BackgroundThe prognostic importance of carotid atherosclerosis in individuals with diabetes is unsettled. We aimed to evaluate the relationships between parameters of carotid atherosclerosis and the future occurrence of micro- and cardiovascular complications in individuals with type 2 diabetes.MethodsUltrasonographic parameters of carotid atherosclerosis, intima-media thickness (CIMT) and plaques, were measured at baseline in 478 participants who were followed-up for a median of 10.8 years. Multivariate Cox analysis was used to examine the associations between carotid parameters and the occurrence of microvascular (retinopathy, renal, and peripheral neuropathy) and cardiovascular complications (total cardiovascular events [CVEs] and cardiovascular mortality), and all-cause mortality. The improvement in risk stratification was assessed by using the C-statistic and the integrated discrimination improvement (IDI) index.ResultsDuring follow-up, 116 individuals had a CVE and 115 individuals died (56 from cardiovascular diseases); 131 newly-developed or worsened diabetic retinopathy, 156 achieved the renal composite outcome (94 newly developed microalbuminuria and 78 deteriorated renal function), and 83 newly-developed or worsened peripheral neuropathy. CIMT, either analysed as a continuous or as a categorical variable, and presence of plaques predicted CVEs occurrence and renal outcomes, but not mortality or other microvascular complications. Individuals with an increased CIMT and plaques had a 1.5- to 1.8-fold increased risk of CVEs and a 1.6-fold higher risk of renal outcome. CIMT and plaques modestly improved cardiovascular risk discrimination over classic risk factors, with IDIs ranging from 7.8 to 8.4%; but more markedly improved renal risk discrimination, with IDIs from 14.8 to 18.5%.ConclusionsCarotid atherosclerosis parameters predicted cardiovascular and renal outcomes, and improved renal risk stratification. Ultrasonographic carotid imaging may be useful in type 2 diabetes management.

The prognostic importances of on-treatment clinic and ambulatory blood pressure (BP) levels have never been investigated in individuals with resistant hypertension. We aimed to evaluate them for the occurrence of incident cardiovascular and mortality outcomes in a prospective cohort of 1726 patients with resistant hypertension. Clinic and ambulatory BPs were measured at baseline and serially during follow-up (analyzed as time-varying and as mean cumulative BPs) and also categorized as controlled/uncontrolled as defined by the traditional and new 2017 American College of Cardiology/American Heart Association criteria. Multivariate Cox analyses examined the associations between BP parameters and the occurrence of total cardiovascular events, major adverse cardiovascular events, and cardiovascular and all-cause mortalities. C statistics and the integrated discrimination improvement indexes evaluated the improvement in risk discrimination. Over a median follow-up of 8.3 years, 417 total cardiovascular events occurred (358 major adverse cardiovascular events) and 391 individuals died (233 cardiovascular deaths). All single systolic BP (SBP) parameters significantly predicted all outcomes, but the associations were stronger for ambulatory SBPs than for clinic SBPs and for on-treatment SBPs (particularly for mean cumulative) than for baseline SBPs, and both improved risk discrimination (with increases in C statistic of up to 0.021 and integrated discrimination improvements of up to 19.7%). These findings were consistent for diastolic BPs. Uncontrolled ambulatory BPs were associated with higher risks for all outcomes, whereas uncontrolled clinic BPs were not. In conclusion, mean cumulative ambulatory BPs during follow-up were the best prognostic markers of adverse cardiovascular outcomes and mortality in patients with resistant hypertension. Serial ambulatory BP monitoring shall be more widely used in resistant hypertension management.

Poor blood glucose and BP control and increased aortic stiffness were the main predictors of development or progression of DKD; ambulatory SBP was a better predictor than BP measured in the clinic. Ambulatory BP monitoring and assessment of aortic stiffness should be more widely used in clinical type 2 diabetes management.

No abstract

The prognostic importance of aortic stiffness in patients with resistant hypertension has never been investigated. We aimed to evaluate it for the occurrence of adverse cardiovascular outcomes and mortality in a prospective cohort of resistant hypertensive patients. Aortic stiffness was assessed by carotid-femoral pulse wave velocity (cf-PWV) at baseline in 891 resistant hypertensive patients who were followed-up for a median of 7.8 years. Multivariate Cox analysis examined the associations between cf-PWV and the occurrence of total cardiovascular events (CVE), major adverse CVEs, and cardiovascular and all-cause mortalities. The improvement in risk stratification was assessed by C statistics and the integrated discrimination improvement index. During follow-up, 138 patients had a CVE (123 major adverse CVE) and 142 patients died (91 from cardiovascular causes). The cf-PWV, analyzed either as a continuous or as a categorical variable, predicted all cardiovascular and mortality outcomes. Patients with increased aortic stiffness (cf-PWV ≥10 m/s after correction for the white-coat effect, or uncorrected directly measured ≥11 m/s) had a significant 2.2- to 2.6-fold increased risk of CVEs and mortality, after adjustments for other risk factors, including 24-hour ambulatory blood pressures and dipping patterns. Aortic stiffness significantly improved cardiovascular risk stratification, with integrated discrimination improvement indices ranging from 13% (for total CVEs) to 18% (for major adverse CVE). In conclusion, increased aortic stiffness predicts adverse cardiovascular outcomes and mortality and improves cardiovascular risk stratification in resistant hypertensive patients. cf-PWV measurement should be included into the routine clinical management of resistant hypertension.