M.T. Nguyen

A large proportion of prediabetes and diabetes goes undiagnosed when only fasting plasma glucose and/or HbA1c are measured in overweight or obese patients

AIMS The purposes of the study were to determine the prevalence of unrecognized dysglycaemia in overweight (body mass index [BMI] 25-29.9 kg/m(2)) and obese (BMI ≥30 kg/m(2)) patients, to assess the extent to which measures of fasting plasma glucose (FPG) and/or HbA(1c), compared with oral glucose tolerance tests (OGTTs), misdiagnose dysglycaemia, and to determine the factors associated with an isolated abnormal post-OGTT glucose value. METHODS OGTT was performed and HbA(1c) was measured in 1283 inpatients with BMI scores ≥ 25 kg/m(2) and no history of dysglycaemia. RESULTS Prediabetes was found in 257 (20.0%) subjects (197 with impaired glucose tolerance, 29 with impaired fasting glucose, 31 with both) and diabetes in 77 (6.0%), including 22 with FPG ≥ 7 mmol/L (WHO definition). The sensitivity of FPG >6 mmol/L, FPG >5.5 mmol/L, HbA(1c) ≥ 6% and the recommendations of the French National Agency of Accreditation and Evaluation in Health Care (ANAES) to identify patients with abnormal OGTTs was 29.9, 41.3, 36.8 and 15.6%, respectively. The factors that were independently associated with diabetes in obese women with FPG <7 mmol/L were age (per 10 years: OR 1.54 [1.00-2.11]; P=0.049) and FPG (OR 6.1 [1.4-30.0]; P=0.014), whereas age (OR 1.26 [1.09-1.44]; P<0.01) and waist circumference (per 10 cm: OR 1.17 [1.01-1.33]; P<0.05) were independently associated with dysglycaemia in obese women with FPG <6.1 mmol/L. CONCLUSION In overweight and obese patients: dysglycaemia is commonly seen; FPG alone, compared with OGTT, failed to diagnose 70% of dysglycaemia cases; FPG >5.5 mmol/L and HbA(1c) ≥ 6.0% are not necessarily substitutes for OGTT; and older age and larger waist circumference should be used to select those obese women with normal FPG who might further benefit from OGTTs to diagnose dysglycaemia.

What would be the outcome if the American Diabetes Association recommendations of 2010 had been followed in our pratice in 1998–2006?

Diabet. Med. 28, 567–574 (2011)

Transthoracic echocardiographic abnormalities in asymptomatic diabetic patients: association with microalbuminuria and silent coronary artery disease.

AIMS This study aimed to assess, on routine echocardiography, cardiac left ventricular (LV) disorders, their determinants and their role in the screening process of silent myocardial ischaemia (SMI) in asymptomatic diabetic patients. METHODS A total of 586 asymptomatic diabetic patients with one or more additional cardiovascular risk factors, but no history of heart failure or myocardial infarction, prospectively underwent rest echocardiography and myocardial scintigraphy. Those with SMI (abnormal scintigraphy) were subsequently screened for angiographic coronary artery disease (CAD). RESULTS LV hypertrophy, LV dilatation, systolic dysfunction and hypokinesia were found in 33.6, 8.6, 3.2 and 6.1%, respectively, of the study population. SMI was found in 156 (26.6%) patients, 55 of whom had silent CAD. On multivariate analysis, age (OR: 1.03 [1.00-1.05], P=0.02), microalbuminuria (OR: 2.2 [1.4-3.2], P<0.0001) and silent CAD (OR: 2.4 [1.3-4.6], P=0.007) were predictive of LV hypertrophy. Creatinine clearance (OR: 0.97 [0.96-0.99], P=0.002) and silent CAD (OR: 3.7 [1.3-10.0]) were associated with LV dilatation. LV systolic dysfunction was associated with microalbuminuria (OR: 3.8 [1.3-11.4], P=0.02) and silent CAD (OR: 3.8 [1.1-12.6], P=0.03). Hypokinesia was associated with retinopathy (OR: 2.4 [1.1-5.4], P=0.04), microalbuminuria (OR: 2.3 [1.1-5.0], P=0.04) and LV dilatation (OR: 3.0 [1.1-8.1], P=0.03). In patients with SMI, the positive predictive value of LV hypertrophy associated with another echocardiographic abnormality (n=19) for CAD was 63.2%. CONCLUSION LV hypertrophy was found in one-third of asymptomatic diabetic patients, while LV dilatation, systolic dysfunction or hypokinesia was seen in<10%. The main predictors of LV abnormalities were microalbuminuria and silent CAD. The presence of LV hypertrophy with another abnormality should raise the possibility of the presence of silent CAD.

The report of male gender and retinopathy status improves the current consensus guidelines for the screening of myocardial ischemia in asymptomatic type 2 diabetic patients

BACKGROUND AND AIMS American Diabetes Association (ADA), French-speaking Societies for diabetes & cardiology (ALFEDIAM-SFC) and Cardiac Radionuclide Imaging (CRI) have proposed guidelines for the screening of silent myocardial ischemia (SMI). The aim of the study was to evaluate their diagnostic values and how to improve them. METHODS AND RESULTS 731 consecutive type 2 diabetic patients with ≥1 additional risk factor were screened between 1992 and 2006 for SMI by stress myocardial scintigraphy and for silent coronary artery disease (CAD) by coronary angiography. A total of 215 (29.4%) patients had SMI, and 79 of them had CAD. ADA (Odds Ratio 1.7 [95% Confidence Interval: 1.2-2.5]; p < 0.05), ALFEDIAM-SFC (OR 1.5 [1.0-2.5], p < 0.05) and CRI criteria (OR 2.0 [1.4-2.8], p < 0.01) predicted SMI. Considering the presence of male gender and retinopathy added to the prediction of SMI allowed by ADA criteria (c statistic: area under the curve AROC 0.651 [0.605-0.697] versus 0.582 [0.534-0.630]), p < 0.01 and ALFEDIAM-SFC criteria (AROC 0.672 [0.620-0.719] versus 0.620 [0.571-0.670], p < 0.05). CRI prediction of SMI was improved by considering the presence of macroproteinuria and retinopathy (AROC 0.621 [0.575-0.667] versus 0.594 [0.548-0.641], p < 0.01). Severe retinopathy (OR 3.4 [1.2-9.4], p < 0.05), smoking habits (OR 2.1 [1.1-4.2], p < 0.05) and triglyceride levels (OR 1.3 [1.0-1.6], p < 0.05) were independent predictors of CAD in the patients with SMI. CONCLUSION Current guidelines criteria are able to predict SMI but prediction may be improved by considering male gender and the presence of retinopathy. CAD is more frequent in the patients with SMI who are current smokers, have severe retinopathy and higher triglyceride levels.

Haemoglobin glycation may partly explain the discordance between HbA1c measurement and oral glucose tolerance test to diagnose dysglycaemia in overweight/obese subjects

AIM This study assessed whether the poor correlation between HbA1c and oral glucose tolerance test (OGTT) for dysglycaemia diagnosis may be explained by haemoglobin glycation (HbG). METHODS A total of 1033 consecutive overweight or obese patients with no known diabetes underwent OGTT and measurement of HbA1c to diagnose diabetes and dysglycaemia (American Diabetes Association criteria). For each OGTT result category, low, medium and high HbG was defined according to the mean HbA1c/fructosamine ratio and mean fructosamine. High HbG was defined as values greater than mean values in each OGTT category for both HbA1c/fructosamine ratio and fructosamine levels, and low HbG was defined as lower values of both. The remaining patients were considered medium HbG. RESULTS Based on OGTT and HbA1c values, 267 (25.8%) and 443 (42.8%) patients had intermediate hyperglycaemia, and 66 (6.4%) and 95 (9.2%) patients had diabetes, respectively. The results were discordant for intermediate hyperglycaemia or diabetes diagnosis in 41.7% and for diabetes diagnosis in 10.0% of the patients. The proportion of patients with HbA1c≥6.5%, but without OGTT-diagnosed diabetes, was 0%, 3.8% and 32.8% in the low-HbG, medium-HbG and high-HbG groups, respectively. In contrast, the proportion of patients with HbA1c<5.7%, but with an abnormal OGTT, was 30.4%, 11.1% and 0%, respectively. The AUROC of HbA1c to detect OGTT-diagnosed diabetes was better in the medium-HbG group [0.874 (0.816-0.931)] than in those with low or high HbG [0.628 (0.489-0.768); P<0.01]. Only age was independently associated with high-HbG status [10-year OR: 1.3 (1.1-1.5); P<0.0001]. CONCLUSION Haemoglobin glycation may explain many of the discordant results between HbA1c and OGTT when used for dysglycaemia diagnosis.

Noninvasive study of coronary microcirculation response to a cold pressor test

The aims of this study were to noninvasively (i) assess the coronary microcirculation changes in response to a cold pressor test (CPT) in control subjects, nondiabetic obese patients and patients with type 2 diabetes and (ii) investigate the response of the coronary microcirculation in patients with diabetes according to the presence or the absence of silent myocardial ischaemia (SMI), asymptomatic coronary stenosis (CS) and left ventricle hypertrophy (LVH).

P 15: Low serum levels of L-Selectin as markers of silent myocardial ischemia and endothelial dysfunction in type 2 diabetic patients

Introduction In a pilot study we previously suggested that a low serum level of soluble L-Selectin, a protein involved in leucocyte adhesion, might be a marker of coronary artery disease in type 2 diabetic patients (T2D). The aim was to confirm this result in a larger cohort and to explore the association with endothelial dysfunction. Patients and Methods L-Selectin was measured in 364 (230 men) asymptomatic patients with T2D for 13.3±7.0 years, 59.9±8.5 years old, with at least one associated cardiovascular risk factor: hypertension 77.1%, dyslipidemia 70.8%, smoking 22.8%, incipient nephropathy 40.8%, peripheral occlusive arterial disease 13.0%, cardiac autonomic neuropathy (assessed on three standard tests) 74.0%. Silent myocardial ischemia (SMI) was detected by stress myocardial scintigraphy in 135 patients, and 45 of them had significant coronary stenoses on angiography. Results L-Selectin levels were lower in the patients with than in those without SMI (788±218 vs 853±244 ng/ml, p Conclusion Serum levels of L-Selectin are low in T2D patients with SMI. This change may account for leucocytes adhesion on activated endothelium, as suggested by the negative correlation between L-Selectin and albuminuria. The association hypertension - cardiac autonomic neuropathy may play a role in endothelium dysfunction.

P36 - Rôle de l’ischémie et de la neuropathie autonome cardiaque dans les altérations de la fonction myocardique chez les patients diabétiques asymptomatiques

Introduction L’alteration de la fonction myocardique du diabetique est d’origine multifactorielle mais peu d’etudes ont evalue le role de l’ischemie myocardique silencieuse (IMS), atteinte microcirculatoire eventuellement associee a des stenoses coronaires (SC), et de la neuropathie autonome cardiaque (NAC). Patients et methodes Nous avons realise une echocardiographie trans-thoracique chez 293 patients, diabetiques depuis 14 ± 7 ans, 172 hommes, 57,8 ± 8,8 ans, asymptomatiques au plan coronarien et sans insuffisance cardiaque clinique mais presentant d’autres facteurs de risque cardiovasculaire. La fonction systolique du ventricule gauche ; la fonction diastolique : E/A mitral, onde ea a l’anneau mitral, E/ea, Vp, E/Vp et 2 indices de performance precocement alteres : l’onde s a l’anneau mitral et l’index de Tei, ont ete mesurees. Une NAC a ete definie par ≥ 1 test anormal parmi 3 tests (respiration profonde, orthostatisme, Valsalva) evaluant la variabilite de la frequence cardiaque. Une scintigraphie myocardique et/ou une echographie cardiaque de stress permettait d’identifier l’IMS. Une coronarographie etait effectuee si l’une de ces epreuves non invasives etait anormale. Resultats Une IMS et une NAC etaient presentes respectivement chez 98 (33,6%) et 183 (62,5%) patients. La presence de SC en cas d’IMS (31 patients) n’etait pas associee a la presence d’une NAC. Les patients avec IMS et/ou NAC avaient une fonction systolique globale (fraction d’ejection : NAC-IMS-/NAC-IMS + / NAC + IMS-/NAC + IMS + 69±6/68±6/67±6/ 64±11% respectivement, p Conclusion Chez les diabetiques asymptomatiques a haut risque cardiovasculaire, l’association IMS/NAC participe a la degradation de la fonction systolique et de la relaxation ventriculaires gauches.

P222 Rôle de l’âge et du sexe dans l’insulinorésistance chez les adolescents de poids normal ou en excédent pondéral

Objectif La sensibilite a l’insuline est reputee diminuer physiologiquement a la puberte, particulierement chez les filles. L’objectif de notre etude etait d’examiner chez les adolescents de poids normal, obeses ou en surpoids de meme âge, les determinants de l’indice HOMA, modele d’evaluation de l’insulinoresistance (IR) valide chez les enfants. Patients et Methodes Il s’agit de 131 adolescents constantinois scolarises (68 filles, 63 garcons), examines en 2007, âges de 12 a 18 ans, indemnes de maladies metaboliques : 89 de poids normal et 42 en excedent ponderal selon les normes de l’IOTF (30 en surpoids et 12 obeses), qui ont beneficie d’un examen clinique et d’un bilan biologique (insulinemie et glycemie a jeun) dans un laboratoire central. Resultats Sur l’ensemble de la population etudiee, le HOMA etait correle significativement a l’âge (p = 0,001) et etait plus eleve chez les filles (2,39 ± 1,22 vs 1,92 ± 1,21 chez les garcons ; p = 0,032). Chez les adolescents de poids normal, le HOMA etait aussi correle a l’âge (p = 0,005) et etait egalement plus eleve chez les filles (2,06 ± 0,94 vs 1,62 ± 0,86 chez les garcons ; p = 0,02). Chez les adolescents en excedent ponderal, cet indice n’etait pas correle a l’âge ni au sexe. L’indice HOMA differait significativement entre les 3 groupes etudies : 1,85 ± 0,93 chez les adolescents sans excedent ponderal, 2,61 ± 1,22 chez ceux en surpoids et 3,42 ± 2,03 chez les obeses (p 2,67 (quartile superieur de la population globale) etait associee dans la population globale a l’âge (p Conclusion Nos donnees confirment que la sensibilite a l’insuline baisse avec l’âge chez les adolescents et suggerent qu’elle est plus faible chez les filles que chez les garcons de poids normal et que l’IR affecterait deux fois plus souvent les adolescents en excedent ponderal.

O4 Intérêt de la revascularisation de la maladie coronaire silencieuse chez le diabétique : une étude rétrospective

Introduction L’interet de la revascularisation est debattu dans la maladie coronaire stable comme dans la coronaropathie silencieuse (CS) chez le diabetique. L’objectif etait de determiner dans une etude retrospective si le pronostic des diabetiques avec CS etait meilleur en cas de revascularisation. Patients et Methodes L’etude porte sur les 93 patients (69 hommes, 61 ± 8 ans, diabetiques depuis 13+8 ans) presentant une CS (stenose coronaire > 70 %) au sein d’une serie de 788 patients asymptomatiques presentant au moins un facteur de risque cardio-vasculaire (nephropathie 43 %, hypertension 76,3 %, dyslipidemie 71,7, tabagisme 35,5 %, autre atteinte arterielle 19,4 %, antecedents familiaux precoces 9,1 %) qui avaient ete depistes pour une ischemie myocardique silencieuse par scintigraphie de stress entre 1992 et 2008 et coronarographie en cas de positivite. Parmi ces 93 patients, 50 avaient des lesions monotronculaires et 16 des lesions tritronculaires. Tous ces patients ont ete suivis pour le premier evenement cardiaque (EC) et l’incidence des EC a ete comparee chez ceux qui avaient eu, sur decision de l’equipe cardiologique, une revascularisation initiale (groupe REVASC : 29 angioplasties, 7 pontages) ou non (groupe MED : n = 57). Resultats La proportion d’hommes etait plus importante dans le groupe REVASC que dans le groupe MED (83,3 vs 53,6 %, p Discussion Ces resultats sont a confirmer par une etude prospective randomisee, testant en particulier les angioplasties avec stent actif. Conclusion Le taux d’EC est tres eleve chez les diabetiques avec CS. Les pontages chez les patients tritronculaires s’accompagnent d’un meilleur pronostic.