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van Oortmerssen JAE, Ntlapo N, Tilly MJ, Bramer WM, den Ruijter HM, Boersma E, Kavousi M, Roeters van Lennep JE. Burden of risk factors in women and men with unrecognized myocardial infarction: a systematic review and meta-analysis †. Cardiovasc Res 2024; 120:1683-1692. [PMID: 39189609 PMCID: PMC11587555 DOI: 10.1093/cvr/cvae188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 06/05/2024] [Accepted: 06/19/2024] [Indexed: 08/28/2024] Open
Abstract
Unrecognized myocardial infarction (MI) is an MI that remains undetected in the acute phase and is associated with an unfavourable prognosis. With this systematic review and meta-analysis, we evaluated the burden of cardiovascular risk factors in individuals with unrecognized MI. We searched general population-based cohort studies diagnosing unrecognized MI by electrocardiogram or myocardial imaging up to 24 November 2023. Pooled mean differences (MDs) or risk ratios (RRs) with 95% confidence intervals (CIs) were determined, and random-effects meta-analyses were performed. Fourteen cohort studies were included involving 200 450 individuals (mean age 62.8 ± 9.9 years, 56.0% women), among which 4322 (2.2%) experienced unrecognized MI (mean age 66.3 ± 8.2 years, 47.8% women) and 4653 (2.1%) recognized MI (mean age 68.5 ± 7.3 years, 33.8% women). Compared to individuals without MI, those with unrecognized MI had higher body mass index (MD 0.27, 95% CI 0.16-0.39) and systolic blood pressure (MD 4.48, 95% CI 2.81-6.15) levels, and higher prevalence of hypertension (RR 1.27, 95% CI 1.06-1.51) and diabetes mellitus (RR 1.67, 95% CI 1.36-2.06). Furthermore, individuals with unrecognized MI had lower prevalence of hypertension (RR 0.92, 95% CI 0.88-0.97) and diabetes mellitus (RR 0.80, 95% CI 0.70-0.92). Individuals with unrecognized MI are characterized by a substantial burden of metabolic risk factors. Our findings suggest insufficient recognition and management of cardiovascular risk factors among individuals with unrecognized MI.
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Affiliation(s)
- Julie A E van Oortmerssen
- Department of Epidemiology, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Noluthando Ntlapo
- Department of Epidemiology, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Martijn J Tilly
- Department of Epidemiology, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Wichor M Bramer
- Medical Library, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Hester M den Ruijter
- Laboratory for Experimental Cardiology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Eric Boersma
- Department of Cardiology, Erasmus MC Cardiovascular Institute, University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Maryam Kavousi
- Department of Epidemiology, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Jeanine E Roeters van Lennep
- Department of Internal Medicine, Erasmus MC Cardiovascular Institute, University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
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Samidurai A, Olex AL, Ockaili R, Kraskauskas D, Roh SK, Kukreja RC, Das A. Integrated Analysis of lncRNA-miRNA-mRNA Regulatory Network in Rapamycin-Induced Cardioprotection against Ischemia/Reperfusion Injury in Diabetic Rabbits. Cells 2023; 12:2820. [PMID: 38132140 PMCID: PMC10742118 DOI: 10.3390/cells12242820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/01/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023] Open
Abstract
The inhibition of mammalian target of rapamycin (mTOR) with rapamycin (RAPA) provides protection against myocardial ischemia/reperfusion (I/R) injury in diabetes. Since interactions between transcripts, including long non-coding RNA (lncRNA), microRNA(miRNA) and mRNA, regulate the pathophysiology of disease, we performed unbiased miRarray profiling in the heart of diabetic rabbits following I/R injury with/without RAPA treatment to identify differentially expressed (DE) miRNAs and their predicted targets of lncRNAs/mRNAs. Results showed that among the total of 806 unique miRNAs targets, 194 miRNAs were DE after I/R in diabetic rabbits. Specifically, eight miRNAs, including miR-199a-5p, miR-154-5p, miR-543-3p, miR-379-3p, miR-379-5p, miR-299-5p, miR-140-3p, and miR-497-5p, were upregulated and 10 miRNAs, including miR-1-3p, miR-1b, miR-29b-3p, miR-29c-3p, miR-30e-3p, miR-133c, miR-196c-3p, miR-322-5p, miR-499-5p, and miR-672-5p, were significantly downregulated after I/R injury. Interestingly, RAPA treatment significantly reversed these changes in miRNAs. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis indicated the participation of miRNAs in the regulation of several signaling pathways related to I/R injury, including MAPK signaling and apoptosis. Furthermore, in diabetic hearts, the expression of lncRNAs, HOTAIR, and GAS5 were induced after I/R injury, but RAPA suppressed these lncRNAs. In contrast, MALAT1 was significantly reduced following I/R injury, with the increased expression of miR-199a-5p and suppression of its target, the anti-apoptotic protein Bcl-2. RAPA recovered MALAT1 expression with its sponging effect on miR-199-5p and restoration of Bcl-2 expression. The identification of novel targets from the transcriptome analysis in RAPA-treated diabetic hearts could potentially lead to the development of new therapeutic strategies for diabetic patients with myocardial infarction.
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Affiliation(s)
- Arun Samidurai
- Division of Cardiology, Pauley Heart Center, Internal Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA; (A.S.); (R.O.); (D.K.); (S.K.R.)
| | - Amy L. Olex
- Wright Center for Clinical and Translational Research, Virginia Commonwealth University, Richmond, VA 23298, USA;
| | - Ramzi Ockaili
- Division of Cardiology, Pauley Heart Center, Internal Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA; (A.S.); (R.O.); (D.K.); (S.K.R.)
| | - Donatas Kraskauskas
- Division of Cardiology, Pauley Heart Center, Internal Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA; (A.S.); (R.O.); (D.K.); (S.K.R.)
| | - Sean K. Roh
- Division of Cardiology, Pauley Heart Center, Internal Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA; (A.S.); (R.O.); (D.K.); (S.K.R.)
| | - Rakesh C. Kukreja
- Division of Cardiology, Pauley Heart Center, Internal Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA; (A.S.); (R.O.); (D.K.); (S.K.R.)
| | - Anindita Das
- Division of Cardiology, Pauley Heart Center, Internal Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA; (A.S.); (R.O.); (D.K.); (S.K.R.)
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Relation of Glycemic Status with Unrecognized MI and the Subsequent Risk of Mortality: The Jackson Heart Study. Am J Prev Cardiol 2022; 11:100348. [PMID: 35600110 PMCID: PMC9119819 DOI: 10.1016/j.ajpc.2022.100348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/20/2022] [Accepted: 05/07/2022] [Indexed: 11/25/2022] Open
Abstract
Background Almost 1/3 to 1/2 of initial myocardial infarctions (MI) may be silent or unrecognized (UMI), which forecasts future clinical events. Further, limited data exist to describe the potential risk for UMI in African-Americans. The relationship of glucose status with UMI was examined in the Jackson Heart Study: a cohort of African-American individuals. Methods and results At baseline, there were 5,073 participants with an initial 12-lead electrocardiogram (ECG) and fasting glucose measured. Of these participants, 106(2.1%) had a UMI, and 268(4.2%) had a recognized MI. This population consisted of 3,233 (63.7%) participants with normal fasting glucose (NFG), 533 (10.5%) with IFG, and 1,039 (20.4%) with DM. Logistic regression investigated the relationship between glucose status and UMI. Cox proportional hazard models determined the significance of all-cause mortality during follow-up by MI status. The sample was 65% female with a mean age of 55.3 ± 12.9 years. Over a mean follow-up of 10.4 years, there were 795 deaths. Relative to NFG, the crude odds ratio (OR) estimates for UMI at baseline with IFG and DM were 1.00(95% CI:0.48–2.14) and 3.22(2.15–4.81), respectively. With adjustment, DM continued to be significantly associated with UMI [2.30 (1.42–3.71)]. Overall, participants with a baseline UMI had an adjusted Hazard ratio (HR) of 2.00(1.39–2.78) of death compared to no prior MI. Compared to those with no MI, those with a recognizedMI had an adjusted HR of 1.70(1.31–2.17) for mortality. Conclusions DM is associated with UMI in African-Americans. Further, a UMI carried similar risk of death compared to those with a recognized MI.
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Abstract
A literature search was conducted to identify publications addressing the early phases of lipid phenotypes in children and adults with either type 1 diabetes or type 2 diabetes. Medline, EMBASE, and Ovid were searched using the following search terms: clinical remission, partial remission, partial clinical remission, honeymoon phase, C-peptide, type 1 or 2 diabetes, children, pediatric type 1 or 2 diabetes, and paediatrics type 1 or 2 diabetes, adults, adult type 1 or type 2 diabetes. Partial clinical remission (PR) of type 1 diabetes (T1D) is characterized by continued endogenous production of insulin and C-peptide following the diagnosis and the introduction of exogenous insulin therapy. PR is associated with improved glycemic control and reduced prevalence of diabetes complications. The theory of hyperglycemic memory was proposed to explain this concept of improved glycemic outcomes in remitters (those who experienced PR) versus non-remitters (those who did not experience PR). However, this theory is incomplete as it does not explain the dichotomy in early lipid phenotypes in T1D based on PR status, which is an understudied area in diabetology and lipidology. To fill this knowledge gap, we propose the Theory of Hyperlipidemic Memory of T1D. This theory is premised on our 5-year research on early post-diagnostic dichotomy in lipid phenotypes between remitters and non-remitters across the lifespan. It provides a more rigorous explanation for the differences in lifelong atherosclerotic cardiovascular disease (ASCVD) risk between remitters and non-remitters. We conducted 4 clinical studies in pediatric and adult subjects with diabetes mellitus to characterize the particulars of the hyperlipidemic memory. In the first investigation, we explored the impact of the presence or absence of PR on lipid parameters in children and adolescents with T1D. In the second, we investigated whether pubertal maturation influenced our findings in T1D; and whether these findings could be replicated in healthy, non-diabetic children and adolescents. In the third, we leveraged our findings from T1D and controls to investigate the mechanisms of early lipid changes in T2D by comparing the earliest lipid phenotype of subjects with type 2 diabetes (T2D) to those of remitters, non-remitters, and controls. In the fourth, we investigated the impact of PR on the earliest lipid phenotypes in adults with T1D and compared these early lipid data to those of T2D subjects and controls. This body of work across the lifespan in children, adolescents, and adults supports the Theory of Hyperlipidemic Memory. This new theory clarifies why PR largely determines the risks for early-phase dyslipidemia, mid-term microvascular disease risk, and long-term ASCVD risk in subjects with T1D.
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Affiliation(s)
- Benjamin Udoka Nwosu
- Division of Endocrinology, Department of Pediatrics, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, United States
- Division of Endocrinology, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, United States
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Chest Pain Severity Rating Is a Poor Predictive Tool in the Diagnosis of ST-Segment Elevation Myocardial Infarction. Crit Pathw Cardiol 2021; 20:88-92. [PMID: 32947377 DOI: 10.1097/hpc.0000000000000241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Current ST-segment elevation myocardial infarction (STEMI) guidelines require persistent electrocardiogram ST-segment elevation, cardiac enzyme changes, and symptoms of myocardial ischemia. Chest pain is the determinant symptom, often measured using an 11-point scale (0-10). Greater severity of chest pain is presumed to be associated with a stronger likelihood of a true positive STEMI diagnosis. This retrospective observational cohort study considered consecutive STEMI patients from May 02, 2009 to December 31, 2018. Analysis of standard STEMI metrics included positive electrocardiogram-to-device and first medical contact-to-device times, presence of comorbidities, false-positive diagnosis, 30-day and 1-year mortality, and 30-day readmission. Chest pain severity was assessed upon admission to the primary percutaneous coronary intervention hospital. We analyzed 1409 STEMI activations (69% male, 66.3 years old ± 13.7 years). Of these, 251 (17.8%) had no obstructive lesion, consistent with false-positive STEMI. Four hundred sixty-six (33.1%) reported chest pain rating of 0 on admission, 378 (26.8%) reported mild pain (1-3), 300 (21.3%) moderate (4-6), and 265 (18.8%) severe (7-10). Patients presenting without chest pain had a significantly higher rate of false-positive STEMI diagnosis. Increasing chest pain severity was associated with decreased time from first medical contact to device, and decreased in-hospital, 30-day and 1-year mortality. Severity of chest pain on admission did not correlate to the likelihood of a true-positive STEMI diagnosis, although it was associated with improved patient prognosis, in the form of improved outcomes, and shorter times to reperfusion.
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Vigili de Kreutzenberg S. Silent coronary artery disease in type 2 diabetes: a narrative review on epidemiology, risk factors, and clinical studies. EXPLORATION OF MEDICINE 2021. [DOI: 10.37349/emed.2021.00029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Silent coronary artery disease (CAD) is one of the manifestations of heart disease that particularly affects subjects with type 2 diabetes mellitus (T2DM). From a clinical point of view, silent CAD represents a constant challenge for the diabetologist, who has to decide whether a patient could or could not be screened for this disease. In the present narrative review, several aspects of silent CAD are considered: the epidemiology of the disease, the associated risk factors, and main studies conducted, in the last 20 years, especially aimed to demonstrate the usefulness of the screening of silent CAD, to improve cardiovascular outcomes in type 2 diabetes.
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Shuldiner SR, Wong LY, Peterson TE, Wolfson J, Jermy S, Saad H, Lumbamba MAJ, Singh A, Shey M, Meintjes G, Ntusi N, Ntsekhe M, Baker JV. Myocardial Fibrosis Among Antiretroviral Therapy-Treated Persons With Human Immunodeficiency Virus in South Africa. Open Forum Infect Dis 2021; 8:ofaa600. [PMID: 33511232 PMCID: PMC7813208 DOI: 10.1093/ofid/ofaa600] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/05/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Heart failure is a prominent cardiovascular disease (CVD) manifestation in sub-Sarahan Africa. Myocardial fibrosis is a central feature of heart failure that we aimed to characterize among persons with human immunodeficiency virus (PWH) in South Africa. METHODS Cardiovascular magnetic resonance (CMR) imaging was performed among PWH with viral suppression and uninfected controls, both free of known CVD. Plasma levels of N-terminal pro B-type natriuretic peptide (NT-proBNP) were measured. Comparisons by human immunodeficiency virus (HIV) status were made using linear and logistic regression, adjusted for age, sex, and hypertension. RESULTS One hundred thirty-four PWH and 95 uninfected persons completed CMR imaging; age was 50 and 49 years, with 63% and 67% female, respectively. Compared with controls, PWH had greater myocardial fibrosis by extracellular volume fraction ([ECV] absolute difference, 1.2%; 95% confidence interval [CI], 0.1-2.3). In subgroup analyses, the effect of HIV status on ECV was more prominent among women. Women (vs controls) were also more likely to have elevated NT-proBNP levels (>125 pg/mL; odds ratio, 2.4; 95% CI, 1.0-6.0). Among all PWH, an elevated NT-proBNP level was associated with higher ECV (3.4% higher; 95% CI, 1.3-5.5). CONCLUSIONS Human immunodeficiency virus disease may contribute to myocardial fibrosis, with an effect more prominent among women. Research is needed to understand heart failure risk among PWH within sub-Saharan Africa.
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Affiliation(s)
- Scott R Shuldiner
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Lye-Yeng Wong
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Tess E Peterson
- School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Julian Wolfson
- School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - S Jermy
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - H Saad
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - A Singh
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - M Shey
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - G Meintjes
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, Cape Town, South Africa
| | - N Ntusi
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - M Ntsekhe
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - J V Baker
- Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Doi S, Suzuki M, Funamizu T, Takamisawa I, Tobaru T, Daida H, Isobe M. Clinical features of potential after-effects of percutaneous coronary intervention in the treatment of silent myocardial ischemia. Heart Vessels 2019; 34:1917-1924. [DOI: 10.1007/s00380-019-01444-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 05/31/2019] [Indexed: 01/11/2023]
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Stokke IM, Li ZB, Cicala S, Okin PM, Kjeldsen SE, Devereux RB, Wachtell K. Association of left bundle branch block with new onset abnormal wall motion in treated hypertensive patients with left ventricle hypertrophy: the LIFE Echo Sub-study. Blood Press 2019; 28:84-92. [PMID: 30698038 DOI: 10.1080/08037051.2019.1569463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
AIMS We aimed to investigate whether left bundle branch block (LBBB) is related to new-onset left ventricle (LV) wall motion abnormalities during treatment in hypertensive patients with electrocardiographic (ECG) defined left ventricular hypertrophy (LVH). METHODS AND RESULTS 960 patients with essential hypertension and ECG-LVH participating in the LIFE Echo Sub-study were investigated at baseline and annually with echocardiography, during randomized antihypertensive therapy. After excluding patients with LV wall motion abnormalities at baseline and patients developing new-onset LBBB during study time, we investigated 784 patients. The participants with (n = 32) and without (n = 752) LBBB were similar regarding most baseline variables. Logistic regression models controlling for LV mass index, Framingham risk score, and randomized treatment assignment were used to assess the odds ratio of developing new-onset abnormal LV wall motion on annual follow-up echocardiograms. The likelihood of developing new global LV wall motion abnormalities in patients with LBBB was not higher compared to those without LBBB except at year 5 (p = .002). The likelihood of developing new segmental LV wall motion abnormalities in patients with LBBB was however higher compared to patients without LBBB after 1 year (OR = 3.1, 95% CI = 0.7-14.2, p = .173); 2 years (OR = 6.9, 2.1-22.4, p = .003); 3 years (OR = 5.3, 2.0-14.3, p < .001), 4 years (OR = 4.0, 1.6-10.3, p = .003 and 5 years (OR = 4.1, 1.0-16.2, p = .394) of treatment. CONCLUSION Among patients with ECG-LVH, undergoing antihypertensive treatment, the presence of LBBB independently identifies individuals with ∼3- to 7-fold greater odds of developing new segmental abnormal LV wall motion. These findings suggest that LBBB may be a marker for progressive myocardial disease.
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Affiliation(s)
- Ildri M Stokke
- a Institute for Clinical Medicine, and Department of Cardiology , Oslo University Hospital, University of Oslo , Oslo , Norway
| | - Zhi Bin Li
- b Department of Medicine , Weill Cornell Medicine , New York , NY , USA
| | - Silvana Cicala
- c UOC di Cardiologia d'Emergenza con UTIC , Caserta , Italy
| | - Peter M Okin
- b Department of Medicine , Weill Cornell Medicine , New York , NY , USA
| | - Sverre E Kjeldsen
- a Institute for Clinical Medicine, and Department of Cardiology , Oslo University Hospital, University of Oslo , Oslo , Norway
| | | | - Kristian Wachtell
- a Institute for Clinical Medicine, and Department of Cardiology , Oslo University Hospital, University of Oslo , Oslo , Norway
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One quarter of total myocardial infarctions are silent manifestation in patients with type 2 diabetes mellitus. J Cardiol 2019; 73:33-37. [DOI: 10.1016/j.jjcc.2018.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 05/09/2018] [Accepted: 05/31/2018] [Indexed: 11/19/2022]
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Stacey RB, Vera T, Morgan TM, Jordan JH, Whitlock MC, Hall ME, Vasu S, Hamilton C, Kitzman DW, Hundley WG. Asymptomatic myocardial ischemia forecasts adverse events in cardiovascular magnetic resonance dobutamine stress testing of high-risk middle-aged and elderly individuals. J Cardiovasc Magn Reson 2018; 20:75. [PMID: 30463565 PMCID: PMC6249873 DOI: 10.1186/s12968-018-0492-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 10/09/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Current guidelines for assessing the risk of experiencing a hospitalized cardiovascular (CV) event discourage stress testing of asymptomatic individuals; however, these recommendations are based on evidence gathered primarily from those aged < 60 years, and do not address the possibility of unrecognized "silent myocardial ischemia" in middle aged and older adults. METHODS We performed dobutamine cardiovascular magnetic resonance (CMR) stress testing in 327 consecutively recruited participants aged > 55 years without CV-related symptoms nor known coronary artery disease, but otherwise at increased risk for a future CV event due to pre-existing hypertension or diabetes mellitus for at least 5 years. After adjusting for the demographics and CV risk factors, log-rank test and Cox proportional hazards models determined the additional predictive value of the stress test results for forecasting hospitalized CV events/survival. Either stress-induced LV wall motion abnormalities or perfusion defects were used to indicate myocardial ischemia. RESULTS Participants averaged 68 ± 8 years in age; 39% men, 75% Caucasian. There were 38 hospitalized CV events or deaths which occurred during a mean follow-up of 58 months. Using Kaplan-Meier analyses, myocardial ischemia identified future CV events/survival (p < 0.001), but this finding was more evident in men (p < 0.001) versus women (p = 0.27). The crude hazard ratio (HR) of myocardial ischemia for CV events/survival was 3.13 (95% CI: 1.64-5.93; p < 0.001). After accounting for baseline demographics, CV risk factors, and left ventricular ejection fraction/mass, myocardial ischemia continued to be associated with CV events/survival [HR: 4.07 (95% CI: 1.95-8.73) p < 0.001]. CONCLUSIONS Among asymptomatic middle-aged individuals with risk factors for a sentinel CV event, the presence of myocardial ischemia during dobutamine CMR testing forecasted a future hospitalized CV event or death. Further studies are needed in middle aged and older individuals to more accurately characterize the prevalence, significance, and management of asymptomatic myocardial ischemia. TRIAL REGISTRATION ( ClinicalTrials.gov identifier): NCT00542503 and was retrospectively registered on October 11th, 2007.
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Affiliation(s)
- R. Brandon Stacey
- Department of Internal Medicine, Cardiovascular Medicine Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1045 USA
| | - Trinity Vera
- Department of Internal Medicine, Cardiovascular Medicine Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1045 USA
| | - Timothy M. Morgan
- Department of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC USA
| | - Jennifer H. Jordan
- Department of Internal Medicine, Cardiovascular Medicine Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1045 USA
| | - Matthew C. Whitlock
- Department of Medicine (Cardiovascular Medicine), Stanford University School of Medicine, Palo Alto, CA USA
| | - Michael E. Hall
- Department of Medicine (Cardiovascular Medicine), University of Mississippi Medical Center, Jackson, MS USA
| | - Sujethra Vasu
- Department of Internal Medicine, Cardiovascular Medicine Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1045 USA
| | - Craig Hamilton
- Department of Radiology (Division of Radiologic Sciences), Wake Forest School of Medicine, Winston-Salem, NC USA
| | - Dalane W. Kitzman
- Department of Internal Medicine, Cardiovascular Medicine Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1045 USA
| | - W. Gregory Hundley
- Department of Internal Medicine, Cardiovascular Medicine Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1045 USA
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Stacey RB, Zgibor J, Leaverton PE, Schocken DD, Peregoy JA, Lyles MF, Bertoni AG, Burke GL. Abnormal Fasting Glucose Increases Risk of Unrecognized Myocardial Infarctions in an Elderly Cohort. J Am Geriatr Soc 2018; 67:43-49. [PMID: 30298627 DOI: 10.1111/jgs.15604] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 07/29/2018] [Accepted: 08/06/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To investigate glucose levels as a risk factor for unrecognized myocardial infarctions (UMIs). DESIGN Cohort SETTING: Cardiovascular Health Study. PARTICIPANTS Individuals aged 65 and older with fasting glucose measurements (N=4,355; normal fasting glucose (NFG), n = 2,041; impaired fasting glucose (IFG), n = 1,706; DM: n = 608; 40% male, 84% white, mean age 72.4 ± 5.6). MEASUREMENTS The relationship between glucose levels and UMI was examined. Participants with prior coronary heart disease (CHD) or UMI on initial electrocardiography were excluded. Using Minnesota codes, UMI was identified according to the presence of pathological Q-waves or minor Q-waves with ST-T abnormalities. Crude and adjusted hazard ratios (HRs) were calculated. Analyses were adjusted for age, sex, body mass index (BMI), hypertension, antihypertensive and lipid-lowering medication use, total cholesterol, high-density lipoprotein cholesterol, and smoking status. RESULTS Over a mean follow-up of 6 years, there were 459 incident UMIs (NFG, n=202; IFG, n=183; DM, n=74). Participants with IFG were slightly more likely than those with NFG to experience a UMI (hazard ratio (HR)=1.11, 95% confidence interval (CI)=0.91-1.36, p = .30), and those with DM were more likely than those with NFG to experience a UMI (HR=1.65, 95% CI=1.25-2.13, p < .001). After adjustment HR for UMI in IFG those with IFG were no more likely than those with NFG to experience a UMI (HR=1.01, 95% CI=0.82-1.24, p = .93), whereas those with DM were more likely than those with NFG to experience a UMI (HR=1.37, 95% CI=1.02-1.81, p = .03). The 2-hour oral glucose tolerance test was not statistically significantly associated with UMI. CONCLUSION Fasting glucose status, particularly in the diabetic range, forecasted UMI during 6 years of follow-up in elderly adults. Further studies are needed to clarify the level of glucose at which risk is greater. J Am Geriatr Soc 67:43-49, 2019.
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Affiliation(s)
- Richard Brandon Stacey
- Section on Cardiology, Department of Internal Medicine, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Janice Zgibor
- Department of Epidemiology and Biostatistics, College of Public Health University of South Florida, Tampa, Florida
| | - Paul E Leaverton
- Department of Epidemiology and Biostatistics, College of Public Health University of South Florida, Tampa, Florida
| | - Douglas D Schocken
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Jennifer A Peregoy
- Department of Epidemiology and Biostatistics, College of Public Health University of South Florida, Tampa, Florida
| | - Mary F Lyles
- Departments of Gerontology, School of Medicine Wake Forest University, Winston-Salem, North Carolina
| | - Alain G Bertoni
- Department of Public Health Sciences, School of Medicine Wake Forest University, Winston-Salem, North Carolina
| | - Gregory L Burke
- Department of Public Health Sciences, School of Medicine Wake Forest University, Winston-Salem, North Carolina
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Abstract
Coronary embolism is an uncommon but distinct clinical entity. It can be diagnosed clinically, and should be suspected when acute myocardial infarction occurs in association with an underlying condition which predisposes to embolism. The most common are valvular heart disease, a prosthetic heart valve, infective endocarditis, cardiomyopathy with mural thrombus and arrhythmia. The diagnosis may be obscured by atypical symptoms and transient ECG changes. The diagnosis is supported by the demonstration of normal coronary arteries by selective coronary arteriography. Treatment with long-term anticoagulants may prevent further emboli. Additional antiplatelet drugs are also necessary in patients with prosthetic heart valves.
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Li HR, Hsu CP, Sung SH, Shih CC, Lin SJ, Chan WL, Wu CH, Lu TM. Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting in Patients with Diabetic Nephropathy and Left Main Coronary Artery Disease. ACTA CARDIOLOGICA SINICA 2017; 33:119-126. [PMID: 28344415 DOI: 10.6515/acs20160623a] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Patients with diabetic nephropathy and unprotected left main (LM) coronary artery disease suffer from high cardiovascular morbidity and mortality. Although surgical revascularization is currently recommended in this special patient population, the optimal revascularization method for this distinct patient group has remained unclear. METHODS We collected 99 consecutive patients with unprotected LM disease and diabetic nephropathy, including 46 patients who had undergone percutaneous coronary intervention (PCI), and 53 who had coronary artery bypass grafting (CABG), with a mean age of 72 ± 10; with 80.8% male. Diabetic nephropathy was defined as overt proteinuria (proteinuria > 500 mg/day) and estimated glomerular filtration rate (eGFR) by the modified Modification of Diet in Renal Disease (MDRD) equation of less than 60 mL/min/1.73 m2. The baseline characteristics, angiographic results and long-term clinical outcomes were retrospectively analyzed. RESULTS The baseline characteristic of all patients were similar except for smokers, low density lipoprotein (LDL) level and extension of coronary artery disease involvement. The median follow-up period was 3.8 years. There were 73 patients (74%) considered as high risk with additive European System for Cardiac Operative Risk Evaluation (EuroSCORE) ≥ 6. During follow-up period, the long term rate of all-cause death (PCI vs. CABG: 45.7% vs. 58.5%, p = 0.20) and all-cause death/myocardial infarction (MI)/stroke (PCI vs. CABG: 52.2% vs. 60.4%, p = 0.41) were comparable between the PCI and CABG group, whereas the repeat revascularization rate was significantly higher in the PCI group (PCI vs. CABG: 32.6% vs. 9.4%, p < 0.01). eGFR remained an independent predictor for all-cause death [hazard ratio: 0.97, 95% confidence interval: 0.96 to 0.99; p = 0.002] in multivariate logistic regression. CONCLUSIONS In the real-world practice of high-risk patients with unprotected LM disease and diabetic nephropathy, we found that PCI was a comparable alternative to CABG in terms of long-term risks of all-cause death/MI/stroke, with significantly higher repeat revascularization rate. Given the small patient number and retrospective nature, our findings should be validated by larger-scale randomized studies.
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Affiliation(s)
- Hsin-Ru Li
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University
| | - Chiao-Po Hsu
- Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital; ; School of Medicine, National Yang-Ming University
| | - Shih-Hsien Sung
- School of Medicine, National Yang-Ming University; ; Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chun-Che Shih
- Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital; ; School of Medicine, National Yang-Ming University
| | - Shing-Jong Lin
- School of Medicine, National Yang-Ming University; ; Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Leong Chan
- School of Medicine, National Yang-Ming University; ; Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cheng-Hsueh Wu
- Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tse-Min Lu
- School of Medicine, National Yang-Ming University; ; Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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15
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Halawa A. Evaluation of the Cardiovascular Prior to Transplantation; An Endless Debate. ACTA ACUST UNITED AC 2017. [DOI: 10.15406/unoaj.2017.04.00126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Rendina D, Ippolito R, De Filippo G, Muscariello R, De Palma D, De Bonis S, Schiano di Cola M, Benvenuto D, Galderisi M, Strazzullo P, Galletti F. Risk factors for silent myocardial ischemia in patients with well-controlled essential hypertension. Intern Emerg Med 2017; 12:171-179. [PMID: 27565986 DOI: 10.1007/s11739-016-1527-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 08/18/2016] [Indexed: 02/02/2023]
Abstract
Silent myocardial ischemia (SMI) is frequently observed in patients with essential hypertension (EH). The major risk factor for SMI is uncontrolled blood pressure (BP), but SMI is also observed in patients with well-controlled BP. To evaluate the prevalence of SMI and the factors associated with SMI in EH patients with well-controlled BP. The medical records of 859 EH patients who underwent simultaneous 24-h ambulatory blood pressure monitoring (ABPM) and 24-h ambulatory electrocardiogram recording (AECG) were retrospectively evaluated. Each SMI episode was characterized by: (a) ST segment depression ≥0.5 mm; (b) duration of ST segment depression >60 s; and (c) reversibility of the ST segment depression. Overall 126 EH patients (14.7 %) had at least one episode of SMI. The SMI events were more frequent among patients with poorly controlled compared to those with well-controlled BP [86/479 (17.95 %) vs. 40/380 (10.52 %), p < 0.01]. Among EH patients with well-controlled BP, current and past smoking as well as the presence of an additional metabolic syndrome (MetS) constitutive element (obesity, impaired fasting glucose level or dyslipidemia) were significantly associated with the occurrence of SMI. In all EH patients with well-controlled BP and AECG evidence of SMI, there were one or more coronary artery stenotic lesions greater than 50 % found at coronary angiography. In EH patients who are current smokers, or have one or more additional components of a MetS there is markedly reduced benefit associated with good BP control with regard to the occurrence of myocardial ischemia: in this patient category, an AECG may help detect this condition.
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Affiliation(s)
- Domenico Rendina
- Department of Clinical Medicine and Surgery, Federico II University, Via Pansini 5, 80131, Naples, Italy.
- Spinelli Hospital, Belvedere Marittimo, Cosenza, Italy.
| | - Renato Ippolito
- Department of Clinical Medicine and Surgery, Federico II University, Via Pansini 5, 80131, Naples, Italy
| | - Gianpaolo De Filippo
- Department of Clinical Medicine and Surgery, Federico II University, Via Pansini 5, 80131, Naples, Italy
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Unité Diabète-Hypertension-Nutrition de l'Adolescent, Le Kremlin-Bicêtre, France
| | - Riccardo Muscariello
- Department of Clinical Medicine and Surgery, Federico II University, Via Pansini 5, 80131, Naples, Italy
| | - Daniela De Palma
- Department of Clinical Medicine and Surgery, Federico II University, Via Pansini 5, 80131, Naples, Italy
| | - Silvana De Bonis
- Spinelli Hospital, Belvedere Marittimo, Cosenza, Italy
- Cardiology Unit, Ferrari Hospital, Castrovillari, Cosenza, Italy
| | - Michele Schiano di Cola
- Department of Clinical Medicine and Surgery, Federico II University, Via Pansini 5, 80131, Naples, Italy
| | | | - Maurizio Galderisi
- Department of Advanced Clinical Sciences, Federico II University, Naples, Italy
| | - Pasquale Strazzullo
- Department of Clinical Medicine and Surgery, Federico II University, Via Pansini 5, 80131, Naples, Italy
| | - Ferruccio Galletti
- Department of Clinical Medicine and Surgery, Federico II University, Via Pansini 5, 80131, Naples, Italy
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Prabhakar A, Ma JG, Woodall A, Kaye AD. Diabetes Mellitus. Anesthesiology 2017. [DOI: 10.1007/978-3-319-50141-3_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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18
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Bangalore S. Diagnostic, Therapeutic, and Clinical Trial Conundrum of Patients With Chronic Kidney Disease. JACC Cardiovasc Interv 2016; 9:2110-2112. [DOI: 10.1016/j.jcin.2016.08.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 08/16/2016] [Accepted: 08/22/2016] [Indexed: 11/26/2022]
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19
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Zhang ZM, Rautaharju PM, Prineas RJ, Rodriguez CJ, Loehr L, Rosamond WD, Kitzman D, Couper D, Soliman EZ. Race and Sex Differences in the Incidence and Prognostic Significance of Silent Myocardial Infarction in the Atherosclerosis Risk in Communities (ARIC) Study. Circulation 2016; 133:2141-8. [PMID: 27185168 PMCID: PMC4889519 DOI: 10.1161/circulationaha.115.021177] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 04/04/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Race and sex differences in silent myocardial infarction (SMI) are not well established. METHODS AND RESULTS The analysis included 9498 participants from the Atherosclerosis Risk in Communities (ARIC) study who were free of cardiovascular disease at baseline (visit 1, 1987-1989). Incident SMI was defined as ECG evidence of MI without clinically documented MI (CMI) after the baseline until ARIC visit 4 (1996-1998). Coronary heart disease and all-cause deaths were ascertained starting from ARIC visit 4 until 2010. During a median follow-up of 8.9 years, 317 participants (3.3%) developed SMI and 386 (4.1%) developed CMI. The incidence rates of both SMI and CMI were higher in men (5.08 and 7.96 per 1000-person years, respectively) than in women (2.93 and 2.25 per 1000-person years, respectively; P<0.0001 for both). Blacks had a nonsignificantly higher rate of SMI than whites (4.45 versus 3.69 per 1000-person years; P=0.217), but whites had higher rate of CMI than blacks (5.04 versus 3.24 per 1000-person years; P=0.002). SMI and CMI (compared with no MI) were associated with increased risk of coronary heart disease death (hazard ratio, 3.06 [95% confidence interval, 1.88-4.99] and 4.74 [95% confidence interval, 3.26-6.90], respectively) and all-cause mortality (hazard ratio, 1.34 [95% confidence interval, 1.09-1.65] and 1.55 [95% confidence interval, 1.30-1.85], respectively). However, SMI and CMI were associated with increased mortality among both men and women, with potentially greater increased risk among women (interaction P=0.089 and 0.051, respectively). No significant interactions by race were detected. CONCLUSIONS SMI represents >45% of incident MIs and is associated with poor prognosis. Race and sex differences in the incidence and prognostic significance of SMI exist that may warrant considering SMI in personalized assessments of coronary heart disease risk.
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Affiliation(s)
- Zhu-Ming Zhang
- From Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, Division of Public Health Sciences(Z.M.Z., P.M.R., R.J.P., E.Z.S.), Department of Internal Medicine, Section of Cardiology(C.J.R., D.K., E.Z.S.), and Department of Epidemiology and Prevention, Division of Public Health Sciences(C.J.R.), Wake Forest School of Medicine, Winston-Salem, NC; and Department of Epidemiology, Gillings School of Global Public Health(L.L., W.D.R.) and Gillings School of Global Public Health (D.C.), University of North Carolina at Chapel Hill.
| | - Pentti M Rautaharju
- From Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, Division of Public Health Sciences(Z.M.Z., P.M.R., R.J.P., E.Z.S.), Department of Internal Medicine, Section of Cardiology(C.J.R., D.K., E.Z.S.), and Department of Epidemiology and Prevention, Division of Public Health Sciences(C.J.R.), Wake Forest School of Medicine, Winston-Salem, NC; and Department of Epidemiology, Gillings School of Global Public Health(L.L., W.D.R.) and Gillings School of Global Public Health (D.C.), University of North Carolina at Chapel Hill
| | - Ronald J Prineas
- From Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, Division of Public Health Sciences(Z.M.Z., P.M.R., R.J.P., E.Z.S.), Department of Internal Medicine, Section of Cardiology(C.J.R., D.K., E.Z.S.), and Department of Epidemiology and Prevention, Division of Public Health Sciences(C.J.R.), Wake Forest School of Medicine, Winston-Salem, NC; and Department of Epidemiology, Gillings School of Global Public Health(L.L., W.D.R.) and Gillings School of Global Public Health (D.C.), University of North Carolina at Chapel Hill
| | - Carlos J Rodriguez
- From Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, Division of Public Health Sciences(Z.M.Z., P.M.R., R.J.P., E.Z.S.), Department of Internal Medicine, Section of Cardiology(C.J.R., D.K., E.Z.S.), and Department of Epidemiology and Prevention, Division of Public Health Sciences(C.J.R.), Wake Forest School of Medicine, Winston-Salem, NC; and Department of Epidemiology, Gillings School of Global Public Health(L.L., W.D.R.) and Gillings School of Global Public Health (D.C.), University of North Carolina at Chapel Hill
| | - Laura Loehr
- From Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, Division of Public Health Sciences(Z.M.Z., P.M.R., R.J.P., E.Z.S.), Department of Internal Medicine, Section of Cardiology(C.J.R., D.K., E.Z.S.), and Department of Epidemiology and Prevention, Division of Public Health Sciences(C.J.R.), Wake Forest School of Medicine, Winston-Salem, NC; and Department of Epidemiology, Gillings School of Global Public Health(L.L., W.D.R.) and Gillings School of Global Public Health (D.C.), University of North Carolina at Chapel Hill
| | - Wayne D Rosamond
- From Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, Division of Public Health Sciences(Z.M.Z., P.M.R., R.J.P., E.Z.S.), Department of Internal Medicine, Section of Cardiology(C.J.R., D.K., E.Z.S.), and Department of Epidemiology and Prevention, Division of Public Health Sciences(C.J.R.), Wake Forest School of Medicine, Winston-Salem, NC; and Department of Epidemiology, Gillings School of Global Public Health(L.L., W.D.R.) and Gillings School of Global Public Health (D.C.), University of North Carolina at Chapel Hill
| | - Dalane Kitzman
- From Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, Division of Public Health Sciences(Z.M.Z., P.M.R., R.J.P., E.Z.S.), Department of Internal Medicine, Section of Cardiology(C.J.R., D.K., E.Z.S.), and Department of Epidemiology and Prevention, Division of Public Health Sciences(C.J.R.), Wake Forest School of Medicine, Winston-Salem, NC; and Department of Epidemiology, Gillings School of Global Public Health(L.L., W.D.R.) and Gillings School of Global Public Health (D.C.), University of North Carolina at Chapel Hill
| | - David Couper
- From Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, Division of Public Health Sciences(Z.M.Z., P.M.R., R.J.P., E.Z.S.), Department of Internal Medicine, Section of Cardiology(C.J.R., D.K., E.Z.S.), and Department of Epidemiology and Prevention, Division of Public Health Sciences(C.J.R.), Wake Forest School of Medicine, Winston-Salem, NC; and Department of Epidemiology, Gillings School of Global Public Health(L.L., W.D.R.) and Gillings School of Global Public Health (D.C.), University of North Carolina at Chapel Hill
| | - Elsayed Z Soliman
- From Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, Division of Public Health Sciences(Z.M.Z., P.M.R., R.J.P., E.Z.S.), Department of Internal Medicine, Section of Cardiology(C.J.R., D.K., E.Z.S.), and Department of Epidemiology and Prevention, Division of Public Health Sciences(C.J.R.), Wake Forest School of Medicine, Winston-Salem, NC; and Department of Epidemiology, Gillings School of Global Public Health(L.L., W.D.R.) and Gillings School of Global Public Health (D.C.), University of North Carolina at Chapel Hill
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20
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Vinik AI, Casellini C, Névoret ML. Alternative Quantitative Tools in the Assessment of Diabetic Peripheral and Autonomic Neuropathy. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2016; 127:235-85. [PMID: 27133153 DOI: 10.1016/bs.irn.2016.03.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Here we review some seldom-discussed presentations of diabetic neuropathy, including large fiber dysfunction and peripheral autonomic dysfunction, emphasizing the impact of sympathetic/parasympathetic imbalance. Diabetic neuropathy is the most common complication of diabetes and contributes additional risks in the aging adult. Loss of sensory perception, loss of muscle strength, and ataxia or incoordination lead to a risk of falling that is 17-fold greater in the older diabetic compared to their young nondiabetic counterparts. A fall is accompanied by lacerations, tears, fractures, and worst of all, traumatic brain injury, from which more than 60% do not recover. Autonomic neuropathy has been hailed as the "Prophet of Doom" for good reason. It is conducive to increased risk of myocardial infarction and sudden death. An imbalance in the autonomic nervous system occurs early in the evolution of diabetes, at a stage when active intervention can abrogate the otherwise relentless progression. In addition to hypotension, many newly recognized syndromes can be attributed to cardiac autonomic neuropathy such as orthostatic tachycardia and bradycardia. Ultimately, this constellation of features of neuropathy conspire to impede activities of daily living, especially in the patient with pain, anxiety, depression, and sleep disorders. The resulting reduction in quality of life may worsen prognosis and should be routinely evaluated and addressed. Early neuropathy detection can only be achieved by assessment of both large and small- nerve fibers. New noninvasive sudomotor function technologies may play an increasing role in identifying early peripheral and autonomic neuropathy, allowing rapid intervention and potentially reversal of small-fiber loss.
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Affiliation(s)
- A I Vinik
- Eastern Virginia Medical School, Strelitz Diabetes and Neuroendocrine Center, Norfolk, VA, United States.
| | - C Casellini
- Eastern Virginia Medical School, Strelitz Diabetes and Neuroendocrine Center, Norfolk, VA, United States
| | - M-L Névoret
- Impeto Medical Inc., San Diego, CA, United States
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21
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Lai H, Moore R, Celentano DD, Gerstenblith G, Treisman G, Keruly JC, Kickler T, Li J, Chen S, Lai S, Fishman EK. HIV Infection Itself May Not Be Associated With Subclinical Coronary Artery Disease Among African Americans Without Cardiovascular Symptoms. J Am Heart Assoc 2016; 5:e002529. [PMID: 27013538 PMCID: PMC4943239 DOI: 10.1161/jaha.115.002529] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background The key objectives of this study were to examine whether HIV infection itself is associated with subclinical coronary atherosclerosis and the potential contributions of cocaine use and antiretroviral therapies (ARTs) to subclinical coronary artery disease (CAD) in HIV‐infected persons. Methods and Results Between June 2004 and February 2015, 1429 African American (AA) adults with/without HIV infection in Baltimore, Maryland, were enrolled in an observational study of the effects of HIV infection, exposure to ART, and cocaine use on subclinical CAD. The prevalence of subclinical coronary atherosclerosis was 30.0% in HIV‐uninfected and 33.7% in HIV‐infected (P=0.17). Stratified analyses revealed that compared to HIV‐uninfected, HIV‐infected ART naïve were at significantly lower risk for subclinical coronary atherosclerosis, whereas HIV‐infected long‐term ART users (≥36 months) were at significantly higher risk. Thus, an overall nonsignificant association between subclinical coronary atherosclerosis and HIV was found. Furthermore, compared to those who were ART naïve, long‐term ART users (≥36 months) were at significantly higher risk for subclinical coronary atherosclerosis in chronic cocaine users, but not in those who never used cocaine. Cocaine use was independently associated with subclinical coronary atherosclerosis. Conclusions Overall, HIV infection, per se, was not associated with subclinical coronary atherosclerosis in this population. Cocaine use was prevalent in both HIV‐infected and ‐uninfected individuals and itself was associated with subclinical disease. In addition, cocaine significantly elevated the risk for ART‐associated subclinical coronary atherosclerosis. Treating cocaine addiction must be a high priority for managing HIV disease and preventing HIV/ART‐associated subclinical and clinical CAD in individuals with HIV infection.
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Affiliation(s)
- Hong Lai
- Department of Radiology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Richard Moore
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - David D Celentano
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Gary Gerstenblith
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Glenn Treisman
- Department of Psychiatry, Johns Hopkins School of Medicine, Baltimore, MD
| | - Jeanne C Keruly
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Thomas Kickler
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Ji Li
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Shaoguang Chen
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Shenghan Lai
- Department of Radiology, Johns Hopkins School of Medicine, Baltimore, MD Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD Department of Psychiatry, Johns Hopkins School of Medicine, Baltimore, MD Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Elliot K Fishman
- Department of Radiology, Johns Hopkins School of Medicine, Baltimore, MD
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Xie C, Hu J, Motloch LJ, Karam BS, Akar FG. The Classically Cardioprotective Agent Diazoxide Elicits Arrhythmias in Type 2 Diabetes Mellitus. J Am Coll Cardiol 2015; 66:1144-1156. [PMID: 26337994 DOI: 10.1016/j.jacc.2015.06.1329] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 06/06/2015] [Accepted: 06/23/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND Type 2 diabetes mellitus (T2DM) is associated with an enhanced propensity for ventricular tachyarrhythmias (VTs) under conditions of metabolic demand. Activation of mitochondrial adenosine triphosphate-sensitive potassium (KATP) channels by low-dose diazoxide (DZX) improves hypoglycemia-related complications, metabolic function, and triglyceride and free fatty acid levels and reverses weight gain in T2DM. OBJECTIVES In this study, we hypothesized that DZX prevents ischemia-mediated arrhythmias in T2DM via its putative cardioprotective and antidiabetic property. METHODS Zucker obese diabetic fatty (ZO) rats (n = 43) with T2DM were studied. Controls consisted of Zucker lean (ZL; n = 13) and normal Sprague-Dawley (SprD; n = 30) rats. High-resolution optical action potential mapping was performed before and during challenge with no-flow ischemia for 12 min. RESULTS Electrophysiological properties were relatively stable in T2DM hearts at baseline. In contrast, ischemia uncovered major differences between groups, because action potential duration (APD) in T2DM failed to undergo progressive adaptation to ischemic challenge. DZX promoted the incidence of arrhythmias, because all DZX-treated T2DM hearts exhibited ischemia-induced VTs that persisted on reperfusion. In contrast, untreated T2DM and controls did not exhibit VT during ischemia. Unlike DZX, pinacidil promoted ischemia-mediated arrhythmias in both control and T2DM hearts. Rapid and spatially heterogeneous shortening of APD preceded the onset of arrhythmias in T2DM. DZX-mediated proarrhythmia in T2DM was not related to changes in the messenger ribonucleic acid expression of Kir6.1, Kir6.2, SUR1A, SUR1B, SUR2A, SUR2B, or ROMK (renal outer medullary potassium channel). CONCLUSIONS Ischemia uncovers a paradoxical resistance of T2DM hearts to APD adaptation. DZX reverses this property, resulting in rapid and heterogeneous APD shortening. This promotes reentrant VT during ischemia. DZX should be avoided in diabetic patients at risk of ischemic events.
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Affiliation(s)
- Chaoqin Xie
- Cardiac Bioelectricity Research Laboratory, Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jun Hu
- Cardiac Bioelectricity Research Laboratory, Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lukas J Motloch
- Cardiac Bioelectricity Research Laboratory, Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Basil S Karam
- Cardiac Bioelectricity Research Laboratory, Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Fadi G Akar
- Cardiac Bioelectricity Research Laboratory, Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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Khazai B, Luo Y, Rosenberg S, Wingrove J, Budoff MJ. Coronary Atherosclerotic Plaque Detected by Computed Tomographic Angiography in Subjects with Diabetes Compared to Those without Diabetes. PLoS One 2015; 10:e0143187. [PMID: 26600086 PMCID: PMC4658152 DOI: 10.1371/journal.pone.0143187] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Accepted: 11/01/2015] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Little data are available regarding coronary plaque composition and semi-quantitative scores in individuals with diabetes; the extent to which diabetes may affect the presence and extent of Coronary Artery Calcium (CAC) needs more evaluation. Considering that this information may be of great value in formulating preventive interventions in this population, we compared these findings in individuals with diabetes to those without. METHODS Multi-Detector Computed Tomographic (MDCT) images of 861 consecutive patients with diabetes who were referred to Los Angeles Biomedical Research Institute from January 2000 to September 2012, were evaluated using a 15-coronary segment model. All 861 patients underwent calcium scoring and from these; 389 had coronary CT angiography (CTA). CAC score was compared to 861 age, sex and ethnicity matched controls without diabetes after adjustment for Body Mass Index (BMI), family history of coronary artery disease, hyperlipidemia, hypertension and smoking. Segment Involvement Score (SIS; the total number of segments with any plaque), Segment Stenosis Score (SSS; the sum of maximal stenosis score per segment), Total Plaque Score (TPS; the sum of the plaque amount per segment) and plaque compositionwere compared to 389 age, sex and ethnicity matched controls without diabetes after adjustment for BMI, family history of coronary artery disease, hyperlipidemia, hypertension and smoking. RESULTS Diabetes was positively correlated to the presence and extent of CAC (P<0.0001 for both). SIS, SSS and TPS were significantly higher in those with diabetes (P<0.0001). Number of mixed and calcified plaques were significantly higher in those with diabetes (P = 0.018 and P<0.001 respectively) but there was no significant difference in the number of non-calcified plaques between the two groups (P = 0.398). CONCLUSIONS Patients with diabetes have higher CAC and semi-quantitative coronary plaque scores compared to the age, gender and ethnicity matched controls without diabetes after adjustment for cardiovascular risk factors. Since mixed plaque is associated with worse long-term clinical outcomes, these findings support more aggressive preventive measures in this population.
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Affiliation(s)
- Bahram Khazai
- Department of Cardiology, University of Miami Miller School of Medicine, Miami, Florida, United States of America
- * E-mail:
| | - Yanting Luo
- Department of Cardiology, Los Angeles Biomedical Research Institute at Harbor-UCLA, UCLA School of Medicine, Torrance, California, United States of America
| | | | - James Wingrove
- CardioDx, Inc., Palo Alto, California, United States of America
| | - Matthew J Budoff
- Department of Cardiology, Los Angeles Biomedical Research Institute at Harbor-UCLA, UCLA School of Medicine, Torrance, California, United States of America
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Prediabetes and the association with unrecognized myocardial infarction in the multi-ethnic study of atherosclerosis. Am Heart J 2015; 170:923-8. [PMID: 26542500 DOI: 10.1016/j.ahj.2015.08.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 08/05/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND With one-quarter of initial myocardial infarctions (MI) being unrecognized MI (UMI), recognition is critical to minimize further cardiovascular risk. Diabetes mellitus is an established risk factor for UMI. If impaired fasting glucose (IFG) also increased the risk for UMI, it would represent a significant public health challenge due to the rapid worldwide increase in IFG prevalence. We compared participants with IFG to those with normal fasting glucose (NFG) to determine if IFG was associated with UMIs. METHODS We performed cross-sectional analyses from the MESA, a population-based cohort study. There were 6,814 participants recruited during July 2000 to September 2002 from the general community at 6 field sites. After excluding those with diabetes mellitus or missing variables, 5,885 participants were included. At baseline, there were 4,955 participants with NFG and 930 participants with IFG. The main outcome was an UMI defined by the presence of pathological Q waves or minor Q waves with ST-T abnormalities on initial 12-lead electrocardiogram. Logistic regression was used to generate crude ORs and adjust for covariates. RESULTS There was a higher prevalence of UMI in those with IFG compared with those with NFG [3.5% (n = 72) vs 1.4% (n = 30)]. After adjustment for multiple risk factors, there was a higher odds of an UMI among those with IFG compared with those with NFG [OR: 1.60 (95% CI: 1.0-2.5); P = .048]. CONCLUSIONS Impaired fasting glucose is associated with unrecognized myocardial infarctions in a multi-ethnic population free of baseline cardiovascular disease.
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Balcıoğlu AS, Müderrisoğlu H. Diabetes and cardiac autonomic neuropathy: Clinical manifestations, cardiovascular consequences, diagnosis and treatment. World J Diabetes 2015; 6:80-91. [PMID: 25685280 PMCID: PMC4317320 DOI: 10.4239/wjd.v6.i1.80] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 09/24/2014] [Accepted: 12/01/2014] [Indexed: 02/05/2023] Open
Abstract
Cardiac autonomic neuropathy (CAN) is a frequent chronic complication of diabetes mellitus with potentially life-threatening outcomes. CAN is caused by the impairment of the autonomic nerve fibers regulating heart rate, cardiac output, myocardial contractility, cardiac electrophysiology and blood vessel constriction and dilatation. It causes a wide range of cardiac disorders, including resting tachycardia, arrhythmias, intraoperative cardiovascular instability, asymptomatic myocardial ischemia and infarction and increased rate of mortality after myocardial infarction. Etiological factors associated with autonomic neuropathy include insufficient glycemic control, a longer period since the onset of diabetes, increased age, female sex and greater body mass index. The most commonly used methods for the diagnosis of CAN are based upon the assessment of heart rate variability (the physiological variation in the time interval between heartbeats), as it is one of the first findings in both clinically asymptomatic and symptomatic patients. Clinical symptoms associated with CAN generally occur late in the disease process and include early fatigue and exhaustion during exercise, orthostatic hypotension, dizziness, presyncope and syncope. Treatment is based on early diagnosis, life style changes, optimization of glycemic control and management of cardiovascular risk factors. Medical therapies, including aldose reductase inhibitors, angiotensin-converting enzyme inhibitors, prostoglandin analogs and alpha-lipoic acid, have been found to be effective in randomized controlled trials. The following article includes the epidemiology, clinical findings and cardiovascular consequences, diagnosis, and approaches to prevention and treatment of CAN.
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Abstract
Diabetes is a common disease in Germany. Due to diabetes-associated end-organ disease, such as large and small vessel disease and neuropathy, diabetic patients require more intense anesthesia care during the perioperative phase. An in-depth and comprehensive medical history focusing on hemodynamic alterations, gastroparesis, neuropathy and stiff joint syndrome is a cornerstone of perioperative care and may affect outcome of diabetes patients more than specific anesthetic medications or the anesthetic procedure. Intraoperative anesthetic care needs to focus on preservation of hemodynamic stability, perioperative infection control and maintenance of glucose homeostasis. Whereas some years ago strict glucose control by aggressive insulin therapy was adamantly advocated, the results of recent studies have put the risk of such therapeutic algorithms into perspective. Therefore, optimized perioperative care of diabetic patients consists of setting a predefined targeted blood glucose level, evidence-based therapeutic approaches to reach that goal and finally adequate and continuous monitoring and amendment of the therapeutic approach if required.
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27
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Li Y, Dawood FZ, Chen H, Jain A, Walsh JA, Alonso A, Lloyd-Jones DM, Soliman EZ. Minor isolated Q waves and cardiovascular events in the MESA study. Am J Med 2013; 126:450.e9-450.e16. [PMID: 23582938 PMCID: PMC3741651 DOI: 10.1016/j.amjmed.2012.10.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 10/31/2012] [Accepted: 10/31/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND The significance of minor isolated Q waves in the resting electrocardiograms (ECGs) of apparently healthy individuals is unknown. OBJECTIVE To examine the association between minor isolated Q waves and incident cardiovascular disease events in the Multi-Ethnic Study of Atherosclerosis (MESA). DESIGN This analysis included 6551 MESA participants (38% white, 28% black, 22% Hispanic, 12% Chinese) who were free of cardiovascular disease at enrollment. Cox proportional hazards models were used to examine the association between minor isolated Q waves defined by the Minnesota ECG Classification with adjudicated incident cardiovascular events. RESULTS During up to 7.8 years of follow-up, 423 events occurred, with a rate of 10.7 events per 1000 person-years. A significant interaction between minor isolated Q waves and race/ethnicity was observed (P=.030). In models stratified by race/ethnicity and adjusted for demographics, socioeconomic status, common cardiovascular risk factors, and other ECG abnormalities, presence of isolated minor Q waves was significantly associated with incident cardiovascular events in Hispanics (hazard ratio [HR] 2.62; 95% confidence interval [CI], 1.42-4.82), but not in whites (HR 0.65; 95% CI, 0.32-1.33) or blacks (HR 1.46; 95% CI, 0.74-2.89). Despite the statistically significant association in the Chinese population, the small number of events precluded solid conclusions in this race/ethnicity. CONCLUSION The prognostic significance of minor isolated Q waves varies across races/ethnicities; they carry a high risk for future cardiovascular events in apparently healthy Hispanics, but not in whites or blacks.
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Affiliation(s)
- Yabing Li
- Epidemiological Cardiology Research Center (EPICARE), Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
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Pride YB, Piccirillo BJ, Gibson CM. Prevalence, consequences, and implications for clinical trials of unrecognized myocardial infarction. Am J Cardiol 2013; 111:914-8. [PMID: 23276472 DOI: 10.1016/j.amjcard.2012.11.042] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2012] [Revised: 11/27/2012] [Accepted: 11/27/2012] [Indexed: 11/26/2022]
Abstract
Patients with myocardial infarction (MI) generally present with chest pain or pressure at rest or minimal exertion and have associated electrocardiographic changes and/or elevation of the biomarkers of myocardial necrosis. A subset of patients, however, experience little chest discomfort or do not present to medical attention despite experiencing symptoms. Unrecognized MI might be detected using electrocardiographic or imaging techniques, such as echocardiography, nuclear imaging, or cardiovascular magnetic resonance imaging. Unrecognized MI is a common clinical entity, with an incidence as great as 35% in high-risk populations. Moreover, the risk of a subsequent major adverse cardiovascular event might be similar to the risk after a clinically apparent MI. In the present review, we examined the incidence of unrecognized MI across broad groups of subjects and the subsequent risk of adverse cardiovascular events. Finally, we explored the potential role of including unrecognized MI as a major adverse outcome in randomized clinical trials of agents aimed at reducing cardiovascular morbidity.
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Vinik AI, Erbas T, Casellini CM. Diabetic cardiac autonomic neuropathy, inflammation and cardiovascular disease. J Diabetes Investig 2013; 4:4-18. [PMID: 23550085 PMCID: PMC3580884 DOI: 10.1111/jdi.12042] [Citation(s) in RCA: 219] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2012] [Accepted: 11/14/2012] [Indexed: 12/16/2022] Open
Abstract
One of the most overlooked of all serious complications of diabetes is cardiovascular autonomic neuropathy. There is now clear evidence that suggests activation of inflammatory cytokines in diabetic patients and that these correlate with abnormalities in sympathovagal balance. Dysfunction of the autonomic system predicts cardiovascular risk and sudden death in patients with type 2 diabetes. It also occurs in prediabetes, providing opportunities for early intervention. Simple tests that can be carried out at the bedside with real-time output of information - within the scope of the practicing physician - facilitate diagnosis and allow the application of sound strategies for management. The window of opportunity for aggressive control of all the traditional risk factors for cardiovascular events or sudden death with intensification of therapy is with short duration diabetes, the absence of cardiovascular disease and a history of severe hypoglycemic events. To this list we can now add autonomic dysfunction and neuropathy, which have become the most powerful predictors of risk for mortality. It seems prudent that practitioners should be encouraged to become familiar with this information and apply risk stratification in clinical practice. Several agents have become available for the correction of functional defects in the autonomic nervous system, and restoration of autonomic balance is now possible.
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Affiliation(s)
- Aaron I Vinik
- The Strelitz Diabetes Research Center and Neuroendocrine Unit, The Department of Medicine and Pathology/Anatomy/Neurobiology, Eastern Virginia Medical School Norfolk, Virginia, USA
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Karayannis G, Giamouzis G, Cokkinos DV, Skoularigis J, Triposkiadis F. Diabetic cardiovascular autonomic neuropathy: clinical implications. Expert Rev Cardiovasc Ther 2013; 10:747-65. [PMID: 22894631 DOI: 10.1586/erc.12.53] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Diabetic cardiovascular autonomic neuropathy (DCAN), the impairment of the autonomic balance of the cardiovascular system in the setting of diabetes mellitus (DM), is frequently observed in both Type 1 and 2 DM, has detrimental effects on the quality of life and portends increased mortality. Clinical manifestations include: resting heart rate disorders, exercise intolerance, intraoperative cardiovascular lability, orthostatic alterations in heart rate and blood pressure, QT-interval prolongation, abnormal diurnal and nocturnal blood pressure variation, silent myocardial ischemia and diabetic cardiomyopathy. Clinical tests for autonomic nervous system evaluation, heart rate variability analysis, autonomic innervation imaging techniques, microneurography and baroreflex analysis are the main diagnostic tools for DCAN detection. Aldose reductase inhibitors and antioxidants may be helpful in DCAN therapy, but a regular, more generalized and multifactorial approach should be adopted with inclusion of lifestyle modifications, strict glycemic control and treatment of concomitant traditional cardiovascular risk factors, in order to achieve the best therapeutic results. In the present review, the authors provide aspects of DCAN pathophysiology, clinical presentation, diagnosis and an algorithm regarding the evaluation and management of DCAN in DM patients.
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Abstract
Autonomic neuropathy, once considered to be the Cinderella of diabetes complications, has come of age. The autonomic nervous system innervates the entire human body, and is involved in the regulation of every single organ in the body. Thus, perturbations in autonomic function account for everything from abnormalities in pupillary function to gastroparesis, intestinal dysmotility, diabetic diarrhea, genitourinary dysfunction, amongst others. "Know autonomic function and one knows the whole of medicine!" It is now becoming apparent that before the advent of severe pathological damage to the autonomic nervous system there may be an imbalance between the two major arms, namely the sympathetic and parasympathetic nerve fibers that innervate the heart and blood vessels, resulting in abnormalities in heart rate control and vascular dynamics. Cardiac autonomic neuropathy (CAN) has been linked to resting tachycardia, postural hypotension, orthostatic bradycardia and orthostatic tachycardia (POTTS), exercise intolerance, decreased hypoxia-induced respiratory drive, loss of baroreceptor sensitivity, enhanced intraoperative or perioperative cardiovascular lability, increased incidence of asymptomatic ischemia, myocardial infarction, and decreased rate of survival after myocardial infarction and congestive heart failure. Autonomic dysfunction can affect daily activities of individuals with diabetes and may invoke potentially life-threatening outcomes. Intensification of glycemic control in the presence of autonomic dysfunction (more so if combined with peripheral neuropathy) increases the likelihood of sudden death and is a caveat for aggressive glycemic control. Advances in technology, built on decades of research and clinical testing, now make it possible to objectively identify early stages of CAN with the use of careful measurement of time and frequency domain analyses of autonomic function. Fifteen studies using different end points report prevalence rates of 1% to 90%. CAN may be present at diagnosis, and prevalence increases with age, duration of diabetes, obesity, smoking, and poor glycemic control. CAN also cosegregates with distal symmetric polyneuropathy, microangiopathy, and macroangiopathy. It now appears that autonomic imbalance may precede the development of the inflammatory cascade in type 2 diabetes and there is a role for central loss of dopaminergic restraint on sympathetic overactivity. Restoration of dopaminergic tone suppresses the sympathetic dominance and reduces cardiovascular events and mortality by close to 50%. Cinderella's slipper can now be worn!
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Affiliation(s)
- Aaron I Vinik
- Eastern Virginia Medical School, Strelitz Diabetes Center, Division of Endocrinology and Metabolism, Eastern Virginia Medical School, Norfolk, VA, USA.
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32
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Diogo CV, Suski JM, Lebiedzinska M, Karkucinska-Wieckowska A, Wojtala A, Pronicki M, Duszynski J, Pinton P, Portincasa P, Oliveira PJ, Wieckowski MR. Cardiac mitochondrial dysfunction during hyperglycemia--the role of oxidative stress and p66Shc signaling. Int J Biochem Cell Biol 2012; 45:114-22. [PMID: 22776741 DOI: 10.1016/j.biocel.2012.07.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Revised: 06/15/2012] [Accepted: 07/01/2012] [Indexed: 01/25/2023]
Abstract
Diabetes mellitus is a chronic disease caused by a deficiency in the production of insulin and/or by the effects of insulin resistance. Insulin deficiency leads to hyperglycemia which is the major initiator of diabetic cardiovascular complications escalating with time and driven by many complex biochemical and molecular processes. Four hypotheses, which propose mechanisms of diabetes-associated pathophysiology, are currently considered. Cardiovascular impairment may be caused by an increase in polyol pathway flux, by intracellular advanced glycation end-products formation or increased flux through the hexosamine pathway. The latter of these mechanisms involves activation of the protein kinase C. Cellular and mitochondrial metabolism alterations observed in the course of diabetes are partially associated with an excessive production of reactive oxygen species (ROS). Among many processes and factors involved in ROS production, the 66 kDa isoform of the growth factor adaptor shc (p66Shc protein) is of particular interest. This protein plays a key role in the control of mitochondria-dependent oxidative balance thus it involvement in diabetic complications and other oxidative stress based pathologies is recently intensively studied. In this review we summarize the current understanding of hyperglycemia induced cardiac mitochondrial dysfunction with an emphasis on the oxidative stress and p66Shc protein. This article is part of a Directed Issue entitled: Bioenergetic dysfunction, adaptation and therapy.
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Affiliation(s)
- Catia V Diogo
- CNC - Center for Neuroscience and Cell Biology, University of Coimbra, Portugal
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Rizk DV, Gutierrez O, Levitan EB, McClellan WM, Safford M, Soliman EZ, Warnock DG, Muntner P. Prevalence and prognosis of unrecognized myocardial infarctions in chronic kidney disease. Nephrol Dial Transplant 2011; 27:3482-8. [PMID: 22167594 DOI: 10.1093/ndt/gfr684] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Unrecognized myocardial infarctions (UMIs) are common in the general population but have not been well studied in patients with chronic kidney disease (CKD). The purpose of this study was to determine the prevalence and prognosis for mortality of UMI among adults with CKD. METHODS The current study included 18 864 participants in the population-based REasons for Geographic And Racial Differences in Stroke (REGARDS) study who completed a baseline examination including a 12-lead electrocardiogram (ECG). UMI was defined as the presence of myocardial infarction (MI) by Minnesota ECG classification in the absence of self-reported or recognized MI (RMI). Estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation and albuminuria using albumin-to-creatinine ratio from a spot urine sample. All-cause mortality was assessed over a median 4 years of follow-up. RESULTS The prevalence of UMI was 4, 6, 6 and 13% among participants with eGFR levels of ≥ 60, 45-59.9, 30-44.9 and <30 mL/min/1.73 m(2), respectively, and 4, 5, 7 and 10% among participants with albuminuria levels of <10, 10-29.9, 30-299.9 and ≥ 300 mg/g, respectively. Compared to those with no MI, the multivariable adjusted hazard ratio for all-cause mortality associated with UMI and RMI was 1.65 [95% confidence interval (CI): 1.09-2.49] and 1.65 (95% CI: 1.20-2.26), respectively, among individuals with an eGFR <60 mL/min/1.73 m(2) and 1.49 (95% CI: 1.03-2.16) and 1.88 (95% CI: 1.40-2.52) among individuals with albuminuria ≥ 30 mg/g. Conclusion UMIs are common among individuals with an eGFR <60 mL/min/1.73 m(2) and albuminuria and associated with an increased mortality risk.
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Affiliation(s)
- Dana V Rizk
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
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Karthikeyan V, Ananthasubramaniam K. Coronary risk assessment and management options in chronic kidney disease patients prior to kidney transplantation. Curr Cardiol Rev 2011; 5:177-86. [PMID: 20676276 PMCID: PMC2822140 DOI: 10.2174/157340309788970342] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2008] [Revised: 10/15/2008] [Accepted: 10/18/2008] [Indexed: 02/08/2023] Open
Abstract
Cardiovascular disease remains the most important cause of morbidity and mortality among kidney transplant recipients. Nearly half the deaths in transplanted patients are attributed to cardiac causes and almost 5% of these deaths occur within the first year after transplantation. The ideal strategies to screen for coronary artery disease (CAD) in chronic kidney disease patients who are evaluated for kidney transplantation (KT) remain controversial. The American Society of Transplantation recommends that patients with diabetes, prior history of ischemic heart disease or an abnormal ECG, or age ≥50 years should be considered as high-risk for CAD and referred for a cardiac stress test and only those with a positive stress test, for coronary angiography. Despite these recommendations, vast variations exist in the way these patients are screened for CAD at different transplant centers. The sensitivity and specificity of noninvasive cardiac tests in CKD patients is much lower than that in the general population. This has prompted the use of direct diagnostic cardiac catheterization in high-risk patients in several transplant centers despite the risks associated with this invasive procedure. No large randomized controlled trials exist to date that address these issues. In this article, we review the existing literature with regards to the available data on cardiovascular risk screening and management options in CKD patients presenting for kidney transplantation and outline a strategy for approach to these patients.
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Affiliation(s)
- Vanji Karthikeyan
- Division of Nephrology and Transplantation and the Heart and Vascular Institute, Henry Ford Hospital Detroit MI, USA
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Kadoi Y. Anesthetic considerations in diabetic patients. Part I: preoperative considerations of patients with diabetes mellitus. J Anesth 2010; 24:739-47. [PMID: 20640453 DOI: 10.1007/s00540-010-0987-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Accepted: 06/24/2010] [Indexed: 02/08/2023]
Abstract
Diabetes mellitus is an increasingly common disease that affects people of all ages, resulting in significant morbidity and mortality. Diabetic patients require perioperative care more frequently than their nondiabetic counterparts. The major risk factors for diabetics undergoing surgery are the associated end-organ diseases: cardiovascular disease, autonomic neuropathy, joint collagen tissue, and immune deficiency. Physicians need to pay extra attention to preoperative and preprocedure evaluation and treatment of these diseases to ensure optimal perioperative management.
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Affiliation(s)
- Yuji Kadoi
- Department of Anesthesiology, Gunma University Hospital, Gunma University, Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan.
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Takeda N. Cardiac disturbances in diabetes mellitus. PATHOPHYSIOLOGY 2010; 17:83-8. [DOI: 10.1016/j.pathophys.2009.03.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2008] [Revised: 01/20/2009] [Accepted: 03/20/2009] [Indexed: 10/20/2022] Open
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Hung CL, Hou CJY, Yeh HI, Chang WH. Atypical Chest Pain in the Elderly: Prevalence, Possible Mechanisms and Prognosis. INT J GERONTOL 2010. [DOI: 10.1016/s1873-9598(10)70015-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Chang ST, Chu CM, Hsu JT, Pan KL, Lin PG, Chung CM. Role of ankle-brachial pressure index as a predictor of coronary artery disease severity in patients with diabetes mellitus. Can J Cardiol 2009; 25:e301-5. [PMID: 19746248 DOI: 10.1016/s0828-282x(09)70140-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Previous studies have reported a close correlation between low ankle-brachial pressure index (ABPI) and various cardiovascular risk factors. However, despite the well-established potential hazards of consequent coronary artery disease (CAD), no data exist on the relationship between ABPI and the severity of CAD, particularly in patients with diabetes mellitus (DM). METHODS A total of 840 patients ranging from 35 to 87 years of age (mean [+/- SD] 63.9+/-10.2 years) with suspected CAD in a clinical practice were enrolled. All patients underwent ABPI measurements and coronary angiography. Patients were divided into four groups according to the results of ABPI measurements and the presence or absence of DM: group A had an ABPI value of at least 0.9 but no DM (A-/D-); group B had an ABPI value of at least 0.9 and DM (A-/D+); group C had an ABPI of less than 0.9 but no DM (A+/D-); and group D had an ABPI value of less than 0.9 and DM (A+/D+). RESULTS Age was significantly higher in the A+ (groups C and D) than the A- patients (groups A and B). Moreover, men predominated in all four groups. Comparisons of sex distribution among the four groups revealed that group D had the highest percentage of women, while group A had the lowest. Total cholesterol level did not differ among the four groups, although group D tended to have the highest result. Patients in group D had the highest percentages of hypertension, hypercholesterol, hypertriglyceride, low high-density lipoprotein cholesterol and high low-density lipoprotein cholesterol among the four groups. Group D exhibited the highest triglyceride and uric acid levels, the lowest high-density lipoprotein cholesterol level, and the highest metabolic syndrome criteria number and percentage of metabolic syndrome. Furthermore, group D had the highest mean lesion numbers, mean numbers of target vessel involvement, stenoses with type C classification and complex morphology lesions (chronic total occlusion, diffuse or calcified lesions) among the four groups. There were still significant differences in lesion numbers (P<0.001) and numbers of target vessel involvement (P<0.001) for ABPI predicting CAD severity after controlling for the effects of DM and age. The sensitivity, specificity, positive predictive value and negative predictive value of using an ABPI of less than 0.9 to predict CAD differed significantly between patients with and without DM. CONCLUSIONS ABPI is a useful noninvasive tool for predicting CAD severity, even in patients with DM.
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Affiliation(s)
- Shih-Tai Chang
- Division of Cardiology, Chiayi Chang Gung Memorial Hospital, Chai Yi Hsien, Taiwan.
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Comprehensive evaluation of coronary arteries by multidetector-row cardiac computed tomography according to the glucose level of asymptomatic individuals. Atherosclerosis 2009; 205:156-62. [DOI: 10.1016/j.atherosclerosis.2008.10.041] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2008] [Revised: 10/14/2008] [Accepted: 10/31/2008] [Indexed: 11/21/2022]
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Reunanen A, Suhonen O, Aromaa A, Knekt P, Pyörälä K. Incidence of different manifestations of coronary heart disease in middle-aged Finnish men and women. ACTA MEDICA SCANDINAVICA 2009; 218:19-26. [PMID: 4050549 DOI: 10.1111/j.0954-6820.1985.tb08819.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The incidence of myocardial infarction and symptoms of coronary heart disease (CHD) were investigated in a prospective Finnish population study. Drawn from four geographical areas in Finland the study population comprised 5 438 men and 4 924 women aged 30-59 at entry. The results are based on a re-examination of the study population after a mean follow-up time of six years. The average annual incidence of coronary death was 3.8/1 000, and that of non-fatal infarction 6.5/1 000 in men and 0.4/1 000 and 2.1/1 000 in women. Ten per cent of all infarctions were silent, revealed only by ECG changes. Cases of new angina pectoris comprised 40% of all the new events in men but 80% in women. This descriptive report serves as the basis for subsequent analyses comprising risk factors for different CHD manifestations.
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Kim HW, Klem I, Shah DJ, Wu E, Meyers SN, Parker MA, Crowley AL, Bonow RO, Judd RM, Kim RJ. Unrecognized non-Q-wave myocardial infarction: prevalence and prognostic significance in patients with suspected coronary disease. PLoS Med 2009; 6:e1000057. [PMID: 19381280 PMCID: PMC2661255 DOI: 10.1371/journal.pmed.1000057] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2008] [Accepted: 02/20/2009] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Unrecognized myocardial infarction (UMI) is known to constitute a substantial portion of potentially lethal coronary heart disease. However, the diagnosis of UMI is based on the appearance of incidental Q-waves on 12-lead electrocardiography. Thus, the syndrome of non-Q-wave UMI has not been investigated. Delayed-enhancement cardiovascular magnetic resonance (DE-CMR) can identify MI, even when small, subendocardial, or without associated Q-waves. The aim of this study was to investigate the prevalence and prognosis associated with non-Q-wave UMI identified by DE-CMR. METHODS AND FINDINGS We conducted a prospective study of 185 patients with suspected coronary disease and without history of clinical myocardial infarction who were scheduled for invasive coronary angiography. Q-wave UMI was determined by electrocardiography (Minnesota Code). Non-Q-wave UMI was identified by DE-CMR in the absence of electrocardiographic Q-waves. Patients were followed to determine the prognostic significance of non-Q-wave UMI. The primary endpoint was all-cause mortality. The prevalence of non-Q-wave UMI was 27% (50/185), compared with 8% (15/185) for Q-wave UMI. Patients with non-Q-wave UMI were older, were more likely to have diabetes, and had higher Framingham risk than those without MI, but were similar to those with Q-wave UMI. Infarct size in non-Q-wave UMI was modest (8%+/-7% of left ventricular mass), and left ventricular ejection fraction (LVEF) by cine-CMR was usually preserved (52%+/-18%). The prevalence of non-Q-wave UMI increased with the extent and severity of coronary disease on angiography (p<0.0001 for both). Over 2.2 y (interquartile range 1.8-2.7), 16 deaths occurred: 13 in non-Q-wave UMI patients (26%), one in Q-wave UMI (7%), and two in patients without MI (2%). Multivariable analysis including New York Heart Association class and LVEF demonstrated that non-Q-wave UMI was an independent predictor of all-cause mortality (hazard ratio [HR] 11.4, 95% confidence interval [CI] 2.5-51.1) and cardiac mortality (HR 17.4, 95% CI 2.2-137.4). CONCLUSIONS In patients with suspected coronary disease, the prevalence of non-Q-wave UMI is more than 3-fold higher than Q-wave UMI. The presence of non-Q-wave UMI predicts subsequent mortality, and is incremental to LVEF. TRIAL REGISTRATION Clinicaltrials.gov NCT00493168.
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Affiliation(s)
- Han W. Kim
- Duke Cardiovascular Magnetic Resonance Center, Division of Cardiology, Duke University, Durham, North Carolina, United States of America
| | - Igor Klem
- Duke Cardiovascular Magnetic Resonance Center, Division of Cardiology, Duke University, Durham, North Carolina, United States of America
| | - Dipan J. Shah
- Duke Cardiovascular Magnetic Resonance Center, Division of Cardiology, Duke University, Durham, North Carolina, United States of America
| | - Edwin Wu
- Feinberg Cardiovascular Research Institute, Division of Cardiology, Northwestern University, Chicago, Illinois, United States of America
| | - Sheridan N. Meyers
- Feinberg Cardiovascular Research Institute, Division of Cardiology, Northwestern University, Chicago, Illinois, United States of America
| | - Michele A. Parker
- Duke Cardiovascular Magnetic Resonance Center, Division of Cardiology, Duke University, Durham, North Carolina, United States of America
| | - Anna Lisa Crowley
- Duke Cardiovascular Magnetic Resonance Center, Division of Cardiology, Duke University, Durham, North Carolina, United States of America
| | - Robert O. Bonow
- Feinberg Cardiovascular Research Institute, Division of Cardiology, Northwestern University, Chicago, Illinois, United States of America
| | - Robert M. Judd
- Duke Cardiovascular Magnetic Resonance Center, Division of Cardiology, Duke University, Durham, North Carolina, United States of America
| | - Raymond J. Kim
- Duke Cardiovascular Magnetic Resonance Center, Division of Cardiology, Duke University, Durham, North Carolina, United States of America
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Herlitz J, Karlsson T, Dellborg M, Karlson B, Engdahl J, Sandén W. Occurrence, characteristics, and outcome of patients hospitalized with a diagnosis of acute myocardial infarction who do not fulfill traditional criteria. Clin Cardiol 2009; 21:405-9. [PMID: 9631269 PMCID: PMC6656091 DOI: 10.1002/clc.4960210607] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The diagnosis of acute myocardial infarction (AMI) is traditionally based on clinical history, elevation of serum enzyme activity, and typical changes in the electrocardiogram (ECG); however, not all patients who develop AMI fulfill these criteria on discharge from hospital. HYPOTHESIS The aim of the study was to evaluate (1) the frequency with which the traditional criteria for AMI are not fulfilled among patients diagnosed with AMI on discharge, and (2) whether patients with and without these criteria differ in terms of characteristics, treatment, and outcome. METHODS All patients aged < 75 years and hospitalized in the municipality of Göteborg with a discharge diagnosis of AMI were included. Fulfillment criteria for AMI were two of the following three points: (1) chest pain, (2) increase in cardiac enzymes, and (3) development of Q waves. RESULTS In all, 1,188 admitted patients, 27% of whom were women, were included in the analysis. Of these, 193 (16%) did not fulfill the traditional criteria for AMI. These patients had an in-hospital mortality rate of 48%; of these, 59% died a sudden death, and of those who were autopsied (62%), 96% showed signs of a fresh AMI. The most common symptom on admission to hospital in patients who did not fulfill the traditional criteria was chest pain (34%), followed by dyspnea (27%) and fatigue (14%). Of those who died suddenly, fewer than half had been admitted to the coronary care unit. CONCLUSION Patients diagnosed with AMI who do not fulfill the traditional diagnosis criteria have high mortality. On admission to hospital, the initial suspicion of AMI is often vague. Measures for earlier detection of life-threatening coronary artery disease among these patients are warranted.
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Affiliation(s)
- J Herlitz
- Division of Cardiology, Sahlgrenska University Hospital, Göteborg, Sweden
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Lim S, Kim DJ, Jeong IK, Son HS, Chung CH, Koh G, Lee DH, Won KC, Park JH, Park TS, Ahn J, Kim J, Park KG, Ko SH, Ahn YB, Lee I. A Nationwide Survey about the Current Status of Glycemic Control and Complications in Diabetic Patients in 2006 - The Committee of the Korean Diabetes Association on the Epidemiology of Diabetes Mellitus -. KOREAN DIABETES JOURNAL 2009. [DOI: 10.4093/kdj.2009.33.1.48] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Soo Lim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | - Dae Jung Kim
- Department of Endocrinology and Metabolism, Ajou University School of Medicine, Suwon, Korea
| | - In-Kyung Jeong
- Department of Internal Medicine, Kyung Hee University, East-West Neo Medical Center, Seoul, Korea
| | - Hyun Shik Son
- Department of Internal Medicine, Uijeognbu St. Mary's Hospital, Catholic University Medical College, Uijeongbu, Korea
| | - Choon Hee Chung
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Gwanpyo Koh
- Department of Internal Medicine, Cheju National University Hospital, Cheju National University School of Medicine, Jeju, Korea
| | - Dae Ho Lee
- Department of Internal Medicine, Cheju National University Hospital, Cheju National University School of Medicine, Jeju, Korea
| | - Kyu Chang Won
- Department of Internal Medicine, Yeungnam University College of Medicine, Yeungnam University Hospital, Daegu, Korea
| | - Jeong Hyun Park
- Department of Internal Medicine, Pusan Paik Hospital, College of Medicine, Inje University, Busan, Korea
| | - Tae Sun Park
- Department of Internal Medicine, Chonbuk National University Hospital, Jeonju, Korea
| | - Jihyun Ahn
- Department of Internal Medicine, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Jaetaek Kim
- Department of Internal Medicine, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Keun-Gyu Park
- Department of Internal Medicine, Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Seung Hyun Ko
- Department of Internal Medicine, St. Vincent's Hospital, Catholic University Medical College, Suwon, Korea
| | - Yu-Bae Ahn
- Department of Internal Medicine, St. Vincent's Hospital, Catholic University Medical College, Suwon, Korea
| | - Inkyu Lee
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
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Brandes A, Bethge KP. [Long term electrocardiography (Holter monitoring)]. Herzschrittmacherther Elektrophysiol 2008; 19:107-129. [PMID: 18956158 DOI: 10.1007/s00399-008-0010-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2008] [Accepted: 07/14/2008] [Indexed: 05/27/2023]
Abstract
During the past almost 50 years Holter monitoring has become an established non-invasive diagnostic tool in clinical electrophysiology. It allows ECG recording independent of stationary monitoring facilities during daily life and, therefore, contains much information. In the beginning the main interest was directed towards quantitative and qualitative assessment of arrhythmias, their circadian behaviour, and the circadian behaviour of the heart rate. With advances in technology the analysis spectrum of Holter monitoring expanded, and it was used also for detection of silent myocardial ischaemia. New digital recorders and computers with large capacities made it possible to measure every single heart beat very accurately, which was a prerequisite for heart rate variability and QT-interval analysis, which provided new knowledge about the autonomic modulation of the heart rate and the circadian dynamicity of the QT interval, respectively. Beyond arrhythmia analysis Holter monitoring was increasingly used to assess prognosis in different cardiac conditions. It can also be valuable in assessing transient symptoms possibly related to arrhythmias or device dysfunction, which will not necessarily be revealed by simple device control.
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Affiliation(s)
- Axel Brandes
- Dept of Cardiology B, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark.
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Stone MA, Khunti K, Squire I, Paul S. Impact of comorbid diabetes on quality of life and perception of angina pain in people with angina registered with general practitioners in the UK. Qual Life Res 2008; 17:887-94. [DOI: 10.1007/s11136-008-9363-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2008] [Accepted: 05/22/2008] [Indexed: 12/16/2022]
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Völgyi Z, Szavin M. [Silent myocardial infarction]. Orv Hetil 2007; 148:2027-32. [PMID: 17947195 DOI: 10.1556/oh.2007.28146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION By autopsies of patients expired from different diseases not rarely chronic myocardial infarction is found, that was known before neither to patient nor to medical attendant (silent myocardial infarction) and is interpreted as incidental finding. AIM Study of frequency, role in expectation of life, diagnosis and prognosis of silent myocardial infarction in relation to localisation. METHODS Retrospective study and statistical analysis of 1568 autopsies performed during 10 years. RESULTS Acute or chronic myocardial infarction was found in 470 cases (30%), acute infarction in 177 cases (37%), 90% of which was diagnosed in vivo and patients died of infarction and its direct complications. In 293 cases (63%) chronic myocardial infarction was found, 109 cases (37%) were known and 184 cases (63%) were silent myocardial necrosis, the ratio of female/male patients was nearly the same (90/94 persons). 97 patients (32%) with chronic myocardial infarction died of cardiac cause - mostly in cardiac failure -, 196 (68%) of extracardiac cause, most of them of stroke, predominantly the patients with inferior infarction. CONCLUSION Considering the silent causes, the myocardial infarction is more frequent and has better prognosis, than it is known from epidemiological data without autopsies, because 42% of these patients dies of extracardiac diseases, and the continuity of life is not shorter, than by patients without myocardial infarction. Knowledge of silent infarction gives possibility to estimate the physical charge of patients, their treatment and to prevent recurrence.
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Affiliation(s)
- Zoltán Völgyi
- Gróf Esterházy Kórház, Belgyógyászati Osztály, Pápa, Bella u. 9. 8500.
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Jaffery Z, Hudson MP, Khanal S, Ananthasubramaniam K, Kim H, Greenbaum A, Kugelmass A, Jacobsen G, McCord J. The recognition of acute coronary ischemia in the outpatient setting. J Thromb Thrombolysis 2007; 27:18-23. [PMID: 17898930 DOI: 10.1007/s11239-007-0153-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2007] [Accepted: 09/07/2007] [Indexed: 12/15/2022]
Abstract
BACKGROUND The missed diagnosis of acute myocardial infarction has been studied in the Emergency Department, but few studies have investigated how often coronary ischemia is correctly identified in the outpatient setting. METHODS This was a single center retrospective observational study of patients with Health Alliance Plan medical insurance hospitalized at a US tertiary center with acute myocardial infarction in 2004. Outpatient encounters in the 30 days preceding acute myocardial infarction were reviewed by two independent cardiologists for presenting symptoms and diagnostic decision-making in order to classify patient presentations as acute coronary ischemia, stable angina or neither. RESULTS There were 331 patients with acute myocardial infarction, including 190 (57%) with a primary diagnosis of AMI and evaluated by a physician in the preceding 30 days. This group included 68 patients with 95 documented outpatient encounters by a primary care physician, cardiologist, or other internal medicine specialist which formed the final study population. Mean interval between these encounters and AMI was 17 +/- 11 days. Of these patients, 7 (10%) had symptoms of acute coronary ischemia, 5 (7%) had stable angina symptoms, and 56 (83%) had no symptoms of coronary ischemia at their outpatient encounters. Of the 7 patients with acute coronary ischemic symptoms, 5 were correctly identified and 2 were misidentified. CONCLUSION A majority of patients with subsequent AMI visit an outpatient provider in the month preceding AMI. However, few present with symptoms of coronary ischemia in the outpatient setting (10%) and these symptoms are not always identified as such.
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Affiliation(s)
- Zehra Jaffery
- Department of Internal Medicine, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202, USA.
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Affiliation(s)
- Aaron I Vinik
- Strelitz Diabetes Research Institute, 855 W Brambleton Avenue, Norfolk, VA 23510, USA.
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49
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Silent Ischemia. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Shen R, Wiegers SE, Glaser R. The evaluation of cardiac and peripheral arterial disease in patients with diabetes mellitus. Endocr Res 2007; 32:109-42. [PMID: 18092197 DOI: 10.1080/07435800701743869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Rhuna Shen
- Department of Medicine, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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