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      Isolated Type 2 Diabetes mellitus Causes Myocardial Dysfunction That Becomes Worse in the Presence of Cardiovascular Diseases: Results of the Myocardial Doppler in Diabetes (MYDID) Study 1

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          Abstract

          Aims: Patients with type 2 diabetes mellitus (DM) often suffer disproportionately and have a worse outcome when burdened with cardiovascular complications compared with those without DM. A specific heart muscle disease reportedly caused by DM per se may explain this. We sought to investigate whether an echo Doppler diagnosis of such a myocardial disease is clinically relevant in DM with or without coexistent coronary artery disease (CAD) and/or hypertension (HTN). Subjects and Methods: Two hundred subjects (127 males, 73 females, 56 ± 10 years) including controls (n = 23), patients with HTN (n = 20), CAD (n = 35), uncomplicated DM (n = 59), DM+HTN (n = 27), DM+CAD (n = 16) and DM+CAD+HTN (n = 20) underwent tissue Doppler-enhanced dobutamine stress echocardiography. Myocardial function was assessed by measuring left ventricular myocardial peak systolic velocity (PSV) and early diastolic velocity at rest and during peak stress, besides measurements of standard Doppler variables. Results: Average left ventricular PSV at rest was significantly lower in CAD (4.7 ± 1.5) compared with controls (5.7 ± 1.2) and in DM+CAD+HTN (4.6 ± 1.4) compared with DM (5.6 ± 1.3; all p < 0.05). During peak stress, lower PSV persisted in CAD (9.5 ± 3.1) and DM+CAD+HTN (8.1 ± 2.7), while appearing de novo in DM (11.3 ± 2.6) and HTN (11.0 ± 2.3) unlike in the controls (12.5 ± 2.5; all p < 0.001). When pooled together, DM subjects with CAD and/or HTN or both had significantly lower PSV (9.1 ± 2.7) than those without (10.0 ± 2.8; p < 0.001). Early diastolic velocity response was equally lower in both groups compared with the controls. Conclusion: The results suggest that dobutamine stress unmasks myocardial functional disturbances caused by uncomplicated DM. The discrete disturbances become quantitatively more pronounced in the presence of coexistent cardiovascular diseases.

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          Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes.

          Peter Gæde, Pernille Vedel, Nicolai H. Larsen … (2003)
          Cardiovascular morbidity is a major burden in patients with type 2 diabetes. In the Steno-2 Study, we compared the effect of a targeted, intensified, multifactorial intervention with that of conventional treatment on modifiable risk factors for cardiovascular disease in patients with type 2 diabetes and microalbuminuria. The primary end point of this open, parallel trial was a composite of death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, revascularization, and amputation. Eighty patients were randomly assigned to receive conventional treatment in accordance with national guidelines and 80 to receive intensive treatment, with a stepwise implementation of behavior modification and pharmacologic therapy that targeted hyperglycemia, hypertension, dyslipidemia, and microalbuminuria, along with secondary prevention of cardiovascular disease with aspirin. The mean age of the patients was 55.1 years, and the mean follow-up was 7.8 years. The decline in glycosylated hemoglobin values, systolic and diastolic blood pressure, serum cholesterol and triglyceride levels measured after an overnight fast, and urinary albumin excretion rate were all significantly greater in the intensive-therapy group than in the conventional-therapy group. Patients receiving intensive therapy also had a significantly lower risk of cardiovascular disease (hazard ratio, 0.47; 95 percent confidence interval, 0.24 to 0.73), nephropathy (hazard ratio, 0.39; 95 percent confidence interval, 0.17 to 0.87), retinopathy (hazard ratio, 0.42; 95 percent confidence interval, 0.21 to 0.86), and autonomic neuropathy (hazard ratio, 0.37; 95 percent confidence interval, 0.18 to 0.79). A target-driven, long-term, intensified intervention aimed at multiple risk factors in patients with type 2 diabetes and microalbuminuria reduces the risk of cardiovascular and microvascular events by about 50 percent. Copyright 2003 Massachusetts Medical Society
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            The impact of diabetes on left ventricular filling pattern in normotensive and hypertensive adults: the Strong Heart Study.

            Jennifer Liu, Vittorio Palmieri, Mary Roman … (2001)
            We sought to determine the effect of diabetes mellitus (DM) on left ventricular (LV) filling pattern in normotensive (NT) and hypertensive (HTN) individuals. Diastolic abnormalities have been extensively described in HTN but are less well characterized in DM, which frequently coexists with HTN. We analyzed the transmitral inflow velocity profile at the mitral annulus in four groups from the Strong Heart Study: NT-non-DM (n = 730), HTN-non-DM (n = 394), NT-DM (n = 616) and HTN-DM (n = 671). The DM subjects were further divided into those with normal filling pattern (n = 107) and those with abnormal relaxation (AbnREL) (n = 447). The peak E velocity was lowest in HTN-DM, intermediate in NT-DM and HT-non-DM and highest in the NT-non-DM group (p < 0.001), with a reverse trend seen for peak A velocity (p < 0.001). In multivariate analysis, E/A ratio was lowest in HTN-DM and highest in NT-non-DM, with no difference between NT-DM and HTN-non DM (p < 0.001). Likewise, mean atrial filling fraction and deceleration time were highest in HTN-DM, followed by HTN-non-DM or NT-DM and lowest in NT-non-DM (both p < 0.05). Among DM subjects, those with AbnREL had higher fasting glucose (p = 0.03) and hemoglobin A1C (p = 0.04). Diabetes mellitus, especially with worse glycemic control, is independently associated with abnormal LV relaxation. The severity of abnormal LV relaxation is similar to the well-known impaired relaxation associated with HTN. The combination of DM and HTN has more severe abnormal LV relaxation than groups with either condition alone. In addition, AbnREL in DM is associated with worse glycemic control.
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              Diabetes mellitus: the major risk factor in unstable coronary artery disease even after consideration of the extent of coronary artery disease and benefits of revascularization.

              Bo Lagerqvist, Lars Wallentin, Anna Norhammar … (2004)
              This study was designed to study the influence of diabetes on the outcome of unstable coronary artery disease (CAD). Diabetes mellitus is a major contributor to CAD. Despite improvement in the management of patients with unstable coronary syndromes, this condition is still linked to a substantially increased mortality and morbidity among diabetic patients. Recent evidence advocates early revascularization in unstable coronary syndromes. Diabetic patients subjected to coronary interventions under stable conditions have a higher risk for complications and a more dismal prognosis than nondiabetic subjects. Accordingly, it is of considerable interest to obtain further information regarding the best possible management of diabetic patients with unstable CAD. A total of 2158 patients without and 299 with diabetes mellitus were randomized to an early invasive or a noninvasive strategy. The severity of CAD was expressed as the number and extent of vessel involvement. Three-vessel disease was diagnosed in 42% of diabetic and 31% of nondiabetic patients (p = 0.006). The percentages of patients with ST-depression and troponin-T >0.03 microg/l at admission were comparable among diabetic and nondiabetic patients. Mortality and reinfarction after 12 months were more frequent among diabetic than nondiabetic patients in both treatment groups. Diabetes remained a strong independent predictor for death and myocardial infarction in multivariable analysis. The invasive strategy reduced event rate in nondiabetic patients from 12.0% to 8.9% (odds ratio [OR] = 0.72; confidence interval [CI] 0.54 to 0.95; p = 0.019) and in diabetic patients from 29.9% to 20.6% (OR 0.61; CI 0.36 to 1.04; p = 0.066). In a multivariate analysis including the extent of CAD, diabetes remained a strong independent predictor of the combined end point (relative risk [RR] 2.40; CI 1.47 to 3.91; p = 0.0001) and of mortality (RR 5.43; CI 2.09 to 14.12; p = 0.001). An invasive strategy improved outcome for both diabetic and nondiabetic patients with unstable CAD. However, diabetes mellitus remained an independent and important risk factor for death and myocardial infarction in the invasive group. Thus, factors beyond the extent of flow-limiting coronary lesions are of considerable importance for outcome in diabetic subjects with unstable coronary syndromes.
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                Author and article information

                Journal
                Journal ID (publisher-id): CRD
                Journal ID (nlm-ta): Cardiology
                Journal ID (doi): 10.1159/issn.0008-6312
                Title: Cardiology
                Publisher: S. Karger AG
                ISSN (Print): 0008-6312
                ISSN (Electronic): 1421-9751
                Publication date Subscription-year: 2005
                Publication date (Print): June 2005
                Publication date (Electronic): 10 June 2005
                Volume: 103
                Issue: 4
                Pages: 189-195
                Affiliations
                aBMJ Heart Center, Bangalore, India; Departments of bClinical Physiology and cCardiology, Karolinska University Hospital at Huddinge, Stockholm, Sweden
                Article
                Publisher ID: 85126 Other ID: Cardiology 2005;103:189–195
                DOI: 10.1159/000085126
                PubMed ID: 15832025
                SO-VID: f4473c69-7ee8-4268-900b-2be367a3c46b
                Copyright © © 2005 S. Karger AG, Basel
                License:

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                History
                Date received : 20 July 2004
                Date accepted : 02 August 2004
                Page count
                Figures: 2, Tables: 2, References: 28, Pages: 7
                Categories
                Subject: General Cardiology

                ScienceOpen disciplines: General medicine,Neurology,Cardiovascular Medicine,Internal medicine,Nephrology
                Keywords: Type 2 diabetes,Myocardial velocity,Coronary artery disease,Dobutamine stress echocardiography
                Data availability:
                ScienceOpen disciplines: General medicine, Neurology, Cardiovascular Medicine, Internal medicine, Nephrology
                Keywords: Type 2 diabetes, Myocardial velocity, Coronary artery disease, Dobutamine stress echocardiography

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