Adriana Coppola

Erectile dysfunction as a predictor of cardiovascular events and death in diabetic patients with angiographically proven asymptomatic coronary artery disease: a potential protective role for statins and 5-phosphodiesterase inhibitors.

OBJECTIVES We sought to investigate whether erectile dysfunction (ED) is a predictor of future cardiovascular events and death in diabetic patients with silent coronary artery disease (CAD) and whether there are predictors of cardiovascular events and death among CAD diabetic patients with ED. BACKGROUND Case-control studies showed that ED is associated with CAD in diabetic patients, but no prospective study is available. METHODS Type 2 diabetic men (n = 291) with silent CAD angiographically documented were recruited. Erectile dysfunction was assessed by the International Index Erectile Function-5 questionnaire. RESULTS During a follow-up period of 47.2 +/- 21.8 months (range 4 to 82 months), 49 patients experienced major adverse cardiac events (MACE). The difference in ED prevalence between patients with and those without MACE was significant (61.2% vs. 36.4%; p = 0.001). Cox regression analysis showed that ED predicted MACE (hazard ratio [HR] 2.1; 95% confidence interval [CI] 1.6 to 2.6; p < 0.001). Among patients with CAD and ED, the Kaplan-Meier method showed that the statin (Mantel log-rank test: 3.921; p = 0.048) and 5-phosphodiesterase (5-PDE) inhibitor use (Mantel log-rank test: 4.608; p = 0.032) were associated with a lower rate of MACE. Cox regression analysis showed that statin use (HR 0.66; 95% CI 0.46 to 0.97; p = 0.036) reduced MACE. Treatment with 5-PDE inhibitors did not enter the model, but its p value was very near to the significant level (HR 0.68; 95% CI 0.46 to 1.01; p = 0.056). CONCLUSIONS Our data first show that ED is a powerful predictor of cardiovascular morbidity and mortality in diabetic patients with silent CAD and that the treatment with statins and 5-PDE inhibitors might reduce the occurrence of MACE among CAD diabetic patients with ED.

The role of patient education in the prevention and management of type 2 diabetes: an overview

The management of type 2 diabetes mellitus includes ability and empowerment of the patient to change lifestyle, maintain an adequate diet and physical activity, manage the disease, and follow a specific program of periodic medical checks and education sessions. In addition, the patient should be able to correctly identify and adequately solve problems related to the disease and actively collaborate with the healthcare system. To obtain these goals, therapeutic patient education (TPE) is now considered a crucial element not only in the treatment but also in the prevention of type 2 diabetes. Several trials showed that TPE is able to improve clinical, lifestyle, and psycho-social outcomes. Nevertheless, studies have not clarified the ideal characteristics of a comprehensive patient education program in clinical practice. Other work is needed to answer open questions regarding the type of PTE (individual or group education), themes, frequency and number of education sessions, contact time between educator and patient, background of educators, use of new technologies, and barriers to self-management. The present review discusses these points on the basis of the most recent data of the literature.

Erectile Dysfunction and Coronary Artery Disease in Patients with Diabetes

The review deals with recent findings regarding the association between erectile dysfunction (ED) and coronary artery disease (CAD) in patients with diabetes. Indeed recent longitudinal studies have shown that ED is able to predict future cardiovascular events not only in nondiabetic but also in diabetic patients. In addition, in diabetic patients ED seems to be strongly associated with the presence of silent CAD. The mechanism by which ED is linked to CAD seems to be the presence of endothelial dysfunction. This pathophysiological mechanism has been extensively analysed. The possible clinical usefulness of ED to identify diabetic patients with silent CAD or at particularly high cardiovascular risk has been discussed in the review. At last, the review reports current guidelines and recent data available in the literature on the treatment of ED in patients with and without CAD and on the prevention of CAD in patients with ED.

Transcutaneous Oxygen Tension As a Potential Predictor of Cardiovascular Events in Type 2 Diabetes Comparison with ankle-brachial index

OBJECTIVE Transcutaneous oxygen tension (TcPO2) measures tissue perfusion and is important in the management of peripheral artery disease (PAD). Ankle brachial index (ABI) is used for the diagnosis of PAD and represents a predictor of major adverse cardiovascular events (MACE), even if in diabetes its diagnostic and predictive value seems to be reduced. No study has evaluated TcPO2 as a predictor of cardiovascular events. Aim of this longitudinal study was to assess whether TcPO2 is better than ABI at predicting MACE in type 2 diabetic patients. RESEARCH DESIGN AND METHODS Among 361 consecutive patients with apparently uncomplicated diabetes, 67 MACE occurred during a follow-up period of 45.8 ± 23.2 months. RESULTS The percentage of both subjects with low ABI (≤0.9) and subjects with low TcPO2 (≤46 mmHg as measured by a receiver operating characteristic curve) was significantly (<0.001) greater among patients with than among those without MACEs (ABI 64.2 vs. 40.8; TcPO2 58.2 vs. 34%). The Kaplan-Meier method showed that both low ABI (Mantel log-rank test, 4.087; P = 0.043) and low TcPO2 (Mantel log-rank test, 33.748; P > 0.0001) were associated with a higher rate of MACEs. Cox regression analysis showed that low TcPO2 (hazard ratio 1.78 [95% CI 1.44–2.23]; P < 0.001) was a significant predictor of MACE, while ABI did not enter the model. CONCLUSIONS This longitudinal study showed that TcPO2 may be a potential predictor of MACE among patients with uncomplicated type 2 diabetes and that its predictive value seems to be greater than that of ABI.

Structured therapeutic education in diabetes: is it time to re-write the chapter on the prevention of diabetic complications?

Diabetes mellitus is an epidemic, chronic condition characterized by increased morbidity, disability, and mortality because of frequent complications [1]. Complications mainly affect the heart, brain, limbs, eyes, nerves, and kidneys; in addition, most of the diabetic patients die from cardiovascular events [1]. A strict glycemic control, together with the appropriate management of any associated risk factor, such as hypertension, dyslipidemia, obesity, and thrombotic risk, can significantly decrease the complications of diabetes [2–4]. The tight control of diabetes and other risk factors is usually obtained by treatments with specific medications [2–4]. Therapeutic patient education (TPE) is considered a central element of the management of diabetes [1]. Many studies have shown that a structured TPE is able to determine a significant improvement in several clinical, lifestyle, and psycho-social outcomes in people suffering from diabetes [1]. However, there are a few data regarding the potential direct and indirect role that a structured TPE may have in the prevention of diabetic complications. An early study suggested that complications can occur about 4 times more frequently in diabetic people with no education [5]. In the present issue of Endocrine, Wong and colleagues have shown that a structured TPE, called patient empowerment programme (PEP), can determine a lower incidence rate of all-cause mortality and first macrovascular and microvascular events [6]. Nevertheless, an additional benefit was not observed in obese diabetic subjects who participated in a specific weight management program [6]. However, the present study has confirmed previous data on the effectiveness of PEP in decreasing complications and mortality in people with diabetes [7, 8]. In the recent long-term study with a follow-up of about 13 years, a structured personal care delivered by general practitioners to 1381 newly diagnosed type 2 diabetic patients was able to reduce mortality and morbidity in women but not in men [9]. These findings should open an active debate and stimulate new research on the decisive role that TPE can play in the prevention of diabetic complications and in the reduction of mortality. On the other hand, the American Association of Diabetes Educators has suggested that diabetes self-management education and support should be an essential tool to reduce the risks of complications and death [10]. In other words, a structured TPE should be always added to medications not only to better manage the disease but also to reduce its risks. The new findings suggest some questions: Could TPE improve the impressive results obtained with medications in the prevention of complications and reduction of mortality [2, 11–13]? Could TPE modify the results of the trials which failed to show significant differences in the outcomes between intervention and control group [14, 15]? A sure answer does not exist, but we cannot exclude that TPE could give an additional benefit. Indeed, a synergic effect between medications and TPE on the reduction of complications and death can be hypothesized for at least two reasons: (1) both can improve outcomes in an independent manner and therefore the positive effect may be additive; (2) TPE can optimize effects of medications because of an improvement in adherence [16]. However, if we assume that TPE can prevent the complications, other investigations should explain whether the effectiveness of TPE reported in the published studies [1, 6–9] can be further increased. At the moment, the ideal characteristics of TPE to give the best & Carmine Gazzaruso c.gazzaruso@gmail.com

Fat utilization and arterial hypertension in overweight/obese subjects.

BackgroundThe Respiratory Quotient is a parameter reflecting the utilization of the nutrients by a subject. It is associated with an high rate of subsequent weight gain and with the atherosclerosis. Subjects tending to burn less fat have an increased Respiratory Quotient. Aim of this study was to investigate on the relationship between the Respiratory Quotient and the cardiovascular risk factors.MethodsIn this cross-sectional study we enrolled 223 individuals of both sexes aged 45–75 ys that were weight stable, receiving a balanced diet, and not affected by debilitating disease or cardiovascular disease. The Respiratory Quotient was measured by Indirect Calorimetry. The measurement of the Blood Pressure was obtained by a mercury sphygmomanometer.ResultsWe enrolled 133 female and 90 male. Systolic blood pressure only was positively correlated to the Respiratory Quotient in univariate and multivariate regression analysis (p=0,017). The prevalence of hypertension was significatively different between the quartiles of the Respiratory Quotient, with the highest prevalence in the IV quartile (p=0,024).ConclusionHigh value of the Respiratory Quotient, an index of nutrients utilization, is associated to an high prevalence of Hypertension. It is possible that in the subjects with high Respiratory Quotient and high body mass index, the activation of the renin angiotensin system, in concert to the reduction of the utilization of the endogenous fat stores, could increase the risk of hypertension.

Microbiota and metabolic diseases

The microbiota is a complex ecosystem of microorganisms consisting of bacteria, viruses, protozoa, and fungi, living in different districts of the human body, such as the gastro-enteric tube, skin, mouth, respiratory system, and the vagina. Over 70% of the microbiota lives in the gastrointestinal tract in a mutually beneficial relationship with its host. The microbiota plays a major role in many metabolic functions, including modulation of glucose and lipid homeostasis, regulation of satiety, production of energy and vitamins. It exerts a role in the regulation of several biochemical and physiological mechanisms through the production of metabolites and substances. In addition, the microbiota has important anti-carcinogenetic and anti-inflammatory actions. There is growing evidence that any modification in the microbiota composition can lead to several diseases, including metabolic diseases, such as obesity and diabetes, and cardiovascular diseases. This is because alterations in the microbiota composition can cause insulin resistance, inflammation, vascular, and metabolic disorders. The causes of the microbiota alterations and the mechanisms by which microbiota modifications can act on the development of metabolic and cardiovascular diseases have been reported. Current and future preventive and therapeutic strategies to prevent these diseases by an adequate modulation of the microbiota have been also discussed.

Percutaneous transluminal angioplasty for critical limb ischemia in very elderly diabetic patients.

In diabetic subjects, new less invasive therapies for critical limb ischemia (CLI) are available to obtain limb salvage. One of these is the percutaneous transluminal angioplasty (PTA), a minor surgical intervention which allows obtaining an effective revascularization, avoiding the traditional major surgery and its post-operative complications. Our case report regards a 94-year-old woman with CLI due to critical obstruction (stage IV according to Leriche’s classification) of superficial femoral and popliteal arteries and infrapopliteal arteries that should have been treated by the left limb amputation considering her age, severe co-morbidities, and poor compliance. Instead of this quite common approach, our team treated the patient with PTA. This led to very good outcomes, above all in terms of pain control. PTA is able to avoid major surgery, lower intra and post-operative risks, reduce length of hospital stay, and preserve functional autonomy. Therefore, this procedure should be taken into account also for frail very elderly diabetic patients with peripheral artery disease (PAD).

Role of structured individual patient education in the prevention of vascular complications in newly diagnosed type 2 diabetes: the INdividual Therapeutic Education in Newly Diagnosed type 2 diabetes (INTEND) randomized controlled trial

ObjectiveRecent studies showed that a structured patient therapeutic education (PTE) may decrease both mortality and the development of diabetes complications. Nevertheless, no data are available in the literature on the impact of individual PTE on the complications in newly diagnosed type 2 diabetic patients. Aim of the present randomized controlled trial is to evaluate the impact of individual PTE on the occurrence of macrovascular complications in newly diagnosed type 2 diabetic patients when compared to usual care (UC) and group PTE.Design and methodsSix hundred newly diagnosed type 2 diabetic patients will be enrolled. The patients will be randomly assigned to one of these three groups: individual PTE, group PTE and UC. A comprehensive and complete PTE will be delivered to all the patients: PTE will include eleven themes. Primary composite endpoint of the study is occurrence of vascular complications, including cardiovascular death, non fatal coronary disease, non fatal stroke, peripheral artery disease. Secondary endpoints are: foot ulcers, amputations, sexual dysfunction, quality of life, microvascular complications, bone health, intensification of diabetes and hypertension therapy.Results and ConclusionsThe present trial can give precious information on the features for the most effective PTE.

Erectile dysfunction as a predictor of asymptomatic coronary artery disease in elderly men with type 2 diabetes.

Erectile dysfunction (ED) and coronary artery disease (CAD) are closely linked, as both conditions share the same cardiovascular risk factors.[1] Indeed, these risk factors can determine endothelial dysfunction that represents the common underlying mechanism of both ED and CAD.[1],[2] The prevalence of ED is about three-fold higher among diabetic patients than in the general population[1],[3] and a higher prevalence of CAD has been observed in people with diabetes when compared to non-diabetic subjects.[3] Some studies showed that ED can be a powerful marker of silent CAD[4],[5] and a strong predictor of cardiovascular events in apparently uncomplicated type 2 diabetic patients.[6],[7] Therefore ED is now considered as a sentinel symptom of silent CAD, as ED often precedes the onset of myocardial ischemia itself by many years.[2],[8],[9] Silent CAD can worse the prognosis of diabetic patients and this suggests to identify diabetic patients at higher risk for silent CAD in order to early and effectively treat them.[10]–[13] Current guidelines suggest the screening for CAD when diabetic patients have some clinical conditions or at least two cardiovascular risk factors in addition to diabetes.[14] Unfortunately several studies showed that about 40% of diabetic patients with silent CAD can be missed on the basis of the current guidelines,[15],[16] but ED may interestingly improve sensitivity and specificity of guidelines for CAD screening when it is added to the common cardiovascular risk factors.[16] ED is the most frequently diagnosed sexual dysfunction in the older male population, especially after 70 years, even if it is often underreported and under-diagnosed in the elderly.[17] In addition, CAD prevalence increases with age. So it may be of great interest to understand whether ED remains a risk factor for silent CAD in elderly diabetic patients. To the best of our knowledge, no study has specifically investigated the role of ED as a predictor of silent CAD in type 2 diabetic elderly subjects. Therefore, the aim of the present study was to evaluate whether ED may be a marker of asymptomatic CAD also in elderly patients with diabetes.