Associations of diabetes mellitus and other cardiovascular disease risk factors with decline in the ankle-brachial index

Liraglutide Accelerates Ischemia-Induced Angiogenesis in a Murine Diabetic Model

Background Severe hindlimb ischemia is a chronic disease with poor prognosis that can lead to amputation or even death. This study aimed to assess the therapeutic effect of liraglutide on hind-limb ischemia in type 2 diabetic mice and to elucidate the underlying mechanism. Methods and Results Blood flow reperfusion and capillary densities after treatment with liraglutide or vehicle were evaluated in a mouse model of lower-limb ischemia in a normal background or a background of streptozotocin-induced diabetes. The proliferation, migration, and tube formation of human umbilical vein endothelial cells were analyzed in vitro upon treatment with liraglutide under normal-glucose and high-glucose conditions. Levels of phospho-Akt, phospho-endothelial nitric oxide synthase, and phospho-extracellular signal-related kinases 1 and 2 under different conditions in human umbilical vein endothelial cells and in ischemic muscle were determined by western blotting. Liraglutide significantly improved perfusion recovery and capillary density in both nondiabetic and diabetic mice. Liraglutide also promoted, in a concentration-dependent manner, the proliferation, migration, and tube formation of normal glucose- and high glucose-treated human umbilical vein endothelial cells, as well as the phosphorylation of Akt, endothelial nitric oxide synthase, and extracellular signal-related kinases 1 and 2 both in vitro and in vivo. The liraglutide antagonist exendin (9-39) reversed the promoting effects of liraglutide on human umbilical vein endothelial cell functions. Furthermore, exendin (9-39), LY294002, and PD98059 blocked the liraglutide-induced activation of Akt/endothelial nitric oxide synthase and extracellular signal-related kinases 1 and 2 signaling pathways. Conclusions These studies identified a novel role of liraglutide in modulating ischemia-induced angiogenesis, possibly through effects on endothelial cell function and activation of Akt/endothelial nitric oxide synthase and extracellular signal-related kinases 1 and 2 signaling, and suggested the glucagon-like peptide-1 receptor may be an important therapeutic target in diabetic hind-limb ischemia.

Correlation of leg pain responses with ankle-brachial index and peripheral sensory responses in foot of type 2 diabetes mellitus

Introduction: Type 2 Diabetes Mellitus (T2DM) is associated with changes that occur in the peripheral circulation that affect foot functions. Therefore, there is a need for a risk prediction test on foot abnormalities using the leg pain response parameters in T2DM patients with ankle-brachial index (ABI) and peripheral sensory changes as a preventive effort to manage foot care. Design and Methods: This study employed a cross-sectional design in which 63 T2DM patients in a Public Health Center (PHC) in Malang were investigated. The instruments used include visual analog scale (VAS), monofilament, and foot doppler. Results: The Pearson correlation test showed no relationship between the responses to leg pain and the ABI of the right and left feet (p-values = 0.217 and 0.692), but there was a significant relationship between the left foot ABI and sensory status (p-value 0.002; left foot r = 0.383). Meanwhile, the Pearson's correlation and linear regression test also showed a relationship between the right foot ABI and sensory status (p-value = 0.007; r = 0.338). Furthermore, a multiple linear regression test showed a relationship between the leg pain response and sensory perception of the right and left feet (p-value = 0.035; r = 0.325). Conclusions: The relationship between the sensory status of the right and left feet and the response to leg pain in T2DM patients were moderate with a negative direction. It, therefore, implies that a decrease in the sensory responses increased the leg pain. Meanwhile, the moderate relationship and positive direction between the ABI and sensory status of the feet of T2DM patients indicates that a higher ABI score led to an increase in the sensory status of the foot.

Evaluation of Tear Evaporation Rate in Patients with Diabetes Using a Hand-Held Evaporimeter

Diabetes is a very common disease and is considered a risk factor for many diseases such as dry eye. The aim of the current work was to evaluate the tear evaporation rate (TER) in patients with diabetes using a hand-held evaporimeter. This observational, case–control and non-randomized study included 30 male patients with diabetes (17 controlled and 13 uncontrolled) with a mean ± standard deviation (SD) of 33.1 ± 7.9 years. An age-matched (18–43 years; 32.2 ± 6.5 years) control group consisting of 30 male subjects was also enrolled for comparison. Subjects with thyroid gland disorder, a high body mass index, high blood cholesterol, or thalassemia, contact lens wearers, and smokers were excluded. The TER was measured after the completion of the ocular surface disease index (OSDI) by each participant. The OSDI and TER median scores were significantly (Wilcoxon test, p < 0.05) higher in patients with diabetes (median (interquartile range; IQR) = 12.0 (8.3) and 46.4 (36.7) g/m2h, respectively) compared to the subjects within the control group (5.6 (7.0) and 15.1 (11.9) g/m2h, respectively). The median scores for the OSDI and TER measurements were significantly (Wilcoxon test, p < 0.05) higher among uncontrolled diabetes patients (13.0 (11.5) and 53.4 (14.2) g/m2h, respectively) compared to those obtained for patients with controlled diabetes (11.0 (8.0) and 27.3 (32.6) g/m2h, respectively). The tear evaporation rate in patients with diabetes was significantly higher compared to those obtained in subjects without diabetes. Uncontrolled diabetes patients have a higher tear evaporation rate compared to controlled diabetes patients. Therefore, diabetes can lead to eye dryness, since these patients possibly suffer excessive tear evaporation.

Relationship Between Serum Neopterin Level and Peripheral Arterial Plaque in Patients with Type 2 Diabetes

OBJECTIVE

Neopterin is an inflammatory factor synthesized by monocyte macrophages in response to γ-interferon. It plays an important role in regulating a variety of physiological and pathological processes, including obesity, diabetes, and cardiovascular disease. This study aims to clarify the relationship between peripheral arterial plaque and serum neopterin in type 2 diabetes.

METHODS

We consecutively selected 121 inpatients with type 2 diabetes. After collecting relevant clinical indicators, we collected serum from all patients and measured neopterin levels through enzyme linked immune sorbent assay. Peripheral arterial plaques (the carotid and femoral arteries) were detected by B-mode ultrasound. Multivariate logistic regression was used to determine the independent influencing factors. The correlation between neopterin levels and other variables was analyzed by Spearman correlation analysis. P <0.05 was considered to be statistically significant.

RESULTS

There was no difference in serum neopterin levels between arterial plaques group and no plaques group. Serum neopterin levels in patients with carotid plaque were elevated compared to patients without carotid plaque. Logistic regression analysis showed that a higher serum neopterin level was an independent risk factor for the presence of carotid plaques. Serum neopterin levels were positively correlated with BMI, HOMA-IR, and serum creatinine and negatively correlated with eGFR.

CONCLUSION

Serum neopterin levels were positively and independently associated with carotid plaque in patients with type 2 diabetes.

Association of six-minute walk distance with subsequent lower extremity events in peripheral artery disease

The prognostic significance of the six-minute walk distance for lower extremity events in people with peripheral artery disease (PAD) is unknown. This longitudinal study assessed whether a poorer six-minute walk distance at baseline was associated with higher rates of subsequent lower extremity atherosclerotic disease events in PAD. A total of 369 patients (mean age 69.4 ± 10.0 years; mean ankle-brachial index (ABI) 0.67 ± 0.17; 31% women; 30% black individuals) from Chicago-area medical centers with PAD were enrolled. Participants underwent baseline six-minute walk testing and returned for annual study visits. Lower extremity events consisted of one or more of the following: ABI decline greater than 15% or medical record adjudicated lower extremity revascularization, critical limb ischemia, or amputation. At a mean follow-up of 33.3 months, lower extremity events occurred in 66/123 (53.7%) people in the first (worst) tertile of six-minute walk performance, 55/124 (44.4%) in the second tertile, and 56/122 (45.9%) in the third (best) tertile. After adjusting for age, sex, race, ABI, comorbidities, and other confounders, participants in the first (worst) tertile of six-minute walk distance at baseline had higher rates of lower extremity events during follow-up, compared to those in the best tertile at baseline (HR = 1.74, 95% CI 1.17-2.60, p = 0.0067). Among people with PAD, a poorer six-minute walk distance was associated with higher rates of subsequent lower extremity PAD-related events after adjusting for confounders. Further study is needed to determine whether interventions that improve six-minute walk distance can reduce lower extremity adverse events in people with PAD.

Diabetes Mellitus and Noncardiac Atherosclerotic Vascular Disease-Pathogenesis and Pharmacological Treatment Options

Diabetes mellitus (DM) is also a cause of cardiovascular (CV) disease (CVD). Addressing the atherosclerotic CVD (ASCVD) burden in DM should reduce premature death and improve quality of life. Diabetes mellitus-associated ASCVD can lead to complications in all vascular beds (carotids as well as coronary, lower extremity, and renal arteries). This narrative review considers the diagnosis and pharmacological treatment of noncardiac atherosclerotic vascular disease (mainly in patients with DM). Based on current knowledge and the fact that modern DM treatment guidelines are based on CV outcome trials, it should be noted that patients with noncardiac CVD may not have the same benefits from certain drugs compared with patients who predominantly have cardiac complications. This leads to the conclusion that in the future, consideration should be given to conducting well-designed trials that will answer which pharmacological treatment modalities will be of greatest benefit to patients with noncardiac ASCVD.

Simple-to-use nomogram for evaluating the incident risk of moderate-to-severe LEAD in adults with type 2 diabetes: A cross-sectional study in a Chinese population

This study aimed to analyze the clinical characteristics of lower extremity atherosclerotic disease (LEAD) in Chinese adult type 2 diabetes (T2D) patients, and also explored the risk factors for LEAD and developed simple-to-use nomograms for LEAD and lesion degree in these patients. We retrospectively studied 4422 patients (male = 2084; female = 2338) with T2D who were ≥50. Based on lower extremity arterial ultrasound findings, we divided the patients into three groups: normal, mild, and moderate-to-severe group. The factors related to LEAD in patients with T2D were analyzed by logistic regression analysis. The risk factors for moderate-to-severe LEAD included: high HbA1c (OR = 1.07 95% CI 1.02–1.13), diabetic peripheral neuropathy (OR = 1.93 95% CI 1.57–2.37), and diabetic retinopathy (OR = 1.26 95%CI 1.01–1.57). The overall areas under the receiver operating characteristic curves for the nomograms for predicting the risks of LEAD and moderate-to-severe LEAD in adult T2D patients were 0.793 (95%CI 0.720, 0.824) and 0.736 (95%CI 0.678, 0.795), respectively. The developed nomograms are simple to use and enable preliminary visual prediction of the risk and degree of LEAD in Chinese T2D patients over 50 years. The nomograms are accurate to a certain degree and provide a clinical basis for predicting the occurrence and progression of LEAD.

The relationship of erectile dysfunction and subclinical cardiovascular disease: A systematic review and meta-analysis

Erectile dysfunction (ED) is associated with cardiovascular disease (CVD) and CVD mortality. However, the relationship between ED and subclinical CVD is less clear. We synthesized the available data on the association of ED and measures of subclinical CVD. We searched multiple databases for published literature on studies examining the association of ED and measures of subclinical CVD across four domains: endothelial dysfunction measured by flow-mediated dilation (FMD), carotid intima–media thickness (cIMT), coronary artery calcification (CAC), and other measures of vascular function such as the ankle–brachial index, toe–brachial index, and pulse wave velocity. We conducted random effects meta-analysis and meta-regression on studies that examined an ED relationship with FMD (15 studies; 2025 participants) and cIMT (12 studies; 1264 participants). ED was associated with a 2.64 percentage-point reduction in FMD compared to those without ED (95% CI: –3.12, −2.15). Persons with ED also had a 0.09-mm (95% CI: 0.06, 0.12) higher cIMT than those without ED. In subgroup meta-analyses, the mean age of the study population, study quality, ED assessment questionnaire (IIEF-5 or IIEF-15), or the publication date did not significantly affect the relationship between ED and cIMT or between ED and FMD. The results for the association of ED and CAC were inconclusive. In conclusion, this study confirms an association between ED and subclinical CVD and may shed additional light on the shared mechanisms between ED and CVD, underscoring the importance of aggressive CVD risk assessment and management in persons with ED.

Vascular Complications of Diabetes

Over the last several decades, the global incidence and prevalence of diabetes mellitus has increased significantly. The raised incidence rate is projected to continue as greater numbers of persons adopt a Western lifestyle and diet. Patients with diabetes mellitus are at heightened risk of both adverse microvascular and cardiovascular events. Moreover, once cardiovascular disease develops, diabetes mellitus exacerbates progression and worsens outcomes. The medical management of patients with diabetes mellitus mandates comprehensive risk factor modification and antiplatelet therapy. Recent clinical trials of new medical therapies continue to inform the care of patients with diabetes mellitus to reduce both cardiovascular morbidity and mortality.

Ankle-brachial index and brachial-ankle pulse wave velocity are risk factors for ischemic stroke in patients with Type 2 diabetes

The incidence of ischemic stroke in patients with diabetes is increasing. While brachial-ankle pulse wave velocity (BaPWV) and ankle-brachial index (ABI) are known to be associated with ischemic cardiovascular and cerebrovascular diseases, whether these measures predict the risk of ischemic cerebrovascular disease in diabetic patients remains unclear. 117 patients with type 2 diabetes were enrolled in this study. According to the results of head magnetic resonance imaging, the patients were divided into a diabetes-only group (n = 55) and a diabetes and ischemic stroke group (n = 62). We then performed ABI and BaPWV examinations for all patients. Compared with the diabetes-only group, we found decreased ABI and increased BaPWV in the diabetes and ischemic stroke group. Multivariate logistic regression analyses revealed that BaPWV and ABI were risk factors for ischemic stroke in patients with type 2 diabetes. Our findings indicate that decreased ABI and increased BaPWV are objective indicators of increased risk of ischemic stroke in patients with type 2 diabetes.

High Systolic and Diastolic Blood Pressure Variability Is Correlated with the Occurrence of Peripheral Arterial Disease in the First Decade following a Diagnosis of Type 2 Diabetes Mellitus: A New Biomarker from Old Measurement

Background. To assess whether the visit-to-visit variability in blood pressure (BP) is a risk factor of peripheral arterial disease (PAD) in patients with type 2 diabetes mellitus (T2DM) 10 years after diagnosis. Methods. The electronic medical records of 825 patients, who were diagnosed with type 2 diabetes mellitus (T2DM) during 2000-2002 and regularly followed for 10 years, were retrospectively reviewed. A total of 53,284 clinic visit records, including analysis of BP, BMI, serum glycohemoglobin, and lipid profile, were analyzed. Results. Patients were categorized into two groups according to their visit-to-visit variability in systolic and diastolic BP (SBP and DBP, resp.). The high-risk group included patients with high SBP and DBP visit-to-visit variability; this group had a 1.679-fold (95% CI: 1.141-2.472, P = 0.009) increased risk of PAD compared with patients in the low-risk group. Cox regression analysis also demonstrated that the age at which the patients were diagnosed with T2DM, smoking status, and mean creatinine level was significantly associated with increased risk of PAD with a hazard ration of 1.064 (95% CI: 1.043-1.084, P < 0.001), 1.803 (95% CI: 1.160-2.804, P = 0.009), and 1.208 (95% CI: 1.042-1.401, P = 0.012), respectively. Conclusions. High SBP and DBP visit-to-visit variability is correlated with PAD in the first decade following a diagnosis of T2DM.

Sex and ethnic differences in the associations between lipoprotein(a) and peripheral arterial disease in the Multi-Ethnic Study of Atherosclerosis

OBJECTIVE

Higher lipoprotein(a) [Lp(a)] has been linked with peripheral arterial disease (PAD). Also, elevated Lp(a) serum levels have been observed in women and African Americans (AAs). It remains uncertain if sex and ethnicity modify the association between Lp(a) and PAD.

METHODS

Lp(a) mass concentration was measured with a latex-enhanced turbidimetric immunoassay, from blood collected at baseline clinic visits after a 12-hour fast, in a multiethnic cohort. Also at baseline, the ankle-brachial index was measured. PAD was defined as an ankle-brachial index <1.0. Multivariable logistic regression was used to determine sex and ethnic differences in associations of log-transformed Lp(a) and the presence of PAD.

RESULTS

In 4618 participants, the mean age was 62 ± 10 years; Lp(a) mean was 30 ± 32 mg/dL and median (interquartile range) was 18 (8-40 mg/dL); 48% were male; 36% were European American, 29% were AA, 23% were Hispanic American (HA), and 12% were Chinese American; and 11% had PAD. Across all ethnic groups, serum Lp(a) was higher among women compared with men and highest among AAs compared with other ethnicities. After adjustments for traditional cardiovascular disease risk factors (age, sex, ethnicity, hypertension, diabetes, smoking, total cholesterol, and high-density lipoprotein cholesterol) as well as interleukin-6, fibrinogen, D-dimer, and homocysteine levels, one log unit increase in Lp(a) was associated with greater odds for PAD (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.01-1.25). In fully adjusted models, significant gender(∗)ln[Lp(a)] and ethnicity(∗)ln[Lp(a)] interactions were observed (P = .08 for both). The association between higher Lp(a) and PAD was strongest in HA men (OR, 1.73; 95% CI, 1.07-2.80) and HA women (OR, 1.49; 95% CI, 1.07-2.08). Nonsignificant associations were observed for European American, AA, and Chinese American men and women.

CONCLUSIONS

We observed a significant and independent association between elevated Lp(a) and PAD only among HA women and men, despite higher serum Lp(a) levels among AAs. Future studies are needed to determine the role that lowering of Lp(a) may have on the burden of PAD in HAs.

Associations between metabolomic-identified changes of biomarkers and arterial stiffness in subjects progressing to impaired fasting glucose

OBJECTIVE

We investigated correlations between age-related changes in circulating metabolites and arterial stiffness in impaired fasting glucose (IFG).

DESIGN, SUBJECTS, MEASUREMENT

This prospective cohort study included 602 healthy, normal fasting glucose (NFG) subjects (30-65 years old) who underwent triennial medical evaluation. After 3 years, 9·3% of subjects developed IFG (n = 56). Age, gender, BMI and fasting glucose were used to match the remaining NFG subjects (n = 546) that were included for the control group (NFG group, n = 80).

RESULTS

After 3 years, levels of fasting glucose, insulin and malondialdehyde, and brachial-ankle pulse wave velocity (baPWV) were significantly greater in the IFG group than in the NFG group after adjusting for baseline values. The IFG group had a greater increase in lactosylceramide (P = 0·001, q < 0·05) and a greater reduction in phosphatidylcholine (PC) (18:0/20:4) than the NFG group. Multiple linear regression analysis showed that the change in baPWV was independently and positively associated with changes in fasting glucose and lactosylceramide. In all subjects, lactosylceramide levels positively correlated with changes in baPWV and fasting glucose, while premenopausal women were not shown, and negatively correlated with changes in PC and LDL particle size.

CONCLUSIONS

This study indicates that age-related increase in circulating lactosylceramide is an independent predictor of increased arterial stiffness in subjects with impaired fasting glucose.