The association between the spatial QRS-T angle with cardiac autonomic neuropathy in subjects with Type 2 diabetes mellitus

Relationship Between Index of Cardiac Electrophysiological Balance, Frontal QRS-T Angle and Retinopathy in People with Type 2 Diabetes

BACKGROUND

Diabetic retinopathy (DR) is strongly associated with cardiovascular disease, which is a risk factor for sudden cardiac death (SCD). The index of cardiac electrophysiological balance (iCEB) and the frontal QRS-T angle are recommended to predict the risk of ventricular arrhythmias more than other ECG parameters. However, the relationships between these two markers and DR have not yet been explored. The aim of this study was to investigate the variation in the iCEB, corrected iCEB (iCEBc) and frontal QRS-T angle in different stages of DR and determine whether there are associations between these markers and DR.

METHODS

The sample comprised 665 patients with Type 2 diabetes mellitus (T2DM) who were classified into three groups: no DR (NDR), mild to moderate non-proliferative DR (NPDR), and vision-threatening DR (VTDR). Twelve-lead ECG was performed and the QT, QTc, QRS duration, iCEB, iCEBc and frontal QRS-T angle were recorded and compared across the groups.

RESULTS

The VTDR group had a significantly higher iCEBc and frontal QRS-T angle than the NDR and NPDR groups. After controlling for confounding variables, the correlations between the iCEBc (OR=2.217, 95% CI=1.464-3.358, P<0.001), frontal QRS-T angle (OR=1.017, 95% CI=1.008-1.025, P<0.001) and DR risk remained (P<0.05). Subjects in the fourth iCEBc quartile (adjusted OR=2.612, 95% CI=1.411-4.834, p=0.002) had a much higher chance of developing DR compared to those in the first quartile. In comparison to the first frontal QRS-T angle quartile, subjects in the third (adjusted OR=1.998, 95% CI=1.167-3.422, P=0.012) and fourth (adjusted OR=2.430, 95% CI=1.420-4.160, P=0.001) frontal QRS-T angle quartiles had significantly greater risks of DR.

CONCLUSION

With the progression of DR, the iCEBc and frontal QRS-T angle increase. An increased iCEBc and frontal QRS-T angle are associated with an increased risk of DR.

Intra-subject stability of different expressions of spatial QRS-T angle and their relationship to heart rate

Three-dimensional angle between the QRS complex and T wave vectors is a known powerful cardiovascular risk predictor. Nevertheless, several physiological properties of the angle are unknown or poorly understood. These include, among others, intra-subject profiles and stability of the angle relationship to heart rate, characteristics of angle/heart-rate hysteresis, and the changes of these characteristics with different modes of QRS-T angle calculation. These characteristics were investigated in long-term 12-lead Holter recordings of 523 healthy volunteers (259 females). Three different algorithmic methods for the angle computation were based on maximal vector magnitude of QRS and T wave loops, areas under the QRS complex and T wave curvatures in orthogonal leads, and weighted integration of all QRS and T wave vectors moving around the respective 3-dimensional loops. These methods were applied to orthogonal leads derived either by a uniform conversion matrix or by singular value decomposition (SVD) of the original 12-lead ECG, giving 6 possible ways of expressing the angle. Heart rate hysteresis was assessed using the exponential decay models. All these methods were used to measure the angle in 659,313 representative waveforms of individual 10-s ECG samples and in 7,350,733 individual beats contained in the same 10-s samples. With all measurement methods, the measured angles fitted second-degree polynomial regressions to the underlying heart rate. Independent of the measurement method, the angles were found significantly narrower in females (p &lt; 0.00001) with the differences to males between 10o and 20o, suggesting that in future risk-assessment studies, different angle dichotomies are needed for both sexes. The integrative method combined with SVD leads showed the highest intra-subject reproducibility (p &lt; 0.00001). No reproducible delay between heart rate changes and QRS-T angle changes was found. This was interpreted as a suggestion that the measurement of QRS-T angle might offer direct assessment of cardiac autonomic responsiveness at the ventricular level.

The value of the spatial QRS-T angle for assessing the severity of heart damage in patients with arterial hypertension

Aim      To study the relationship between clinical, echocardiographic, and laboratory indexes with increased QRS-T spatial angle (sQRS-T) in patients with arterial hypertension (AH).Material and methods  The study included 160 patients with AH, 61 (38 %) men and 99 (62 %) women aged 58 [49; 67] years. Patients with ischemic heart disease or His bundle blocks were not included. Echocardiography was used to determine the left ventricular end-diastolic dimension (LV EDD), left ventricular posterior wall thickness (LVPWT), interventricular septal thickness (IVST), relative wall thickness (RWT), left ventricular myocardial mass (LVMM), and LVMM index (LVMMI). Also, the following indexes were analyzed: office systolic and diastolic blood pressure (SBP, DBP), disease duration, body mass index, plasma levels of glucose, cholesterol, and creatinine, and glomerular filtration rate. The QRS-T spatial angle was calculated as an angle between the integral vectors QRS and T using a vectorcardiogram derived from a 12-lead digital electrocardiogram. Data are presented as median (25th percentile; 75th percentile].Results The QRS-T spatial angle for the group was 65 [43; 90]°. The QRS-T spatial angle increased with increases in the AH grade (grade 1 AH, 55 [37; 74]°; grade 2 AH, 60 [41; 82]°; grade 3 AH, 88 [62; 107]°; р&lt;0.0001); the AH stage (stage 1, 50 [41; 77]°; stage 2, 68 [44; 93]°; stage 3, 78 [59; 110]°; р=0.0002), and the cardiovascular risk degree (low and moderate risk, 49 [37; 70]°, high risk, 62 [43; 88]° (р=0.005); very high risk, 88 [61; 117]° vs. high risk, 62 [43; 88]° (р=0.0002). The QRS-T spatial angle was greater with diabetes mellitus (78 [60; 117]°) than without it (63 [43; 89]°) (р=0.03). Weak but significant correlations were found between sQRS-T and body mass index (r=0.2; p&lt;0.01), SBP (r=0.4; p&lt;0.0001), DBP (r=0.2; p&lt;0.01), LV EDD (r=0.2; p&lt;0.01), LV PWT (r=0.3; p&lt;0.001), IVST (r=0.3; p&lt;0.001), LVMM (r=0.3; p&lt;0.001), LVMMI (r=0.3; p&lt;0.001), and blood glucose (r=0.2; p&lt;0.01).Conclusion      In patients with AH, a large QRS-T spatial angle is related with significantly higher values of SBP and DBP, LV dimension, blood glucose, and body mass index.

Nocturnal ventricular arrhythmias are associated with the severity of cardiovascular autonomic neuropathy in type 2 diabetes

BACKGROUND

Cardiovascular autonomic neuropathy (CAN) is a risk factor for arrhythmias and adverse cardiovascular events, but the relationship between CAN severity and nocturnal arrhythmias needs to be clarified. This study evaluated the association between nocturnal arrhythmias and CAN severity in patients with type 2 diabetes (T2D).

METHODS

In all, 219 T2D patients were recruited from January 2017 to May 2018. Subjects were classified into no CAN (NCAN), early CAN (ECAN), definite CAN (DCAN), or advanced CAN (ACAN) based on cardiovascular autonomic reflex tests (CARTs). A 24-hour electrocardiogram was recorded and daytime (0700-2300 hours) and night-time (2300-0700 hours) heartbeats were analyzed separately.

RESULTS

After adjusting for age, the incidence of ventricular arrhythmias increased with CAN severity at night-time (18.6%, 29.9%, 36.2%, and 60.0% in the NCAN, ECAN, DCAN, and ACAN groups, respectively; P_trend  = 0.034). Patients with nocturnal ventricular arrhythmias (NVAs) had higher CART scores (2.0 ± 1.0 vs 1.5 ± 0.9; P < 0.001) and lower heart rate variability (HRV) during deep breathing (9.5 ± 5.7 vs 11.6 ± 6.6 b. p. m; P = 0.021), HRV during the Valsalva maneuver (1.2 ± 0.1 vs 1.2 ± 0.2; P = 0.006), and postural blood pressure change (-8.8 ± 15.5 vs -4.1 ± 11.2 mmHg; P = 0.023). Multivariate regression analysis revealed that CAN stage (odds ratio 1.765; 95% confidence interval 1.184-2.632; P = 0.005) was independently associated with NVAs.

CONCLUSIONS

In T2D, CAN stage was independently associated with the presence of NVAs. Early detection, diagnosis, and treatment of CAN may help predict and prevent adverse cardiovascular events and cardiovascular mortality in diabetes.

ECG-derived spatial QRS-T angle is associated with ICD implantation, mortality and heart failure admissions in patients with LV systolic dysfunction

Background

Increased spatial QRS-T angle has been shown to predict appropriate implantable cardioverter defibrilIator (ICD) therapy in patients with left ventricular systolic dysfunction (LVSD). We performed a retrospective cohort study in patients with left ventricular ejection fraction (LVEF) 31–40% to assess the relationship between the spatial QRS-T angle and other advanced ECG (A-ECG) as well as echocardiographic metadata, with all-cause mortality or ICD implantation for secondary prevention.

Methods

534 patients ≤75 years of age with LVEF 31–40% were identified through an echocardiography reporting database. Digital 12-lead ECGs were retrospectively matched to 295 of these patients, for whom echocardiographic and A-ECG metadata were then generated. Data mining was applied to discover novel ECG and echocardiographic markers of risk. Machine learning was used to develop a model to predict possible outcomes.

Results

49 patients (17%) had events, defined as either mortality (n = 16) or ICD implantation for secondary prevention (n = 33). 72 parameters (58 A-ECG, 14 echocardiographic) were univariately different (p<0.05) in those with vs. without events. After adjustment for multiplicity, 24 A-ECG parameters and 3 echocardiographic parameters remained different (p<2x10^-3). These included the posterior-to-leftward QRS loop ratio from the derived vectorcardiographic horizontal plane (previously associated with pulmonary artery pressure, p = 2x10^-6); spatial mean QRS-T angle (134 vs. 112°, p = 1.6x10^-4); various repolarisation vectors; and a previously described 5-parameter A-ECG score for LVSD (p = 4x10^-6) that also correlated with echocardiographic global longitudinal strain (R² = - 0.51, P < 0.0001). A spatial QRS-T angle >110° had an adjusted HR of 3.4 (95% CI 1.6 to 7.4) for secondary ICD implantation or all-cause death and adjusted HR of 4.1 (95% CI 1.2 to 13.9) for future heart failure admission. There was a loss of complexity between A-ECG and echocardiographic variables with an increasing degree of disease.

Conclusion

Spatial QRS-T angle >110° was strongly associated with arrhythmic events and all-cause death. Deep analysis of global ECG and echocardiographic metadata revealed underlying relationships, which otherwise would not have been appreciated. Delivered at scale such techniques may prove useful in clinical decision making in the future.

A large frontal QRS-T angle is a strong predictor of the long-term risk of myocardial infarction and all-cause mortality in the diabetic population

BACKGROUND

A large angle between the QRS vector and the T-wave vector (QRS-T angle) in electrocardiograms (ECGs) has recently been introduced as a marker of poor prognosis. The prognostic value in diabetes is unknown. We assessed the long-term predictive power of the frontal plane QRS-T angle in the diabetic population.

METHODS

In 1992-93, the diabetic population of the municipality of Horsens, Denmark, was delineated by the prescription method, and an age- and gender-stratified sample of 240 diabetic persons was randomly selected. In 2015, 12-lead ECGs taken in 1993-94 were analyzed. Vital statistics were obtained from the Danish Civil Registration System and data regarding hospitalizations taken from The National Patient Registry in July 2015.

RESULTS

In total, 178 people agreed to participate (74%) in the study, with the mean (sd) age being 58.9 (10.2) years and 56% being male. The total observation time was 21.5 (0.18) years, during which time 122 (69%) persons died, 32 (18%) suffered a myocardial infarction (MI) and 126 (71%) reached the composite endpoint of non-fatal MI or all-cause death. In Cox regression multivariate analysis a QRS-T angle above 90° was found to be an independent predictor of all-cause death (HR=2.2 (95% CI: 1.3-3.8)), MI (HR=2.95 (95% CI: 1.1-7.7)) and MI or all-cause death (HR=2.0 (95% CI: 1.2-3.5)) (all p<0.05), when adjusting for the effects of co-variates (gender, age, length of diabetes, BMI, total cholesterol, diabetes type, hemoglobin A1c, smoking, hypertension and previous MI).

CONCLUSION

A large QRS-T angle is a strong, independent long-term predictor of all-cause mortality, MI and MI or all-cause death in the diabetic population.

T wave axis deviation and QRS-T angle - Controversial indicators of incident coronary heart events

Abnormal orientation of the T-wave axis and increased angle between the QRS complex (depolarization) and the T-wave (repolarization) have long been assumed to provide a global measure of repolarization abnormality, and have been used to assess ventricular repolarization. The ability of the T wave axis deviation and the QRS-T angle to predict incident coronary heart events was examined in several studies. However, conflicting results have led to significant controversy in the literature concerning their purported ability. Potential explanations involve true variation between study populations, non-standardized cut-off values, different baseline cardiovascular risk levels or different patterns of confounding by other concomitant cardiovascular risk factors. In the present article we will attempt to briefly present the rationale and pathophysiology behind these indices, summarize existing knowledge regarding their prognostic significance and their correlation with established cardiovascular disease risk factors. Further prospective studies are necessary to confirm or refute whether T-wave axis deviation, QRS-T angle and ventricular gradient may in the future serve as indicators of incident coronary heart events and mortality, both in populations with higher prevalence of subclinical advanced atherosclerotic heart disease and in apparently healthy subjects.

Comparison of the spatial QRS-T angle derived from digital ECGs recorded using conventional electrode placement with that derived from Mason-Likar electrode position

BACKGROUND

The spatial QRS-T angle is ideally derived from orthogonal leads. We compared the spatial QRS-T angle derived from orthogonal leads reconstructed from digital 12-lead ECGs and from digital Holter ECGs recorded with the Mason-Likar (M-L) electrode positions.

METHODS AND RESULTS

Orthogonal leads were constructed by the inverse Dower method and used to calculate spatial QRS-T angle by (1) a vector method and (2) a net amplitude method, in 100 volunteers. Spatial QRS-T angles from standard and M-L ECGs differed significantly (57°±18° vs 48°±20° respectively using net amplitude method and 53°±28° vs 48°±23° respectively by vector method; p<0.001). Difference in amplitudes in leads V4-V6 was also observed between Holter and standard ECGs, probably due to a difference in electrical potential at the central terminal.

CONCLUSION

Mean spatial QRS-T angles derived from standard and M-L lead systems differed by 5°-9°. Though statistically significant, these differences may not be clinically significant.

Prolonged Tp-e Interval, Tp-e/QT Ratio and Tp-e/QTc Ratio in Patients with Type 2 Diabetes Mellitus

BACKGROUND

Type 2 diabetes mellitus (T2DM) is associated with increased risk of malignant ventricular arrhythmias. Cardiac electrical inhomogeneity may be the leading cause of the increased arrhythmic risk in patients with T2DM. The peak and the end of the T wave (Tp-e) interval and associated Tp-e/QT ratio are promising measures of ventricular repolarization indicating transmural dispersion of repolarization. The aim of this study was to assess ventricular repolarization in patients with T2DM by using Tp-e interval, Tp-e/QT ratio and Tp-e/corrected QT interval (QTc) ratio.

METHODS

Forty-three patients with T2DM and 43 healthy control subjects, matched by gender and age, were studied. All participants underwent electrocardiography (ECG) recording. PR, RR and QT intervals represents the ECG intervals. These are not abbreviations. In all literature these ECG intervals are written like in this text. Tp-e intervals were measured from 12-lead ECG. Rate QTc was calculated by using the Bazett's formula. Tp-e/QT ratio and Tp-e/QTc ratio were also calculated.

RESULTS

Mean Tp-e interval was significantly prolonged in patients with T2DM compared to controls (79.4±10.3, 66.4±8.1 ms, respectively; P<0.001). We also found significantly higher values of Tp-e/QT ratio and Tp-e/QTc ratio in patients with diabetes than controls (0.21±0.03, 0.17±0.02 and 0.19±0.02, 0.16±0.02, respectively; P<0.001). There was no difference in terms of the other ECG parameters between the groups.

CONCLUSION

Tp-e interval, Tp-e/QT ratio and Tp-e/QTc ratio were prolonged in patients with T2DM. We concluded that T2DM leads to augmentation of transmural dispersion of repolarization suggesting increased risk for ventricular arrhythmogenesis.

Changes of Virtual Planar QRS and T Vectors Derived from Holter in the Populations with and without Diabetes Mellitus

Aims

Research related to type 2 diabetes mellitus (DM) and parameters of electrocardiography (ECG) was limited. Patients with and without DM (NDM) were randomly enrolled in a study to exploit the influence of DM on planar QRS and T vectors derived from the Virtual Holter process.

Methods

A total of 216 (NDM) and 127 DM patients were consecutively and randomly recruited. We selected a 1‐minute length of ECG, which was scheduled for analysis at 4 AM. After a series of calculating algorisms, we received the virtual planar vector parameters.

Results

Patients with DM were elderly (65.61 ± 12.08 vs 59.41 ± 16.86 years, P < 0.001); higher morbidity of hypertension (76.38% vs 58.14%, P < 0.001) and coronary artery disease (44.09% vs 32.41%, P = 0.03); thicker interventricular septum (10.92 ± 1.77 vs 10.08 ± 1.96 mm, P < 0.001) and left ventricular posterior wall (9.84 ± 1.38 vs 9.39 ± 1.66 mm, P = 0.03); higher lipid levels and average heart rate (66.67 ± 12.04 vs 61.87 ± 13.36 bpm, P < 0.01); higher angle of horizontal QRS vector (HQRSA, –2.87 ± 48.48 vs –19.00 ± 40.18 degrees, P < 0.01); lower maximal magnitude of horizontal T vector (HTV, 2.33 ± 1.47 vs 2.88 ± 1.89 mm, P = 0.01) and maximal magnitude of right side T vector (2.77 ± 1.55 vs 3.27 ± 1.92 mm, P = 0.03), and no difference in angle of frontal QRS‐T vector (FQRSTA, 32.77 ± 54.20 vs 28.39 ± 52.87 degrees, P = 0.74) compared with patients having NDM. After adjusting for confounding factors, DM was significantly effective on FQRSTA (regression coefficient –40.0, 95%CI –66.4 to –13.6, P < 0.01), HQRSA (regression coefficient 22.6, 95%CI 2.5 to 42.8, P = 0.03), and HTV (regression coefficient 0.9, 95%CI 0.2 to 1.7, P = 0.01). Confounding factors included: sex, 2‐hour postprandial blood glucose, smoking, triglyceride, apolipoprotein A, creatinine, left ventricular ejection fraction, and average heart rate.

Conclusions

The risk factors of DM and lipid metabolism abnormality particularly apolipoprotein A significantly modified parameters of virtual planar QRS and T vector, including frontal QRS‐T angle.

Repolarisation descriptors and heart rate variability in hemodialysed patients

T wave morphology (TWM) descriptors derived from Holter electrocardiograms during hemodialysis (HD) are of potential value for cardiac risk assessment in HD patients. Our knowledge on autonomic regulation of TWM descriptors is limited. The purpose of this study was to investigate the association between TWM parameters and heart rate variability (HRV) during intradialytic monitoring. In each of 81 patients on maintenance HD, continuous electrocardiograms were recorded 5 times during HD on alternate weeks. TWM descriptors were calculated every 5 s in overlapping 10-s ECG segments and Low Frequency (LF) (0.04 Hz to 0.15 Hz), High Frequency (HF) (0.15 Hz to 0.40 Hz) powers of the spectrum of HRV were calculated every five min. The calculated values of TWM and HRV were averaged during the first hour of the recordings and subsequently over all recordings in each subject. Analyzable data for HRV and TWM were available in 71 HD patients (aged 61+/-15, 36 % diabetics, 32 % females). LF in normalized units correlated positively with Total Cosine R to T (r=0.374, p=0.001) and negatively with T wave morphology dispersion (r=-0.253, p=0.033) after adjusting for heart rate. A heart rate independent association between repolarisation descriptors and HRV exists in HD patients. Autonomic modulation needs to be considered when using TWM characteristics for risk profiling of HD patients.

The spatial QRS-T angle: implications in clinical practice

The ventricular gradient (VG) as a concept was conceived in the 1930s and its calculation yielded information that was not otherwise obtainable. The VG was not utilized by clinicians at large because it was not easy to understand and its computation time-consuming. The contemporary spatial QRS-T angle is based on the concept of the VG and defined as its mathematical and physiological integral. Its current major clinical use is to assess the cardiac primary repolarization abnormalities in 3-dimensional spatial vectorial plans which are normally untraced in the presence of secondary electrophysiological activity in a 2-dimensional routine electrocardiogram (ECG). Currently the calculation of the spatial QRS-T angle can be easily computed on the basis of a classical ECG and contributes to localization of arrhythmogenic areas in the heart by assessing overall and local heterogeneity of the myocardial ventricular action potention duration. Recent population-based studies suggest that the spatial QRS-T angle is a dominant ECG predictor of future cardiovascular events and death and it is superior to more conventional ECG parameters. Its assessment warrants consideration for intensified primary and secondary cardiovascular prevention efforts and should be included in everyday clinical practice. This review addresses the nature and diagnostic potential of the spatial QRS-T angle. The main focus is its role in ECG assessment of dispersion of repolarization, a key factor in arrythmogeneity.

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.

Exercise improves cardiac autonomic function in obesity and diabetes

Physical activity is a key element in the prevention and management of obesity and diabetes. Regular physical activity efficiently supports diet-induced weight loss, improves glycemic control, and can prevent or delay type 2 diabetes diagnosis. Furthermore, physical activity positively affects lipid profile, blood pressure, reduces the rate of cardiovascular events and associated mortality, and restores the quality of life in type 2 diabetes. However, recent studies have documented that a high percentage of the cardiovascular benefits of exercise cannot be attributed solely to enhanced cardiovascular risk factor modulation. Obesity in concert with diabetes is characterized by sympathetic overactivity and the progressive loss of cardiac parasympathetic influx. These are manifested via different pathogenetic mechanisms, including hyperinsulinemia, visceral obesity, subclinical inflammation and increased thrombosis. Cardiac autonomic neuropathy is an underestimated risk factor for the increased cardiovascular morbidity and mortality associated with obesity and diabetes. The same is true for the role of physical exercise in the restoration of the heart cardioprotective autonomic modulation in these individuals. This review addresses the interplay of cardiac autonomic function in obesity and diabetes, and focuses on the importance of exercise in improving cardiac autonomic dysfunction.

Smoking cessation predicts amelioration of microalbuminuria in newly diagnosed type 2 diabetes mellitus: a 1-year prospective study

The objective of the study was to assess the effect of smoking cessation on microalbuminuria in subjects with newly diagnosed type 2 diabetes mellitus (DM). From 500 smokers newly diagnosed with type 2 DM and microalbuminuria, only 193 (96 men/97 women; age, 56.4 ± 7.8 years) agreed to participate and were educated on smoking cessation, diet, and exercise. Pharmacological interventions were not different among the studied groups. All subjects were contacted by phone monthly with emphasis on smoking cessation. Anthropometric, biochemical parameters and urine specimens were obtained at baseline and at 12-month follow-up. Microalbuminuria was defined as an albumin to creatinine ratio of 30 to 299.9 μg/mg creatinine. Ankle brachial pressure index was determined by ultrasound. A total of 120 (62.2%) subjects quit smoking. Prevalence of microalbuminuria was reduced at 1 year to 72.6% in the subjects who quit smoking and to 22.5% in those who continued smoking (P = .015). Multivariate logistic regression analysis demonstrated that independently associated with the reduction in albumin to creatinine ratio (84.8 vs 28.7 μg/mg creatinine) were amelioration of glycemic control (P < .001), blood pressure (P = .02), dyslipidemia (P = .02), and insulin resistance (P = .05). Smoking cessation also reduced the prevalence of peripheral vascular disease (P = .03) and neuropathy (P = .04). From the pharmacological and lifestyle interventions, smoking cessation had the highest and an independent contribution to the reduction of microalbuminuria (P < .001). Smoking cessation in newly diagnosed type 2 DM patients is associated with amelioration of metabolic parameters, blood pressure, and the reduction of microalbuminuria. Stricter counseling about the importance of quitting smoking upon type 2 DM diagnosis is necessary to protect against the development of diabetic nephropathy and vascular complications.

The ECG vertigo in diabetes and cardiac autonomic neuropathy

The importance of diabetes in the epidemiology of cardiovascular diseases cannot be overemphasized. About one third of acute myocardial infarction patients have diabetes, and its prevalence is steadily increasing. The decrease in cardiac mortality in people with diabetes is lagging behind that of the general population. Cardiovascular disease is a broad term which includes any condition causing pathological changes in blood vessels, cardiac muscle or valves, and cardiac rhythm. The ECG offers a quick, noninvasive clinical and research screen for the early detection of cardiovascular disease in diabetes. In this paper, the clinical and research value of the ECG is readdressed in diabetes and in the presence of cardiac autonomic neuropathy.