Pathophysiological Effects of Diabetes on Ischemic-Cardiovascular Disease and on Chronic Obstructive Pulmonary Disease (COPD)
Curator: Larry H. Bernstein, MD, FCAP

Article ID #106: Pathophysiological Effects of Diabetes on Ischemic-Cardiovascular Disease and on Chronic Obstructive Pulmonary Disease (COPD). Published 1/15/2014
WordCloud Image Produced by Adam Tubman
This is a multipart article that develops the pathological effects of type-2 diabetes in the progression of a systemic inflammatory disease with a development of neuropathy, and fully developing into cardiovascular disease. It also identifies a systemic relationship to the development of chronic obstructive pulmonary disease (COPD).
The more we learn about diabetes, we learn about its generalized systemic effects.
This article has the following SIX Parts:
Part 1. Role of Autonomic Cardiovascular Neuropathy in Pathogenesis of ischemic heart disease in patients with diabetes mellitus
Part 2. A Longitudinal Cohort Study of the Cardiovascular Experience of Individuals at High Risk for Diabetes
Part 3. Clinical significance of cardiovascular dysmetabolic syndrome
Part 4. Waist circumference a good indicator of future risk for type 2 diabetes and cardiovascular disease
Part 5. How to use C-reactive protein in acute coronary care
Part 6. Chronic obstructive pulmonary disease and glucose metabolism: a bitter sweet symphony
INTRODUCTION
Type 2 diabetes mellitus is a common chronic disease which develops insidiously over time, and is associated with obesity, nutritional imbalance (high fructose beverages, high starch and processed foods, carbohydrate excess intake, and an imbalance of proinflammatory to anti-inflammatory polyunsaturated fatty acids), which makes it an acquired and manageable disease. The long term effects of T2DM is played out on cardiovascular disease and stroke-risk, obstructive sleep apnea, progressive renal insufficiency, development of neuropathy, congestive heart failure and chronic obstructive pulmonary disease, all of which are occuring related to an systemic inflammatory condition that proceeds for some time prior to the identification of overt diabetes.
A detailed story of a significant part of these associations continues in the SIX Part series.
Part 1. Role of Autonomic Cardiovascular Neuropathy in Pathogenesis of ischemic heart disease in patients with diabetes mellitus
This article is an abstract only of a related publication of the pathogenesis of autonomic neuropathy in diabetics leading to ischemic heart disease.
Subjects: Medicine (General), Medicine, Medicine (General),
Health Sciences Authors: Popović-Pejičić Snježana, Todorović-Đilas Ljiljana, Pantelinac Pavle
Publisher: Društvo lekara Vojvodine Srpskog lekarskog društva
Publication: Medicinski Pregled 2006; 59(3-4): Pp 118-123 (2006) ISSN(s): 0025-8105 Added to DOAJ: 2010-11-11
http://dx.doi.org/10.2298/MPNS0604118P http://www.doiserbia.nb.rs/img/doi/0025-8105/2006/0025-81050604118P.pdf
Keywords: diabetes mellitus, autonomic nervous system diseases, heart diseases, myocardial ischemia, comorbidity
Introduction.
Diabetes is strongly associated with macrovascular complications, among which
- ischemic heart disease is the major cause of mortality.
Autonomic neuropathy increases the risk of complications, which calls for an early diagnosis. The aim of this study was to determine
- both presence and extent of cardiac autonomic neuropathy,
in regard to the type of diabetes mellitus, as well as
- its correlation with coronary disease and
- major cardiovascular risk factors.
Material and methods. We have examined 90 subjects, classified into three groups, with 30 patients each: those with type 1 diabetes, type 2 diabetes and control group of healthy subjects. All patients underwent
- cardiovascular tests (Valsalva maneuver, deep breathing test, response to standing, blood pressure response to standing sustained, handgrip test),
- electrocardiogram,
- treadmill exercise test and
- filled out a questionnaire referring to major cardiovascular risk factors: smoking, obesity, hypertension, and dyslipidemia.
Results. Our results showed that cardiovascular autonomic neuropathy was
- more frequent in type 2 diabetes,
- manifesting as autonomic neuropathy.
In patients with autonomic neuropathy, regardless of the type of diabetes,
- the treadmill test was positive, i.e. strongly correlating with coronary disease.
In regard to coronary disease risk factors,
- the most frequent correlation was found for obesity and hypertension.
Discussion
Cardiovascular autonomic neuropathy is considered to be the principal cause of arteriosclerosis and coronary disease. Our results showed that the occurrence of cardiovascular autonomic neuropathy increases the risk of coronary disease due to dysfunction of autonomic nervous system.
Conclusions
Cardiovascular autonomic neuropathy is a common complication of diabetes that significantly correlates with coronary disease. Early diagnosis of cardiovascular autonomic neuropathy points to increased cardiovascular risk, providing a basis for preventive and therapeutic measures.
Part 2. A Longitudinal Cohort Study of the Cardiovascular Experience of Individuals at High Risk for Diabetes
This second part is a description of a longitudinal cohort study of individuals at high-risk for diabetes. Unlike the SSA study, the study is not focused on protein-energy malnutrition.
Protocol for ADDITION-PRO: a longitudinal cohort study of the cardiovascular experience of individuals at high risk for diabetes recruited from Danish primary care
Subjects: Public aspects of medicine, Medicine, Public Health, Health Sciences
Authors: Johansen NB, Hansen Anne-Louise S, Jensen TM, Philipsen A, Rasmussen SS, Jørgensen ME, Simmons RK, Lauritzen T, Sandbæk A, Witte DR
Publisher: BioMed Central Date of publication: 2012 Dec Published in: BMC Public Health 2012; 12(1): 1078 ISSN(s): 1471-2458 Added to DOAJ: 2013-03-12 http://dx.doi.org/10.1186/1471-2458-12-1078 http://www.biomedcentral.com/1471-2458/12/1078
Keywords: Diabetes, Cardiovascular disease, Primary care, Complications, Microvascular, Impaired fasting glucose, Impaired glucose intolerance, Aortic stiffness, Physical activity, Body composition
Background
Screening programmes for type 2 diabetes inevitably find more individuals at high risk for diabetes than people with undiagnosed prevalent disease. While well established guidelines for the treatment of diabetes exist, less is known about treatment or prevention strategies for individuals found at high risk following screening. In order to make better use of the opportunities for primary prevention of diabetes and its complications among this high risk group, it is important to
- quantify diabetes progression rates and to examine
- the development of early markers of cardiovascular disease and
- microvascular diabetic complications.
We also require a better understanding of the
- mechanisms that underlie and drive early changes in cardiometabolic physiology.
The ADDITION-PRO study was designed to address these issues among individuals at different levels of diabetes risk recruited from Danish primary care.
Methods/Design
ADDITION-PRO is a population-based, longitudinal cohort study of individuals at high risk for diabetes. 16,136 eligible individuals were identified at high risk following participation in a stepwise screening programme in Danish general practice between 2001 and 2006.
- All individuals with impaired glucose regulation at screening,
- those who developed diabetes following screening, and
- a random sub-sample of those at lower levels of diabetes risk
were invited to attend a follow-up health assessment in 2009–2011 (n = 4,188), of whom 2,082 (50%) attended. The health assessment included
- detailed measurement of anthropometry,
- body composition,
- biochemistry,
- physical activity and
- cardiovascular risk factors including aortic stiffness and central blood pressure.
All ADDITION-PRO participants are being followed for incident cardiovascular disease and death.
Discussion
The ADDITION-PRO study is designed to increase
- understanding of cardiovascular risk and
- its underlying mechanisms among individuals at high risk of diabetes.
Key features of this study include
- (i) a carefully characterised cohort at different levels of diabetes risk;
- (ii) detailed measurement of cardiovascular and metabolic risk factors;
- (iii) objective measurement of physical activity behaviour; and
- (iv) long-term follow-up of hard clinical outcomes including mortality and cardiovascular disease.
Results will inform policy recommendations concerning cardiovascular risk reduction and treatment among individuals at high risk for diabetes. The detailed phenotyping of this cohort will also allow a number of research questions concerning early changes in cardiometabolic physiology to be addressed.
Part 3. Clinical significance of cardiovascular dysmetabolic syndrome
This study also addresses the issue of diabetes insulin resistance leading to cardiovascular dysmetabolic syndrome.
Subjects: Diseases of the circulatory (Cardiovascular) system,
Specialties of internal medicine, Internal medicine, Medicine, Cardiovascular, Medicine (General), Health Sciences
Authors: Deedwania Prakash C Publisher: BioMed Central Date of publication: 2002 Jan
Published in: Trials 2002; 3: 1(2) ISSN(s): 1468-6708 Added to DOAJ: 2004-06-03
http://dx.doi.org/10.1186/1468-6708-3-2 http://cvm.controlled-trials.com/content/3/1/2
Keywords: cardiovascular dysmetabolic syndrome, coronary heart disease, diabetes mellitus, hyperinsulinemia, insulin resistance
Although diabetes mellitus is predominantly a metabolic disorder,
- recent data suggest that it is as much a vascular disorder.
- Cardiovascular complications are the leading cause
- of death and disability in patients with diabetes mellitus.
A number of recent reports have emphasized that
- many patients already have atherosclerosis in progression
- at the time they are diagnosed with clinical evidence of diabetes mellitus.
The increased risk of atherosclerosis and cardiovascular complications in diabetic patients is related to
- the frequently associated dyslipidemia, hypertension, hyperglycemia, hyperinsulinemia, and endothelial dysfunction.
The evolving knowledge regarding the variety of
- metabolic,
- hormonal, and
- hemodynamic abnormalities in patients with diabetes mellitus
has led to efforts designed for early identification of individuals at risk of subsequent disease. It has been suggested that
- insulin resistance, the key abnormality in type II diabetes,
- often precedes clinical features of diabetes by 5–6 years.
Careful attention to the criteria described for the cardiovascular dysmetabolic syndrome
- should help identify those at risk at an early stage.
The application of nonpharmacologic as well as newer emerging pharmacologic therapies can have beneficial effects
- in individuals with cardiovascular dysmetabolic syndrome and/or diabetes mellitus
- by improving insulin sensitivity and related abnormalities.
Early identification and implementation of appropriate therapeutic strategies would be necessary
- to contain the emerging new epidemic of cardiovascular disease related to diabetes.
Part 4. Waist circumference a good indicator of future risk for type 2 diabetes and cardiovascular disease
Subjects: Public aspects of medicine, Medicine, Public Health, Health Sciences
Authors: Siren Reijo, Eriksson Johan G, Vanhanen Hannu
Publisher: BioMed Central Date of publication: 2012 Aug
Published in: BMC Public Health 2012; 12: 1(631) ISSN(s): 1471-2458 Added to DOAJ: 2013-03-12
http://dx.doi.org/10.1186/1471-2458-12-631 http://www.biomedcentral.com/1471-2458/12/631
Keywords: Waist circumference, Type 2 diabetes, Cardiovascular disease, Middle-aged men
Background
Abdominal obesity is a more important risk factor than overall obesity in
- predicting the development of type 2 diabetes and cardiovascular disease.
From a preventive and public health point of view it is crucial that
- risk factors are identified at an early stage,
- in order to change and modify behaviour and lifestyle in high risk individuals.
Methods
Data from a community based study was used to assess
- the risk for type 2 diabetes,
- cardiovascular disease and
- prevalence of metabolic syndrome in middle-aged men.
In order to identify those with increased risk for type 2 diabetes and/or cardiovascular disease
- sensitivity and specificity analysis were performed, including
- calculation of positive and negative predictive values, and
- corresponding 95% CI for eleven different cut-off points,
- with 1 cm intervals (92 to 102 cm), for waist circumference.
Results
A waist circumference ≥94 cm in middle-aged men,
- identified those with increased risk for type 2 diabetes
- and/or for cardiovascular disease
with a sensitivity of 84.4% (95% CI 76.4% to 90.0%), and a specificity of 78.2% (95% CI 68.4% to 85.5%). The positive predictive value was 82.9% (95% CI 74.8% to 88.8%), and negative predictive value 80.0% (95% CI 70.3% to 87.1%), respectively .
Conclusions
Measurement of waist circumference in middle-aged men
- is a reliable test to identify individuals at increased risk for type 2 diabetes and cardiovascular disease.
This measurement should be used more frequently in daily practice in primary care
- in order to identify individuals at risk and when planning health counselling and interventions.
Part 5. How to use C-reactive protein in acute coronary care
Luigi M. Biasucci, Wolfgang Koenig, Johannes Mair, Christian Mueller, Mario Plebani, Bertil Lindahl, Nader Rifai,Per Venge,Christian Hamm, and the Study Group on Biomarkers in Cardiology of the Acute Cardiovascular Care Association of the European Society of Cardiology
Department of Cardiology B, Aarhus University Hospital, Tage Hansens Gade2, Aarhus DK-8000,Denmark; Germany, U.K., U.S., Italy
European Heart Journal Advance Access published Nov 7, 2013. Current Opinion. http://dx.doi.org/10.1093/eurheartj/eht435
Introduction
CRP has gained interest recently as a marker for risk stratification in acute coronary syndrome (ACS) when measured by high-sensitivity CRP assays. These assays have greater analytical sensitivity and reliably measure CRP concentrations within the reference range with low imprecision (5–10%). Because of evidence that atherosclerosis is an inflammatory disease, high-sensitivity CRP can be used as a biomarker of risk
in primary prevention and in patients with known cardiovascular disease. The aim of this review is to evaluate the use of CRP in patients with acute coronary disease.
The in-vitro stability of high-sensitivity C-reactive protein is excellent. Specific blood sampling conditions aren’t necessary. However, retesting may be necessary with some assays if there is marked lipaemia. Baseline and subsequent measures are in good for agreement for risk stratification despite biological variability of 30–60%.
The upper reference limit is method-dependent but usually 8mg/L for standard assays. The distribution of high-sensitivity CRP concentrations is skewed in both genders with a 50th percentile of_1.5mg/L (excluding women on hormone replacement therapy). Race differences have been reported. Most studies have reported no relationship with age, but to circadian and seasonal variation. CRP concentrations are increased by smoking, obesity, and hormone replacement therapy and reduced by exercise, moderate alcohol drinking, and statin use. Correction for these factors is essential in reference range studies. CRP assays are not standardized. We recommend the use of third-generation high-sensitivity CRP assays that combine features of standard and high-sensitivity CRP assays. Required assay precision should be < 10% in the range of 3 and 10 mg/L.
Biochemical and analytical issues
Critical clinical concepts
(2) CRP test results are method-dependent
- classification of patients into risk categories is usually comparable
(4) No specific patient preparation before blood sampling is necessary
(5) The in-vitro stability of CRP is high
This is only a portion of the published concensus document. What is relevant to this discussion is that the hs-CRP is an extremely valuable marker for inflammatory disease. It is not ordered often enough because of the broad range of values that we have become accustomed to for years, and it is elevated in rheumatologic conditions, but even then, it is widely used in pediatrics because children may present with rapidly emergent sepsis with very minimal sympoms.
The hs-CRP has opened a window to subliminal inflammatory disease that is diabetes, with accompanied arteriolar endothelial inflammation.
Part 6. Chronic obstructive pulmonary disease and glucose metabolism: a bitter sweet symphony
Subjects: Diseases of the circulatory (Cardiovascular) system,
Specialties of internal medicine, Internal medicine, Medicine, Cardiovascular, Medicine (General), Health Sciences
Authors: Mirrakhimov Aibek E
Publisher: BioMed Central Date of publication: Oct 2012 ISSN(s): 1475-2840
Published in: Cardiovascular Diabetology 2012; 11(1):132 Added to DOAJ: 2013-03-12
http://dx.doi.org/10.1186/1475-2840-11-132 http://www.cardiab.com/content/11/1/132
Keywords: COPD, Dysglycemia, Insulin resistance, Obesity, Metabolic syndrome, Diabetes mellitus endothelial dysfunction, Vasculopathy
Chronic obstructive pulmonary disease, metabolic syndrome and diabetes mellitus
- are common and underdiagnosed medical conditions.
It was predicted that chronic obstructive pulmonary disease
- will be the third leading cause of death worldwide by 2020.
The healthcare burden of this disease is even greater
- if we consider the significant impact of chronic obstructive pulmonary disease on
- the cardiovascular morbidity and mortality.
Chronic obstructive pulmonary disease
- may be considered as a novel risk factor for new onset type 2 diabetes mellitus via
multiple pathophysiological alterations such as:
- inflammation and oxidative stress,
- insulin resistance,
- weight gain and
- alterations in metabolism of adipokines.
On the other hand, diabetes may act as an independent factor,
- negatively affecting pulmonary structure and function.
Diabetes is associated with an increased risk of
- pulmonary infections,
- disease exacerbations and
- worsened COPD outcomes.
On the top of that, coexistent OSA
- may increase the risk for type 2 DM in some individuals.
The current scientific data necessitate a greater outlook on chronic obstructive pulmonary disease and
- chronic obstructive pulmonary disease may be viewed as a risk factor for
- the new onset type 2 diabetes mellitus.
Conversely, both types of diabetes mellitus should be viewed as
- strong contributing factors for the development of obstructive lung disease.
Such approach can potentially improve the outcomes and medical control for both conditions,
- and, thus, decrease the healthcare burden of these major medical problems.
CONCLUSIONS
This discussion presents a spectrum of cardiovascular risk associated with type 2 diabetes mellitus, with high risk for CVD, stroke, endothelial dysfunction, and an association with obesity, measured by waist circumference, and an underlying proinflammatory state that can be measured by CRP.