Factors associated with carotid intima-media thickness and carotid plaques in type 2 diabetic patients. J Hypertens. 2012;30:940-947. [PMID: 22495135 DOI: 10.1097/hjh.0b013e328352aba6]

Common carotid artery intima media thickness (CIMT) in patients with prediabetes and newly diagnosed type 2 diabetes mellitus

AIM

To evaluate the relationship between common carotid artery intima media thickness (CIMT) in patients with prediabetes and new-onset diabetes mellitus without proven cardiovascular disease and some classic cardio-metabolic risk factors.

PATIENTS AND METHODS

The study included 461 obese patients with an average age of 53.2 ± 10.7 years, divided into three groups - group 1 without carbohydrate disturbances (n = 182), group 2 with prediabetes (n = 193) and group 3 with newly diagnosed diabetes mellitus (n = 86).

RESULTS

The patients with new-onset diabetes had significantly higher mean CIMT values compared to those with prediabetes or without carbohydrate disturbances and a higher frequency of abnormal IMT values. CIMT correlated significantly with age, systolic BP, diastolic BP and fasting blood glucose and showed a high predictive value for the presence of diabetic neuropathy and sudomotor dysfunction. Patients with abnormal CIMT values had a higher incidence of arterial hypertension, dyslipidemia, metabolic syndrome, peripheral neuropathy, and sudomotor dysfunction. Patients who developed type 2 diabetes during follow-up had a significantly higher initial mean CIMT, which showed the highest predictive value for the risk of new-onset diabetes, with CIMT≥0.7 mm having 53 % sensitivity and 83 % specificity for the risk of progression to diabetes mellitus.

CONCLUSION

Patients with new-onset diabetes mellitus had significantly greater intima media thickness of the common carotid artery and a greater frequency of abnormal CIMT values compared to those with normoglycemia and prediabetes. CIMT has a high predictive value for the presence of diabetic neuropathy, sudomotor dysfunction and the risk of new onset diabetes.

Carotid Artery Disease in Subjects with Type 2 Diabetes: Risk Factors and Biomarkers

Carotid atherosclerosis (CA) and, especially, carotid artery stenosis (CAS), are associated with a high risk of cardiovascular events in subjects with type 2 diabetes (T2D). In this study, we aimed to identify risk factors and biomarkers of subclinical CA and CAS in T2D individuals. High-resolution ultrasonography of carotid arteries was performed in 389 patients. Ninety-five clinical parameters were evaluated, including diabetic complications and comorbidities; antihyperglycemic, hypolipidemic, and antihypertensive therapy; indices of glycemic control and glucose variability (GV); lipid panels; estimated glomerular filtration rate (eGFR); albuminuria; blood cell count; and coagulation. Additionally, serum levels of calponin-1, relaxin, L-citrulline, and matrix metalloproteinase-2 and -3 (MMP-2, -3) were measured by ELISA. In univariate analysis, older age, male sex, diabetes duration, GV, diabetic retinopathy, chronic kidney disease, coronary artery disease, peripheral artery disease, and MMP-3 were associated with subclinical CA. In addition to these factors, long-term arterial hypertension, high daily insulin doses, eGFR, and L-citrulline were associated with CAS. In multivariate logistic regression, age, male sex, BMI, GV, and eGFR predicted CA independently; male sex, BMI, diabetes duration, eGFR, and L-citrulline were predictors of CAS. These results can be used to develop screening and prevention programs for CA and CAS in T2D subjects.

The association between carotid disease, arterial stiffness and diabetic retinopathy in type 2 diabetes: the Fremantle Diabetes Study Phase II

AIM

To determine whether macrovascular disease assessed by carotid ultrasonography and arterial stiffness by pulse wave velocity are independently associated with diabetic retinopathy in type 2 diabetes.

METHODS

A random subgroup of surviving participants with type 2 diabetes from the Fremantle Diabetes Study Phase II were invited to take part in this sub-study in 2018-2019. In addition to standardized questionnaires, a physical examination and fasting biochemical tests, each underwent dilated colour fundus photography, carotid arterial ultrasonography with measurement of the intima-media thickness (IMT) and quantification of the degree of stenosis, and pulse wave analysis calculation of the carotid-femoral pulse wave velocity (cfPWV). The cross-sectional association between arterial disease parameters and diabetic retinopathy was assessed using generalized estimating equation models which enabled both eyes to be included in the analysis.

RESULTS

Some 270 participants [mean ± sd age 72 ± 9 years, 153 (57%) men and median (IQR) diabetes duration 15 (11-22) years] were included in analysis. Of 524 assessable eyes, 82 (16%) had diabetic retinopathy. In multivariable analysis, significant independent associates of diabetic retinopathy were age at diabetes diagnosis (inversely), HbA_1c , insulin treatment and urinary albumin to creatinine ratio (all P ≤ 0.022), as well as cfPWV [odds ratio (OR) 1.13, 95% confidence interval (CI) 1.03, 1.23 per 1 m/s increase; P = 0.008] and common carotid artery (CCA) IMT ≥1 mm (OR 2.95, 95% CI 1.21, 7.23; P = 0.018).

CONCLUSIONS

The association between diabetic retinopathy and CCA IMT suggests that carotid disease may share cardiovascular risk factors with diabetic retinopathy. The association between diabetic retinopathy and cfPWV may reflect the consequences of altered intravascular haemodynamics.

Subclinical atherosclerosis in the carotid artery: can the ankle-brachial index predict it in type 2 diabetes patients?

Atherosclerosis is a progressive asymmetrical systemic disease that progresses faster in patients with diabetes comorbidity. Therefore, type 2 diabetic (T2DM) patients who have a high risk of, or have already detected, early atherosclerosis should be treated aggressively to prevent premature mortality. We hypothesised that subclinical atherosclerosis is predictable with the ankle-brachial index (ABI). There are currently only a few studies to indicate which specific value of ABI can predict atherosclerosis in the carotid artery. Our study aimed to examine ABI ≤ 1.1 ability to predict ultrasound-visualised atherosclerosis in carotid arteries in patients with T2DM, who had not been previously diagnosed with atherosclerosis. A population-based cross-sectional multicentric study was performed in 216 participants (mean age 59 ± 8 years). Carotid artery intima-medial thickness (IMT) ≥1 mm ± plaque was defined as a marker for subclinical atherosclerosis and was compared with ABI. Mean duration of T2DM was 7.05 ± 6.0 years. Atherosclerosis in the carotid artery was found in 96 (44%) patients, with no significant differences between genders (47 vs 53%, p = .206). ABI ≤1.1 was associated with the carotid artery mean IMT ≥1 mm (p = .037), plaque (p = .027) and IMT ≥1 mm ± plaque (p = .037). The association between ABI ≤ 1.1 and IMT ≥ 1 mm ± plaque remained significant after adjustment for risk factors and age >50 years. Observations demonstrated that ABI ≤ 1.1 could be an indicator of subclinical atherosclerosis for T2DM male patients over 50 years old.

Traditional and non-traditional risk factors for peripheral artery disease development/progression in patients with type 2 diabetes: the Rio de Janeiro type 2 diabetes cohort study

BACKGROUND

The prognostic importance of non-traditional risk factors for peripheral artery disease (PAD) development/progression is scarcely studied in diabetes. We investigated if carotid intima-media thickness (CIMT) and carotid-femoral pulse wave velocity (cf-PWV) added prognostic information beyond traditional cardiovascular risk markers for PAD outcomes.

METHODS

Ankle-brachial index (ABI) was measured at baseline and after a median of 91 months of follow-up in 681 individuals with type 2 diabetes. Multivariate Cox regressions examined the associations between the candidate variables and the outcome. PAD development/progression was defined by a reduction in ABI ≥ 0.15 (to a level < 0.9) or limb revascularization procedures, lower-extremity amputations or death due to PAD. The improvement in risk discrimination was assessed by increases in C-statistics of the models.

RESULTS

Seventy-seven patients developed/progressed PAD: 50 reduced ABI to < 0.9, seven had lower-limb revascularizations, and 20 had amputations or death. Age, male sex, diabetes duration, presence of microvascular complications (peripheral neuropathy and diabetic kidney disease), baseline HbA_1c, 24-h systolic BP (SBP) and mean cumulative office SBP and LDL-cholesterol were associated with PAD development/progression in several models. CIMT and cf-PWV were additionally associated with PAD outcomes, and their inclusion further improved risk discrimination (with C-statistic increases between 0.025 and 0.030). The inclusion of ambulatory 24-h SBP, instead of office SBP, also improved PAD risk discrimination.

CONCLUSIONS

Increased CIMT and aortic stiffness are associated with greater risks of developing/progressing PAD, beyond traditional risk factors, in type 2 diabetes.

Carotid Disease and Retinal Optical Coherence Tomography Angiography Parameters in Type 2 Diabetes: The Fremantle Diabetes Study Phase II

OBJECTIVE

To use optical coherence tomography angiography (OCTA) to determine whether retinal microvascular parameters are associated with carotid arterial disease in people with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Participants (community-based) underwent detailed assessments including carotid ultrasonography and OCTA. Ultrasound images were assessed for mean intima-media thickness (IMT) and the presence of stenosis. OCTA image analysis provided measures of vessel density, foveal avascular zone (FAZ) area, blood flow areas, and retinal thickness. For each OCTA variable, the most parsimonious model was generated using generalized estimating equations, then ipsilateral and contralateral carotid disease-related variables were added to determine their significance.

RESULTS

A total of 474 eyes from 261 participants (mean ± SD age 72.0 ± 9.3 years, 57.1% males, median diabetes duration 15.4 years [interquartile range 11.1-22.4]) were analyzed. When carotid variables were added to the most parsimonious models, the ipsilateral natural logarithm of common carotid artery IMT (coefficient -2.56 [95% CI -4.76, -0.35], P = 0.023) and presence of any ipsilateral stenosis (-0.82 [-1.48, -0.17], P = 0.014) were statistically significantly associated with a lower parafoveal density in the deep capillary plexus. A mean bifurcation IMT ≥1 mm was associated with a decreased vessel density in the 300-μm ring surrounding the FAZ (coefficient -0.79 [-1.50, -0.08], P = 0.030)). Contralateral carotid disease-related variables were also significantly associated with retinal microvascular parameters.

CONCLUSIONS

This is the first study to show that carotid disease is an independent associate of retinal microvascular disease assessed by OCTA in type 2 diabetes. Appropriately intensive management of carotid disease may improve the retinal microcirculation.

Uncontrolled hypertension associates with subclinical cerebrovascular health globally: a multimodal imaging study

OBJECTIVES

The study aimed to analyze the association between hypertension control and subclinical cerebrovascular health using a comprehensive multimodal imaging approach.

METHODS

The study included 200 hypertensive older males without previous cardiovascular diseases. Clinic blood pressure (BP) was measured using a standard approach. Cerebrovascular health was evaluated using magnetic resonance imaging in the following four aspects: Intracranial atherosclerosis as determined by vessel wall imaging; Vascular rarefaction (defined as less discernible vessels on angiography) was evaluated using a custom-developed technique. Cerebral blood flow (CBF) and white matter hyperintensity (WMH) were assessed using arterial spin-labeling imaging and fluid-attenuated inversion recovery imaging, respectively.

RESULTS

A total of 189 subjects had MRI scans. The mean age was 64.9 (± 7.2) years. For intracranial atherosclerosis, there was a significant association between uncontrolled hypertension and presence of intracranial plaque. When systolic and diastolic BP were analyzed separately, the association remained significant for both. For vascular rarefaction, uncontrolled hypertension was associated with less discernible vessel branches or shorter vessel length on angiography. Further analysis revealed that this is due to uncontrolled diastolic BP, but not uncontrolled systolic BP. There was an association between uncontrolled hypertension and reduced CBF, which was also mainly driven by uncontrolled diastolic BP. We also found that uncontrolled diastolic BP, but not uncontrolled systolic BP, was associated with increased WMH volume.

CONCLUSIONS

Uncontrolled hypertension was associated with subclinical cerebrovascular injury globally, with both small and medium-to-large arteries being affected.

KEY POINTS

• In this study, we leveraged the advantage of a series of cutting-edge MR imaging and analysis techniques and found uncontrolled hypertension is associated with subclinical globally compromised cerebrovascular health. • The detrimental consequences of uncontrolled BP affect not only the small vessels but also the medium-to-large arteries, and uncontrolled systolic and diastolic BP are both independently associated with certain types of cerebrovascular injury. • Our data suggest that cerebrovascular health is impaired globally in uncontrolled hypertension before the onset of stroke.

The relationship between carotid disease and retinopathy in diabetes: a systematic review

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.

Does retinopathy predict stroke recurrence in type 2 diabetes patients: A retrospective study?

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.

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

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.

Relationship Between Glycated Haemoglobin and Carotid Atherosclerotic Disease Among Patients with Acute Ischaemic Stroke

Objectives

This study aimed to determine the relationship between glycaemic control and carotid atherosclerotic disease among patients with acute ischaemic stroke (AIS).

Methods

This retrospective cross-sectional study took place in the Neurology Department of King Fahad Hospital of University, Khobar, Saudi Arabia, from April to October 2017. Data were collected from the medical records of 244 patients with a diagnosis of AIS confirmed by computed tomography. Doppler ultrasounds of the carotid artery were performed to determine the presence of increased carotid intima media thickness (CIMT) and plaques.

Results

Significantly higher mean glycated haemoglobin (HbA1c) levels were noted in cases with high CIMT values (P = 0.002), but not in cases with carotid plaques (P = 0.360). In addition, there was a significant association between diabetes mellitus (DM) and high CIMT (P = 0.045), but not with carotid plaques (P = 0.075). Finally, while dyslipidaemia and age were independently correlated with high CIMT values (P = 0.034 and <0.001, respectively) and carotid plaques (P <0.001 each), no independent relationships were noted in terms of gender and other risk factors like DM, hypertension and smoking (P >0.050 each).

Conclusion

High HbA1c levels were associated with high CIMT values, but not with carotid plaques. Therefore, HbA1c levels may be useful as an indirect marker of the initial stages of carotid artery atherosclerosis.

Increased aortic intima-media thickness may be used to detect macrovascular complications in adult type II diabetes mellitus patients

Background

Carotid intima media thickness (C-IMT) and aortic IMT (A-IMT) increase in adult and pediatric patients with diabetes mellitus (DM), respectively. In both age groups IMT is used for early detection of macrovascular complications. In adult DM patients, A-IMT is still not a routine examination and is not used frequently. We aimed to determine whether there is an increase in A-IMT values measured from abdominal aorta besides traditional C-IMT in patients with type II DM and to determine parameters closely related to A-IMT in the same patient group.

Methods

We included 114 type II DM patients and 100 healthy control subjects similar in age and sex in our study. Bilateral C-IMT and A-IMT values were measured by B-mode ultrasonography (USG) in addition to anamnesis, physical examination and routine examinations of all patients.

Results

When the clinical, demographic and laboratory data of patients with and without DM were compared, there was a high level of glucose and HbA1c and low hemoglobin levels in the DM patient group. All other parameters were found to be similar between the two groups. When the B-mode USG findings were examined, it was found that C-IMT and A-IMT were increased in patients with DM, with the A-IMT increase being more prominent. A-IMT values were found to be strongly and positively correlated with age, systolic blood pressure, blood urea nitrogen, DM onset time and HbA1c levels, and a negatively and significantly correlated with hemoglobin levels (p < 0.05, for each). In the regression model, the parameters correlating most closely with A-IMT were DM diagnosis onset time, HbA1c and hemoglobin levels (p = 0.001 and β = 0.353, p = 0.014 and β = 0.247 and p < 0.001 and β = − 0.406).

Conclusions

As in pediatric DM patients also in adult DM patients A-IMT can easily be measured with new model USG devices. A-IMT must be measured during abdominal USG which is routine in adult DM patients. A-IMT is an easy, reproducible and non-invasive parameter that may be used in the diagnosis of macrovascular complications of adult type II DM.

Usefulness of Carotid Plaques as Predictors of Obstructive Coronary Artery Disease and Cardiovascular Events in Asymptomatic Individuals With Diabetes Mellitus

Carotid intima-media thickness (CIMT) measurement and carotid plaque detection by B-mode ultrasound are frequently used as surrogates to predict coronary artery disease (CAD). However, their systematic use in routine clinical management of asymptomatic patients with diabetes mellitus (DM) has not been studied. The aim of the study was to identify carotid parameters that predict cardiovascular events in patients with asymptomatic type 2 DM by evaluating the relation between carotid disease and CAD. This multicenter, observational, prospective study included 259 asymptomatic patients with type 2 DM followed-up for 34 months after measurement of CIMT and carotid plaque with carotid ultrasound, and CAD assessment with computed tomography coronary angiography. Statistically significant differences between patients with and without carotid plaque were found for coronary plaque >50% stenosis (59 vs 36, p = 0.02). Greater maximal CIMT was associated with an increased risk of coronary plaque >50% (odds ratio 1.21 [1.02, 1.44], p = 0.03) and >70% stenosis (odds ratio 1.23 [1.01, 1.50], p = 0.04) after adjusting for traditional risk factors. At 34-month follow-up, the occurrence of total major adverse cardiovascular event was estimated to be 7.1% (mean age 68 years, 6% male and 1.1% female) in the whole study population. The subgroup of patients with carotid plaque showed increased incidence of major adverse cardiovascular event compared with patients with no carotid plaque (p = 0.005). In conclusion, carotid plaque was a strong predictor of future cardiovascular events and may be a prognostic marker in asymptomatic patients with type 2 DM. Carotid plaque and maximal intima-media thickness were independently associated with obstructive CAD.

Exposure to Cigarette Smoke and the Carotid Arteries Calcification Index in Patients with Essential Hypertension

The arteries calcification index is a quantitative, mathematically estimated parameter characterizing the total amount of calcium within atherosclerotic plaques in the walls of arteries. The objective is to determine a relationship between exposure to cigarette smoke and the carotid arteries calcification index in patients with essential hypertension. The tested group included 66 patients with essential hypertension: 19 active smokers (subgroup A), 20 non-smokers, environmentally exposed to cigarette smoke (subgroup B) and 27 persons without exposure to cigarette smoke (subgroup C). The tested group was subjected to computed tomography angiography of carotid arteries. Evaluation of the carotid arteries calcification indexes was conducted. The average value of the total calcification index of the carotid arteries (CAci) amounted to 368.28 ± 384.21. In subgroup A and B in relation to subgroup C, CAci was significantly higher. In summary, active and passive smoking in patients with essential hypertension may be associated with a higher calcification index of carotid arteries.

Exposure to Cigarette Smoke and the Morphology of Atherosclerotic Plaques in the Extracranial Arteries Assessed by Computed Tomography Angiography in Patients with Essential Hypertension

The aim of the study was to determine the relationship between exposure to cigarette smoke and the morphology of atherosclerotic plaques in the extracranial arteries assessed by computed tomography angiography in patients with hypertension. The study included 61 hypertensive patients: 17 active smokers (group A), 18 non-smokers, declaring environmental exposure to tobacco smoke (group B), and 26 non-smokers, not declaring exposure to cigarette smoke (group C). The number of segments with plaques was significantly higher in group A compared to groups B and C. The number of segments with non-calcified and mixed plaques was significantly higher in group A and group B than in group C. A positive correlation between cigarette-years and the number of segments with atherosclerotic plaques was noted. In summary, both active smoking and environmental exposure to tobacco smoke appear to increase the number of segments of the extracranial arteries with non-calcified and mixed atherosclerotic plaques.

Estimation of cardiovascular risk and detection of subclinical carotid atheromatosis in patients with diabetes without a history of cardiovascular disease

Objectives

Cardiovascular risk estimated by several scores in patients with diabetes mellitus without a cardiovascular disease history and the association with carotid atherosclerotic plaque (CAP) were the aims of this study.

Materials and methods

Cardiovascular risk was calculate using United Kingdom Prospective Diabetes Study (UKPDS) risk engine, Framingham risk score for cardiovascular (FSCV) and coronary disease (FSCD), and the new score (NS) proposed by the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol. Ultrasound was used to assess CAP occurrence. A receiver operating characteristic (ROC) analysis was performed.

Results

One hundred seventy patients (mean age 61.4 ± 11 years, 58.8% men) were included. Average FSCV, FSCD and NS values were 33.6% ± 21%, 20.6% ± 12% and 24.8% ± 18%, respectively. According to the UKPDS score, average risk of coronary disease and stroke were 22.1% ± 16% and 14.3% ± 19% respectively. Comparing the risks estimated by the different scores a significant correlation was found. The prevalence of CAP was 51%, in patients with the higher scores this prevalence was increased. ROC analysis showed a good discrimination power between subjects with or without CAP.

Conclusion

The cardiovascular risk estimated was high but heterogenic. The prevalence of CAP increased according to the strata of risk. Understanding the relationship between CAP and scores could improve the risk estimation in subjects with diabetes.

Clinical and dietary predictors of common carotid artery intima media thickness in a population with type 1 and type 2 diabetes: A cross-sectional study

AIM

To determine the clinical and dietary predictors of common carotid artery intima media thickness (CCA IMT) in a cohort of subjects with type 1 and type 2 diabetes.

METHODS

Participants with type 1 (n = 23) and type 2 diabetes (n = 127) had mean and mean maximum CCA IMT measured using B mode ultrasound. Dietary intake was measured using a food frequency questionnaire. Clinical and dietary predictors of mean and mean maximum CCA IMT were determined using linear regression analysis adjusted for potential confounders.

RESULTS

The main predictors of mean and mean maximum CCA IMT were age and weight. After multivariate adjustment there were no dietary predictors of CCA IMT. However, in subjects that were not prescribed a lipid lowering medication alcohol consumption was positively associated with CCA IMT after multivariate adjustment. No difference existed in CCA IMT between subjects with type 1 or type 2 diabetes once age was adjusted for.

CONCLUSION

CCA IMT was predominantly predicted by age and weight in these subjects with diabetes. The finding that CCA IMT was not different between people with type 1 and type 2 diabetes warrants further investigation in a larger cohort.

Relationship between dyslipidemia and carotid plaques in a high-stroke-risk population in Shandong Province, China

INTRODUCTION

The precise associations between stroke and carotid plaques and dyslipidemia are unclear. This population-based study aimed to examine the relationship between carotid plaques and dyslipidemia in a high-stroke-risk population.

METHODS

Ultrasonography of left and right carotid arteries was conducted in 22,222 participants in a second screening survey of individuals with high stroke risk. Subjects were divided into two groups according to the presence or absence of carotid plaques. Blood TC (total cholesterol), TG (total triglycerides), and LDL-C (low-density lipoprotein cholesterol) levels were recorded.

RESULTS

Multivariate logistic regression analysis, controlled for gender, age, education, geographic region, smoking, exercise, and overweight (Model 2), identified TG as a predictor of carotid-plaque risk (odds ratio [OR] = 1.109, 95% confidence interval [CI]: 1.038-1.185, P = 0.002), and the association between carotid plaques and LDL-C (OR = 0.967, 95%CI: 0.949-0.994, P = 0.019) was less significant, whereas there was no association between carotid plaques and TC (OR = 1.002, 95%CI: 0.932-1.007, P = 0.958). After additional adjustment for hypertension, diabetes, and atrial fibrillation (Model 3), TG remained a risk factor for carotid plaques (OR = 1.086, 95%CI: 1.016-1.161, P = 0.015), but no associations were observed between carotid plaques and LDL-C (OR = 0.972, 95%CI: 0.910-1.038, P = 0.394) or TC (OR = 1.003, 95%CI: 0.933-1.079, P = 0.928). Only the association between TG and carotid plaques (OR = 1.084, 95%CI: 1.014-1.159, P = 0.017) was independent of all covariates (covariates in Model 3 plus history of stroke or transient ischemic attack, and stroke family history) in Model 4.

CONCLUSION

These findings indicate that TG was an independent risk factor for carotid plaques in high-risk population for stroke, whereas LDL-C and TC were not associated with the appearance of carotid plaques independently.

Relationship of Vascular Factors on Electrophysiologic Severity of Diabetic Neuropathy

OBJECTIVE

To investigate the impact of vascular factors on the electrophysiologic severity of diabetic neuropathy (DPN).

METHODS

Total 530 patients with type 2 diabetes were enrolled retrospectively. We rated severity of DPN from 1 (normal) to 4 (severe) based on electrophysiologic findings. We collected the data concerning vascular factors (including brachial-ankle pulse wave velocity [PWV], ankle brachial index, ultrasound of carotid artery, lipid profile from the blood test, and microalbuminuria [MU] within 24 hours urine), and metabolic factors of diabetes (such as glycated hemoglobin [HbA1c]). We analyzed the differences among the four subgroups using χ(2) test and ANOVA, and ordinal logistic regression analysis was performed to investigate the relationship between significant variables and severity of DPN.

RESULTS

The severity of DPN was significantly associated with duration of diabetes, HbA1c, existence of diabetic retinopathy and nephropathy, PWV, presence of plaque, low density lipoprotein-cholesterol and MU (p<0.05). Among these variables, HbA1c and presence of plaque were more significantly related with severity of DPN in logistic regression analysis (p<0.001), and presence of plaque showed the highest odds ratio (OR=2.52).

CONCLUSION

Our results suggest that markers for vascular wall properties, such as PWV and presence of plaque, are significantly associated with the severity of DPN. The presence of plaque was more strongly associated with the severity of DPN than other variables.

Prognostic importance of baseline and serial glycated hemoglobin levels in high-risk patients with type 2 diabetes: the Rio de Janeiro Type 2 Diabetes Cohort Study

The prognostic importance of baseline and serial glycated hemoglobin (HbA1c) changes for cardiovascular outcomes is still debated. We aimed to evaluate it in 620 high-risk individuals with type 2 diabetes (mean age 60.4 years, 37 % males, 55 % Caucasians). Patients had HbA1c levels measured at study entry and serially during follow-up. Primary end points were total cardiovascular events (CVEs), major CVEs (non-fatal myocardial infarctions and strokes plus cardiovascular deaths) and all-cause mortality. Cardiovascular and non-cardiovascular mortalities were secondary end points. HbA1c was evaluated either as a continuous variable and categorized at clinically relevant cutoffs. Multivariate Cox regressions assessed the associations with end points. After a median follow-up of 6.6 years, 125 total CVEs occurred (90 major CVEs), and 111 patients died (64 from cardiovascular diseases). After statistical adjustments for other cardiovascular risk factors, baseline and mean first-year HbA1c predicted all end points, except non-cardiovascular deaths; and hazard ratios tended to be higher for mean first year than for baseline HbA1c. Each 1 % (10.9 mmol/mol) increase in mean first-year HbA1c increased 27 % the risk of major CVEs occurrence (95 % CI 11-45 %). Updating HbA1c for values obtained beyond the second year of follow-up did not improve its predictive performance. The cardiovascular protection was observed until HbA1c values lower than 6.5 % (48 mmol/mol). Moreover, the magnitude of HbA1c reduction during the first year of follow-up was predictive of better cardiovascular outcomes, independent of baseline HbA1c levels. In conclusion, better glycemic control, especially during the first year of follow-up, is determinant of better cardiovascular outcomes in high-risk patients with type 2 diabetes, without any detectable lower threshold level of HbA1c.

Carotid hemodynamics is associated with monocyte count determined by serum homocysteine level in patients with essential hypertension

To examine the association between pulsatility index (PI) in the common carotid artery (CCA) as a marker of vascular resistance and cardiovascular risk factors, including serum homocysteine and inflammation, 67 hypertensive patients were enrolled. PI correlated with homocysteine and interleukin-6, monocyte count, gender, age and BMI, with monocyte count and age being independent determinants for PI. In turn, monocyte count correlated with homocysteine, tumor necrosis factor-alpha, and HDL-cholesterol, BMI, and gender, with HDL-cholesterol and homocysteine being independent determinants for monocyte count. These results indicated monocyte count determined by homocysteine is associated with arterial stiffness in hypertensive patients.

Relationships between reduced heart rate variability and pre-clinical cardiovascular disease in patients with type 2 diabetes

AIMS

Reduced heart rate variability (HRV), an early sign of diabetic cardiovascular autonomic neuropathy (CAN), is associated with worse cardiovascular outcomes. The objective was to evaluate relationships between HRV parameters and three pre-clinical cardiovascular disease markers (left ventricular hypertrophy [LVH], aortic stiffness and carotid atherosclerosis) in type 2 diabetes.

METHODS

In a cross-sectional study, 313 patients with type 2 diabetes performed 24-h Holter monitoring, carotid ultrasonography (intima-media thickness and plaques measurements), aortic pulse wave velocity measurement and echocardiography (left ventricular mass index [LVMI] measurement). Time-domain HRV parameters were the standard deviation of all normal RR intervals (SDNN), the standard deviation of the averaged normal RR intervals for all 5min segments (SDANN), the root mean square of differences between adjacent R-R intervals (rMSSD), and the percentage of adjacent R-R intervals that varied by >50ms (pNN50). Multivariate linear and logistic regressions assessed associations between HRV parameters and the three markers of pre-clinical cardiovascular disease.

RESULTS

Patients with reduced HRV had longer diabetes duration, greater prevalences of microvascular complications, lower physical fitness, and higher heart rate, glycated hemoglobin, albuminuria and LVMI than patients with normal HRV. On multivariate regressions, after adjustments for several confounders, reduced SDNN and SDANN were independently associated with LVH and aortic stiffness. No HRV parameter was associated with carotid atherosclerosis.

CONCLUSIONS

Two reduced HRV parameters, SDNN and SDANN, which reflect cardiovascular autonomic imbalance, were associated with LVH and aortic stiffness, markers of pre-clinical cardiovascular disease. These findings may offer insights into physiopathological mechanisms linking CAN to worse cardiovascular prognosis.

Hyperhomocysteinemia is one of the risk factors associated with cerebrovascular stiffness in hypertensive patients, especially elderly males

Hyperhomocystemia has been reported to be associated with cardiovascular disease, especially stroke. The resistive index (RI) estimated by carotid ultrasound is an established variable for estimating the risk of cerebral infarction. The aim of this study was to evaluate the relationship between homocysteine concentration and carotid RI, a marker of cerebral vascular resistance in essential hypertensive patients. We measured serum total homocysteine and carotid RI in 261 patients. Multiple linear regression analysis was used to determine the association of homocysteine with carotid RI and intima media thickness (IMT). Age, sex, BMI, systolic blood pressure (SBP), homocysteine, total cholesterol, high density lipoprotein-cholesterol (HDL-C), uric acid, CRP, HbA1c, estimated glomerular filtration rate, and use of antihypertensive agents were included as independent variables. Age, sex, use of antihypertensive agents, HDL-C and homocysteine levels were shown to be significant predictors of carotid RI, but not IMT. Multiple regression analysis in men older than 65 years showed homocysteine and SBP were associated significantly with carotid RI. In elderly male patients, homocysteine was the strongest predictor of carotid RI (B = 0.0068, CI = 0.0017-0.0120, P = 0.011) in the multivariate model. In conclusion, hyperhomocysteinemia is associated with carotid RI, a surrogate marker of cerebral vascular resistance, especially in elderly men.

Factors associated with abnormal T-wave axis and increased QRS-T angle in type 2 diabetes

Frontal plane T-wave axis and QRS-T angle are novel electrocardiographic ventricular repolarization parameters that have been scarcely evaluated in type 2 diabetes. The aim was to investigate the factors associated with these parameters of abnormal ventricular repolarization in a cross-sectional analysis of 594 patients with type 2 diabetes. Clinical, laboratory, 2D-echocardiographic, ambulatory blood pressure (BP) monitoring, aortic pulse wave velocity (PWV) and carotid ultrasonographic data were obtained. Digital 12-lead ECG was recorded, and frontal plane T-wave axis and QRS-T angle were automatically measured. T-wave axis was considered abnormal if >75° or <15° and QRS-T angle if ≥73° in men and ≥67° in woman. Associations were assessed by bivariate tests and multivariate logistic regressions. One hundred and four (20.9 %) patients had abnormal T-wave axis, and 84 (14 %) had increased QRS-T angle. Patients with abnormal ventricular repolarization were older and had greater prevalence of micro- and macrovascular diabetic complications than patients with normal repolarization. They had higher office and ambulatory BPs, greater prevalence of the non-dipping pattern, and greater left ventricular mass, aortic PWV and carotid intima-media thickness. On multivariate analysis, abnormal ventricular repolarization parameters were independently associated with left ventricular hypertrophy, non-dipping pattern, higher ambulatory systolic BPs, glycated hemoglobin and common carotid intima-media thickness, and with the presence of coronary artery disease. In conclusion, abnormal frontal plane T-wave axis and QRS-T angle are independently associated with several markers of pre-clinical atherosclerotic disease; whether these associations represent additional cardiovascular risk in type 2 diabetes shall be confirmed in prospective studies.

Association between CDH13 variants and cardiometabolic and vascular phenotypes in a Korean population

PURPOSE

Although some CDH13 single nucleotide polymorphisms (SNPs) have been shown to be determinants of blood adiponectin levels, the clinical implications of CDH13 variants are not yet completely understood. The purpose of this study was to evaluate the effects of SNPs of CDH13 on metabolic and vascular phenotypes.

MATERIALS AND METHODS

We included 238 hypertensive subjects and 260 age- and sex-matched controls. Seven tagging-SNPs were identified in the CDH13 gene by whole gene sequencing. The association between these SNP variants and the risk of hypertension, metabolic traits, and carotid intima-media thickness (IMT) was examined.

RESULTS

Minor allele carriers of rs12444338 had a lower risk of hypertension, but the association turned out just marginal after adjusting confoudners. Blood glucose levels were higher in the minor allele carriers of c.1407C>T (p=0.01), whereas low-density lipoprotein-cholesterol levels were greater in those of rs6565105 (p=0.02). The minor allele of rs1048612 was associated with a higher body mass index (p=0.01). In addition, the mean carotid IMT was significantly associated with rs12444338 (p=0.02) and rs1048612 (p=0.02).

CONCLUSION

These results provide evidence that CDH13 variants are associated with metabolic traits and carotid atherosclerosis in Koreans. This study shows the multifaceted effects of CDH13 variants on cardiometabolic risk.

Microalbuminuria is independently associated with arterial stiffness and vascular inflammation but not with carotid intima-media thickness in patients with newly diagnosed type 2 diabetes or essential hypertension

The association between microalbuminuria (MAU) and the indices of macrovascular complication in patients with newly diagnosed type 2 diabetes (D) or essential hypertension (H) was evaluated. Total 446 patients were classified into four groups according to the urinary albumin-to-creatinine ratio: MAU-D (n = 104), normoalbuminuria (NAU)-D (n = 114), MAU-H (n = 116), and NAU-H (n = 112). The indices of macrovascular complication including arterial stiffness evaluated by pulse-wave-velocity (PWV), carotid intima-media thickness (IMT), and vascular inflammation marked by high-sensitivity C-reactive protein (hsCRP) were assessed. PWV, IMT, and hsCRP were higher in patients with MAU than in those with NAU in both diabetes and hypertension groups. In both MAU-D and MAU-H groups, PWV and hsCRP levels were positively correlated with MAU level (MAU-D: r = 0.47, 0.41, MAU-H: r = 0.36, 0.62, respectively, P < 0.05). Additionally, PWV and hsCRP were independent factors predicting MAU (diabetes group: OR 1.85, 1.54, hypertension group: OR 1.38, 1.51, respectively, P < 0.001), but not IMT. MAU is independently associated with arterial stiffness and vascular inflammation but not with IMT in patients with newly diagnosed type 2 diabetes or essential hypertension, which emphasizes the importance of proactive clinical investigations for atherosclerotic complications in patients with MAU, even in newly diagnosed diabetes or hypertension.