Predictors of macrovascular disease in patients with type 2 diabetes mellitus

Precision prognostics for cardiovascular disease in Type 2 diabetes: a systematic review and meta-analysis

BACKGROUND

Precision medicine has the potential to improve cardiovascular disease (CVD) risk prediction in individuals with Type 2 diabetes (T2D).

METHODS

We conducted a systematic review and meta-analysis of longitudinal studies to identify potentially novel prognostic factors that may improve CVD risk prediction in T2D. Out of 9380 studies identified, 416 studies met inclusion criteria. Outcomes were reported for 321 biomarker studies, 48 genetic marker studies, and 47 risk score/model studies.

RESULTS

Out of all evaluated biomarkers, only 13 showed improvement in prediction performance. Results of pooled meta-analyses, non-pooled analyses, and assessments of improvement in prediction performance and risk of bias, yielded the highest predictive utility for N-terminal pro b-type natriuretic peptide (NT-proBNP) (high-evidence), troponin-T (TnT) (moderate-evidence), triglyceride-glucose (TyG) index (moderate-evidence), Genetic Risk Score for Coronary Heart Disease (GRS-CHD) (moderate-evidence); moderate predictive utility for coronary computed tomography angiography (low-evidence), single-photon emission computed tomography (low-evidence), pulse wave velocity (moderate-evidence); and low predictive utility for C-reactive protein (moderate-evidence), coronary artery calcium score (low-evidence), galectin-3 (low-evidence), troponin-I (low-evidence), carotid plaque (low-evidence), and growth differentiation factor-15 (low-evidence). Risk scores showed modest discrimination, with lower performance in populations different from the original development cohort.

CONCLUSIONS

Despite high interest in this topic, very few studies conducted rigorous analyses to demonstrate incremental predictive utility beyond established CVD risk factors for T2D. The most promising markers identified were NT-proBNP, TnT, TyG and GRS-CHD, with the highest strength of evidence for NT-proBNP. Further research is needed to determine their clinical utility in risk stratification and management of CVD in T2D.

Risk factors for carotid plaque formation in type 2 diabetes mellitus

OBJECT

Patients with type 2 diabetes mellitus (T2DM) are at higher risk of developing atherosclerosis. Previous studies have analyzed the factors associated with diabetic macrovascular disease, although whether these factors are applicable to T2DM patients with carotid atherosclerosis remains unclear. Therefore, the aim of this study was to investigate the risk factors for the formation of carotid atherosclerotic plaque in hospitalized T2DM patients and to provide a theoretical basis for early prevention and treatment of carotid atherosclerosis in these patients.

METHODS

A total of 949 patients with T2DM were included in the study. Carotid ultrasound identified 531 patients with carotid atherosclerotic plaque. The waist-to-hip ratio (WHR), blood glucose, liver and kidney function, blood lipid profile, islet function, and other indicators were measured at the same time to identify the risk factors and predictive significance of T2DM carotid plaque.

RESULTS

The proportions of men, diabetes nephropathy (DN) and hypertension in T2DM patients with carotid plaque are higher than those without carotid plaque(P < 0.05). Age, duration of diabetes, WHR, Postprandial glucose (PPG), lipoprotein (a) [Lip (a)], carcinoembryonic antigen(CEA) and estimated glomerular filtration rate (eGFR) in T2DM patients with carotid plaque were higher than those without plaque (P < 0.05). Age, WHR, duration of diabetes, hypertension, males, and Lip (a) were independent risk factors for T2DM patients with carotid plaque. Age, WHR, duration of diabetes, and Lip (a) had a higher AUC to predict T2DM with carotid artery plaque (AUC: 0.750, 0.640, 0.678, 0.552 respectively; P all < 0.001). After constructing the logit (P) value of the above risk factors, the area under the ROC curve was 0.816 (0.789-0.842, P < 0.001).

CONCLUSION

Age, WHR, duration of diabetes, hypertension, males, and Lip (a) levels are the main risk factors for the formation of carotid plaque in T2DM patients. Combining the above risk factors provides a better prediction of carotid plaque formation in T2DM.

Serum/plasma biomarkers and the progression of cardiometabolic multimorbidity: a systematic review and meta-analysis

Background

The role of certain biomarkers in the development of single cardiometabolic disease (CMD) has been intensively investigated. Less is known about the association of biomarkers with multiple CMDs (cardiometabolic multimorbidity, CMM), which is essential for the exploration of molecular targets for the prevention and treatment of CMM. We aimed to systematically synthesize the current evidence on CMM-related biomarkers.

Methods

We searched PubMed, Embase, Web of Science, and Ebsco for relevant studies from inception until August 31st, 2022. Studies reported the association of serum/plasma biomarkers with CMM, and relevant effect sizes were included. The outcomes were five progression patterns of CMM: (1) no CMD to CMM; (2) type 2 diabetes mellitus (T2DM) followed by stroke; (3) T2DM followed by coronary heart disease (CHD); (4) T2DM followed by stroke or CHD; and (5) CHD followed by T2DM. Newcastle-Ottawa Quality Assessment Scale (NOS) was used to assess the quality of the included studies. A meta-analysis was conducted to quantify the association of biomarkers and CMM.

Results

A total of 68 biomarkers were identified from 42 studies, which could be categorized into five groups: lipid metabolism, glycometabolism, liver function, immunity, and others. Lipid metabolism biomarkers were most reported to associate with CMM, including TC, TGs, HDL-C, LDL-C, and Lp(a). Fasting plasma glucose was also reported by several studies, and it was particularly associated with coexisting T2DM with vascular diseases. According to the quantitative meta-analysis, HDL-C was negatively associated with CHD risk among patients with T2DM (pooled OR for per 1 mmol/L increase = 0.79, 95% CI = 0.77-0.82), whereas a higher TGs level (pooled OR for higher than 150 mg/dL = 1.39, 95% CI = 1.10-1.75) was positively associated with CHD risk among female patients with T2DM.

Conclusion

Certain serum/plasma biomarkers were associated with the progression of CMM, in particular for those related to lipid metabolism, but heterogeneity and inconsistent findings still existed among included studies. There is a need for future research to explore more relevant biomarkers associated with the occurrence and progression of CMM, targeted at which is important for the early identification and prevention of CMM.

Prognostic value of the prognostic nutritional index for patients with acute myocardial infarction undergoing percutaneous coronary intervention with variable glucose metabolism statuses: a retrospective cohort study

BACKGROUND

The prognostic nutritional index (PNI) and different glucose metabolisms have been separately reported to be correlated with long-term prognosis in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). However, PNI application in patients with an impaired glucose metabolism has not been well validated, especially in pre-diabetic patients. This study evaluated whether PNI influences a long-term risk of mortality along different glucose metabolism statuses.

METHODS

A total of 17,697 patients with AMI and a history of PCI were enrolled in this retrospective observational cohort study from January 2007 to December 2020. Three subgroups with different glucose metabolism statuses, including normal glucose regulation (NGR), pre-diabetes mellitus (pre-DM), and diabetes mellitus (DM), were divided into three groups according to the tertiles of PNI, respectively.

RESULTS

All-cause mortality occurred in 2613 (14.8%) patients within a median of 4.1 years of follow-up. Upon analyzing the Kaplan-Meier plots for the NGR, pre-DM, and DM groups, the incidence of all-cause or cardiovascular mortality in the low PNI (PNI-L, ≤ 42.7) subgroup was significantly higher than that in the median PNI (PNI-M, > 42.7 and ≤ 48.2) and high PNI (PNI-H, > 48.2) subgroups (all, P < 0.001). After adjusting for confounding factors, the hazard ratio (HR) for all-cause mortality in the PNI-L group significantly increased compared to that in the PNI-H subgroups of the NGR group (HR, 1.35; 95% CI 1.14-1.66; P < 0.001), pre-DM group (HR, 1.29; 95% CI 1.02-1.62; P < 0.001), and DM group (HR, 1.36; 95% CI 1.13-1.63; P < 0.001). Given that there was evidence of interactions between PNI and different glucose statuses (P for interaction < 0.001), patients were divided into nine subgroups, and we found that DM patients with PNI-L statuses had the highest risk of all-cause mortality compared to NGR patients with PNI-H statuses (HR, 1.69; 95% CI 1.42-2.01; P < 0.001).

CONCLUSION

Lower PNI is a significant and independent risk factor for all-cause mortality in AMI patients undergoing PCI with different glucose metabolism statuses, and this risk further increases with DM compared to NGR or pre-DM statuses.

Precision Prognostics for Cardiovascular Disease in Type 2 Diabetes: A Systematic Review and Meta-analysis

Background Precision medicine has the potential to improve cardiovascular disease (CVD) risk prediction in individuals with type 2 diabetes (T2D). Methods We conducted a systematic review and meta-analysis of longitudinal studies to identify potentially novel prognostic factors that may improve CVD risk prediction in T2D. Out of 9380 studies identified, 416 studies met inclusion criteria. Outcomes were reported for 321 biomarker studies, 48 genetic marker studies, and 47 risk score/model studies. Results Out of all evaluated biomarkers, only 13 showed improvement in prediction performance. Results of pooled meta-analyses, non-pooled analyses, and assessments of improvement in prediction performance and risk of bias, yielded the highest predictive utility for N-terminal pro b-type natriuretic peptide (NT-proBNP) (high-evidence), troponin-T (TnT) (moderate-evidence), triglyceride-glucose (TyG) index (moderate-evidence), Genetic Risk Score for Coronary Heart Disease (GRS-CHD) (moderate-evidence); moderate predictive utility for coronary computed tomography angiography (low-evidence), single-photon emission computed tomography (low-evidence), pulse wave velocity (moderate-evidence); and low predictive utility for C-reactive protein (moderate-evidence), coronary artery calcium score (low-evidence), galectin-3 (low-evidence), troponin-I (low-evidence), carotid plaque (low-evidence), and growth differentiation factor-15 (low-evidence). Risk scores showed modest discrimination, with lower performance in populations different from the original development cohort. Conclusions Despite high interest in this topic, very few studies conducted rigorous analyses to demonstrate incremental predictive utility beyond established CVD risk factors for T2D. The most promising markers identified were NT-proBNP, TnT, TyG and GRS-CHD, with the highest strength of evidence for NT-proBNP. Further research is needed to determine their clinical utility in risk stratification and management of CVD in T2D.

Lipoprotein(a) and the Risk for Recurrent Atherosclerotic Cardiovascular Events Among Adults With CKD: The Chronic Renal Insufficiency Cohort (CRIC) Study

Rationale & Objective

Many adults with chronic kidney disease (CKD) and atherosclerotic cardiovascular disease (ASCVD) have high lipoprotein(a) levels. It is unclear whether high lipoprotein(a) levels confer an increased risk for recurrent ASCVD events in this population. We estimated the risk for recurrent ASCVD events associated with lipoprotein(a) in adults with CKD and prevalent ASCVD.

Study Design

Observational cohort study.

Setting & Participants

We included 1,439 adults with CKD and prevalent ASCVD not on dialysis enrolled in the Chronic Renal Insufficiency Cohort study between 2003 and 2008.

Exposure

Baseline lipoprotein(a) mass concentration, measured using a latex-enhanced immunoturbidimetric assay.

Outcomes

Recurrent ASCVD events (primary outcome), kidney failure, and death (exploratory outcomes) through 2019.

Analytical Approach

We used Cox proportional-hazards regression models to estimate adjusted HR (aHRs) and 95% CIs.

Results

Among participants included in the current analysis (mean age 61.6 years, median lipoprotein(a) 29.4 mg/dL [25th-75th percentiles 9.9-70.9 mg/dL]), 641 had a recurrent ASCVD event, 510 developed kidney failure, and 845 died over a median follow-up of 6.6 years. The aHR for ASCVD events associated with 1 standard deviation (SD) higher log-transformed lipoprotein(a) was 1.04 (95% CI, 0.95-1.15). In subgroup analyses, 1 SD higher log-lipoprotein(a) was associated with an increased risk for ASCVD events in participants without diabetes (aHR, 1.23; 95% CI, 1.02-1.48), but there was no evidence of an association among those with diabetes (aHR, 0.99; 95% CI, 0.88-1.10, P comparing aHRs = 0.031). The aHR associated with 1 SD higher log-lipoprotein(a) in the overall study population was 1.16 (95% CI, 1.04-1.28) for kidney failure and 1.02 (95% CI, 0.94-1.11) for death.

Limitations

Lipoprotein(a) was not available in molar concentration.

Conclusions

Lipoprotein(a) was not associated with the risk for recurrent ASCVD events in adults with CKD, although it was associated with a risk for kidney failure.

Accumulated hypertension burden on atrial fibrillation risk in diabetes mellitus: a nationwide population study

BACKGROUND

Patients with diabetes mellitus have an increased risk of incident atrial fibrillation (AF). The effect of accumulated hypertension burden is a less well-known modifiable risk factor. We explored the relationship between accumulated hypertension burden and incident AF in these patients.

METHODS

We evaluated data for 526,384 patients with diabetes who underwent three consecutive health examinations, between 2009 and 2012, from the Korean National Health Insurance Service. Hypertension burden was calculated by assigning points to each stage of hypertension in each health examination: 1 for stage 1 hypertension (systolic blood pressure [SBP] 130-139 mmHg; diastolic blood pressure [DBP] 80-89 mmHg); 2 for stage 2 (SBP 140-159 mmHg and DBP 90-99 mmHg); and 3 for stage 3 (SBP ≥ 160 mmHg or DBP ≥ 100 mmHg). Patients were categorized into 10 hypertensive burden groups (0-9). Groups 1-9 were then clustered into 1-3, 4-6, and 7-9.

RESULTS

During a mean follow-up duration of 6.7 ± 1.7 years, AF was newly diagnosed in 18,561 (3.5%) patients. Compared to patients with hypertension burden 0, those with burden 1 to 9 showed a progressively increasing risk of incident AF: 6%, 11%, 16%, 24%, 28%, 41%, 46%, 57%, and 67% respectively. Clusters 1-3, 4-6, and 7-9 showed increased risks by 10%, 26%, and 45%, respectively, when compared to a hypertension burden of 0.

CONCLUSIONS

Accumulated hypertension burden was associated with an increased risk of incident AF in patients with diabetes. Strict BP control should be emphasized for these patients.

Remnant Cholesterol and Cardiovascular Mortality in Patients With Type 2 Diabetes and Incident Diabetic Nephropathy

CONTEXT

The association between remnant cholesterol (remnant-C) and cardiovascular mortality in patients with type 2 diabetes (T2D) and incident diabetic nephropathy remains unclear.

OBJECTIVE

To examinie the association between remnant-C and cardiovascular mortality in patients with T2D, chronic kidney disease (CKD) stages 3 to 5, and newly diagnosed DN.

METHODS

This study determined the baseline lipid profile and searched for deaths with cardiovascular disease (CVD) within 2 years of baseline among 2282 adults enrolled between January 1, 2015 and December 31, 2016, who had T2D, CKD stages 3 to 5, and newly diagnosed DN. Adjusted logistic regression models were used to assess the associations between lipid, especially remnant-C concentration (either as continuous or categorical variables), and risk of cardiovascular mortality.

RESULTS

In multivariable-adjusted analyses, low-density lipoprotein cholesterol (LDL-C) (odds ratio [OR], 1.022; 95% CI, 1.017-1.026, per 10 mg/dL), high-density lipoprotein cholesterol (HDL-C) (OR, 0.929; 95% CI, 0.922-0.936, per 5 mg/dL), non-HDL-C (OR, 1.024; 95% CI, 1.021-1.028, per 10 mg/dL), and remnant-C (OR, 1.115; 95% CI, 1.103-1.127, per 10 mg/dL), but not triglycerides were associated with cardiovascular mortality. Atherogenic dyslipidemia (triglycerides > 150 mg/dL [1.69 mmol/L] and HDL-C < 40 mg/dL in men or < 50 mg/dL in women) was also associated with cardiovascular mortality (OR, 1.073; 95% CI, 1.031-1.116). Remnant-C greater than or equal to 30 mg/dL differentiated patients at a higher risk of cardiovascular mortality from those with lower concentrations, especially with interaction with LDL-C level greater than 100 mg/dL: The highest risk was found in patients with higher levels both of remnant-C and LDL-C (OR, 1.696; 95% CI, 1.613-1.783).

CONCLUSION

In patients with T2D, CKD stages 3 to 5, and incident DN, remnant-C was associated with a higher risk of death with CVD. Different from the general population, the interaction of remnant-C and LDL-C was associated with the highest risk of cardiovascular mortality.

The association between lipoprotein (a) and carotid atherosclerosis in patients with type 2 diabetes without pre-existing cardiovascular disease: A cross-sectional study

AIMS

Lipoprotein (a) [Lp(a)] has been considered a determinant of residual cardiovascular risk. We aimed to investigate associations between serum Lp(a) levels and carotid atherosclerosis.

METHODS

This cross-sectional study included 662 type 2 diabetic patients without cardiovascular disease. The mean value of three right and left measurements was used to indentify increased carotid intima-media thickness (CIMT). A carotid plaque was defined as a focal wall thickening >50% of the surrounding IMT or its CIMT ≥1.5 mm. The presence of carotid atherosclerosis was defined as having CIMT ≥1.0 mm or carotid plaque.

RESULTS

A total of 34.3% of patients had carotid atherosclerosis. The median Lp(a) level was significantly higher in subjects with carotid atherosclerosis (14.6 vs. 10.2 mg/dL, P < 0.001). The log-transformed Lp(a) level per 1-standard deviation increase was significantly associated with higher risk of the presence of carotid atherosclerosis (odds ratio [OR] 1.46; 95% confidence interval [CI] 1.16 - 1.84, P = 0.001) after adjusting other parameters. The log Lp(a) level was still significantly associated with the risk of carotid atherosclerosis in subjects with optimal low-density lipoprotein cholesterol (LDL-C) <100 mg/dL (OR 1.48; 95% CI 1.16 - 1.88, P = 0.001). Higher Lp(a) and LDL-C had an additive effect on the presence of carotid atherosclerosis.

CONCLUSION

Elevated Lp(a) was significantly associated with the presence of carotid atherosclerosis in patients with type 2 diabetes, independent of conventional cardiometabolic risk factors.

Diabetes Mellitus and Stroke - A cross Sectional Study of 2.5 Million Adults in the United States

Objectives: The main purpose of this work is to study diabetes mellitus and stroke in the United States during the years 2007-2017 and to find not only statistically significant predictors for diabetes, but also a possible association between diabetes and stroke. Methods: Chi-square test and One-way analysis of variance (ANOVA) were the statistical methods used to derive the results of this work in order to check the statistical significance of diabetes mellitus in relation to patients' socioeconomic factors. In addition, a multivariate logistic regression analysis was used to obtain odds ratio and find statistically significant prognostic factors for both diabetes and stroke. Results: According to multiple logistic regression analysis, the risk for diabetes mellitus is four times higher in widowed men and two times higher in unemployed male subjects who had previously worked. In addition, marital status and employment have been shown to be prognostic risks for stroke. Conclusion: The results describe for the first time the importance of deprivation (of work and partner) as a primary prognostic risk factor for diabetes. Moreover, the same factor was proved to be the primary prognostic risk factor for both stroke and diabetes, which implies a nexus between diabetes mellitus and stroke.

Serum triglycerides as a risk factor for cardiovascular diseases in type 2 diabetes mellitus: a systematic review and meta-analysis of prospective studies

Objective

The importance of triglycerides (TG) level as a risk factor for cardiovascular diseases (CVD) has been extensively investigated in the general population; however, their relationship in patients with type 2 diabetes mellitus (T2DM) is uncertain. We aimed to assess the association of TG with CVD in T2DM individuals.

Research design and methods

We searched bibliographic databases for studies published until June 2018, reporting on the relationship between TG and CVD in T2DM people. A random-effects model with inverse variance weighting was used to compute pooled estimates of the most fully adjusted risk ratios (RR) and corresponding 95% confidence intervals (CI) according to TG categories, unit TG, and logarithm (log) of TG for CVD.

Results

A total of 31 studies were included, involving 132,044 T2DM patients with 10,733 incident cardiovascular events. The pooled RR (95% CI) of CVD for an increase in baseline TG, log TG by 1-mmol/l and categorized in the highest vs. the lowest TG in T2DM were 1.06 (1.02, 1.09), 1.30 (1.18, 1.42) and 1.30 (1.16, 1.46), corresponding to a CVD risk increase of 6%, 30% and 30%, respectively. The pooled RR (95% CI) of CVD for per 1-mmol/L TG increment in eight studies and TG categories in three studies were 1.03 (0.98, 1.08) and 1.39 (0.92, 2.1) in T2DM patients adjusted for other lipids parameter, respectively.

Conclusions

In T2DM patients, an elevated triglyceride level cannot serve as an independent marker for an increased risk of cardiovascular events, but still, the higher serum TG levels tend to be associated with increased risks of CVD.

Electronic supplementary material

The online version of this article (10.1186/s12933-019-0851-z) contains supplementary material, which is available to authorized users.

Predictors of vascular complications among type 2 diabetes mellitus patients at University of Gondar Referral Hospital: a retrospective follow-up study

BACKGROUND

Type 2 Diabetes Mellitus is a serious metabolic disease that is often associated with vascular complications. There are 1.9 million people living with Diabetes in Ethiopia; diabetes mellitus is found to be the ninth leading cause of death related to its complications. Although the rate of vascular complications continues to rise, there is limited information about the problem. This study aimed to estimate the incidence and predictors of vascular complications among type 2 diabetes mellitus patients at University of Gondar Referral Hospital.

METHODS

Institution based retrospective follow-up study was conducted at University of Gondar Referral Hospital with 341 newly diagnosed type 2 DM patients from September 2005 to March 2017 and the data were collected by reviewing their records. Schoenfeld residuals test and interaction of each covariate with time were used to check proportional hazard assumption. The best model was selected by using Akaike Information Criteria (AIC). Hazards ratio (HR) with its respective 95% confidence interval were reported to show strength of association.

RESULT

The selected patients were followed retrospectively for a median follow up time of 81.50 months (Inter quartile range (IQR) = 67.2-103.3). The mean age (± Standard deviation (SD)) of patients at baseline was 51.7(SD: ±11.5 years) and 57.48% were females. The incidence rate of vascular complications was 40.6 cases/ 1000 person years of observation. The significant predictors for vascular complications where found to be male sex (Adjusted hazard ratio (AHR) = 0.50, 95% CI: 0.27, 0.94), having hypertension at baseline(AHR = 3.99, 95% CI: 1.87, 8.56), positive protein urea at base line (AHR = 1.69, 95% CI: 1.03, 2.78), high density lipoprotein cholesterol(HDL-C) level ≥ 40 mg per deciliter (mg/dl) (AHR = 0.43, 95% CI: 0.24, 0.77), low density lipoprotein cholesterol(LDL-C) level > 100 mg/dl (AHR = 3.05, 95% CI: 1.47, 6.35) and triglyceride > 150 mg/dl (AHR = 2.74, 95% CI: 1.28, 5.84).

CONCLUSION

The incidence of vascular complications among type 2 diabetes patients remains a significant public health problem. Hypertension at baseline, LDL-C > 100 mg/dl, triglyceride > 150 mg/dl, HDL-C ≥ 40 mg/dl and male sex were significant predictors of vascular complication. In the light of these findings targeted interventions should be given to diabetes patients with hypertension comorbidity and dyslipidemia at follow up clinics.

Diabetes mellitus and stroke: A clinical update

Cardiovascular disease including stroke is a major complication that tremendously increases the morbidity and mortality in patients with diabetes mellitus (DM). DM poses about four times higher risk for stroke. Cardiometabolic risk factors including obesity, hypertension, and dyslipidaemia often co-exist in patients with DM that add on to stroke risk. Because of the strong association between DM and other stroke risk factors, physicians and diabetologists managing patients should have thorough understanding of these risk factors and management. This review is an evidence-based approach to the epidemiological aspects, pathophysiology, diagnostic work up and management algorithms for patients with diabetes and stroke.

Impact of Lipoprotein(a) on Long-term Outcomes in Patients With Diabetes Mellitus Who Underwent Percutaneous Coronary Intervention

Patients with diabetes mellitus (DM) are at twofold to fourfold higher cardiovascular risk than those without DM. Serum levels of lipoprotein(a) (Lp(a)) can be risk factors for adverse events. However, the clinical implications of Lp(a) in patients with DM who underwent percutaneous coronary intervention (PCI) is unknown. The aim of the study was to determine the role of Lp(a) in patients with DM who underwent PCI. A total of 3,508 patients were treated by PCI from 1997 to 2011 at our institution. Among them, we analyzed consecutive 1,546 patients with DM. Eligible 1,136 patients were divided into 2 groups (high Lp(a) [n = 575] and low Lp(a) [n = 561]) by the median of Lp(a) levels. The number of chronic kidney disease, multivessel disease, and the level of LDL-C were higher in the group with high Lp(a) than with low Lp(a). The median follow-up period was 4.7 years. Event rate of all-cause death was same between the 2 groups (p = 0.37). However, cumulative incidence of cardiac death and acute coronary syndrome was significantly higher in the high Lp(a) than in the low Lp(a) group (p = 0.03). Multivariable analysis selected a high Lp(a) level as an independent predictor of cardiac death and acute coronary syndrome (hazard ratio 1.20; 95% confidence interval 1.00 to 1.42; p = 0.04). In conclusion, a high Lp(a) value could be associated with advanced cardiac events after PCI for patients with DM.

Associations Between the Continuity of Ambulatory Care of Adult Diabetes Patients in Korea and the Incidence of Macrovascular Complications

Objectives:

The goal of this study was to identify association between the continuity of ambulatory care of diabetes patients in South Korea (hereafter Korea) and the incidence of macrovascular complications of diabetes, using claims data compiled by the National Health Insurance Services of Korea.

Methods:

This study was conducted retrospectively. The subjects of the study were 43 002 patients diagnosed with diabetes in 2007, who were over 30 years of age, and had insurance claim data from 2008. The macrovascular complications of diabetes mellitus were limited to ischemic heart disease and ischemic stroke. We compared the characteristics of the patients in whom macrovascular complications occurred from 2009 to 2012 to the characteristics of the patients who had no such complications. Multiple logistic regression was used to assess the effects of continuity of ambulatory care on diabetic macrovascular complications. The continuity of ambulatory diabetes care was estimated by metrics such as the medication possession ratio, the quarterly continuity of care and the number of clinics that were visited.

Results:

Patients with macrovascular complications showed statistically significant differences regarding sex, age, comorbidities, hypertension, dyslipidemia and continuity of ambulatory diabetes care. Visiting a lower number of clinics reduced the odds ratio for macrovascular complications of diabetes. A medication possession ratio below 80% was associated with an increased odds ratio for macrovascular complications, but this result was of borderline statistical significance.

Conclusions:

Diabetes care by regular health care providers was found to be associated with a lower occurrence of diabetic macrovascular complications. This result has policy implications for the Korean health care system, in which the delivery system does not work properly.

Lipoprotein(a) and cardiovascular disease in diabetic patients

Lipoprotein(a) (Lp[a]) is a LDL-like particle consisting of an ApoA moiety linked to one molecule of ApoB(100). Recent data from large-scale prospective studies and genetic association studies provide highly suggestive evidence for a potentially causal role of Lp(a) in affecting risk of cardiovascular disease (CVD) in general populations. Patients with Type 2 diabetes display clustered metabolic abnormalities and elevated risk of CVD. Lower plasma Lp(a) levels were observed in diabetic patients in several recent studies. Epidemiology studies of Lp(a) and CVD risk in diabetic patients generated inconsistent results. We recently found that Lp(a)-related genetic markers did not predict CVD in two diabetic cohorts. The current data suggest that Lp(a) may differentially affect cardiovascular risk in diabetic patients and in the general population. More prospective studies, Mendelian randomization analysis and functional studies are needed to clarify the causal relationship of Lp(a) and CVD in diabetic patients.

Prediction of cardiovascular events with consideration of general and central obesity measures in diabetic adults: results of the 8.4-year follow-up

BACKGROUND

Obesity is one of the most important cardiovascular disease (CVD) risk factors among diabetic populations. We evaluated the ability of different anthropometric measures for predicting CVD among type 2 diabetic patients.

METHODS

The study consisted of 411 men and 599 women, aged ≥30 years, free of CVD at baseline with a median follow-up of 8.4 years. The adjusted hazard ratios (HRs) for CVD were calculated for a 1 standard deviation change in body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), and waist-to-height ratio (WHtR) using Cox proportional regression analysis.

RESULTS

A total of 188 CVD events occurred (men, 90; women, 98). In women, in confounder-adjusted analysis [age, fasting plasma glucose (instead of glycosylated hemoglobin), and positive family history of CVD], WHR was associated with incident CVD [1.32 (1.06-1.65)], followed by WC and WHtR, which were marginally significant (P=0.06 and 0.08, respectively); after adjustment for hypertension and hypercholesterolemia, only WHR predicted CVD significantly. In men, the confounder-adjusted (age, fasting plasma glucose, and aspirin use) HR to predict CVD was significant only for WHR [HR 1.21(1.00-1.48)].

CONCLUSION

This study showed WHR was the most powerful predictor of CVD among anthropometric measures, followed by WHtR, in diabetic population.

Excess risk of mortality and cardiovascular events associated with smoking among patients with diabetes: meta-analysis of observational prospective studies

BACKGROUND

Numerous studies have demonstrated that both smoking and diabetes are risk factors for mortality and caused-specific cardiovascular events. However, few studies systematically investigated to what extent the excess risk could be attributed to smoking among diabetic patients.

METHODS

Literature references were searched up to April 2011 in MEDLINE and EMBASE, supplemented by manual searches. Inclusion criteria were prospective cohort studies, assessment of the association between smoking and total mortality, cardiovascular death, incidence of coronary heart disease (CHD), stroke and myocardial infarction (MI) in diabetic patients.

RESULTS

Of 3758 studies in the literature searched, 46 were eligible with approximately 130,000 diabetic patients. The relative risk (RR) comparing smokers with nonsmokers was 1.48[95% confidential interval (CI): 1.34-1.64] for total mortality (27 studies), 1.36(1.22-1.52) for cardiovascular mortality (9 studies), 1.54(1.31-1.82) for CHD (13 studies), 1.44(1.28-1.61) for stroke (9 studies) and 1.52(1.25-1.83) for MI (7 studies). Furthermore, the excess risk was observed among former and current smokers with a greater risk in current smokers. Subgroup analysis showed that the increased risk appeared to be consistent regardless of several study characteristics with the RRs ranging from 1.31 to 1.94 for all-cause mortality, 1.37 to 2.28 for CHD, 1.21 to 1.87 for stroke, 1.13 to 1.74 for cardiovascular mortality and 1.15 to 2.01 for MI.

CONCLUSION

Smoking amplified the risk of mortality as well as cardiovascular events and the effect size for CHD appeared to be higher than other events in diabetic patients. Moreover, a trend of decreasing risk was observed among smoking quitters.

Genetic variants, plasma lipoprotein(a) levels, and risk of cardiovascular morbidity and mortality among two prospective cohorts of type 2 diabetes

AIMS

To examine the relations between genetic loci, plasma lipoprotein(a) [Lp(a)] levels, and cardiovascular disease (CVD) risk among diabetic patients and compare with the observations in the general population.

METHODS AND RESULTS

In two prospective cohorts of patients with type 2 diabetes (n= 2308) from the Nurses' Health Study and the Health Professional Follow-Up Study, we performed (i) genome-wide association (GWA) scans for plasma Lp(a); (ii) prospective analysis of plasma Lp(a) for CVD risk and mortality; and (iii) genetic association analysis for CVD risk and mortality. Meta-analysis of the two GWA scans yielded 71 single-nucleotide polymorphisms (SNPs) on chromosome 6q associated with plasma Lp(a) levels at a genome-wide significance level (P< 5 × 10(-8)). The SNP rs10455872 in LPA was most strongly associated with Lp(a) (P= 4.60 × 10(-39)). Forward-selection analysis indicated that rs10455872 and other five SNPs in a region encompassing LPA, PLG, SLC22A3, and LPAL2 genes were independently associated with Lp(a) levels and jointly explained ∼20% of variation in diabetic patients. In prospective analysis, we did not find any significant association between plasma levels and CVD incidence; the relative risk for coronary heart disease (CHD), CVD, and CVD death was 1.05 [95% confidence interval (CI): 0.95-1.15], 1.05 (0.96-1.15), and 1.21 (0.99-1.47) per 1-SD higher log-transformed Lp(a) levels, respectively. Consistently, none of the Lp(a) SNPs were associated with CVD risk or mortality (all P> 0.09). For the best SNP rs10455872 for plasma Lp(a) levels, the OR for CHD, CVD, and CVD death was 0.94 (95% CI: 0.69-1.28), 0.97 (0.72-1.29), and 1.23 (0.79-1.92), respectively. The genetic effect on CHD risk showed a significant heterogeneity between the diabetic and the general populations (P= 0.006).

CONCLUSION

Our data indicate that the effect of Lp(a) on CVD risk among diabetic patients might be different from that in the general population. Diabetes status may attenuate the relation between Lp(a) and cardiovascular risk.

Metabolic profiling in personalized medicine: bridging the gap between knowledge and clinical practice in Type 2 diabetes

Type 2 diabetes mellitus (DM2) is the most commonly diagnosed metabolic disease and its prevalence is expected to increase. Epidemiological studies clearly show excess mortality associated with DM2, as well as an increased risk of DM2-related complications. Advances in personalized medicine would greatly improve patient care in the field of diabetes and other metabolic diseases. Prediction of the disease in asymptomatic patients as well as its harsh complications in patients already diagnosed is becoming a necessity, with the considerable increase in the cost of the treatment. In the current article, we review the known clinical, molecular metabolic and genetic biomarkers that should be integrated in a future bioinformatic platform to be used at the point-of-care, and discuss the challenges we face in applying this vision of personalized medicine for diabetes into reality.

Incidence of diabetes in patients with schizophrenia: a population-based study

OBJECTIVE

To detect the incidence of diabetes in patients with schizophrenia in Taiwan.

METHODS

The National Health Research Institute provided a database of 1 million random subjects for study, from which we drew a random sample of 617 068 subjects aged 18 years and older in the year 2000. Subjects who had at least one service claim during this year, with a primary diagnosis of schizophrenia, diabetes, or with a prescription for treatment of diabetes, were identified. We compared initial diagnosis of diabetes between patients with schizophrenia and the general population in 2000. We also followed a cohort of subjects with schizophrenia from 2000 to 2005.

RESULTS

The incidence of diabetes was higher in patients with schizophrenia than in the general population (1.46% and 1.12%, respectively; OR 1.47; 95% CI 1.09 to 1.97) in 2000. Compared with the general population, patients with schizophrenia showed a higher incidence of diabetes in the group aged 18 to 29 years; among females; among those with insurance of more than US$1281; among those living in the northern region; and among those residing in urban areas. The average annual incidence of diabetes in patients with schizophrenia was 1.84% from 2000 to 2005. Higher incidence of diabetes in patients with schizophrenia was associated with increased age, females, hypertension, and hyperlipidemia.

CONCLUSIONS

Patients with schizophrenia had a higher incidence of diabetes for the youngest adult age group and for females than for the general population. Increased age, females, hypertension, and hyperlipidemia were risk factors of diabetes in patients with schizophrenia.

Impaired insulin-mediated vasorelaxation in diabetic Goto-Kakizaki rats is caused by impaired Akt phosphorylation

Insulin resistance associated with Type 2 diabetes contributes to impaired vasorelaxation. Previously, we showed the phosphorylation of myosin-bound phosphatase substrate MYPT1, a marker of the vascular smooth muscle cell (VSMC) contraction, was negatively regulated by Akt (protein kinase B) phosphorylation in response to insulin stimulation. In this study we examined the role of Akt phosphorylation on impaired insulin-induced vasodilation in the Goto-Kakizaki (GK) rat model of Type 2 diabetes. GK VSMCs had impaired basal and insulin-induced Akt phosphorylation as well as increases in basal MYPT1 phosphorylation, inducible nitric oxide synthase (iNOS) expression, and nitrite/nitrate production compared with Wistar-Kyoto controls. Both iNOS expression and the inhibition of angiotensin (ANG) II-induced MYPT1 phosphorylation were resistant to the effects of insulin in diabetic GK VSMC. We also measured the isometric tension of intact and denuded GK aorta using a myograph and observed significantly impaired insulin-induced vasodilation. Adenovirus-mediated overexpression of constitutively active Akt in GK VSMC led to significantly improved insulin sensitivity in terms of counteracting ANG II-induced contractile signaling via MYPT1, myosin light chain dephosphorylation, and reduced iNOS expression, S-nitrosylation and survivin expression. We demonstrated for the first time the presence of Akt-independent iNOS expression in the GK diabetic model and that the defective insulin-induced vasodilation observed in the diabetic vasculature can be restored by the overexpression of active Akt, which advocates a novel therapeutic strategy for treating diabetes.

Diabetes and stroke: Part one—Risk factors and pathophysiology

Diabetes is a major risk factor for stroke and is associated with an increase in overall stroke mortality. The metabolic syndrome associated with insulin resistance is also a significant risk factor for stroke. The etiology of stroke in diabetics is frequently microvascular disease from fibrinoid necrosis, which causes small subcortical infarcts designated as lacunar strokes. Diabetics also have an increased incidence of large vessel intracranial vascular disease. Although strict control of blood sugar has not been shown to reduce the overall incidence of stroke in diabetics, careful management of other associated risk factors, particularly hypercholesterolemia and hypertension, are imperative for the prevention of stroke in diabetic patients.

Nitric oxide modulates vascular inflammation and intimal hyperplasia in insulin resistance and the metabolic syndrome

Type 2 diabetes mellitus (DM) and the metabolic syndrome, both characterized by insulin resistance, are associated with an accelerated form of atherosclerotic vascular disease and poor outcomes following vascular interventions. These vascular effects are thought to stem from a heightened inflammatory environment and reduced bioavailability of nitric oxide (NO). To better understand this process, we characterized the vascular injury response in the obese Zucker rat by examining the expression of adhesion molecules, the recruitment of inflammatory cells, and the development of intimal hyperplasia. We also evaluated the ability of exogenous NO to inhibit the sequela of vascular injury in the metabolic syndrome. Obese and lean Zucker rats underwent carotid artery balloon injury. ICAM-1 and P-selectin expression were increased following injury in the obese animals compared with the lean rats. The obese rats also responded with increased macrophage infiltration of the vascular wall as well as increased neointima formation compared with their lean counterparts (intima/media = 0.91 vs. 0.52, P = 0.001). After adenovirus-mediated inducible NO synthase (iNOS) gene transfer, ICAM-1, P-selectin, inflammatory cell influx, and oxidized low-density lipoprotein (LDL) receptor expression were all markedly reduced versus injury alone. iNOS gene transfer also significantly inhibited proliferative activity (54% and 73%; P < 0.05) and neointima formation (53% and 67%; P < 0.05) in lean and obese animals, respectively. The vascular injury response in the face of obesity and the metabolic syndrome is associated with increased adhesion molecule expression, inflammatory cell infiltration, oxidized LDL receptor expression, and proliferation. iNOS gene transfer is able to effectively inhibit this heightened injury response and reduce neointima formation in this proinflammatory environment.

Effect of diabetes on uremic dyslipidemia

Elevated intermediate-density lipoprotein (IDL), a remnant lipoprotein, is an independent risk factor for atherosclerosis in patients with end-stage renal disease (ESRD). Since the presence of diabetes mellitus further increases the risk of cardiovascular mortality in ESRD, we examined the effect of diabetes on IDL among ESRD patients. The subjects were 330 healthy control subjects and 287 patients with end-stage renal disease including 80 patients with type 2 diabetes. As compared with the healthy subjects, the nondiabetic ESRD patients had increased plasma triglyceride and IDL cholesterol. Diabetic patients with ESRD showed a further increase in plasma triglyceride and IDL cholesterol compared with the nondiabetic group. However, the difference in IDL levels between the ESRD groups was no longer significant when subjects were stratified by plasma triglyceride. Plasma triglyceride was correlated with IDL cholesterol. Increased hemoglobin A(1c) was significantly associated with IDL cholesterol in a multiple regression model including age, gender, and the presence of ESRD. Such an association was no longer significant in another model including plasma triglyceride as an additional covariate. Further analysis indicated the positive effects of diabetes and hyperglycemia on plasma triglyceride. These results indicate that increased IDL in ESRD is further deteriorated in the presence of diabetes, and that the adverse effect is accounted for at least partly by hypertriglyceridemia associated with chronic hyperglycemia.

[Prognosis of diabetic patients with ischemic cardiopathy]

The prevalence of diabetes in Spain is about 6% and increases with age and obesity. Diabetes is present in approximately 25% of patients with coronary heart disease (CHD). Pre-diabetic and diabetic patients have a higher incidence of CHD and poorer prognosis, with high short- and long-term mortality. The protective effect of pre-menopause status is suppressed by diabetes. Diabetes has a synergic effect with other cardiovascular risk factors. Primary prevention in diabetic patients should be approached as in non-diabetic post-infarction patients. In diabetes, a healthy life-style and strict control of blood sugar and the other cardiovascular risk factors, particularly hypertension, is mandatory.