Este remodelado cardiaco incluye alteraciones en la vasculatura coronaria, apoptosis celular y fibrosis, que favorecen el desarrollo de eventos cardiovasculares posteriores 6. Se trata, por lo tanto, de un complejo fenotipo predictor de eventos cardiovasculares y no de una simple respuesta adaptativa. Left ventricular hypertrophy is associated with worse survival independent of ventricular function and number of coronary arteries severely narrowed. Am J Cardiol.
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Identification of predictors of increased cardiovascular risk in diabetic patients is of particular interest in order to establish more effective preventive strategies. While it is accepted that diabetic microangiopathy is mainly associated with hyperglycemia, the role of factors associated with the disease is less well understood. The principal aim of this project, which forms part of the ESODIAH study observational study in diabetic patients with hypercholesterolemia , was to assess predictors of cardiovascular disease in a sample of Spanish diabetic patients with hypercholesterolemia over a 2-year follow-up period.
The secondary aims were to describe the incidence of cardiovascular disease in that group and the prevalence of cardiovascular risk factors, along with the level of management of those factors. These lipid concentrations must have been confirmed 3 months after having received dietary advice.
In all patients, clinical assessment and laboratory analyses were performed at the baseline visit visit 1 and subsequently every 4 months over a period of 2 years visits 2 to 7 ; patients completed the follow-up period Table 1. Ischemic manifestations of cardiovascular disease such as angina, symptomatic or silent electrocardiographic findings myocardial infarction, transient ischemic attack, stroke, and peripheral artery disease, which included intermittent claudication and revascularization or amputation procedures, were assessed.
Recording of these manifestations included medical visits and review of patient charts. For recording of physical activity, patients were considered sedentary if they walked for less than 20 minutes per day, moderately active if they walked for 20 to 60 minutes per day, and active if they walked for more than 60 minutes per day or undertook other sporting activities.
The other variables collected in the study were as follows: a history of diabetes, hypercholesterolemia, or heart disease in first-degree relatives; b date of appearance of diabetes and diagnosis of hypercholesterolemia; c retinopathy; d diabetic nephropathy; e anthropometric variables weight, height, waist circumference, and hip circumference , electrocardiogram, and resting systolic and diastolic blood pressure; and f drug treatment at the beginning of the study.
In terms of drug treatment at the beginning of the study, Antihypertensive treatment was used in Oral antidiabetic treatment was used by The study was approved by the ethics committee of Bellvitge University Hospital and conducted in accordance with the Declaration of Helsinki.
Excretion of albumin in urine was measured in hour urine samples, or when such samples were unavailable, recent urine. Samples with positive findings in urine culture or abnormal urine sedimentation were excluded. An independent company was used to manage the data, which was subject to quality control checks. Bivariate Kaplan-Meier survival analysis was used to select variables for inclusion in a Cox regression model. A P value less than. Statistical analyses were performed using the statistical package SPSS Table 1 shows the baseline patient characteristics of the study group.
Of all the patients included in the study, Nine of the 81 ischemic episodes were fatal, 8 due to ischemic heart disease and 1 due to stroke. Three patients who did not present an ischemic event died as a result of noncardiovascular disease.
Table 2 shows the baseline characteristics that were significantly different between patients who presented clinical signs of cardiovascular disease during follow-up and those who did not.
The former included a higher proportion of individuals aged more than 65 years, with poor management of blood sugar, and the majority of the individuals were sedentary. Likewise, patients who developed ischemic episodes more often had a history of cardiovascular disease and had a higher prevalence of retinopathy and abnormal albuminuria. Episodes of cardiovascular disease were more frequent in patients with a history of ischemia than in those without 58 out of [ Table 4 shows the significant results obtained in the bivariate Kaplan-Meier analysis of time free of signs of cardiovascular disease.
A history of cardiovascular disease or microangiopathy retinopathy or abnormally high albuminuria was associated with a shorter period free of disease. Poor control of blood sugar levels, obesity, sedentary lifestyle, hypercholesterolemia, hypertriglyceridemia, increased ratio of total cholesterol to HDL-C, and elevated non-HDL cholesterol during follow-up were also associated with reduced survival free of cardiovascular disease.
Cox regression analysis was performed with inclusion of those variables that had previously shown significant differences in the Kaplan-Meier analysis.
This prospective study performed in a group of Spanish diabetic patients with hypercholesterolemia shows that cardiovascular risk, that is, the risk of coronary heart disease, stroke, or peripheral artery disease, is strongly and independently associated with a history of ischemic disease, elevated LDL-C, poor management of hyperglycemia, and obesity.
These data show that, as in other geographic regions, 16 the control of atherogenic factors in diabetic patients is not strictly achieved and highlight the need for improved strategies to achieve the therapeutic targets recommended by the relevant scientific societies and expert panels. Prior history of ischemic heart disease was the strongest predictor of cardiovascular disease and was associated with a 4 times greater risk of presenting new ischemic episodes.
Cerebrovascular disease and peripheral artery disease were also associated with increased cardiovascular risk, although to a lesser degree. In agreement with our results, other studies undertaken in diabetic patients with a history of ischemia also showed increased morbidity and mortality.
A consensus is yet to be achieved on whether diabetic patients present an increased risk compared with ischemic patients who are not diabetic. Taking into account the data from various observational and follow-up studies performed in a Finnish population, 21 the guidelines of the NCEP indicate that the cardiovascular risk in patients with type-2 diabetes is equivalent to that of patients with ischemic heart disease, 15 and our results concur with that definition.
However, in another study performed in a Scottish population, the patients with infarction presented a greater risk than diabetic patients, 22 a finding that was attributed to a longer period with diabetes than that observed in the patients from the Finnish study. Resolving this apparent discrepancy is not easy and requires other prospective studies to be undertaken in patients recently diagnosed with type-2 diabetes and myocardial infarction, with adjustment for age and atherogenic factors.
Prior history of microangiopathy, including diabetic retinopathy or pathologic albuminuria, was more common in patients who presented an episode of cardiovascular disease during follow-up. However, microangiopathy was not found to be an independent predictor in the multivariate analysis, in which the remaining cardiovascular risk factors were included.
This lack of predictive power has been observed in other studies 23 and may be attributable to the strong association between other atherogenic factors, particularly hyperglycemia, and microangiopathy, a finding that would indicate that it is more a consequence than a cause of arterial disease. There is increasing evidence, based on pathophysiology and epidemiology as well as clinical trials, indicating that hyperglycemia plays an important role in the origin of cardiovascular disease in diabetic patients.
On the other hand, it has been observed that management of hyperglycemia, expressed by a reduction in HbA 1C levels, reduces cardiovascular risk.
LDL-C was the lipid variable that showed the greatest predictive power for cardiovascular disease. The predictive power for cardiovascular disease of the triglycerides is disputed, probably as a result of the high within-individual variability and the strong inverse correlation with HDL-C concentration. Two recent studies highlighted the role of the ratio of total cholesterol to HDL-C and of non-HDL cholesterol in the prediction of cardiovascular disease in the diabetic population, 30,31 particularly in patients with hypertriglyceridemia.
The third report of the NCEP recognized the significance of non-HDL-C in diabetes and considered it to be a secondary therapeutic target 15 ; nevertheless, LDL-C is defined as the main therapeutic target in the management of diabetic dyslipidemia. Increasing amounts of data have demonstrated the benefit of reducing LDL-C through the use of statins in the diabetic population, 29,32,33 even in those individuals with cholesterol levels that are slightly elevated or fall within the reference values.
These findings have led to treatment with statins being recommended in all diabetic patients with increased cardiovascular risk, even in the absence of elevated concentrations of cholesterol. Obesity is a risk factor for the presentation of diabetes and increases the severity of the disease in individuals who are already diabetic, while weight loss improves the management of hyperglycemia. The diabetic population studied presented a high level of short-term cardiovascular morbidity and mortality.
The main predictors of presenting the disease were history of ischemia, particularly in the coronary arteries, and excess LDL-C. The high prevalence and inadequate control of hypercholesterolemia and atherogenic factors highlight the need to improve measures to prevent cardiovascular disease in this population.
Correspondence: Dr. Servicio de Medicina Interna. Hospital Universitari de Bellvitge. E-mail: xpinto csub. Received March 21, Accepted for publication November 2, Factores predictivos del riesgo de enfermedad cardiovascular en los pacientes con diabetes tipo 2 e hipercolesterolemia.
Descargar PDF. TABLE 1. TABLE 2. TABLE 3. TABLE 4. Palabras clave:. Diabetes mellitus. Introduction and objectives. We investigated the pattern of cardiovascular disease and the factors that predict such disease in outpatients with type-2 diabetes and hypercholesterolemia.
This prospective open observational study included outpatients of both sexes mean age 62  years with type-2 diabetes and hypercholesterolemia. Clinical manifestations of cardiovascular disease e. Overall, patients completed follow-up. During follow-up, 81 patients 9. Cardiovascular events were more frequent in patients with a history of an ischemic condition than in those without: 58 of The incidence of cardiovascular disease in this southern European population of patients with type-2 diabetes and hypercholesterolemia was high.
A history of an ischemic condition and a high LDL-cholesterol level during follow-up were the strongest predictors of cardiovascular disease.. Texto completo. Global burden of diabetes prevalence, numerical estimates, and projections.. Diabetes Care, 21 , pp. Diabetes y enfermedad cardiovascular. Una mirada hacia la nueva epidemia del siglo XXI.. Rev Esp Cardiol, 55 , pp. The independent effect of type 2 diabetes mellitus on ischaemic heart disease, stroke, and death. A population-based study of men and women with 20 years of follow-up..
Arch Int Med, , pp. Obesity Res, 10 , pp. Diabetes, other risk factors, and yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial.. Diabetes Care, 16 , pp. Interplay of diabetes and coronary heart disease on cardiovascular mortality.. Heart, 90 , pp. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes.. N Engl J Med, , pp. Implications of the United kingdom prospective diabetes study. Diabetes Care.
The effect of interventions to prevent cardiovascular disease in patients with type 2 diabetes mellitus.. Am J Med, , pp.
Prediabetes in Colombia: Expert Consensus.
Identification of predictors of increased cardiovascular risk in diabetic patients is of particular interest in order to establish more effective preventive strategies. While it is accepted that diabetic microangiopathy is mainly associated with hyperglycemia, the role of factors associated with the disease is less well understood. The principal aim of this project, which forms part of the ESODIAH study observational study in diabetic patients with hypercholesterolemia , was to assess predictors of cardiovascular disease in a sample of Spanish diabetic patients with hypercholesterolemia over a 2-year follow-up period. The secondary aims were to describe the incidence of cardiovascular disease in that group and the prevalence of cardiovascular risk factors, along with the level of management of those factors.
Godinez Gutierrez, Sergio Arturo
LIMA 1. Type 2 diabetes mellitus T2DM is increasing in prevalence worldwide, and those non-diagnosed or misdiagnosed comprise a significant group compared to those diagnosed. Accumulated scientific evidence indicate that the current diagnostic markers fasting glycemia, 2h glycemia after an oral glucose load and HbA1c are indeed late diagnostic criteria when considering the incidence of diabetes-related complications and comorbidities, which are also at high risk in some groups among normoglycemic individuals. Insulin resistance and hyperhormonemia insulin, amylin, glucagon are non-disputable hallmarks of T2DM, which already takes place among these normoglycemic, otherwise health subjects, characterizing a state of subclinical diabetes.