How can we best prolong life? Benefits of coronary risk factor reduction in non-diabetic and diabetic subjects

The burden of diabetes and hypertension on healthy life expectancy in Bangladesh

Diabetes and hypertension are among the leading causes of death in Bangladesh. This study examined hypertension, diabetes, and either or both, free life expectancy, to measure the effect of the diseases on the overall health of individuals in Bangladesh with regional variations. We utilized data from Bangladesh Sample Vital Statistics 2018 for mortality and Bangladesh Demographic and Health Survey 2017-2018 for diabetes and hypertension. The Sullivan method was employed to estimate age-specific hypertension and diabetes-free life expectancy. Altogether, 10.3% of the people aged 18-19 years lived with either diabetes or hypertension. The hypertension-free life expectancy was 40.4 years, and the diabetes-free life expectancy was 53.2 years for those aged 15-19. Overall, individuals would expect to spend 38.7% of their lives with either of the diseases. Females suffered more from hypertension and males from diabetes. Still, females suffered more from the aggregate of both. Rural people had more diabetes and hypertension-free life expectancy than those of urban. Individuals of Mymensingh had the highest life expectancy free of both diseases compared to other divisions of Bangladesh. Diabetes and hypertension affect a considerable proportion of the life of the population in Bangladesh. Policy actions are needed to guide the prevention, diagnosis, and treatment of both diseases, specifically focusing on women and urban populations. Widespread health-enhancing actions need to be taken to diminish the effect of these two diseases in Bangladesh.

Hyaluronan Inhibition as a Therapeutic Target for Diabetic Kidney Disease: What Is Next?

Diabetic kidney disease (DKD) is the leading cause of CKD and ESKD in the United States and worldwide. Pharmacotherapy and lifestyle modifications for glycemia, dyslipidemia, and BP control have shown success in slowing the progression of DKD. Traditional treatments, such as angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and more recently the use of sodium-glucose cotransporter 2 inhibitors, nonsteroidal selective mineralocorticoid receptor antagonists, such as finerenone, and glucagon-like peptide 1 receptor agonists, have led to added benefits on various outcomes. However, significant residual risk for DKD progression remains despite the current standard-of-care approaches. Arteriolar hyalinosis (AH) is among the key findings seen on kidney biopsies of patients with DKD. It results from the excessive accumulation of hyaluronan (HA) in the arterioles. AH has not been targeted specifically by any of the therapeutic methods currently being used. We discuss in this manuscript the potential use of a selective therapy targeting AH and the increased total renal HA deposits using a HA synthesis inhibitor in DKD.

Smoking Cessation in People With and Without Diabetes After Acute Coronary Syndrome

INTRODUCTION

People with diabetes smoke at similar rates as those without diabetes, with cardiovascular consequences. Smoking cessation rates were compared between people with and without diabetes 1 year after an acute coronary syndrome (ACS).

AIMS AND METHODS

People with ACS who smoked and were part of an observational prospective multicenter study in Switzerland were included from 2007 to 2017 and followed for 12 months. Seven-day point prevalence abstinence was assessed at 12 months follow-up. Association between diabetes and smoking cessation was assessed using multivariable-adjusted logistical regression model.

RESULTS

2457 people with ACS who smoked were included, the mean age of 57 years old, 81.9% were men and 13.3% had diabetes. At 1 year, smoking cessation was 35.1% for people with diabetes and 42.6% for people without diabetes (P-value .01). After adjustment for age, sex, and educational level, people with diabetes who smoked were less likely to quit smoking compared with people without diabetes who smoked (odds ratio [OR] 0.76, 95% confidence interval [CI] 0.59-0.98, P-value = .037). The multivariable-adjusted model, with further adjustments for personal history of previous cardiovascular disease and cardiac rehabilitation attendance, attenuated this association (OR 0.85, 95% CI 0.65-1.12, P-value = .255). Among people with diabetes, cardiac rehabilitation attendance was a positive predictor of smoking cessation, and personal history of cardiovascular disease was a negative predictor of smoking cessation.

CONCLUSIONS

People with diabetes who smoke are less likely to quit smoking after an ACS and need tailored secondary prevention programs. In this population, cardiac rehabilitation is associated with increased smoking cessation.

IMPLICATIONS

This study provides new information on smoking cessation following ACSs comparing people with and without diabetes. After an ACS, people with diabetes who smoked were less likely to quit smoking than people without diabetes. Our findings highlight the importance of tailoring secondary prevention to people with diabetes.

Are lifestyle changes from online information associated with discussing the information with a doctor? A cross -sectional study

BACKGROUND

The prevalence of diabetes and the use of electronic health (eHealth) are increasing. Lifestyle changes in a positive direction may reduce morbidity and mortality in patients with diabetes. The main objective of this study was to test the association between lifestyle changes based on online information seeking and discussing the information with a doctor.

METHODS

In this cross-sectional study we used e-mail survey data from 1250 members of The Norwegian Diabetes Association, collected in 2018. Included in the analyses were 847 men and women aged 18 to 89 years diagnosed with diabetes and who reported use of eHealth within the previous year. We used descriptive statistics to estimate lifestyle changes based on information from the internet. Logistic regressions were used to estimate the associations between lifestyle changes after online information seeking and discussing the information with a doctor. Analyses were adjusted for gender, age, education, and self-rated health.

RESULTS

Lifestyle changes accomplished after online information seeking was reported by 46.9% (397/847) of the participants. The odds of changing lifestyle were more than doubled for those who had discussed information from the internet with a doctor (odds ratio 2.54, confidence interval 1.90-3.40). The odds of lifestyle changes were lower in the age groups 30-39 years and 60 years and over, compared to those aged 18-29 years (the reference group). Lifestyle changes were not associated with gender, education, or self-rated health.

CONCLUSIONS

Our findings indicate that health-care professionals can play an important role in lifestyle changes additional to health-advice found on the internet. This study underlines the importance of easily accessible high-quality online information, as well as the importance of making room for discussing lifestyle in the clinical encounter.

Assessing the efficacy and impact of a personalised smoking cessation intervention among type 2 diabetic smokers: study protocol for an open-label randomised controlled trial (DISCGO-RCT)

INTRODUCTION

Few studies have assessed the efficacy of smoking cessation interventions in individuals with type 2 diabetes, but interventions adapted to the specific needs of this population are warranted. The aim of this study is to assess the efficacy of a smoking cessation intervention in a population of smokers with type 2 diabetes and to measure the metabolic impact of smoking cessation.

METHODS AND ANALYSIS

The study is an open-label, randomised control trial. Participants recruited from a sanitary region of Switzerland will be randomly allocated to either the intervention or the control arm. The intervention group will have four individual counselling sessions over 12 weeks. Trained research nurses will conduct the behavioural intervention, using motivational interviews and addressing diabetes and gender specificities. The control group will have one short counselling session at baseline and will be given written information on smoking cessation. Both groups will have a follow-up visit at 26 and 52 weeks. Demographic and medical data will be collected at baseline and follow-up, along with blood and urine samples. The primary study outcome is continuous smoking abstinence validated by expired-air carbon monoxide from week 12 to week 52. Secondary study outcomes are continuous and 7-day point prevalence smoking abstinence at 12 and 26 weeks; change in motivation to quit and cigarette consumption; and change in glycosylated haemoglobin levels, body weight, waist circumference and renal function after smoking cessation. In a subsample of 80 participants, change in stool microbiota from baseline will be measured at 3, 8 and 26 weeks after smoking cessation.

ETHICS AND DISSEMINATION

Ethical approval has been obtained by the competent ethics committee (Commission cantonale d'éthique de la recherche sur l'être humain, CER-VD 2017-00812). The results of the study will be disseminated through publications in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBERS

ClinicalTrials.gov NCT03426423 and SNCTP000002762; Pre-results.

Four Years’ Treatment Efficacy of Patients with Severe Hyperlipidemia. Lipid Lowering Drugs versus LDL-Apheresis

A total of 47 patients suffering from heterozygous hyperlipidemia were treated with LDL-apheresis (24 patients, aged 49.5±11.5 years), diet and/or lipid-lowering drugs or with diet and lipid-lowering drugs only (23 patients, aged 48.0±11.9 years). After treatment periods of 44.4±14.3 (apheresis group) and 33.5±15.9 (drug group) months, respectively, the ensuing results revealed significant differences (p<0.0001): total cholesterol decreased from 10.4 to 5.5 vs 9.9 to 8.7 mmol/l, LDL from 7.4 to 3.9 vs 6.6 to 5.2 mmol/l, triglycerides from 5.8 to 3.7 vs 4.8 to 4.1 mmol/l and the LDL/HDL-ratio decreased from 7.1 to 3.4 vs 6.7 to 5.8. In the apheresis group one patient died from myocardial infarction vs one non-fatal myocardial infarction and the manifestation of coronary heart disease in three cases in the drug group. There were no severe side-effects in either group. All patients in the apheresis group experienced an increased clinical performance. On the other hand physological well-being of these patients was lower than that of the drug group (scores 42.3±8.9 vs 50.2±9.9, p<0.002). The present trial suggests that a continuing reduction in serum lipid concentrations may lower in a dose dependent manner the risk of development and progression of coronary heart disease. With respect to clinical and laboratory results, LDL-apheresis seems safe and appears to be the most effective therapy.

A retrospective cohort study on the risk of stroke in relation to a priori health knowledge level among people with type 2 diabetes mellitus in Taiwan

Background

Intervention of diabetes care education with regular laboratory check-up in outpatient visits showed long-term benefits to reduce the risk of macrovascular complications among people with type 2 diabetes. However, research on the level of a priori health knowledge to the prevention of diabetic complications in community settings has been scarce. We therefore aimed to investigate the association of health knowledge and stroke incidence in patients with type 2 diabetes in Taiwan.

Methods

A nationally representative sample of general Taiwanese population was selected using a multistage systematic sampling process from Taiwan National Health Interview Survey (NHIS) in 2005. Subjects were interviewed by a standardized face-to-face questionnaire in the survey, obtaining information of demographics, socioeconomic status, family medical history, obesity, health behaviors, and 15-item health knowledge assessment. The NHIS dataset was linked to Taiwan National Health Insurance claims data to retrieve the diagnosis of type 2 diabetes in NHIS participants at baseline and identify follow-up incidence of stroke from 2005 to 2013. Univariate and multivariate Cox regressions were used to estimate the effect of baseline health knowledge level to the risk of stroke incidence among this group of people with type 2 diabetes.

Results

A total of 597 diabetic patients with a mean age of 51.28 years old and nearly half of males were analyzed. During the 9-year follow-up period, 65 new stroke cases were identified among them. Kaplan–Meier curves comparing the three groups of low/moderate/high knowledge levels revealed a statistical significance (p-value of log-rank test <0.01). After controlling for potential confounders, comparing to the group of low health knowledge level, the relative risk of stroke was significantly lower for those with moderate (adjusted hazard ratio [AHR] = 0.63; 95% CI, 0.33–1.19; p-value = 0.15) and high level of health knowledge (AHR = 0.43; 95% CI, 0.22–0.86; p-value = 0.02), with a significant linear trend (p-value = 0.02).

Conclusions

An exposure-response gradient of moderate to high health knowledge levels to the prevention of stroke incidence among people with type 2 diabetes in community was found with 9 years of follow-up in Taiwan. Development and delivery of health education on stroke prevention to people with type 2 diabetes are warranted.

Smoking and arterial stiffness in youth with type 1 diabetes: the SEARCH Cardiovascular Disease Study

OBJECTIVE

To evaluate the effects of smoking on early markers of cardiovascular disease (arterial stiffness) in adolescents with and without type 1 diabetes (T1D) in the SEARCH Cardiovascular Disease Study.

STUDY DESIGN

Participants included 606 youth (18.9 ± 3.3 years, 83% non-Hispanic white; 50% male). Six groups were defined: (1) smokers with T1D (n = 80); (2) former smokers with T1D (n = 88); (3) nonsmokers with T1D (n = 232); (4) smokers without T1D (n = 40); (5) former smokers without T1D former (n = 51); and (6) nonsmokers without T1D (n = 115). Arterial stiffness measurements included pulse wave velocity (PWV), augmentation index, and brachial distensibility. Multivariate linear regression was used to assess the independent and joint effects of T1D and smoking on arterial stiffness.

RESULTS

Nearly 20% of both youth with and without T1D and T1D were smokers. In youth without T1D, smokers had higher trunk and arm PWV. After adjustment for potential confounders, T1D, but not smoking, was an independent predictor of PWV (P < .05). Moreover, smoking status did not modify the association between T1D and increased arterial stiffness.

CONCLUSIONS

We found a high prevalence of smoking among youth with and without T1D; however, smoking status was not independently associated with increased arterial stiffness in youth with T1D.

LDL-apheresis: technical and clinical aspects

The prognosis of patients suffering from severe hyperlipidemia, sometimes combined with elevated lipoprotein (a) levels, and coronary heart disease refractory to diet and lipid-lowering drugs is poor. For such patients, regular treatment with low-density lipoprotein (LDL) apheresis is the therapeutic option. Today, there are five different LDL-apheresis systems available: cascade filtration or lipid filtration, immunoadsorption, heparin-induced LDL precipitation, dextran sulfate LDL adsorption, and the LDL hemoperfusion. There is a strong correlation between hyperlipidemia and atherosclerosis. Besides the elimination of other risk factors, in severe hyperlipidemia therapeutic strategies should focus on a drastic reduction of serum lipoproteins. Despite maximum conventional therapy with a combination of different kinds of lipid-lowering drugs, sometimes the goal of therapy cannot be reached. Hence, in such patients, treatment with LDL-apheresis is indicated. Technical and clinical aspects of these five different LDL-apheresis methods are shown here. There were no significant differences with respect to or concerning all cholesterols, or triglycerides observed. With respect to elevated lipoprotein (a) levels, however, the immunoadsorption method seems to be most effective. The different published data clearly demonstrate that treatment with LDL-apheresis in patients suffering from severe hyperlipidemia refractory to maximum conservative therapy is effective and safe in long-term application.

Smoking as an independent risk factor for myocardial infarction or stroke in type 2 diabetes: a report from the Swedish National Diabetes Register

BACKGROUND

Few earlier studies have analysed smoking as a risk factor for myocardial infarction (MI) or stroke in type 2 diabetic patients.

DESIGN AND METHODS

A longitudinal study involved 13 087 female and male patients with type 2 diabetes from the Swedish National Diabetes Register with no previous MI or stroke at baseline, aged 30-74 years, and with data available for all analysed variables, followed up for mean 5.7 years.

RESULTS

Adjusted hazard ratios (HRs) for smoking and first-incident fatal/nonfatal MI, stroke and total mortality were 1.7 [95% confidence interval (CI): 1.4-2.0; P<0.001], 1.3 (95% CI: 1.1-1.6; P = 0.006) and 1.8 (95% CI: 1.5-2.2; P<0.001), respectively, by Cox regression analysis, adjusted for age, sex, diabetes duration, hypoglycaemic treatment, haemoglobin A1c, blood pressure, body mass index, microalbuminuria, antihypertensive and lipid-lowering drugs. Adjusted HR was higher for fatal MI, 2.1 (95% CI: 1.7-2.7; P<0.001), than for nonfatal MI, 1.4 (95% CI: 1.2-1.7; P<0.001). The highest HRs were observed in more frequently smoking (22%), middle-aged patients (age <60 years) for fatal/nonfatal MI, 2.3 (95% CI: 1.8-3.1; P<0.001) and for total mortality, 2.5 (95% CI: 1.6-3.8, P<0.001), whereas lower HRs were observed in older and less smoking patients. With predicted cessation of smoking in patients aged below 60 years, 24% (95% CI: 15-33%) of cases of fatal/nonfatal MI and 24% (11-37%) of cases of total mortality may have been prevented.

CONCLUSION

The risk for MI and total mortality associated with smoking is high in type 2 diabetes, especially in more frequently smoking, middle-aged patients, and was higher for MI than for stroke, and also higher for fatal than for nonfatal events. Smoking cessation would strongly affect risk reduction.

Results of the application of the American Diabetes Association guidelines regarding tobacco dependency in subjects with diabetes mellitus

The objective of the study was to evaluate the stages of change for cessation in smoking after the application of American Diabetes Association recommendations in diabetic patients who smoke. This longitudinal descriptive study involved smokers with diabetes mellitus (DM) who were attended for their DM between September 2003 and December 2006. Intervention used was dependent on the stage of change for cessation (according to Prochaska and Di Clemente). For precontemplation subjects, a brief session was carried out where information regarding the risks of smoking in conjunction with DM was given. Patients at the contemplation stage of smoking cessation were offered the chance to participate in a cessation program. Later evaluation was carried out after a follow-up of more than 6 months. Seven hundred thirty-three subjects with DM were evaluated, including 156 smokers (21.28%): 103 (66.02%) in the precontemplation stage, 25 (16.02%) in the contemplation stage, 12 (7.69%) in the preparation stage, 12 (7.69%) in the action stage, and 4 (2.56%) in the maintenance stage. By the last follow-up, 65 (41.6%) subjects had quit smoking (36 ex-smokers), of whom 20 (30.77%) had subsequently relapsed. The use of the American Diabetes Association recommendations for the treatment of tobacco dependence in diabetes treatment results in an increased change of smoking cessation stages in subjects with DM as well as a higher overall percentage in abstinence.

Life-years gained among US adults from modern treatments and changes in the prevalence of 6 coronary heart disease risk factors between 1980 and 2000

Has the recent US decline in coronary heart disease (CHD) mortality increased life expectancy? The authors estimated the number of life-years gained from CHD treatments and changes in the prevalence of cardiovascular disease risk factors for the US population between 1980 and 2000. The previously validated IMPACT model was used to integrate data on numbers of CHD patients, treatment uptake, treatment effectiveness, population risk factor trends, and median survival among US adults. There were 308,900 fewer CHD deaths in 2000 among Americans aged 25-84 years than if 1980 mortality rates had applied. These 308,900 fewer deaths represented approximately 3,147,800 life-years gained (sensitivity analysis range, 2,448,900-3,744,900). Treatments for patients accounted for approximately 1,092,400 (751,700-1,387,000) life-years gained, whereas changes in the prevalence of population risk factors accounted for a gain of 2,055,500 (1,697,200-2,346,300) life-years. However, the 2,770,500 life-years gained through decreased levels of smoking, cholesterol, blood pressure, and physical inactivity were diminished by a loss of 715,000 life-years attributable to increased rates of obesity and diabetes. Therefore, modest reductions in the prevalence of several major cardiovascular disease risk factors accounted for more than twice as many life-years gained as did treatments. Unfortunately, these gains were partially offset by substantial increases in obesity and diabetes.

Hyperhomocysteinemia and lower extremity wounds

Chronic lower extremity wounds include ulceration of the leg and foot. The underlying pathology that causes these conditions includes venous insufficiency, arterial disease, diabetes, and other less common disorders. Since the introduction of the homocysteine theory more than 30 years ago, considerable evidence has demonstrated hyperhomocysteinemia to be an independent risk factor for venous and arterial thrombosis, atherosclerosis and cardiovascular disease. Although any cause-effect relationship remains to be determined, hyperhomocysteinemia as a risk factor for these events suggests that elevated levels of homocysteine may also be a marker of chronic lower limb ulceration. This review addresses the metabolism of homocysteine, mechanisms of vascular injury, a role for hyperhomocysteinemia in lower extremity wounds and possible means of treatment.

Cost-effectiveness of treatments reducing coronary heart disease mortality in Ireland, 2000 to 2010

OBJECTIVE

Coronary heart disease (CHD) is associated with a large burden of disease in Ireland and is responsible for more than 6000 deaths annually. This study examined the cost-effectiveness of specific CHD treatments in Ireland.

METHODS

Irish epidemiological data on patient numbers and median survival in specific groups, plus the uptake, effectiveness, and costs of specific interventions, all stratified by age and sex, were incorporated into a previously validated CHD mortality model, the IMPACT model. This model calculates the number of life-years gained (LYGs) by specific cardiology interventions to generate incremental cost-effectiveness ratios (ICERs) per LYG for each intervention.

RESULTS

In 2000, medical and surgical treatments together prevented or postponed approximately 1885 CHD deaths in patients aged 25 to 84 years, and thus generated approximately 14,505 extra life-years (minimum 7270, maximum 22,475). In general, all the cardiac interventions investigated were highly cost-effective in the Irish setting. Aspirin, beta-blockers, ACE inhibitors, spironolactone, and warfarin for specific conditions were the most cost-effective interventions (< euro 3000/LYG), followed by the statins for secondary prevention (< euro 6500/LYG). Revascularization for chronic angina and primary angioplasty for myocardial infarction, although still cost-effective, had the highest ICER (between euro 12,000 and euro 20,000/LYG).

CONCLUSIONS

Using a comprehensive standardized methodology, cost-effectiveness ratios in this study clearly favored simple medical treatments for myocardial infarction, secondary prevention, angina, and heart failure.

Smoking cessation in patients with diabetes mellitus: results from a controlled study of an intervention programme in primary healthcare in Sweden

OBJECTIVE

To evaluate an intervention programme on smoking cessation in patients with diabetes mellitus in primary healthcare.

DESIGN

Regional controlled intervention study.

SETTING

Seventeen primary healthcare centres in Sweden.

INTERVENTION

In the intervention centres, nurses with education in diabetes were given one half-day of training in motivational interviewing and smoking cessation. An invitation to participate in a smoking cessation group was mailed to patients from the intervention centres followed by a telephone call from the patient's diabetes nurse. The nurses who intervened were specially educated in smoking cessation. The control group received a letter containing advice to stop smoking and information about a one-year follow-up.

PATIENTS

Daily smokers with diabetes mellitus, 30-75 years of age. In the intervention centres 241 patients fulfilled the criteria and in the control centres 171 patients.

MAIN OUTCOME MEASURES

Self-reported smoking habits after one year.

RESULTS

In total, 21% of the smokers accepted group treatment. After 12 months, 20% (42/211) in the intervention centres reported that they had stopped smoking and 7% (10/140) in the control centres; 40% (19/47) of the smokers who had participated in group treatment reported that they had stopped smoking.

CONCLUSION

A computerized record system for patients in primary healthcare was used to identify diabetic patients who were smokers. The selected group was invited to a stop smoking programme. At a one-year follow-up significantly more patients in the intervention centres had stopped smoking compared with patients in the control centres.

Insulin resistance, diabetes and cardiovascular risk: approaches to treatment

The prevalence of diabetes is increasing worldwide. Insulin resistance and diabetes mellitus are major predictors of cardiovascular ischaemic disease. Other risk factors for cardiovascular death including hypertension, dyslipidaemia, smoking and visceral obesity are especially lethal in diabetics. C-reactive protein, plasminogen activator inhibitor-1, matrix metalloproteinases and other emerging risk factors and their roles are continually being researched and discovered. Treatment of this syndrome must be aimed at lifestyle modification, glycaemic control and management of concomitant risk factors. Diet and exercise play a vital role in the treatment of diabetes and the metabolic syndrome. Weight reduction and increased physical activity will improve insulin resistance, hyperglycaemia, hypertension and dyslipidaemia. Hypertension management has been shown to be especially important in diabetics to prevent cardiovascular events. Likewise, multiple clinical trials show that reduction of cholesterol is even more vital in diabetics than the general population for risk reduction of coronary disease. There is a great deal of evidence that tight control of glycaemia is essential to treatment of this condition. There are a variety of available pharmacological agents available including metformin, insulin secretagogues, alpha-glucosidase inhibitors, thiazolidinediones and insulin. The mechanisms and side effects of these medications are discussed. As macrovascular disease is the major cause of morbidity and mortality, an early, aggressive, multi-factorial approach to treatment of the metabolic syndrome and diabetes is vital to prevent adverse cardiac outcomes.

Life-years gained from modern cardiological treatments and population risk factor changes in England and Wales, 1981-2000

OBJECTIVES

We estimated life-years gained from cardiological treatments and cardiovascular risk factor changes in England and Wales between 1981 and 2000.

METHODS

We used the IMPACT model to integrate data on the number of coronary heart disease patients, treatment uptake and effectiveness, risk factor trends, and median survival in coronary heart disease patients.

RESULTS

Compared with 1981, there were 68230 fewer coronary deaths in 2000. Approximately 925415 life-years were gained among people aged 25-84 years (range: 745 195-1 138 655). Cardiological treatments for patients accounted for approximately 194145 life-years gained (range: 142505-259225), and population risk factor changes accounted for approximately 731270 life-years gained (range; 602695-879430).

CONCLUSIONS

Modest reductions in major risk factors led to gains in life-years 4 times higher than did cardiological treatments. Effective policies to promote healthy diets and physical activity might achieve even greater gains.

Cardiovascular risk factors in type 2 diabetic patients: Multifactorial intervention in primary care

BACKGROUND

Cardiovascular disease is the main cause of morbidity and mortality in patients with type 2 diabetes mellitus (DM). Intervention on cardiovascular risk factors (CVRF) is essential to obtain clinical results reducing the excess of cardiovascular risk (CVR) in these patients.

METHODS

The objective of this study was to describe the association of type 2 DM with modifiable cardiovascular risk factors and the degree of control of these in a population of type 2 diabetics in attendance in primary care clinics, and also to establish prospectively whether an integral and multifactorial intervention on uncontrolled cardiovascular risk factors, carried out in conditions of routine clinical practice by applying an open protocol, could significantly reduce the estimated CVR according to the Framingham scale. The proposed intervention included both actions aimed at modifying habits, and pharmacologic intervention to achieve an optimum level of control in accordance with international recommendations for the objectives and treatment for type 2 diabetes.

RESULTS

A total of 3466 patients with a mean age of 58 +/- 7.5 years were studied and followed-up for 1 year. Of these, 90.4% of patients had high blood pressure; 60.1% of men and 32.7% of women presented CVR >20% in 10 years according to the Framingham scale by categories. Intervention at 1 year of follow-up had achieved statistically significant reductions in blood pressure, glycated hemoglobin, and lipid levels, but not of patients' body weight. After 1 year of follow-up, 29% of males and 24% of women with a high CVR (>20%) at the start of the study presented reduced risk levels.

CONCLUSION

The results of the study demonstrate that an integrated and multifactorial intervention in type 2 diabetic patients can achieve clinically significant reductions in CVR. However, conducted in effective conditions, it is not able to achieve optimum levels of control in spite of the initial proposal, possibly due to some degree of inertia in routine clinical practice.

Smoking is associated with increased HbA1c values and microalbuminuria in patients with diabetes--data from the National Diabetes Register in Sweden

OBJECTIVES

The aim was to examine trends in the proportion of smoking in diabetes patients, and to study associations between smoking, glycaemic control, and microalbuminuria.

METHODS

Smoking habits were reported to the Swedish National Diabetes Register (NDR), with data from hospitals and primary health care. Patient characteristics included were age, gender, type of treatment, diabetes duration, HbA1c, BMI, blood pressure, antihypertensive and lipid-lowering drugs, and microalbuminuria.

RESULTS

The proportion of smokers in type 1 diabetes was 12-15% during 1996-2001, it was high in females<30 years (12-16%), and was higher in the age group 30-59 years (13-17%) than in older (6-9%) patients. The corresponding proportion of smoking in type 2 diabetes was 10-12%, higher in those less than 60 years of age (17-22%) than in older (7-9%) patients. Smoking type 1 and type 2 patients in 2001 had higher mean HbA1c but lower mean BMI values than non-smokers. Smokers also had higher frequencies of microalbuminuria, in both type 1 (18 vs 14%) and type 2 (20% vs 13%) diabetes. Multiple logistic regression analyses disclosed that smoking was independently associated with elevated HbA1c levels (p<0.001) and microalbuminuria (p<0.001), but negatively with BMI (p<0.001), in both type 1 and type 2 diabetes.

CONCLUSIONS

Smoking in patients with diabetes was widespread, especially in young female type 1, and in middle-aged type 1 and type 2 diabetes patients, and should be the target for smoking cessation campaigns. Smoking was associated with both poor glycaemic control and microalbuminuria, independently of other study characteristics.

Metabolic syndrome in subjects with type-2 diabetes mellitus

BACKGROUND

Each component of metabolic syndrome (MS) conveys increased cardiovascular disease risk, but as a combination they become much more powerful. Vigorous early management of the syndrome may have a significant impact on the prevention of both diabetes and cardiovascular disease.

AIM

This study aims to determine the frequency of occurrence of MS and its relation to cardiovascular events among patients with type-2 diabetic mellitus.

METHODS

The study group consisted of 218 type-2 diabetic patients. These were screened for hypertension, hyperlipidemia, obesity, microalbuminuria, and cardiovascular events.

RESULTS

There were 128 (58.7%) males and 90 (41.3%) females. The mean age was 53.4 +/- 6.3 years and a mean body mass index (BMI) of 25.5 +/- 5.4 (males-23.4 +/- 4.2; females-26.2 +/- 5.7). MS was present in 55 (25.2%) of the study population. Systemic hypertension was the most common component of MS seen in 84 (38.5%) patients. The mean serum total cholesterol was 168.6 +/- 25.8 mg% (men 153 +/- 23; women 169 +/- 19; p > 0.05). Eight female and 12 male patients had serum total cholesterol > or = 200 mg%. Dyslipidemia occurs more commonly in males than females. Obesity was more common in female patients than in males. Out of 128 male type-2 patients with diabetes seen, 111 (86.7%) were without microalbuminuria. The corresponding figure among the females was 90% (81 out of 90 patients).

CONCLUSIONS

The study demonstrated that MS was present in 25.2% of the study population. The syndrome and its different components were positively associated with a higher risk of stroke, peripheral vascular disease, and occurrence of microalbuminuria, p < 0.001. Ischemic heart disease occurs rarely in the population. A long-term, targeted, intensive intervention involving multiple cardiovascular risk factors is recommended to reduce the risk of both cardiovascular and microvascular events among patients with type-2 diabetic mellitus.

Preventing macrovascular disease in patients with type 2 diabetes mellitus

Type 2 diabetes mellitus (DM) is associated with an increased risk for both micro-and macrovascular complications, and cardiovascular diseases (CVD) are the most common causes of death in these patients, accounting for almost 70% of the deaths. Given the high prevalence of the condition and the expected global increase in the prevalence of type 2 DM, a case is made for prevention of these serious complications in order to reduce the individual morbidity and the economic burden on society. In this review we present the knowledge of how macrovascular disease in patients with type 2 DM may be prevented, and suggest possible strategies for doing so.A thorough search of the published literature was conducted and we first present relevant epidemiological studies demonstrating the impact of important risk factors for CVD in DM, such as dyslipidemia, hyperglycemia, hypertension, smoking, familial premature coronary heart disease and some non-classical risk factors such as hyperinsulinemia, insulin resistance, endothelial dysfunction and inflammation. Secondly, we review the results from published randomized controlled clinical trials and meta-analysis of these, evaluate the findings and suggest strategies for preventing CVD in patients with type 2 DM using non-pharmacological and pharmacological approaches. Present knowledge indicates that most patients with type 2 DM either have manifest CVD or have a high risk for future cardiovascular events, men with DM have a 2- to 4-fold; and women with DM a 3- to 5-fold increased risk for cardiovascular death compared with non-diabetic individuals. Care of patients with type 2 DM should include yearly risk assessment by the use of published risk equations or risk charts. On the background of this assessment, an individual risk reducing strategy should be tailored to each patient's need, including the treatment of hyperglycemia, hypertension and dyslipidemia together with the use of aspirin (acetylsalicylic acid) and ACE inhibitors. Such measures can reduce the risk of cardiovascular events in patients with type 2 DM.

Improving survival with metformin: the evidence base today

Establishing and maintaining control of glycaemia is a key step in the reduction of diabetic microvascular complications. By contrast, macrovascular disease which is the most important complication and shortens the lives of many people with type 2 diabetes is not reduced by glycaemic control alone. The landmark UK Prospective Diabetes Study (UKPDS) showed that intensive glycaemic management with metformin significantly reduced the risk of a range of debilitating and/or life-threatening macrovascular complications, compared with other oral agents, diet and insulin who achieved similar overall glycaemic control. The benefits observed included diabetes-related mortality (reduced by 42%, compared with diet treatment, p=0.017), all-cause mortality (reduced by 36%, p=0.011), myocardial infarction (reduced by 39%, p=0.01), and any diabetes-related endpoint (reduced by 32%, p=0.002). Other clinical and experimental studies have shown metformin to be associated with improved outcomes and support the conclusions from the UKPDS. In addition, a well-designed retrospective analysis has shown significantly lower mortality rates in patients receiving metformin compared with patients treated with sulphonylurea monotherapy. Metformin provides a greater degree of cardiovascular protection than would be expected from its antihyperglycaemic actions alone and is the first drug of choice for the treatment of type 2 diabetes unless there are contraindications in the individual patient.

Low-density lipoprotein apheresis: an overview

Atherosclerosis with myocardial infarction, stroke, and peripheral cellular disease still maintains its position at the top of morbidity and mortality statistics in industrialized nations. Established risk factors widely accepted are smoking, arterial hypertension, diabetes mellitus, and central obesity. Furthermore, there is a strong correlation between hyperlipidemia and atherosclerosis. The prognosis of patients suffering from severe hyperlipidemia, sometimes combined with elevated lipoprotein (a) (Lpa) levels, and coronary heart disease (CHD) refractory to diet and lipid-lowering drugs is poor. For such patients, regular treatment with low-density lipoprotein (LDL) apheresis is the therapeutic option. Today, there are four different LDL apheresis systems available: immunoadsorption, heparin-induced extracorporeal LDL/fibrinogen precipitation, dextran sulfate LDL adsorption and LDL hemoperfusion. Regarding the different LDL apheresis systems used, there is no significant difference with respect to the clinical outcome or concerning total cholesterol, LDL, high-density lipoprotein (HDL), or triglyceride concentrations. With respect to elevated Lpa levels, however, the immunoadsorption method seems to be the most effective. In 45 patients (25 women, 20 men) suffering from familial hypercholesterolemia resistant to diet and lipid lowering drugs, low-density lipoprotein (LDL) apheresis was performed over 95.6 +/- 44.7 months. Four different systems (Liposorber, 32 of 45, Kaneka, Osaka, Japan; Therasorb, 6 of 45, Baxter, Munich, Germany; Lipopak, 2 of 45, Pocard, Moscow, Russia; and Dali, 5 of 45, Fresenius, St. Wendel, Germany) were used. With all methods, average reductions of 57% for total cholesterol, 55.9% for LDL, 75.8% for lipoprotein a (Lpa), and 45.9% for triglycerides, and an average increase of 14.3% for HDL were reached. Severe side-effects such as shock or allergic reactions were very rare (0.3%) in all methods. In the course of treatment, an improvement in general well-being and increased performance were experienced by 44 of 45 patients. The present data demonstrate that treatment with LDL apheresis of patients suffering from familial hypercholesterolemia resistant to maximum conservative therapy is very effective and safe even in long-term application.

Life-years gained from coronary heart disease mortality reduction in Scotland: prevention or treatment?

Coronary Heart Disease (CHD) death rates have fallen considerably in many countries. We estimated the life-years-gained (LYG) in Scotland between 1975 and 1994 attributable to cardiology treatments, and population reductions in major CHD risk factors, using a previously validated mortality model. This combines published effectiveness data with information on uptake of CHD treatments; risk factor trends; and median survival by age and sex. Compared with 1975, there were 4,536 fewer CHD deaths in 1994, resulting in approximately 48,016 LYG among those aged 45-84 (maximum estimate 53,317; minimum estimate 36,867). Medical and surgical treatments for CHD patients gained approximately 12,025 life-years; the largest contribution coming from pharmacologic secondary prevention. Population reductions in major risk factors (smoking, cholesterol, and blood pressure) accounted for some 35,991 LYG, reductions in smoking accounted for over 50% of this. Modern cardiologic treatments gained many thousands of life-years in Scotland, but modest reductions in risk factors gained almost three times as many life-years.

The National Diabetes Register in Sweden: an implementation of the St. Vincent Declaration for Quality Improvement in Diabetes Care

OBJECTIVE

To monitor glycemic control, treatable risk factors, and treatment profile for quality assessment of diabetes care on a national scale.

RESEARCH DESIGN AND METHODS

Four samples of 23,546, 32,903, 30,311, and 29,769 patients with diabetes (1996-1999) were studied based on a repeated national screening and quality assessment of diabetes care by the National Diabetes Register, Sweden, with participation of both hospitals and primary health care. Clinical characteristics included were age, sex, diabetes duration and treatment, glycemic control (HbA(1c)), office blood pressure (BP), BMI, smoking habits, and use of lipid-lowering drugs in patients with type 1 or type 2 diabetes.

RESULTS

Favorable decreases of mean HbA(1c) and BP values were registered during the 4-year study period for both type 1 (HbA(1c) 7.5-7.3% and BP 130/75-130/74 mmHg) and type 2 diabetic patients (HbA(1c) 7.0-6.7% and BP 151/82-147/80 mmHg). Treatment aims of HbA(1c) and BP levels were also achieved in increasing proportions for type 1 (HbA(1c) <7.5%: 50-58% and BP </=140/85 mmHg: 77-79%), and type 2 diabetic patients (HbA(1c) <7.5%: 66-73% and BP </=140/85 mmHg: 32-42%). The use of lipid-lowering drugs increased for type 1 (4-11%) and type 2 diabetic patients (10-22%). In type 2 diabetic patients, treatment with oral agents alone decreased, but combination therapy (insulin and oral agents) increased during the study period. Mean BMI increased during 1996-1999 in type 2 diabetic patients. High HbA(1c) and BP values in 1999 were predicted by high BMI values 1996 and by high increase of BMI during the period, independent of diabetes duration, age, and sex.

CONCLUSIONS

Decreasing mean HbA(1c) and BP levels and the wider use of lipid-lowering drugs during the late 1990s in patients with diabetes in a national sample from Sweden should translate into clinical benefits regarding micro- and macrovascular complications as well as diabetes-related mortality.

Effectiveness of long-term heparin-induced extracorporeal LDL precipitation (HELP) in improving coronary calcifications

There is clear clinical evidence that a drastic lowering of plasma LDL-Cholesterol (LDL) concentrations significantly reduces the rate of total and coronary mortality as well as the incidence of cardiovascular events in high risk hypercholesterolemic patients. We describe the case of a 51-year-old woman with coronary heart disease (CHD) who presented with increasing angina on exertion in 1995, at the age of 45. She suffered from a heterozygous familial hypercholesterolemia and in 1985 her total cholesterol (TCHO) was 328 +/- 62 mg/dl (mean value of ten analysis). After ten years of statins her mean values (20 analysis, 2 per year) were: TCHO 259 +/- 71, LDL 209 +/- 47, HDL 35 +/- 7 mg/dl. Coronary angiography (CA) performed in 1995 disclosed three vessel coronary heart disease with significant stenoses of the distal right coronary artery, multiple calcifications of the interventricularis artery and multiple plaques with significant stenoses in the ramus circumflexus. The woman underwent coronary by-pass surgery. Thereafter the patient was treated for six years with HELP in biweekly intervals, in combination with statins. TCHO, LDL, HDL and fibrinogen (fb) levels were measured before and after each treatment. Their mean values for an amount of 120 sessions were: TCHO pre 216 +/- 23, post 111 +/- 18 LDL pre 152 +/- 16 post 67 +/- 18, HDL pre 42 +/- 5 post 35 +/- 4 fb pre 306 +/- 48 post 125 +/- 31. In 2001 a new CA was performed. Calcifications disappeared and stenoses were identical to the previous CA or reduced. There were no further clinical manifestations of CHD. We trust that the clinical benefit of the HELP procedure will be substantial for those patients who have problems in clearing LDL from their plasma pool and who are at the same time sensitive to elevated LDL levels by the development of premature coronary sclerosis.

Smoking and relation to other risk factors in postmenopausal women with coronary artery disease, with particular reference to whole blood viscosity and beta-cell function

OBJECTIVES

To investigate possible associations between smoking habits and other coronary risk factors in postmenopausal women with known coronary heart disease (CHD).

SETTING

The study was conducted at a university clinic.

SUBJECTS

A total of 118 postmenopausal women with CHD verified with angiography, consecutively recruited.

INTERVENTIONS

Conventional treatment for CHD. The women were randomized to hormone replacement therapy (HRT) with transdermal 17-beta oestradiol and medroxyprogesterone acetate, or to a control group.

RESULTS

Smokers were younger (P = 0.005), had lower body mass index (P = 0.04) and lipoprotein Lp(a) levels (P = 0.02) compared with nonsmokers. Smokers had reduced beta-cell function (homeostasis model assessment, P = 0.006), whereas whole blood viscosity (WBV) was higher at all shear rates. WBV was not affected by HRT over a 12-month period. Oestrone levels were higher in smokers.

CONCLUSIONS

Smoking adversely affects insulin secretion (beta-cell function) and WBV in postmenopausal women with established CHD, which could be of importance as a mechanism for the increased risk of CHD in smokers. The importance of smoking as a risk factor, overrides the effect of Lp(a), which is lower in smokers compared with nonsmokers.

A case-control study of risk factors for development of type 2 diabetes: emphasis on physical activity

The aim of this case-control study was to evaluate the association between the lifestyle risk factors, especially physical activity, and the prevalence of type 2 diabetes and the comorbidity of type 2 diabetes and dyslipidemia in middle-aged Japanese urban population. Subjects (279 males and 119 females, 53.5+/-6.8 years old) were selected from one city office in Tokyo and consisted of type 2 diabetes cases (n=53), dyslipidemia cases (n=130), the comorbidity cases (n=58) and sex- and age-matched controls (n=155). A self-administered questionnaire was used to collect physical activity data using Baecke's questionnaire translated and other lifestyle data. Our results revealed that physical activity was significantly associated with the reduction of the prevalence of type 2 diabetes and the comorbidity, and the sex- and age-adjusted odds ratios of the fourth quartile to the lowest one were 0.31 (95%CI:0.12-0.81) and 0.32 (95%CI:0.13-0.81), respectively. Family history of diabetes and smoking were independent risk factors for the prevalence of type 2 diabetes and the comorbidity.

Cigarette smoking: an important renal risk factor - far beyond carcinogenesis

In recent years, it has become apparent that smoking has a negative impact on renal function, being one of the most important remediable renal risk factors. It has been clearly shown that the risk for high-normal urinary albumin excretion and microalbuminuria is increased in smoking compared to non-smoking subjects of the general population. Data from the Multiple Risk Factor Intervention Trial (MRFIT) indicate that at least in males, smoking increases the risk to reach end-stage renal failure. Smoking is particularly "nephrotoxic" in older subjects, subjects with essential hypertension and patients with preexisting renal disease. Of interest, the magnitude of the adverse renal effect of smoking seems to be independent of the underlying renal disease. Death-censored renal graft survival is decreased in smokers, indicating that smoking also damages the renal transplant. Cessation of smoking has been show to reduce the rate of progression of renal failure both in patients with renal disease or a renal transplant. The mechanisms of smoking-induced renal damage are only partly understood and comprise acute hemodynamic (e.g., increase in blood pressure and presumably intraglomerular pressure) and chronic effects (e.g., endothelial cell dysfunction). Renal failure per se leads to an increased cardiovascular risk. The latter is further aggravated by smoking. Particularly survival of smokers with diabetes mellitus on hemodialysis is abysmal. In the present review article the current state of knowledge about the renal risks of smoking is reviewed. It is the aim of the article to point out that smoking not only increases the risk of renal cell carcinoma or uroepithelial cell carcinoma, but also the risk of a faster decline of renal function. The latter is a relatively new negative aspect which has not been widely recognized.

Teaching patients to monitor their risk factors retards the progression of vascular complications in high-risk patients with Type 2 diabetes mellitus--a randomized prospective study

AIMS

Intensive management of risk parameters in diabetic patients may retard the progression of both micro- and macrovascular complications. Intensified care requires expert staff and is expensive. The aim of the present study was to examine whether sharing the therapeutic responsibility with the patients will improve the outcome.

METHODS

A randomized prospective study of 165 patients with diabetes mellitus Type 2, hypertension (> 140/90 mmHg) and hyperlipidaemia (LDL-C > 120 mg/dl). Patients were randomly allocated to standard annual consultation (SC) or to a patient participation programme (PP). The medical care for both groups was administered by primary care physicians, who were unaware of the nature of the intervention.

RESULTS

At 4 years the mean blood pressure was 148/88 (+/- 6.1/1.7) mmHg in the SC patients vs. 142/84 (+/- 5.8/1.8) mmHg in the PP group (P = 0.02). The mean LDL-C was 124 +/- 8 and 114 +/- 6 mg/dl (P = 0.01) and the mean HbA1c was 8.9 +/- 1.2% and 8.2 +/- 1.5% (P = 0.04) in the SC and PP groups, respectively. The average annual fall in estimated glomerular filtration rate was 3.5 ml/min per year in the SC group vs. 2.25 in the PP group (P < 0.05). Albumin/creatinine ratio > 300 mg/g developed in four SC patients vs. none of the PP patients. There was a total of 36 cardiovascular events in the SC group vs. 23 in the PP group (P = 0.04). All patients in the PP group received ACE inhibitors (or AII blockers) and statins vs. 52% and 43%, respectively, in the SC group. Glucose-lowering regimens were similar.

CONCLUSIONS

Well-informed and motivated patients were more insistent to reach and maintain target values of the main risk factors of diabetic complications. The differences between the PP and SC groups were of the same order of magnitude as those between intensive and standard care groups in other studies albeit with, comparatively, a very modest cost.

Low-density lipoprotein apheresis: clinical results with different methods

In 40 patients (22 women, 18 men) suffering from familial hypercholesterolemia resistant to diet and lipid lowering drugs, low-density lipoprotein (LDL) apheresis was performed over 84.9 +/- 43.2 months. Four different systems (Liposorber, 28 of 40, Kaneka, Osaka, Japan; Therasorb, 6 of 40, Baxter, Munich, Germany; Lipopak, 2 of 40, Pocard, Moscow, Russia; and Dali, 4 of 40, Fresenius, St. Wendel, Germany) were used. With all methods, average reductions of 50.6% for total cholesterol, 52.2% for LDL, 64.3% for lipoprotein (a) (Lp[a]), and 43.1% for triglycerides, and an average increase of 10.3% for high-density lipoprotein (HDL) were reached. Severe side effects such as shock or allergic reactions were very rare (0.5%) in all methods. In the course of treatment, an improvement in general well being and increased performance were experienced by 39 of 40 patients. Assessing the different apheresis systems used, at the end of the trial, there were no significant differences with respect to the clinical outcome experienced with the patients' total cholesterol, LDL, HDL, and triglyceride concentrations. However, to reduce high Lp(a) levels, the immunoadsorption method with special Lp(a) columns (Lipopak) seems to be most effective: -59% versus -25% (Kaneka) - (Baxter), and -29% (Dali). The present data demonstrate that treatment with LDL apheresis of patients suffering from familial hypercholesterolemia resistant to maximum conservative therapy is very effective and safe even in long-term application.

Management After Myocardial Infarction

Individuals who survive an acute myocardial infarction (MI) have up to a ninefold greater risk of cardiovascular morbidity and mortality compared with the general population. The modification of traditional coronary risk factors, including hypertension, hyperlipidemia, tobacco use, and diabetes mellitus, constitutes one of the cornerstones of management after acute MI. Therapies aimed at reversing the pathophysiologic disorders that lead to endothelial dysfunction, thrombosis, and atherosclerotic plaque instability may improve the prognosis for patients after acute MI. Aggressive risk stratification diagnostic testing can identify patients at the highest risk for adverse events. Prior to hospital discharge, patients should have an evaluation of left ventricular systolic function, an assessment for the risk for residual myocardial ischemia, and a clinical assessment of the risk for serious ventricular arrhythmias. An array of pharmaceutical agents is available for the secondary prevention of MI, including antiplatelet agents, beta-blockers, angiotensin-converting enzyme inhibitors, and statins.

Diabetic Cardiomyopathy

Diabetes mellitus is a major risk factor for the development of congestive heart failure (CHF). Diabetic cardiomyopathy has been acknowledged as a distinct disease entity that is an additional risk for diabetic patients to develop CHF, especially when they are affected by hypertension or epicardial coronary artery disease. Moreover, diabetic cardiomyopathy has been documented to lead to CHF even in the absence of other risk factors. As the combination of hypertension and diabetes has shown to be particularly detrimental, aggressive blood pressure control with a goal of less than 130/85 mm Hg is of critical importance. The first choice for pharmacologic treatment is angiotensin-converting enzyme inhibitors. Double- or triple-drug therapy is frequently required for good control. The increased risk of epicardial coronary artery disease in patients with diabetes warrants stringent treatment of dyslipidemia. If dilated cardiomyopathy with low ejection fraction is present, therapy with angiotensin-converting enzyme inhibitors, digoxin, diuretics, beta-blockers, and spironolactone (for patients with New York Heart Association class III to IV functional status) is indicated. If cardiac dysfunction consists predominantly of impaired diastolic function, heart rate control with a beta-blocker or a calcium antagonist is of particular importance. Control of blood glucose should be achieved, with hemoglobin A(1c) levels of less than 7%. Hyperinsulinemia should be avoided when possible; therefore, insulin-sensitizing agents are preferred over insulin-secretion-enhancing agents. Symptoms of CHF and acutely decompensated CHF should be treated no differently than nondiabetic patients. Care for patients with diabetes always includes lifestyle changes consisting of smoking cessation, decreasing obesity, regular exercise, and a heart-healthy diabetic diet.

Smoking and mortality among women with type 2 diabetes: The Nurses' Health Study cohort

OBJECTIVE

To assess the relationship between cigarette smoking and mortality among women with type 2 diabetes in the Nurses' Health Study cohort.

RESEARCH DESIGN AND METHODS

The Nurses' Health Study, a prospective cohort of U.S. female registered nurses, included 7,401 women with type 2 diabetes diagnosed at baseline or during follow-up from 1976 to 1996. Total and cause-specific mortality of these diabetic women were the outcomes of interest.

RESULTS

We documented 724 deaths during 20 years of follow-up (67,420 person-years) among women with type 2 diabetes. In multivariate analyses, adjusting for age, history of high blood pressure and high cholesterol, and other cardiovascular risk factors, compared with never smokers, the RRs of mortality were 1.31 (95% CI 1.11-1.55) for past smokers, 1.43 (0.96-2.14) for current smokers of 1-14 cigarettes/day, 1.64 (1.24-2.17) for current smokers of 15-34 cigarettes/day, and 2.19 (1.32-3.65) for current smokers of > or =35 cigarettes/day (P for trend = 0.0002). Women with type 2 diabetes who had stopped smoking for > or =10 years had a mortality RR of 1.11 (0.92-1.35) compared with diabetic women who were never smokers.

CONCLUSIONS

Cigarette smoking is associated in a dose-response manner with an increased mortality among women with type 2 diabetes. Furthermore, quitting smoking appears to decrease this excess risk substantially. Diabetes patients should be strongly advised against smoking.

Current topics on low-density lipoprotein apheresis

The prognosis of patients suffering from severe hyperlipidemia, sometimes combined with elevated lipoprotein (a) (Lp[a]) levels, and coronary heart disease (CHD) refractory to diet and lipid-lowering drugs is poor. For such patients, regular treatment with low-density lipoprotein (LDL) apheresis is the therapeutic option. Today, there are four different LDL-apheresis systems available: immunoadsorption, heparin-induced extracorporeal LDL/fibrinogen precipitation, dextran sulfate LDL-adsorption, and LDL-hemoperfusion. Despite substantial progress in diagnostics, drug therapy, and cardiosurgical procedures, atherosclerosis with myocardial infarction, stroke, and peripheral cellular disease still maintains its position at the top of morbidity and mortality statistics in industrialized nations. Established risk factors widely accepted are smoking, arterial hypertension, diabetes mellitus, and central obesity. Furthermore, there is a strong correlation between hyperlipidemia and atherosclerosis. Besides the elimination of other risk factors, in severe hyperlipidemia (HLP) therapeutic strategies should focus on a drastic reduction of serum lipoproteins. Despite maximum conventional therapy with a combination of different kinds of lipid-lowering drugs, however, sometimes the goal of therapy cannot be reached. Mostly, the prognosis of patients suffering from severe HLP, sometimes combined with elevated Lp(a) levels and CHD refractory to diet and lipid-lowering drugs is poor. Hence, in such patients, treatment with LDL-apheresis can be useful. Regarding the different LDL-apheresis systems used, there were no significant differences with respect to the clinical outcome or concerning total cholesterol, LDL, high-density lipoprotein, or triglyceride concentrations. With respect to elevated Lp(a) levels, however, the immunoadsorption method seems to be the most effective. The published data clearly demonstrate that treatment with LDL-apheresis in patients suffering from severe hyperlipidemia refractory to maximum conservative therapy is effective and safe in long-term application.

Adverse effects of smoking in the renal patient

Smoking is a known risk factor for cardiovascular diseases, cancer, and several other health problems. It is the number one preventable cause of death in modern countries. The first evidence that smoking may be a renal risk factor was published in 1978. Since then, several studies documented that smoking is nephrotoxic in patients with diabetic and non-diabetic renal disease. Data from the Multiple Risk Factor Intervention Trial indicate that smoking even increases the renal risk in the general male population: an increased relative risk for end-stage renal failure (ESRF) was found for smokers as compared to non-smokers (up to 1.69 for heavy smokers). Several potential mechanisms of smoking-induced renal damage have been discussed, e.g. increase in blood pressure, alteration of intrarenal hemodynamics, as well as activation of the sympathetic nerve, the reninangiotensin and the endothelin systems. The pathomechanisms are, however, only partly understood. Once ESRF has become established, the failure to discontinue smoking adversely affects the prognosis of patients on renal replacement therapy, mainly by increasing the risk of cardiovascular complications. Discontinuation of smoking has been shown to improve both renal and cardiovascular prognosis in the renal patient and is probably the single most effective measure to retard progression of renal failure.

Smoking and diabetes in Chinese men

Smoking is a major cardiovascular risk factor and cause of death. Diabetes mellitus is also associated with an increased mortality and morbidity. Evidence concerning whether smoking increases the incidence of diabetes remains conflicting. Glycaemic status and smoking habits were analysed in 3718 Chinese subjects in order to assess the possible association between smoking and risk of diabetes in the Chinese population. The World Health Organisation 1998 criteria were used for the diagnosis of glucose intolerance. Smoking was defined as current cigarette smoking or ex-smoking without regard to daily consumption. The smoking habits of the studied subjects were correlated with glycaemic status. There were 3003 (80.8%) women and 715 (19.2%) men. The mean age (SD) was 38.4 (12.8) years (median 35.0, range 12-88 years). Of the 3718 subjects, 786 (21.1%) had diabetes, 708 (19.1%) had impaired glucose tolerance, and 2224 (59.8%) had normal results. Of the 3003 women, only 87 (2.9%) were smokers. The female smokers were younger, heavier, and had higher alcohol consumption than non-smokers. The prevalence of diabetes was similar between female smokers and non-smokers after adjustment for age, body mass index, family history of diabetes, and alcohol. Of the 715 men, 175 (24.5%) were smokers. The male smokers were younger, had lower blood pressure, and higher alcohol consumption. After adjustment for age, body mass index, family history of diabetes and alcohol, the male smokers had lower blood pressure, higher one hour plasma glucose, and more diabetes. Using logistic regression analysis (stepwise forward) with age, body mass index, alcohol, smoking, and family history of diabetes as independent variables to predict the risk of having diabetes, age and body mass index are independently associated with diabetes in both men and women. In addition, smoking is independently associated with the risk of diabetes in men, the odds ratio (95% confidence interval, CI) being 1.705 (1.106 to 2.630). Family history of diabetes is independently associated with the risk of diabetes in women, and the odds ratio (95% CI) is 1.643 (1.314, to 2.053). In conclusion, it was found that smoking is independently associated with diabetes after adjustment for age, body mass index, alcohol, and family history of diabetes in Hong Kong Chinese men, the odds ratio being 1.7. The prevalence of smoking in Hong Kong Chinese women is low and its association with diabetes is inconclusive.

Quality improvement in primary health care using computerised journal, exemplified by a smoking cessation programme for diabetic patients

OBJECTIVE

To study the possibility of using the computerised journal for quality improvement in diabetes care.

DESIGN

The computerised journal was used to reach all diabetic smokers aged 30-75 years and to invite them to a structured smoking cessation programme. The follow-up time was 18 months.

SETTING

Habo, a Swedish community with 9600 inhabitants, with one primary health care centre.

SUBJECTS

147 subjects, aged 30-75 years, were registered with the diagnosis of diabetes mellitus in the computerised journal at the primary health care centre. Altogetber 25 of these patients were registered as smokers in the journal. All of them were invited to a smoking cessation group.

RESULTS

Information about smoking habits in the journal was available for all but 11%. After 18 months' follow-up, 9 of the 14 patients (64%) who started in the smoking cessation group had become non-smokers. Of those 11 subjects who did not attend the group, 6 had stopped smoking during the follow-up time in spite of not participating in the structured programme.

CONCLUSION

The computerised journal is a useful tool for quality improvement, giving the opportunity for directed preventive efforts on selected patient groups.

Transatlantic Conference on Clinical Trial Guidelines in Peripheral Arterial Disease: clinical trial methodology. Basel PAD Clinical Trial Methodology Group

Guidelines for the clinical development of drugs in peripheral arterial disease (PAD) have been issued by the Food and Drug Administration for the United States and by the regulatory agency of the European Union for Europe. With increasing globalization, transatlantic cooperation in drug research and development is essential for the future and would be substantially facilitated by the existence of transatlantic guidelines. A conference was held in Basel, Switzerland, in November 1997 to discuss the scientific background of the existing guidelines on the basis of published evidence and the extensive knowledge of clinical investigators and experienced regulators. The meeting was attended by 52 invited experts from the United States and Europe, as well as by representatives from the 2 regulatory authorities. The main conclusions from the meeting are presented and may serve as a reference for the future development of transatlantic guidelines for the evaluation of pharmacotherapy in PAD.

Effects of intensified antihypertensive treatment in diabetic nephropathy: mortality and morbidity results of a prospective controlled 10-year study

OBJECTIVE

The aim of this study was to describe the effect of intensified antihypertensive therapy based on a structured teaching and treatment programme on the prognosis of hypertensive type 1 (insulin-dependent) diabetic patients with kidney disease.

DESIGN

The study was a controlled, prospective, parallel, 10-year follow-up trial.

PATIENTS AND INTERVENTIONS

A sequential sample of 91 hypertensive type 1 diabetic patients with overt diabetic nephropathy was prospectively followed for 10 years. Forty-five patients (intensified antihypertensive therapy; IT group) participated in an intensified antihypertensive therapy programme and 46 patients received routine antihypertensive treatment as provided by family physicians, consultants and local hospitals (routine antihypertensive therapy; RT group).

OUTCOME MEASURES

The main endpoint was death; secondary endpoints were renal replacement therapy, blindness and amputation.

RESULTS

Blood pressure was reduced in the IT group and increased in the RT group. During the follow-up period, 29 patients died, seven in the IT group and 22 in the RT group. The survival curves were significantly different (P = 0.0008). The main causes of death were cardiac. In a multiple Cox proportional hazards model, allocation to the IT group reduced the mortality risk [relative risk (RR) = 0.213; 95% confidence interval 0.089-0.509, P = 0.00051, while age (P = 0.0039) and mean blood pressure (P= 0.0113) increased this risk. In multiple Cox or multiple logistic regression models, the risks of dialysis (RR = 0.269, 95% confidence interval 0.110-0.656, P = 0.0039), blindness (odds ratio = 0.158, 95% confidence interval 0.037-0.684, P= 0.0136), and amputation (RR = 0.181, 95% confidence interval 0.047-0.703, P= 0.0135) were significantly lower in the IT group compared with the RT group (log rank P = 0.0008).

CONCLUSION

We conclude that intensified antihypertensive treatment, based on a hypertension teaching and treatment programme, reduces long-term morbidity and mortality in patients with diabetic nephropathy.

Aspirin usage in a large teaching hospital diabetes clinic setting

AIM

To document aspirin usage and the prevalence of large and small vessel complications in patients with diabetes mellitus (DM) attending the outpatient diabetes clinics of a large public hospital.

METHODS

All patients attending diabetes outpatient clinics at The Royal Melbourne Hospital in Melbourne, Australia were surveyed over a 3-month period.

RESULTS

Complete data were available on 629 of 632 (296 male) patients surveyed. Of the 29.3% of patients who were suffering from one or more macrovascular complication (ischaemic heart disease, cerebrovascular disease or peripheral vascular disease), 63% were currently on aspirin treatment. Of those not on aspirin, 65% had no contra-indication to aspirin treatment and a further 19% had only a relative contra-indication of either aspirin or warfarin treatment recorded.

CONCLUSIONS

The published recommendations for the use of aspirin in patients with macrovascular disease were generally being followed in this clinic-based population. However, a significant proportion of patients without a contra-indication to treatment were still not receiving aspirin. The lack of clear evidence-based guidelines for aspirin use may be a factor in its under-prescription. This survey suggests clear evidence-based guidelines should be established and disseminated.

Developing risk stratification charts for diabetic and nondiabetic subjects

AIMS

To provide estimates of the 10-year risk of coronary heart disease events for diabetic and nondiabetic men and women with different levels of risk factors and, for diabetic subjects, with and without microalbuminuria.

METHODS

Use of risk coefficients derived from the Framingham Study and a meta-analysis of the influence of microalbuminuria on cardiovascular disease. The risk of a coronary heart disease event has been calculated for men and women with and without diabetes mellitus, and among diabetic subjects, with and without microalbuminuria, according to age, systolic blood pressure and the ratio of total to high density lipoprotein cholesterol.

RESULTS

These risk estimates have been developed as a series of colour charts. The use of Framingham estimates of risk have been validated by comparing them with estimates derived from the Dundee Risk Disk and from the PROCAM Study, these estimates providing reasonable agreement despite the geographical and temporal differences in their development.

CONCLUSIONS

These charts permit the overall level of risk to be derived, which can inform decision making about thresholds for therapeutic interventions, as well as assisting in patient education.