Sabita S. Soedamah-Muthu

Alcohol consumption and risk of recurrent cardiovascular events and mortality in patients with clinically manifest vascular disease and diabetes mellitus: The Second Manifestations of ARTerial (SMART) disease study

OBJECTIVE This study investigated the relation between alcohol consumption and specific vascular events and mortality in a high risk population of patients with clinical manifestations of vascular disease and diabetes. METHODS Patients with clinically manifest vascular disease or diabetes (n=5447) from the SMART study were followed for cardiovascular events and mortality. Alcohol consumption was assessed with a baseline questionnaire and analysed in relation with coronary heart disease (CHD), amputations, stroke, and all-cause and vascular death. RESULTS After a follow up of 4.7 years, we documented 363 cases of CHD, 187 cases of stroke, 79 amputations and 641 cases of all-cause death, of which 382 were vascular. In multivariate-adjusted models, alcohol consumption was inversely associated with CHD (p(linear trend)=0.007) and stroke (p(linear trend)=0.051) with respective hazard ratios of 0.39 (95%CI: 0.20-0.76) and 0.67 (0.31-1.46) for consuming 10-20 drinks/week compared with abstainers. We observed significant U-shaped associations between alcohol consumption and amputations (p(quadratic trend)=0.001), all-cause death (p(quadratic trend)=0.001) and vascular death (p(quadratic trend)=0.013). Hazard ratios for consuming 10-20 drinks/week were 0.29 (0.07-1.30) for amputations, 0.40 (0.24-0.69) for all-cause death and 0.34 (0.16-0.71) for vascular death compared with abstainers. Similar associations were observed for red wine consumption only. CONCLUSION Moderate alcohol consumption (1-2 drinks/day) is not only associated with a reduced risk of vascular and all-cause death in a high risk patients with clinical manifestations of vascular disease, but also with reduced risks of non-fatal events like CHD, stroke and possibly amputations.

Metabolic syndrome and incidence of type 2 diabetes in patients with manifest vascular disease

Risk reduction in patients with clinically manifest vascular disease focuses on preventing new vascular events and not on prevention of type 2 diabetes. However, given the common pathophysiological pathways involved in the development of atherosclerosis and type 2 diabetes, it is probable that people with atherosclerotic vascular disease have an elevated risk of type 2 diabetes. The present prospective cohort study investigated the incidence of type 2 diabetes and the effect of the presence of metabolic syndrome on the incidence of type 2 diabetes in 4,022 patients with clinically manifest atherosclerosis, included in the study from September 1996 to June 2006. Patients who died (n=456), who were lost to follow-up (n=84) and those with diabetes at baseline (n=558) were excluded, leaving 2,924 patients for analysis. The incidence of diabetes was assessed by questionnaire (self-reported diabetes). During 13,726 person-years of follow-up (median follow-up 4.3 years, range 2.4–7.0 years), there were 152 type 2 diabetes cases (5.2%), corresponding to an incidence rate of 11.1 (95% CI 9.4–13.0) per 1,000 person-years. Patients with metabolic syndrome were at increased risk of incident type 2 diabetes compared to those without metabolic syndrome, with an adjusted hazard ratio of 5.7 (95% CI 3.7–8.9) for Revised National Cholesterol Education Program, 6.0 (4.1–9.0) for National Cholesterol Education Program and 4.0 (2.7–6.1) for International Diabetes Federation definitions of metabolic syndrome. Of all metabolic syndrome components, abdominal obesity was most strongly associated with incident type 2 diabetes (94% higher risk of type 2 diabetes for 1 standard deviation (11.3 cm) increase in waist circumference). In conclusion, patients with manifest atherosclerosis are at high risk of developing type 2 diabetes. Metabolic syndrome identifies those at the highest risk and is an easy to use clinical tool. Abdominal obesity is a strong individual predictor of type 2 diabetes. Patients with manifest atherosclerosis and metabolic syndrome may derive particular benefit from lifestyle interventions focusing on weight reduction.

Improved care of type 2 diabetes patients as a result of the introduction of a practice nurse: 2003–2007

OBJECTIVE The main objective is to examine the effect of the introduction of a practice nurse (PN) on the quality of type 2 diabetes care. METHODS Retrospective cohort study in 397 type 2 diabetes patients recruited from five general practices in the Netherlands. Measurements were performed in 2003, 2005 and 2007, to estimate the effects before (2003) and after the introduction of the PN (2005) as well as the changed diabetes guidelines (2007). Process measures indicated whether measurements of HbA(1c), systolic blood pressure, lipid profile, funduscopy, foot examination and annual check-ups were carried out. Outcome measures comprised actual levels of HbA(1c), systolic blood pressure, lipid levels and BMI. RESULTS All process measures - except performance of funduscopy - improved significantly. Mean HbA(1c) decreased from 6.8% to 6.5% (2003-2007: ns, 2005-2007: p<0.01), mean LDL-cholesterol from 3.2 to 2.7 mmol/L (p<0.0001) and mean total cholesterol/HDL-cholesterol ratio from 4.5 to 3.7 (p<0.0001). For systolic blood pressure, the number of patients reaching targets increased considerably in 2007. Analyses for both study populations at different time points as well as for patients present at all time points showed comparable results. CONCLUSIONS Delegating diabetes care to a PN leads to significant improvements in diabetes care. General practitioners should seriously consider close collaboration with PNs to delegate diabetes care tasks.

Waist circumference and metabolic risk factors have separate and additive effects on the risk of future Type 2 diabetes in patients with vascular diseases. A cohort study

Diabet. Med. 28, 932–940 (2011)

Leisure-time physical activity and risk of type 2 diabetes in patients with established vascular disease or poorly controlled vascular risk factors

AIM To investigate the effect of leisure-time physical activity on the incidence of type 2 diabetes (T2DM) in patients with manifest arterial disease, or poorly controlled risk factors. METHODS We examined 3940 patients with manifest arterial disease, hypertension or hyperlipidemia, aged 55.2+/-12.2 years. Leisure-time physical activity was measured by a questionnaire and metabolic equivalent (MET) hours per week (h/wk) were calculated. Incident T2DM was evaluated by a specific diabetes questionnaire. RESULTS Most patients (65%) were physically inactive (0METh/wk), 12% were insufficiently physically active (0-10.5METh/wk) and 23% were sufficiently physically active (>or=10.5METh/wk). During a mean follow-up of 4.7 years, 194 (5%) incident cases of T2DM occurred. Sufficiently physically active patients had a lower incidence of diabetes (hazard ratio (HR) 0.55, 95% confidence interval (CI) 0.37-0.83). Patients who were physically active and not-obese (BMI<30kg/m(2)) were at the lowest risk for developing T2DM (HR 0.18, 95% CI 0.12-0.28) compared with patients who were physically inactive and obese. CONCLUSIONS Leisure-time physical activity is associated with a decreased risk of T2DM in patients with manifest arterial disease, or poorly controlled risk factors. The combination of physical activity and non-obesity is associated with an even lower risk of the development of type 2 diabetes than the sum of their independent, protective effect.

Trends in vascular risk factors and medication use in patients with various manifestations of vascular diseases or type 2 diabetes mellitus from 1996 to 2007: the Second Manifestations of ARTerial disease study.

Aims To investigate time trends in vascular risk factors and medication use for patients referred to a vascular specialist with manifest vascular disease or type 2 diabetes mellitus (DM2). Methods and results Change in risk factor profile and medication use at referral over a 12-year period was evaluated and compared between patients with coronary heart disease, cerebrovascular disease, peripheral arterial disease, abdominal aortic aneurysm, and DM2, who participated in the Second Manifestations of ARTerial disease study in the period of 1996–2007. A total of 4731 patients were included (mean age 59 ± 11 years, 75% male) in the period 1996–2007. Obesity (body mass index ≥ 30 kg/m2) prevalence increased from 14 to 24%, and no change in smoking behavior was observed. The prevalence of hyperlipidemia (total cholesterol ≥ 4.5 mmol/l or low-density lipoprotein cholesterol ≥ 2.5 mmol/l) at referral declined from 92% in 1996–1997 to 45% in 2006–2007. The proportion of patients with blood pressure above 140/90 mmHg decreased from 66 to 51%. The use of lipid-lowering, blood pressure-lowering, and antithrombotic medication at referral increased over the observation period. Conclusion An improvement in risk factor profile was seen in patients referred with manifest vascular disease or DM2 over a 12-year period. Nevertheless, the prevalence of modifiable risk factors is still high leaving patients at elevated vascular risk.

Cardiovascular disease morbidity and mortality in patients with type 1 diabetes mellitus: management strategies

There is an increased risk of cardiovascular disease (CVD) mortality and morbidity in patients with type 1 diabetes mellitus compared with the general population as shown by epidemiologic studies measuring cardiovascular endpoints, as well as by autopsy, angiographic, and coronary calcification studies. Most of the excess CVD risk associated with type 1 diabetes is concentrated in the subset of approximately 35% of patients who develop diabetic nephropathy (after 20 years of diabetes duration), who also typically have dyslipidemias, elevated blood pressure, and hyperglycemia, factors contributing to CVD. For reasons that remain speculative, the relative risks from CVD are higher in women than in men with type 1 diabetes compared with the general population, which effectively eliminates the gender differences in CVD. As in the general population and in patients with type 2 diabetes, education and lifestyle changes, interventions to reduce hyperglycemia, blood pressure, microalbuminuria, lipid control, and the use of aspirin are important management areas in order to reduce the increased risk of CVD. Whether management with aspirin and statins should be started in type 1 diabetic patients at a younger age or at a lower risk score than in the general population is still under investigation. There is a need for a better understanding of the pathophysiology of vascular complications in type 1 diabetes, more specific risk engines in type 1 diabetes, and accurate estimations of the absolute and relative risk for CVD in order to improve management of CVD in these high-risk patients.

Prognostic value of the Rose questionnaire: a validation with future coronary events in the SMART study

Aim: The Rose questionnaire was developed in epidemiological studies to obtain a reproducible diagnosis of angina pectoris. We studied the prognostic value of this questionnaire with respect to the occurrence of future coronary events. Methods and results: We studied 7916 consecutive patients (mean age 56 years; 67% men) with clinically manifest vascular disease or cardiovascular risk factors, enrolled in the Second Manifestations of ARTerial disease (SMART) study from 1996 to 2009. At inclusion, all patients completed the Rose questionnaire. We investigated the prognostic value of four definitions of angina pectoris that were based on the following elements of the questionnaire (1) the full questionnaire; (2) three key questions concerning chest pain; (3) one question about discomfort or pain in the chest; (4) two questions about complaints when slowing down or stopping activities (the definition that is used in the SMART study). All patients were followed for new coronary events and interventions for an average of 4.6 years. Analyses were with multivariable Cox regression models. Discriminatory ability of the four definitions as assessed with areas under the receiver-operator characteristics curves was similar (range 0.708–0.726) for coronary events in isolation as well as in combination with coronary interventions. The models were assessed for their ability to improve risk stratification compared with each other; differences between definitions are small. Conclusion: Our data implicate that the use of a subset of questions of the Rose questionnaire performs equally well compared with the full Rose questionnaire regarding the prediction of coronary events.

The impact of Type 2 diabetes and microalbuminuria on future cardiovascular events in patients with clinically manifest vascular disease from the Second Manifestations of ARTerial disease (SMART) study

Aims  Type 2 diabetes mellitus and microalbuminuria are important risk factors for cardiovascular disease (CVD). Whether these two complications are important and independent risk factors for future CVD events in a high‐risk population with clinically manifest vascular disease is unknown. The objectives of this study were to examine the impact of Type 2 diabetes and microalbuminuria on future CVD events.

Easily obtainable clinical features increase the diagnostic accuracy for latent autoimmune diabetes in adults: An evidence-based report

BACKGROUND Latent autoimmune diabetes in adults (LADA) represents a subgroup of diabetes mellitus. LADA is characterised by adult-onset diabetes and circulating autoimmune antibodies. LADA patients may need a different therapeutic approach than the usual type 2 diabetes mellitus. When LADA is inadequately diagnosed as type 2 diabetes mellitus, LADA patients will mistakenly be exposed to a high dose of oral glucose lowering drugs and their possible side effects. AIM To assess which clinical features predict the presence or absence of LADA in patients older than 25 years presenting with hyperglycemia. METHODS A structured Medline and Embase search was conducted. Titles and abstracts were screened using predetermined selection criteria. Critical appraisal was based on standardized validity criteria for diagnostic research. RESULTS One-hundred and eighty-four papers were retrieved of which after assessment of relevance and validity 2 studies remained for further analysis. One study reported a probability of LADA of 0.99 with one or two out of the following five clinical features: age at onset <50 years; acute symptoms; BMI<25 kg/m(2); a history of autoimmune disease; a family history positive for diabetes mellitus. The other study reported a probability of LADA of zero with none of the following clinical features and of 0.32 with one out of three: fasting blood glucose> or =15 mmol/l and/or HbA(1c)> or =10%; 10% reduction in body weight in the previous 3 months; BMI<25 kg/m(2). CONCLUSION Further testing for LADA by measurement of autoimmune antibodies appears to be unnecessary in the absence of a specific set of clinical features. Before initiating therapy applying the above criteria may help to separate LADA from usual type 2 diabetes.