Association Between Silent Coronary Artery Disease, Diabetes, and Autonomic Neuropathy: Fact or Fallacy?

Airaksinen, Juhani; Koistinen, M. Juhani

doi:10.2337/diacare.15.2.288

Cited by 47 publications

(25 citation statements)

References 34 publications

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“…On the contrary, the role of autonomic neuropathy as predictor of silent CAD remains unclear (8,31). Indeed, although some studies documented that autonomic neuropathy involving the cardiac system may be the cause of silent CAD in diabetic patients, others did not (31). In our survey, a significant association between impairment of autonomic function and angiographically documented asymptomatic CAD was not found.…”

Section: Methodological Considerationscontrasting

confidence: 40%

“…However, in our survey, the CAD group showed HDL levels significantly lower than the NO CAD group in univariate analysis; cholesterol was higher in the CAD group, but the difference was not statistically significant. On the contrary, the role of autonomic neuropathy as predictor of silent CAD remains unclear (8,31). Indeed, although some studies documented that autonomic neuropathy involving the cardiac system may be the cause of silent CAD in diabetic patients, others did not (31).…”

Section: Methodological Considerationsmentioning

confidence: 99%

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Assessment of Asymptomatic Coronary Artery Disease in Apparently Uncomplicated Type 2 Diabetic Patients

Gazzaruso

Garzaniti²,

Giordanetti³

et al. 2002

Diabetes Care

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OBJECTIVE -In patients with uncomplicated diabetes, there is low probability of finding significant coronary artery disease (CAD) by noninvasive tests. Therefore, screening for its presence is not justified, and it is important to find reliable predictors of silent CAD to identify patients with uncomplicated diabetes for further screening. The relationship between lipoprotein(a) [Lp(a)], apolipoprotein(a) [apo(a)] polymorphism, and silent CAD has never been studied. We investigated the association of Lp(a) and apo(a) polymorphism with angiographically documented asymptomatic CAD in type 2 diabetic patients without evident complications. RESEARCH DESIGN AND METHODS-A total of 1,323 diabetic patients without any clinical and electrocardiographic evidence of CAD were evaluated. Of 121 patients with highly positive results of exercise electrocardiography (ECG) (n ϭ 30) or positive results on exercise thallium scintigraphy (n ϭ 91), 103 subjects showed angiographically documented CAD (CAD group). Of 1,106 patients with negative results on exercise ECG, 103 subjects without CAD (NO CAD group) were selected and matched by age, gender, and duration of diabetes to patients in the CAD group. In patients in the NO CAD group, results of exercise ECG, 48-h ambulatory ECG, and stress echocardiography were negative for CAD.RESULTS -The CAD group had higher Lp(a) levels (21.7 Ϯ 17.7 vs. 15.2 Ϯ 19.0 mg/dl; P ϭ 0.0093) than the NO CAD group, and a percentage of subjects had at least one small apo(a) isoform (68.9 vs. 29.1%; P ϭ 0.0000) higher than the NO CAD group. Logistic regression analysis showed that apo(a) phenotypes (odds ratio [OR] 8.13, 95% CI 3.65-21.23), microalbuminuria (5.38, 2.44 -11.88), smoking (2.72, 1.31-5.64), and Lp(a) levels (2.41, 1.15-5.03) were predictors of asymptomatic CAD. CONCLUSIONS -Our investigation reports the first evidence of an independent association of Lp(a) and apo(a) polymorphism with asymptomatic CAD. This suggests that Lp(a) levels and apo(a) phenotypes could be used together with other risk factors as markers of asymptomatic CAD in patients with diabetes. Diabetes Care 25:1418 -1424, 2002D iabetes is associated with a more than threefold-increased risk of coronary artery disease (CAD) (1). In patients with diabetes, CAD is often asymptomatic (2-4). Asymptomatic CAD is a strong predictor of future coronary events and early death, especially in patients with diabetes (5,6). Early identification of diabetic patients with silent CAD can allow reduction of mortality and morbidity for cardiovascular events (7,8). In patients with uncomplicated diabetes, there is low probability of finding significant CAD by noninvasive tests. Therefore, screening for its presence is not justified (2), and it is important to find reliable predictors of silent CAD to identify patients with uncomplicated diabetes for further screening.Lipoprotein(a) [Lp(a)] is a powerful risk factor for CAD (9). Recent studies report that the polymorphism of the specific apolipoprotein of Lp(a), called apolipoprotein(a) [apo(a)], ...

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Section: Methodological Considerationscontrasting

confidence: 40%

Section: Methodological Considerationsmentioning

confidence: 99%

Assessment of Asymptomatic Coronary Artery Disease in Apparently Uncomplicated Type 2 Diabetic Patients

Gazzaruso

Garzaniti²,

Giordanetti³

et al. 2002

Diabetes Care

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“…Many subjects had clinical features (that were probably underestimated) suggesting autonomic neuropathy, and most patients had significant hypoglycemia unawareness, both of which could predispose patients to asymptomatic CAD (16). Compared with age-and duration- ESTϩ 4 1 5 ESTϪ 19 29 48 Total 23 30 53 MPIϩ 1 2 3 MPIϪ 22 28 50 Total 23 30 matched type 1 diabetes control subjects, ITX candidates have more hypoglycemia (10) but lower blood glucose levels (17), which may lower the risk of developing CAD.…”

Section: Prediction Of a Low-risk Subgroupmentioning

confidence: 99%

Coronary Artery Disease Is Common in Nonuremic, Asymptomatic Type 1 Diabetic Islet Transplant Candidates

Senior

Welsh²,

McDonald³

et al. 2005

Diabetes Care

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OBJECTIVE -Coronary artery disease (CAD) is the most common cause of death in patients with type 1 diabetes. Asymptomatic CAD is common in uremic diabetic patients, but its prevalence in nonuremic type 1 diabetic patients is unknown. The prevalence of CAD was determined by coronary angiography and the performance of noninvasive cardiac investigation evaluated in type 1 diabetic islet transplant (ITX) candidates with preserved renal function. RESEARCH DESIGN AND METHODS-A total of 60 consecutive type 1 diabetic ITX candidates (average age 46 years [mean 24 -64], 23 men, and 47% ever smokers) underwent coronary angiography, electrocardiographic stress testing (EST), and myocardial perfusion imaging (MPI) in a prospective cohort study. CAD was indicated on angiography by the presence of stenoses Ͼ50%. Models to predict CAD were examined by logistic regression.RESULTS -Most subjects (53 of 60) had no history or symptoms of CAD; 23 (43%) of these asymptomatic subjects had stenoses Ͼ50%. CAD was associated with age, duration of diabetes, hypertension, and smoking. Although specific, EST and MPI were not sensitive as predictors of CAD on angiography (specificity 0.97 and 0.93, sensitivity 0.17 and 0.04, respectively) but helped identify two of three subjects requiring revascularization. EST and MPI did not enhance logistic regression models. A clinical algorithm to identify low-risk subjects who may not require angiography was highly sensitive but was applicable only to a minority (n ϭ 8, sensitivity 1.0, specificity 0.27, negative predictive value 1.0).CONCLUSIONS -Nonuremic type 1 diabetic patients with hypoglycemic unawareness and/or metabolic lability referred for ITX are at high risk for asymptomatic CAD despite negative noninvasive investigations. Aggressive management of cardiovascular risk factors and further investigation into optimal cardiac risk stratification in type 1 diabetes are warranted. Diabetes Care 28:866 -872, 2005T ype 1 diabetes is associated with a more than threefold increase in mortality compared with that in the general population, mainly due to cardiovascular disease (1). Clinical assessment and management of this high-risk population are challenging because they frequently have multiple cardiovascular risk factors, suffer from comorbid diseases, and may lack typical symptoms of ischemia (silent myocardial ischemia and infarction).Islet transplantation (ITX) can cure hypoglycemia and stabilize glycemia and may be indicated for type 1 diabetic patients with severe hypoglycemia (usually with hypoglycemia unawareness) and metabolic lability despite optimal therapy (2). The nephrotoxicity of immunosuppressants excludes those with significant renal impairment. Most ITX candidates have long-standing diabetes and many have neuropathy. Diabetes per se, a long duration of diabetes (3), and autonomic neuropathy (4) are risk factors for coronary artery disease (CAD), which may be asymptomatic (5-7). Furthermore, the long-term impact of ITX on CAD is unknown.Current data indicating a high prevalence of ...

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“…Cardiac autonomic neuropathy has been suggested as a predictor of silent myocardial ischemia [51] yet the relationship between silent CAD and autonomic neuropathy has not been clearly established [52]. Indeed, although some studies documented that autonomic neuropathy involving the cardiac system may be the cause of silent CAD in diabetic patients, others have not [53]. There are other risk factors (indicators) reported to be associated with silent CAD, such as lipoprotein a concentration, apo(a) polymorphism, and homocysteine levels [54], but larger studies are needed to confirm these associations.…”

Section: Conclusion and Discussionmentioning

confidence: 99%

The Association of Silent Coronary Artery Disease and Metabolic Syndrome in Chinese with Type 2 Diabetes Mellitus

Tsai¹,

Chang²,

Chung³

et al. 2004

Rev Diab Stud

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■ AbstractOBJECTIVES: Cardiovascular diseases account for approximately 75% of the deaths that occur in patients with diabetes. Because the clinical signs of coronary artery disease (CAD) in diabetic patients are hard to detect and routine screening is costly, it would be of great benefit to try to either prevent CAD from occurring or to detect it early and provide optimal care. Therefore, we analyzed the risk factors that might predict CAD in type 2 diabetes mellitus (T2DM) patients with no classical cardiac ischemic symptoms. METHODS: Using a resting 12-lead ECG, exercise treadmill test, or thallium myocardial scintigraphy with exercise testing and dipyridamole injection, we screened diabetic patients already enrolled in a disease management program for possible CAD. We used diagnostic coronary angiography to confirm its presence. The definition and criteria of metabolic syndrome we used were modified from those outlined by the WHO classification and criteria of NCEP-ATP III. RESULTS: A total of 850 T2DM patients without clinical and electrocardiographic evidence of CAD were studied. Three hundred and sixty-eight asymptomatic patients with normal resting ECG were examined by exercise ECG test or thallium scintigraphy examination. Sixty patients considered to have a strong positive test or significant thallium myocardial ischemia received a diagnostic coronary angiography. Fifty-one were found to have significant coronary artery stenosis; 9 showed no significant ischemic lesion. While gender, patients' age, known diabetes duration, serum uric acid level, smoking status, and the presence of WHOmetabolic syndrome defined hypertension and nephropathy were associated with silent CAD, logistic regression analysis found that the only predictor of silent CAD was the presence of nephropathy. The components of NCEP-ATP IIImetabolic syndrome were not found to be associated with silent CAD. CONCLUSIONS: A considerable proportion of T2DM patients have silent CAD. A diabetic patient with incipient or overt nephropathy should be examined for the presence of CAD. The definition of metabolic syndrome may be modified for early detection of CAD in patients with T2DM.

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Association Between Silent Coronary Artery Disease, Diabetes, and Autonomic Neuropathy: Fact or Fallacy?

Cited by 47 publications

References 34 publications

Assessment of Asymptomatic Coronary Artery Disease in Apparently Uncomplicated Type 2 Diabetic Patients

Assessment of Asymptomatic Coronary Artery Disease in Apparently Uncomplicated Type 2 Diabetic Patients

Coronary Artery Disease Is Common in Nonuremic, Asymptomatic Type 1 Diabetic Islet Transplant Candidates

The Association of Silent Coronary Artery Disease and Metabolic Syndrome in Chinese with Type 2 Diabetes Mellitus

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