = 0.035) after multivariable-adjusted trend analysis. No significant association between presence of CAD or extent score and activin A was observed. CONCLUSION In patients with T2DM, increased activin A may reflect chronic underlying pathophysiological processes involved in development of cardiovascular disease.
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Affiliation(s)
- Thor Ueland
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Norway.
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12
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Katsiki N, Yovos JG, Gotzamani-Psarrakou A, Karamitsos DT. Adipokines and vascular risk in type 2 diabetes mellitus. Angiology 2012; 62:601-4. [PMID: 21990548 DOI: 10.1177/0003319711409201] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Niki Katsiki
- First Propedeutic Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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13
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Hallén J, Johansen OE, Birkeland KI, Gullestad L, Aakhus S, Endresen K, Tjora S, Jaffe AS, Atar D. Determinants and prognostic implications of cardiac troponin T measured by a sensitive assay in type 2 diabetes mellitus. Cardiovasc Diabetol 2010; 9:52. [PMID: 20843304 PMCID: PMC2946276 DOI: 10.1186/1475-2840-9-52] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2010] [Accepted: 09/15/2010] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The cardiac troponins are biomarkers used for diagnosis of myocardial injury. They are also powerful prognostic markers in many diseases and settings. Recently introduced high-sensitivity assays indicate that chronic cardiac troponin elevations are common in response to cardiovascular (CV) morbidity. Type 2 diabetes mellitus (T2DM) confers a high risk of CV disease, but little is known about chronic cardiac troponin elevations in diabetic subjects. Accordingly, we aimed to understand the prevalence, determinants, and prognostic implications of cardiac troponin T (cTnT) elevations measured with a high-sensitivity assay in patients with T2DM. METHODS cTnT was measured in stored, frozen serum samples from 124 subjects enrolled in the Asker and Bærum Cardiovascular Diabetes trial at baseline and at 2-year follow-up, if available (96 samples available). Results were analyzed in relation to baseline variables, hospitalizations, and group assignment (multifactorial intensive versus conventional diabetes care for lowering CV risk). RESULTS One-hundred thirteen (90%) had detectable cTnT at baseline and of those, 22 (18% of the total population) subjects had values above the 99th percentile for healthy controls (13.5 ng/L). Levels at baseline were associated with conventional CV risk factors (age, renal function, gender). There was a strong correlation between cTnT levels at the two time-points (r=0.92, p>0.001). Risk for hospitalizations during follow-up increased step-wise by quartiles of hscTnT measured at baseline (p=0.058). CONCLUSIONS Elevations of cTnT above the 99th percentile measured by a highly sensitive assay were encountered frequently in a population of T2DM patients. cTnT levels appeared to be stable over time and associated with conventional CV risk factors. Although a clear trend was present, no statistically robust associations with adverse outcomes could be found.
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Affiliation(s)
- Jonas Hallén
- Department of Cardiology, Oslo University Hospital, Faculty of Medicine, University of Oslo, Oslo, Norway.
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Johansen OE. Cardiovascular disease and type 2 diabetes mellitus: a multifaceted symbiosis. Scandinavian Journal of Clinical and Laboratory Investigation 2008; 67:786-800. [PMID: 17852797 DOI: 10.1080/00365510701408558] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Chronic hyperglycaemia (e.g. type 2 diabetes mellitus (T2DM) and prediabetes) in humans is associated with an increased risk of cardiovascular (CV) complications, and, vice versa, the presence of CV complications (e.g. myocardial infarction, stroke or intermittent claudication) among patients heightens the risk of T2DM or prediabetes. In both cases (i.e. chronic hyperglycaemia and CV complications), significant diagnostic and treatment challenges resulting from a broad range of factors may serve as barriers to reducing the deleterious societal impact of T2DM and prediabetes. These challenges often include clinicians: failing to intervene early and aggressively enough among patients with T2DM to achieve CV risk factor control; failing to efficaciously identify T2DM patients with already established CV complications; and failing proactively to assess individuals at high risk for T2DM. This review discusses the apparent symbiosis between CV disease and T2DM, with a focus on identifying patients with established T2DM or at risk for T2DM; traditional and novel risk factors and markers for CV disease in T2DM; challenges related to diagnosing CV disease in T2DM; and organization of T2DM care in order to prevent CV complications. These are issues that require attention because identifying patients at high risk for T2DM can halt or reduce their further glycaemic deterioration if addressed properly, and because novel markers and non-invasive tests could be applied in patients with T2DM as a means of detecting and possibly treating unrecognized CV disease in time. Furthermore, several approaches for T2DM care can be effective in controlling the CV risk factors contributing to CV complications.
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Affiliation(s)
- O E Johansen
- Medical Department, Asker and Baerum Hospital, Rud, Norway.
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Johansen OE, Bjurö T, Endresen K, Blaasaas KG, Birkeland K, Aakhus S, Gullestad L. Heart rate adjustments and analysis of recovery patterns of ST-segment depression in type 2 diabetes. Int J Cardiol 2007; 127:129-32. [PMID: 17532067 DOI: 10.1016/j.ijcard.2007.04.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2007] [Accepted: 04/01/2007] [Indexed: 01/19/2023]
Abstract
AIMS To investigate the diagnostic value for coronary artery disease (CAD) detection of evaluating time- and heart rate (HR)-related ST-segment changes (the ST/HR-slope) and the post-exercise recovery pattern (the ST/HR-recovery loop) in patients with type 2 diabetes mellitus (T2DM). METHODS AND RESULTS Ninety-one patients (22 female, age 59+/-9 years) with T2DM (diabetes duration 6+/-6 years) performed an exercise ECG-test that was evaluated using the ST/HR slope (cut-off</=-2.4 microV/bpm) and -recovery loop patterns (abnormal versus normal) and compared to the conventional >/=1 mm ST-segment depression criterion and dobutamine stress echo-cardiography, all evaluated against coronary angiography irrespective of stress test results. Coronary angiography revealed CAD in 20 men and 3 women (25%). Sensitivity for the conventional exercise test and stress echocardiography was low (0.35 and 0.30), but increased significantly using the ST/HR-slope (0.45), the recovery loop (0.86) or the combined ST/HR slope and recovery loop criterion (0.91). The associations between angiographic CAD-detection and the different tests expressed by the Odds ratio demonstrated an added value of performing ST/HR analysis both over pre-test CAD risk profile and the established techniques. CONCLUSION T2DM patients capable of performing an exercise test could be assessed with the ST/HR-analysis for selecting patients to angiography. However, further studies including a higher number of patients are needed to confirm the diagnostic value of this approach.
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