Minh Tuan Nguyen

Diagnostic and Prognostic Performances Over 9 Years of a Selective Screening Strategy for Gestational Diabetes Mellitus in a Cohort of 18,775 Subjects

OBJECTIVE We aimed to evaluate a selective screening strategy for gestational diabetes mellitus (GDM) based on the presence of risk factors: BMI ≥25 kg/m2, age ≥35 years, family history of diabetes, personal history of GDM, or birth of a child with macrosomia. RESEARCH DESIGN AND METHODS Of 20,630 deliveries between 2002 and 2010, we selected 18,775 deliveries in women with no known diabetes and for whom all risk factors were known. GDM was universally screened and defined as fasting plasma glucose level ≥5.3 mmol/L and/or 2-h postload (75 g) glucose level ≥7.8 mmol/L. RESULTS The prevalence of at least one risk factor has increased since 2002 (P < 0.001) from 51.7 to 61.5%, with no change in the GDM prevalence (mean 14.4%, intention to screen). At least one risk factor was present in 58.5% of women who represented 65.3% of all those with GDM. The presence of risk factors was significantly associated with GDM (odds ratio 1.4 [95% CI 1.3–1.5], P < 0.001) and with GDM-related events (preeclampsia/large for gestational age/dystocia) (P < 0.001) with the following incidences: no GDM/no risk factor 8.8%, no GDM/risk factor 11.1%, GDM/no risk factor 16.7%, and GDM/risk factor 18.2%. CONCLUSIONS The presence of risk factors increased during the last decade. This condition is predictive of GDM and GDM-related events. However, a selective screening would lead to missing one-third of the women with GDM who, even without risk factors, had more events than women without GDM. Therefore, these data stand against the present selective screening currently proposed in the French guidelines.

Cardiovascular Risk Prediction Is Improved by Adding Asymptomatic Coronary Status to Routine Risk Assessment in Type 2 Diabetic Patients

OBJECTIVE To evaluate if silent myocardial ischemia (SMI) and silent coronary artery disease (CAD) provide significant additional value to routine cardiovascular risk assessment in type 2 diabetic patients. RESEARCH DESIGN AND METHODS We followed up to a first cardiovascular event 688 subjects (322 men, aged 59 ± 8 years) out of 731 consecutive asymptomatic type 2 diabetic patients with ≥1 additional risk factor who had been prospectively screened between 1992 and 2006 for SMI by stress myocardial scintigraphy and for silent CAD by coronary angiography. RESULTS SMI was found in 207 (30.1%) patients and CAD in 76 of those with SMI. Of the patients, 98 had a first cardiovascular event during a 5.4 ± 3.5 (range: 0.1–19.2) year follow-up period. Cox regression analysis considering parameters predicting events but not SMI and CAD (“routine assessment”) showed in univariate analyses that macroproteinuria (hazard ratio [HR] 3.33 [95% CI 1.74–6.35]; P < 0.001), current multifactorial care (0.27 [0.15–0.47]; P < 0.001), and peripheral/carotid occlusive arterial disease (PCOAD; 4.33 [2.15–8.71]; P < 0.001) independently predicted cardiovascular events. When added into the model, SMI (HR 1.76 [1.00–3.12]; P = 0.05) and CAD (2.28 [1.24–4.57]; P < 0.01) were also independently associated with events. SMI added to the prediction of an event in the following 5 years above and beyond routine assessment risk prediction (c statistic with or without SMI 0.788 [0.720–0.855] and 0.705 [0.616–0.794], respectively). CONCLUSIONS Although screening for SMI and silent CAD should not be systematic, these complications are predictive of cardiovascular events in type 2 diabetic patients in addition to routine risk predictors, especially represented by PCOAD, macroproteinuria, and nonintensive management.

Glycation Gap Is Associated With Macroproteinuria but Not With Other Complications in Patients With Type 2 Diabetes

OBJECTIVE We investigated whether glycation gap (G-Gap), an index of intracellular glycation of proteins, was associated with diabetes complications. RESEARCH DESIGN AND METHODS We measured concomitantly HbA1c and fructosamine in 925 patients with type 2 diabetes to calculate the G-Gap, defined as the difference between measured HbA1c, and fructosamine-based predicted HbA1c. Patients were explored for retinopathy, nephropathy, peripheral neuropathy, cardiac autonomic neuropathy (n = 512), and silent myocardial ischemia (n = 506). RESULTS Macroproteinuria was the only complication that was associated with G-Gap (prevalence in the first, second, and third tertile of G-Gap: 2.9, 6.2, and 11.0%, respectively; P < 0.001). The G-Gap was higher in patients with macroproteinuria than in those without (1.06 ± 1.62 vs. 0.03 ± 1.30%; P < 0.0001). Because HbA1c was associated with both G-Gap (HbA1c 7.0 ± 1.4, 7.9 ± 1.4, and 10.1 ± 1.8% in the first, second, and third G-Gap tertile, respectively; P < 0.0001) and macroproteinuria (HbA1c 8.8 ± 2.2% if macroproteinuria, 8.3 ± 2.0% if none; P < 0.05), and because it could have been a confounder, we matched 54 patients with macroproteinuria and 200 patients without for HbA1c. Because macroproteinuria was associated with lower serum albumin and fructosamine levels, which might account for higher G-Gap, we calculated in this subpopulation albumin-indexed fructosamine and G-Gap; macroproteinuria was independently associated with male sex (odds ratio [OR] 3.2 [95% CI 1.5–6.7]; P < 0.01), hypertension (2.9 [1.1–7.5]; P < 0.05), and the third tertile of albumin-indexed G-Gap (2.3 [1.1–4.4]; P < 0.05) in multivariate analysis. CONCLUSIONS In type 2 diabetic patients, G-Gap was associated with macroproteinuria, independently of HbA1c, albumin levels, and confounding factors, suggesting a specific role of intracellular glycation susceptibility on kidney glomerular changes.

Evidence for a Specific Diabetic Cardiomyopathy: An Observational Retrospective Echocardiographic Study in 656 Asymptomatic Type 2 Diabetic Patients

Aim. Our aim was to assess the prevalence of subclinical diabetic cardiomyopathy, occurring among diabetic patients without hypertension or coronary artery disease (CAD). Methods. 656 asymptomatic patients with type 2 diabetes for 14 ± 8 years (359 men, 59.7 ± 8.7 years old, HbA1c 8.7 ± 2.1%) and at least one cardiovascular risk factor had a cardiac echography at rest, a stress cardiac scintigraphy to screen for silent myocardial ischemia (SMI), and, in case of SMI, a coronary angiography to screen for silent CAD. Results. SMI was diagnosed in 206 patients, and 71 of them had CAD. In the 157 patients without hypertension or CAD, left ventricular hypertrophy (LVH: 24.1%) was the most frequent abnormality, followed by left ventricular dilation (8.6%), hypokinesia (5.3%), and systolic dysfunction (3.8%). SMI was independently associated with hypokinesia (odds ratio 14.7 [2.7–81.7], p < 0.01) and systolic dysfunction (OR 114.6 [1.7–7907], p < 0.01), while HbA1c (OR 1.9 [1.1–3.2], p < 0.05) and body mass index (OR 1.6 [1.1–2.4], p < 0.05) were associated with systolic dysfunction. LVH was more prevalent among hypertensive patients and hypokinesia in the patients with CAD. Conclusion. In asymptomatic type 2 diabetic patients, diabetic cardiomyopathy is highly prevalent and is predominantly characterized by LVH. SMI, obesity, and poor glycemic control contribute to structural and functional LV abnormalities.

Flow-mediated-paradoxical vasoconstriction is independently associated with asymptomatic myocardial ischemia and coronary artery disease in type 2 diabetic patients

BackgroundTo investigate whether flow-mediated dilation (FMD) impairment, which precedes overt atherosclerosis, is associated with silent myocardial ischemia (SMI) and asymptomatic coronary artery disease (CAD) in type 2 diabetes.MethodsForearm FMD was measured by ultrasonography in 25 healthy control, 30 non-diabetic overweight or obese patients and 118 asymptomatic type 2 diabetic patients with a high cardiovascular risk profile. SMI (abnormal stress myocardial scintiscan and/or stress dobutamine echocardiogram) and CAD (coronary angiography in the patients with SMI) were assessed in the diabetic cohort.ResultsFMD was lower in diabetic patients (median 0.61% (upper limits of first and third quartiles -1.22;3.2)) than in healthy controls (3.95% (1.43;5.25), p < 0.01) and overweight/obese patients (4.25% (1.74;5.56), p < 0.01). SMI was present in 60 diabetic patients, including 21 subjects with CAD. FMD was lower in patients with SMI than in those without (0.12% (-2.3;1.58) vs 1.64% (0;3.69), p < 0.01), with a higher prevalence of paradoxical vasoconstriction (50.0% vs 29.3%, p < 0.05). FMD was also lower in patients with than without CAD (-1.22% (-2.5;1) vs 1.13% (-0.4;3.28), p < 0.01; paradoxical vasoconstriction 61.9% vs 34.4%, p < 0.05). Logistic regression analyses considering the parameters predicting SMI or CAD in univariate analyses with a p value <0.10 showed that paradoxical vasoconstriction (odds ratio 2.7 [95% confidence interval 1.2-5.9], p < 0.05) and nephropathy (OR 2.6 [1.2-5.7], p < 0.05) were independently associated with SMI; and only paradoxical vasoconstriction (OR 3.1 [1.2-8.2], p < 0.05) with CAD. The negative predictive value of paradoxical vasoconstriction to detect CAD was 88.7%.ConclusionsIn diabetic patients, FMD was independently associated with SMI and asymptomatic CAD.Trial registrationTrial registration number NCT00685984.

0334: Coronary artery calcium score as a predictor of myocardial ischemia in asymptomatic diabetic patients

Background and aims High coronary artery calcium (CAC) scores were shown to predict a higher likelihood of inducible myocardial ischemia and to be associated with a poor cardio-vascular prognosis. However the predictive value for coronary stenoses (CS) has not been tested in asymptomatic diabetic patients. This study aimed to evaluate the predictive value of a high CAC score for silent myocardial ischemia (SMI) and CS in high risk asymptomatic diabetic patients. Materials and methods CAC score was measured by computed tomography in 150 diabetic patients without cardiac history or symptom, with a normal resting ECG and ≥1 additional risk factors. SMI was assessed using stress myocardial scintigraphy and/or stress echocardiography, and CS using coronary angiography in those with an abnormal SMI test. Results CAC score was ≥100 Agatston units in 35.3% of the patients. SMI was detected in 27 patients (18.0%). A coronary angiography was performed in 17 of SMI patients and detected significant CS in six of them. CAC score was associated with coronary status (no SMI: median value 14 (range 0-2900); SMI without CS: 101 (23-3230) and SMI with CS: 800 (76-2978); (p Conclusion These data suggest that in asymptomatic high risk diabetic patients CAC score is associated with cardiac ischemic status, with a 3.4-fold increased risk of SMI when the score is ≥100. The negative predictive value of CAC score for SMI is an interesting finding. The predictive value for CS remains to be determined in a larger sample of patients with CS.

096: Diabetic cardiomyopathy: data from a series of 656 asymptomatic diabetic patients with known cardiac ischemic status

Background The aim of the study was to assess the prevalence of subclinical cardiomyopathy among patients with type 2 diabetes without hypertension or coronary artery disease (CAD). Materials and methods: 656 patients with type 2 diabetes for 14±8 yrs (359 men, 59.7±8.7 years, HbA1c 8.7±2.1%), without cardiac symptom and at least one cardiovascular risk factor (hypertension 74%; dyslipidemia 70%; smoking habits 22%; peripheral occlusive arterial disease 10%, nephropathy 39%) had a contributive cardiac echography at rest; underwent a stress cardiac scintigraphy to screen for silent myocardial ischemia (SMI), and in case of SMI, a coronary angiography to screen for silent CAD. Results SMI was diagnosed in 206 patients, and 71 of them had silent CAD. In the patients without hypertension or CAD (n=157), left ventricular hypertrophy (LVH: 24.1%) was the most frequent abnormality, followed by left ventricular dilation (8.6%), hypokinesia (5.3%), abnormal type 1 relaxation (4.8%) and systolic dysfunction (3.8%). No parameter was associated with LVH neither with LV dilation nor with abnormal relaxation. In multivariate analysis, the parameters associated with hypokinesia were SMI (Odds ratio 14.7 [2.7-81.7] p Conclusion In asymptomatic type 2 diabetic patients, diabetic cardiomyopathy is highly prevalent and is characterized by LVH. SMI, obesity and poor glycemic control contribute to systolic dysfunction and/or hypokinesia. Hypertension is associated with more LVH, and CAD with more hypokinesia.

P48 Dysglycémie méconnue et risque de diabète chez les coronariens

Rationnel Des anomalies glycemiques meconnues seraient tres frequentes chez les coronariens. Le score finlandais de risque de survenue de diabete a 10 ans (Findrisc) a ete valide en population generale vis-a-vis du risque de presenter un diabete meconnu. Le but etait d’apprecier la frequence des dysglycemies meconnues et d’apprecier le risque de diabete futur chez des patients coronariens hospitalises en cardiologie. Patients et Methodes L’etude a porte sur une serie consecutive de 188 patients âges de 67,1 ± 4,2 ans, hospitalises pour syndrome coronarien aigu ou bilan d’une maladie coronaire stable. Tous etaient indemnes d’anomalies glycemiques connues. La glycemie a ete dosee a jeun ainsi que les parametres lipidiques usuels et le Findrisc a ete calcule. Resultats Une anomalie glycemique etait decouverte chez 53 patients (28,2%), en faveur d’une hyperglycemie a jeun chez 29 d’entre eux et d’un diabete chez 24 patients. Le Findrisc etait entre 12 et 14, temoignant d’un risque modere de devenir diabetique (1/6 dans les 10 ans) chez 48 patients, et = 15, temoignant d’un risque eleve ou tres eleve (1/3 a 1/2) chez 27 patients (14,4 %) dont 9 etaient dysglycemiques. Il correlait significativement avec l’âge (p = 0,02), le statut glycemique (normal, hyperglycemie a jeun ou diabete) (p = 0,02), l’IMC (p Conclusion Ces donnees confortent l’importance du depistage des anomalies glycemiques chez les coronariens et l’interet d’evaluer le risque de diabete par un score simple. Un Findrisc eleve doit conduire a evaluer et suivre plus rigoureusement le statut glycemique.