Silent myocardial ischemia is associated with autonomic neuropathy and other cardiovascular risk factors in type 1 and type 2 diabetic subjects, especially in those with microalbuminuria

Identification of Silent Myocardial Ischemia in Patients with Long-Term Type 1 and Type 2 Diabetes

(1) Background: This study aimed to analyze epidemiological data to identify risk factors for silent myocardial ischemia in patients with long-term type 1 and type 2 diabetes. (2) Methods: An analysis was performed on 104 patients with long-term type 1 and type 2 diabetes who had not previously been diagnosed with cardiovascular disease. During hospitalization, patients were subjected to a standard ECG exercise test on a treadmill. If the test could not be performed or the result was uncertain, a pharmacological exercise test with dobutamine was performed. In the case of a positive exercise ECG test or a positive dobutamine test, the patient underwent coronary angiography. (3) Results: Atherosclerotic lesions were found in 24 patients. Patients with silent ischemia were significantly older and had a lower mean left ventricular ejection fraction and a higher incidence of carotid atherosclerosis. The presence of microvascular complications did not increase the risk of silent ischemia. (4) Conclusions: Silent heart ischemia is more common in type 2 than type 1 diabetes. Predisposing factors include older age, coexistence of carotid atherosclerosis, lower left ventricular ejection fraction, and smoking in patients with type 1 diabetes. Concomitant microvascular complications are not a risk factor.

Occult Perforated Gangrenous Gallbladder Found on Magnetic Resonance Cholangiopancreatography

Acute gangrenous cholecystitis is a life-threatening disease that is most often diagnosed intraoperatively and can be missed on mildly symptomatic patients without the proper imaging modality. We present a case of a 69-year-old male with a history of hypertension, hyperlipidemia, and type 2 diabetes, and a recent right pontine infarct that arrived with 3 out of 10 right-sided abdominal pain. His liver ultrasound and computed tomography (CT) with contrast demonstrated acute cholecystitis. He was initially worked up conservatively and was scheduled for an elective cholecystectomy per surgery recommendation. However erring on the side of caution, the medical team had ordered a magnetic resonance cholangiopancreatography (MRCP), which demonstrated perforated gangrenous cholecystitis. Of note, the imaging modalities were ordered within a 24-hour window. The patient's antibiotics were promptly broadened, and he was emergently sent to the operating room. Moving forward, we will identify atypical clinical presentations of gangrenous cholecystitis and consider ordering an MRCP when clinical suspicion remains high and initial imaging is inconclusive. Perforated gangrenous cholecystitis is a severe disease and can cause rapid demise if not identified and treated early.

Admission ECG changes predict short term-mortality after acute myocardial infarction less reliable in patients with diabetes

Prior studies examined association between short-term mortality and certain changes in the admission ECG in acute myocardial infarction (AMI). Nevertheless, little is known about possible differences between patients with diabetes and without diabetes in this regard. So the aim of the study was to investigate the association between 28-day case fatality according to certain ECG changes comparing AMI cases with and without diabetes from the general population. From 2000 until 2017 a total of 9756 AMI cases was prospectively recorded in the study Area of Augsburg, Germany. Each case was assigned to one of the following groups according to admission ECG: ‘ST-elevation’, ‘ST-depression’, ‘only T-negativity’, ‘predominantly bundle branch block’, ‘unspecific changes’ and ‘normal ECG’ (the last two were put together for regression analyses). Multivariable adjusted logistic regression models were calculated to compare 28-day case-fatality between the ECG groups for the total sample and separately for diabetes and non-diabetes cases. For the non-diabetes group, the parsimonious logistic regression model revealed significantly better 28-day-outcome for the ‘normal ECG / unspecific changes’ group (OR: 0.47 [0.29–0.76]) compared to the reference group (STEMI). Contrary, in AMI cases with diabetes the category ‘normal ECG / unspecific changes’ was not significantly associated with lower short-term mortality (OR: 0.87 [0.49–1.54]). Neither of the other ECG groups was significantly associated with 28-day-mortality in the parsimonious logistic regression models. Consequently, the absence of AMI-typical changes in the admission ECG predicts favorable short-term mortality only in non-diabetic cases, but not so in patients with diabetes.

Gangrenous cholecystitis: A silent but potential fatal disease in patients with diabetic neuropathy. A case report

Gangrenous cholecystitis (GC) is a severe and potentially deadly complication of acute cholecystitis. We present a 83-year-old gentleman with a past medical history of type 2 diabetes mellitus with significant associated neuropathy, presenting to a community hospital in a major metropolitan area with 10 days nausea and vomiting and a benign abdominal exam. While the patient was admitted for hyperglycemia, he was subsequently found to have severe GC requiring urgent surgical intervention.

Symptoms Suggestive of Acute Coronary Syndrome: When Is Sex Important?

BACKGROUND

Studies have identified sex differences in symptoms of acute coronary syndrome (ACS); however, retrospective designs, abstraction of symptoms from medical records, and variations in assessment forms make it difficult to determine the clinical significance of sex differences.

OBJECTIVE

The aim of this study is to determine the influence of sex on the occurrence and distress of 13 symptoms for patients presenting to the emergency department for symptoms suggestive of ACS.

METHODS

A total of 1064 patients admitted to 5 emergency departments with symptoms triggering a cardiac evaluation were enrolled. Demographic and clinical variables, symptoms, comorbid conditions, and functional status were measured.

RESULTS

The sample was predominantly male (n = 664, 62.4%), white (n = 739, 69.5%), and married (n = 497, 46.9%). Women were significantly older than men (61.3 ± 14.6 vs 59.5 ± 13.6 years). Most patients were discharged with a non-ACS diagnosis (n = 590, 55.5%). Women with ACS were less likely to report chest pain as their chief complaint and to report more nausea (odds ratio [OR], 1.56; confidence interval [CI], 1.00-2.42), shoulder pain (OR, 1.76; CI, 1.13-2.73), and upper back pain (OR, 2.92; CI, 1.81-4.70). Women with ACS experienced more symptoms (6.1 vs 5.5; P = .026) compared with men. Men without ACS had less symptom distress compared with women.

CONCLUSIONS

Women and men evaluated for ACS reported similar rates of chest pain but differed on other classic symptoms. These findings suggest that women and men should be counseled that ACS is not always accompanied by chest pain and multiple symptoms may occur simultaneously.

Prevalence and control of hypertension and albuminuria in South Korea: focus on obesity and abdominal obesity in the Korean National Health and Nutrition Examination Survey, 2011-2012

BACKGROUND

Albuminuria is associated with cardiovascular disease, and the relationship between albuminuria and hypertension is well established in many studies. So the control of hypertension is critical for decreasing cardiovascular events and albuminuria. Obesity and abdominal obesity are also associated with hypertension and albuminuria. Therefore, we analyzed the relationship between albuminuria and the prevalence and control of hypertension in the general Korean population according to obesity status.

METHODS

We analyzed data from the 2011-2012 Korea National Health and Nutrition Examination Survey, and 9,519 subjects were included. Subjects were divided into four groups: non-obese/normal waist circumference, non-obese/high waist circumference, obese/normal waist circumference, and obese/high waist circumference.

RESULTS

Systolic blood pressure and diastolic blood pressure were positively associated with albumin-creatinine ratio in all groups (all p values <0.005). Non-obese/normal waist circumference group were more likely to have hypertension (odds ratios [95% confidential intervals (CIs)] were 3.20 [2.21-4.63] in microalbuminuria level and 3.09 [1.05-9.14] in macroalbuminuria level), and less likely to have controlled hypertension (odds ratios <1 for both albuminuria levels) after adjusting for all covariates. Obese/normal waist circumference group were also more likely to have hypertension (odds ratio [95% CI] were 3.10 [1.56-6.15] in microalbuminuria level and 21.75 [3.66-129.04] in macroalbuminuria level), and less likely to have controlled hypertension in macroalbuminuria level (odds ratio [95% CI], 0.04 [0.01-0.15]).

CONCLUSIONS

Non-obese and normal waist circumference subjects have an increased prevalence and decreased control of hypertension in microalbuminuria and macroalbuminuria levels. Screening for albuminuria may provide helpful information about hypertension and blood pressure control, particularly in the non-obese and normal waist circumference subjects.

Cardiac autonomic neuropathy in patients with diabetes mellitus

Cardiac autonomic neuropathy (CAN) is an often overlooked and common complication of diabetes mellitus. CAN is associated with increased cardiovascular morbidity and mortality. The pathogenesis of CAN is complex and involves a cascade of pathways activated by hyperglycaemia resulting in neuronal ischaemia and cellular death. In addition, autoimmune and genetic factors are involved in the development of CAN. CAN might be subclinical for several years until the patient develops resting tachycardia, exercise intolerance, postural hypotension, cardiac dysfunction and diabetic cardiomyopathy. During its sub-clinical phase, heart rate variability that is influenced by the balance between parasympathetic and sympathetic tones can help in detecting CAN before the disease is symptomatic. Newer imaging techniques (such as scintigraphy) have allowed earlier detection of CAN in the pre-clinical phase and allowed better assessment of the sympathetic nervous system. One of the main difficulties in CAN research is the lack of a universally accepted definition of CAN; however, the Toronto Consensus Panel on Diabetic Neuropathy has recently issued guidance for the diagnosis and staging of CAN, and also proposed screening for CAN in patients with diabetes mellitus. A major challenge, however, is the lack of specific treatment to slow the progression or prevent the development of CAN. Lifestyle changes, improved metabolic control might prevent or slow the progression of CAN. Reversal will require combination of these treatments with new targeted therapeutic approaches. The aim of this article is to review the latest evidence regarding the epidemiology, pathogenesis, manifestations, diagnosis and treatment for CAN.

The prevalence, characteristics, and clinical significance of abnormal albuminuria in patients with hypertension

Kidney function and cardiovascular disease are closely connected and albuminuria is a proven marker of cardiovascular risk. The present study investigated the prevalence and characteristics of albuminuria in patients with hypertension. Outpatients with essential hypertension under medical treatment were enrolled in this study (n = 350, 70.0 ± 11.4 years old). Urine samples were collected for the measurement of albumin concentration, which are expressed as the ratio of urine albumin to creatinine concentration (mg/g Cr). Cross-sectional analyses were also performed of the relationships between urinary albumin and other variables. Urinary albumin was detected in 88.3% of patients, while only 35.4% showed abnormal albuminuria (≥30 mg/g Cr). The presence of abnormal albuminuria was independently correlated with systolic blood pressure, B-type natriuretic peptide, and C-reactive protein by multivariate analysis (P < 0.05). Furthermore, multivariate regression analysis identified systolic blood pressure, serum creatinine, B-type natriuretic peptide, and C-reactive protein as the only factors showing independent correlation with urinary albumin (P < 0.05). Thus, approximately 35% of hypertensive patients had abnormal albuminuria. Urinary albumin was closely associated with blood pressure, C-reactive protein, and B-type natriuretic peptide, indicating that the severity of albuminuria parallels that of systemic inflammation, cardiac load, and blood pressure.

The prevalence and characteristics of microalbuminuria in the general population: a cross-sectional study

Background

Microalbuminuria is a marker of cardiovascular events. This study investigated the prevalence of microalbuminuria in the general population and the factors that can affect urinary excretion of albumin.

Methods

Apparently healthy subjects who participated in a health checkup at our hospital were enrolled in this study (n = 7963, male 64.0%, 56.2 ± 11.8 years old) Urine samples were collected for the measurement of albumin concentrations, which were expressed as the ratio of urinary albumin to creatinine concentrations (UACR [mg/g Cr]). Individual salt intake was assessed by estimating the 24-hour urinary salt excretion of subjects.

Results

The mean blood pressure was 124 ± 15/76 ± 10 mmHg and 31.6%, 7.4%, and 44.1% of subjects had hypertension, diabetes mellitus, and dyslipidemia, respectively. Urinary albumin was detected in 7265 subjects (91.2%: UACR ≥ 300 mg/g Cr, 0.5%; 300 > UACR ≥ 30 mg/g Cr, 4.6%; 30 > UACR ≥ 20 mg/g Cr, 2.4%; 20 > UACR ≥ 10 mg/g Cr, 8.7%; 10 > UACR ≥ 5 mg/g Cr, 21.8%; UACR < 5 mg/g Cr, 53.2%). In subjects with detectable albuminuria, UACR was independently correlated with age, systolic blood pressure, serum creatinine, fasting plasma glucose, and salt intake after adjustment for possible factors (P < 0.0001).

Conclusion

The prevalence of microalbuminuria was found to be 4.6% in the general population. The urinary excretion of albumin was closely associated with blood pressure and salt intake. These data indicated the importance of salt restriction for the prevention of cardiovascular disease and end-stage renal disease.

Myocardial perfusion scintigraphy in the detection of silent ischemia in asymptomatic diabetic patients

OBJECTIVE: This study was aimed to evaluate myocardial perfusion in asymptomatic patients with type 1 (DM1) and type 2 diabetes mellitus (DM2) without previous diagnoses of coronary artery disease (CAD) or cerebral infarction. MATERIALS AND METHODS: Fifty-nine consecutive asymptomatic patients (16 DM1, 43 DM2) underwent myocardial perfusion scintigraphy with 99mTc-sestamibi (MPS). They were evaluated for body mass index, metabolic control of DM, type of therapy, systemic arterial hypertension, dyslipidemia, nephropathy, retinopathy, peripheral neuropathy, smoking, and familial history of CAD. RESULTS: MPS was abnormal in 15 patients (25.4%): 12 (20.3%) with perfusion abnormalities, and 3 with isolated left ventricular dysfunction. The strongest predictors for abnormal myocardial perfusion were: age 60 years and above (p = 0.017; odds ratio [OR] = 6.0), peripheral neuropathy (p = 0.028; OR = 6.1), nephropathy (p = 0.031; OR = 5.6), and stress ECG positive for ischemia (p = 0.049; OR = 4.08). CONCLUSION: Silent myocardial ischemia occurs in more than one in five asymptomatic diabetic patients. The strongest predictors of ischemia in this study were: patient age, peripheral neuropathy, nephropathy, retinopathy and a stress ECG positive for ischemia.

Silent myocardial infarction in women with type II diabetes mellitus and microalbuminuria

Introduction:

The aim of this study was to investigate whether asymptomatic women with diabetes mellitus (DM) without previous history of ischemic heart disease (IHD) and normal electrocardiogram (ECG) have suffered silent myocardial infarction (MI).

Methods:

The study population consisted of 64-years old women with DM and albuminuria (n = 15) and aged- and body mass index-matched controls (n = 16). The patients were selected after screening of 240 women with previously known or unknown DM. The individuals with previous history of IHD and ECG suggesting the presence of IHD were excluded. All subjects were investigated with magnetic resonance imaging (MRI).

Results:

MRI investigation has revealed the presence of subendocardial MI in the two DM women (13%). No MI was detected in the control group. MR coronary angiography detected the presence of significant stenosis in the proximal segment of left anterior descending (LAD) coronary artery in one DM woman. This patient developed unstable angina 1 week after the MRI investigation. The conventional angiography has confirmed the presence of significant stenosis in LAD demanding invasive revascularization by percutaneous coronary angioplasty. No difference was found in indices of left ventricular (LV) systolic function while diastolic function was disturbed in the DM group. There was a tendency for increased LV mass in the DM group. No difference was found in the LV volumes.

Conclusion:

Clinically significant proportion of the women with DM and albuminuria without previous history of IHD have had silent MI. MRI screening of these high risk female patient is valuable diagnostic tool which may increase diagnostic accuracy and improve prognosis in DM patients with IHD.

Erectile dysfunction can improve the effectiveness of the current guidelines for the screening for asymptomatic coronary artery disease in diabetes

About 40% of diabetic patients with asymptomatic coronary artery disease (CAD) are missed on the basis of the current screening guidelines. Erectile Dysfunction (ED) is a powerful marker of asymptomatic CAD. Aim of the study is to evaluate whether ED can improve the effectiveness of the current guidelines for the screening of CAD in diabetes. From among 299 consecutive men with newly diagnosed type 2 diabetes without any apparent vascular complication, 293 (mean age 56.6±5.9 years) were enrolled. Among them, 219 did not have myocardial ischemia (NO CAD group) and 74 men had a coronary stenosis angiographically proven (CAD group). Five risk factors (RFs) of the current screening guidelines (hypertension, dyslipidemia, family history for CAD, smoking e micro/macroalbuminuria) and ED were assessed. ED was significantly more prevalent in the CAD than in the NO CAD group (37.8 versus 15.1%; P<0.001) and was a predictor of asymptomatic CAD (OR: 4.4; 95%CI: 2.1-9.0; P<0.001). If ED is added to the list of RFs, it can increase the sensitivity of the current guidelines from 62 to 89%, without a significant variation in specificity (from 60 to 57%). The negative predictive value can increase from 82 to 94%. ED can reduce from 37.84 to 10.81% the percentage of patients with silent CAD missed at the screening. This study first shows that ED can improve the effectiveness in discriminating diabetic men to screen for asymptomatic CAD, when it is added to the list of RFs of the current screening guidelines.

Incidence and predictors of silent myocardial infarction in type 2 diabetes and the effect of fenofibrate: an analysis from the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study

AIMS

To determine the incidence and predictors of, and effects of fenofibrate on silent myocardial infarction (MI) in a large contemporary cohort of patients with type 2 diabetes in the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study.

METHODS AND RESULTS

Routine electrocardiograms taken throughout the study were assessed by Minnesota-code criteria for the presence of new Q-waves without clinical presentation and analysed with blinding to treatment allocation and clinical outcome. Of all MIs, 36.8% were silent. Being male, older age, longer diabetes duration, prior cardiovascular disease (CVD), neuropathy, higher HbA(1c), albuminuria, high serum creatinine, and insulin use all significantly predicted risk of clinical or silent MI. Fenofibrate reduced MI (clinical or silent) by 19% [hazard ratio (HR) 0.81, 95% confidence interval (CI) 0.69-0.94; P = 0.006], non-fatal clinical MI by 24% (P = 0.01), and silent MI by 16% (P = 0.16). Among those having silent MI, fenofibrate reduced subsequent clinical CVD events by 78% (HR 0.22, 95% CI 0.08-0.65; P = 0.003).

CONCLUSION

Silent and clinical MI have similar risk factors and increase the risk of future CVD events. Fenofibrate reduces the risk of a first MI and substantially reduces the risk of further clinical CVD events after silent MI, supporting its use in type 2 diabetes.

The association of diabetes and older age with the absence of chest pain during acute coronary syndromes

Cardiac autonomic neuropathy associated with diabetes can cause silent myocardial ischemia and may influence the way that patients perceive symptoms of acute coronary syndromes (ACS). The purpose of this study was to examine symptoms of ACS in patients with and without diabetes while controlling for length of time with diabetes. A convenience sample of 256 patients from two large medical centers in the Midwest participated. Patients with diabetes comprised 33.2% of the sample and reported significantly less chest pain and more unusual fatigue. Patients with diabetes of longer duration (10 or more years) reported more difficulty breathing than did patients with diabetes of shorter duration (fewer than 10 years). Older patients with the same diabetes status also reported less chest pain. For older patients and for patients with diabetes, lack of chest pain during ACS could delay treatment and is thus a concern.

Symptoms Across the Continuum of Acute Coronary Syndromes: Differences Between Women and Men

Background The urgency and level of care provided for acute coronary syndromes partially depends on the symptoms manifested.

Objectives To detect differences between women and men in the type, severity, location, and quality of symptoms across the 3 clinical diagnostic categories of acute coronary syndromes (unstable angina, myocardial infarction without ST-segment elevation, and myocardial infarction with ST-segment elevation) while controlling for age, diabetes, functional status, anxiety, and depression.

Methods A convenience sample of 112 women and 144 men admitted through the emergency department and hospitalized for acute coronary syndromes participated. Recruitment took place at 2 urban teaching hospitals in the Midwest. Data were collected during structured interviews in each patient’s hospital room. Forty-eight symptom descriptors were assessed. Demographic characteristics, health history, functional status, anxiety, and depression levels also were measured.

Results Regardless of clinical diagnostic category, women reported significantly more indigestion (β = 0.25; confidence interval [CI] = 0.01–0.49), palpitations (β = 0.31; CI = 0.06–0.56), nausea (β = 0.37; CI = 0.10–0.65), numbness in the hands (β = 0.29; CI = 0.02–0.57), and unusual fatigue (β = 0.60; CI = 0.27–0.93) than men reported. Differences between men and women in dizziness, weakness, and new-onset cough did differ by diagnosis. Reports of chest pain did not differ between men and women.

Conclusions Women with acute coronary syndromes reported a higher intensity of 5 symptoms (but not chest pain) than men reported. Whether differences between the sexes in less typical symptoms are clinically significant remains unclear.

An interactive model of pain and myocardial ischemia

The biopsychosocial model has been used to describe the intertwined factors that may act as mechanisms in cardiovascular disease, as well as those found in pain conditions. This model may also prove useful in understanding a diagnosis that overlaps these two areas, angina. This article reviews the literature related to biological, psychological, and social mechanisms of painful ischemic episodes and discusses the interactions of those variables. We propose an integrated model that incorporates the biopsychosocial mechanisms that may be responsible for the variability in pain reporting with ischemic episodes. We show how sex differences manifested in various biopsychosocial factors may interact to influence the presence of painful versus silent myocardial ischemia. We present a plan for future research to elucidate this interaction.

Reviewing myocardial silent ischemia: specific patient subgroups

Silent myocardial ischemia (SMI) is a relatively common, yet poorly understood, clinical entity. The most accurate means of detecting SMI and the precise treatment endpoints remain unclear. However, the presence of SMI correlates with the likelihood of future adverse cardiac events. Evidence suggests that patients at high risk of severe cardiac ischemia, even with the absence of symptoms, derive the greatest benefit from an aggressive diagnostic and therapeutic approach. This paper is giving a detailed review of SMI in regards to specific patient subgroups, i.e. populations with diabetes mellitus, hypertension, elderly patients, post-revascularization patients, women, the suggested screening procedures for each subgroup, as well as the emersion of new markers for the selection of high-risk patients for screening.