Effect of glycemic control on markers of subclinical atherosclerosis in patients with type 2 diabetes mellitus: A review

Abstract

Cardiovascular disease is the predominant cause of death in type 2 diabetes mellitus (T2DM). Evidence suggests a strong association between duration and degree of hyperglycemia and vascular disease. However, large trials failed to show cardiovascular benefit after intensive glycemic control, especially in patients with longer diabetes duration. Atherosclerosis is a chronic and progressive disease, with a long asymptomatic phase. Subclinical atherosclerosis, which is impaired in T2DM, includes impaired vasodilation, increased coronary artery calcification (CAC), carotid intima media thickness, arterial stiffness, and reduced arterial elasticity. Each of these alterations is represented by a marker of subclinical atherosclerosis, offering a cost-effective alternative compared to classic cardiac imaging. Their additional use on top of traditional risk assessment strengthens the predictive risk for developing coronary artery disease (CAD). We, herein, review the existing literature on the effect of glycemic control on each of these markers separately. Effective glycemic control, especially in earlier stages of the disease, attenuates progression of structural markers like intima-media thickness and CAC. Functional markers are improved after use of newer anti-diabetic agents, such as incretin-based treatments or sodium-glucose co-transporter-2 inhibitors, especially in T2DM patients with shorter disease duration. Larger prospective trials are needed to enhance causal inferences of glycemic control on clinical endpoints of CAD.

Carotid pulse wave velocity by ultrafast ultrasound: A step forward for noninvasive assessment of diabetic patients

“…Another important comment is related to the duration of diabetes, with a mean of 4.9 years in all diabetic patients and significantly higher in patients with microangiopathy. This is particularly relevant because it has been previously demonstrated that a diabetes duration of more than 5 years can accelerate stiffness of the arteries and this can have an impact in the results obtained, because it was not included in the adjustment made in multivariable analysis 5 . In addition, nonlinearity of the wall's stress–strain relationship is more pronounced at high pressure, making ES more dependent on systolic pressure than BS on diastolic pressure and results should also be adjusted to consider blood pressure, despite similar mean values in both groups 2 .…”

“…This is particularly relevant because it has been previously demonstrated that a diabetes duration of more than 5 years can accelerate stiffness of the arteries and this can have an impact in the results obtained, because it was not included in the adjustment made in multivariable analysis. 5 In addition, nonlinearity of the wall's stressstrain relationship is more pronounced at high pressure, making ES more dependent on systolic pressure than BS on diastolic pressure and results should also be adjusted to consider blood pressure, despite similar mean values in both groups. 2 Finally, it has been demonstrated previously that in patients without evident macrovascular involvement, higher insulin levels remain a significant predictor of PWV even after adjustment for other well established risk factors for atherosclerosis.…”

“…Finally, it has been demonstrated previously that in patients without evident macrovascular involvement, higher insulin levels remain a significant predictor of PWV even after adjustment for other well established risk factors for atherosclerosis. Normalization of insulin resistance can have beneficial effects on PWV, as well as reduction of inflammation 5 . For that reason, the level of glycemic control is essential.…”

“…[2][3][4] In this issue of the journal, An et al evaluated carotid PWV by ultrafast ultrasound imaging in a group of diabetic patients (both with and without microangiopathy) and in a control group of 1544 healthy volunteers from the Multicenter Study Group on Normal Values of Color Pulse Wave Velocity in Chinese Han Adults study. 5 They studied 77 patients with Type 2 diabetes, of whom, 45 with microangiopathy.…”

“…Normalization of insulin resistance can have beneficial effects on PWV, as well as reduction of inflammation. 5 For that reason, the level of glycemic control is essential. The study population does not have an adequate blood glucose control, with very high levels of glycated hemoglobin (mean values >10%).…”