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The incidence of cardiovascular risk factors was studied in 83 renal transplant recipients: 84.3% showed at least one cardiovascular risk factor, hyperuricaemia was found in 42.2%, hypertension in 39.7%, hypercholesterolaemia in 31.3%, hypertriglyceridaemia in 27.7%, diabetes mellitus in 19.3%, obesity in 14% and nicotine abuse in 13.2% of the patients. Patients aged from 30 to 39 and 40 to 49 showed a mean incidence of 2.7 and 2.9, respectively out of the 7 investigated cardiovascular risk factors. The results demonstrate that renal transplant patients are a high-risk group for the development of degenerative cardiovascular diseases.
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PMID:[Frequency of cardiovascular risk factors in renal transplant patients (author's transl)]. 35 73

The impact of cardiovascular disease was compared in non-diabetics and diabetics in the Framingham cohort. In the first 20 years of the study about 6% of the women and 8% of the men were diagnosed as diabetics. The incidence of cardiovascular disease among diabetic men was twice that among non-diabetic men. Among diabetic women the incidence of cardiovascular disease was three times that among non-diabetic women. Judging from a comparison of standardized coefficients for the regression of incidence of cardiovascular disease on specified risk factors, there is no indication that the relationship of risk factors to the subsequent development of cardiovascular disease is different for diabetics and non-diabetics. This study suggests that the role of diabetes as a cardiovascular risk factor does not derive from an altered ability to contend with known risk factors.
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PMID:Diabetes and cardiovascular risk factors: the Framingham study. 75 26

The objective of this study was to determine whether a less favorable risk factor pattern for cardiovascular disease among persons with impaired glucose tolerance could be explained by fasting insulin, obesity, and/or a central distribution of body fat. Between 1984 and 1988, cardiovascular risk factors were examined cross-sectionally in Hispanic and non-Hispanic white participants in the San Luis Valley Diabetes Study who had either impaired (n = 173) or normal (n = 1,107) glucose tolerance. Sex-specific analysis of covariance models were constructed to adjust risk factor levels for age, age and insulin, and age, insulin, body mass index, and centrality index. Both males and females with impaired glucose tolerance had higher age-adjusted mean diastolic blood pressures, heart rates, uric acid levels, and triglyceride levels and lower levels of high density lipoprotein (HDL) cholesterol and HDL3 cholesterol than normal subjects; differences were significant for all risk factors except HDL cholesterol and HDL3 cholesterol in males. Differences in diastolic blood pressure in males, and differences in heart rate and triglyceride in both sexes, remained significant after adjustment for all covariates. However, differences in uric acid in males and differences in diastolic blood pressure and HDL3 cholesterol in females were attenuated to borderline significance levels. Differences in uric acid and HDL cholesterol in females were diminished to nonsignificant levels, especially after adjustment for obesity-related measures. With few exceptions, fasting insulin did not appear to play a major role in accounting for differences in these risk factors. With adjustment, ethnic differences (Hispanic vs. non-Hispanic white) were smaller and were statistically significant less often than differences observed between impaired and normal glucose tolerant groups. The authors concluded that hyperinsulinemia, obesity, and a central body fat distribution accounted for some, but usually not all, of the less favorable cardiovascular risk factor pattern found in subjects with impaired glucose tolerance.
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PMID:The roles of insulin, obesity, and fat distribution in the elevation of cardiovascular risk factors in impaired glucose tolerance. The San Luis Valley Diabetes Study. 146 70

Does poor health insurance coverage contribute to increased microvascular complications (nephropathy and retinopathy) in Mexican Americans with non-insulin-dependent diabetes? Mexican-American subjects with diabetes were identified in a population-based cardiovascular risk factor survey, the San Antonio Heart Study. Retinopathy, nephropathy, source of health care, and type and extent of health insurance coverage were assessed in a special diabetes complications exam. Among Mexican-American subjects with non-insulin-dependent diabetes diagnosed prior to their participation in the survey (n = 255), 26% (n = 67) lacked any type of health insurance, and 28% relied on county- or federal-funded clinics rather than private doctors as their primary source of care. Among those with health insurance (188 of 255), only 68% (127 of 188) or 24% of the total sample had private health insurance, and, of those with private insurance, 48% (35 of 73) received reimbursement for outpatient doctor visits and 57% for outpatient medications. Microvascular complications were more common among those who received their health care from a clinic versus a private doctor, and among those who lacked health insurance coverage for outpatient doctor visits and medications. Thus, poor health insurance coverage in the outpatient setting correlates with higher rates of microvascular complications among Mexican Americans with non-insulin-dependent diabetes mellitus.
J Diabetes Complications
PMID:The influence of outpatient insurance coverage on the microvascular complications of non-insulin-dependent diabetes in Mexican Americans. 148 81

Longitudinal studies have shown a large excess of cardiovascular mortality in insulin-dependent diabetic patients (IDDM) as compared to non-diabetic controls. Although diabetes appears to be an independent cardiovascular risk factor, increases in total and LDL-cholesterol together with a decrease of HDL-cholesterol are more pronounced in diabetics with cardiovascular disease. The general opinion, however, derived from a large number of cross-sectional studies, is that in well-controlled IDDM lipoprotein abnormalities are modest and only slightly different from matched non-diabetic controls. Most of the studies, however, used absolute criteria based on consensus statements and do not take the internal relations of the lipoproteins into account. When atherogenic indices (such as the relationship between total cholesterol and HDL-cholesterol or the Apo A1/apo B quotient) are used, 20 to 30% of an IDDM population considered to be in clinically acceptable control have to be considered pathological. This observation is even more important since the recent Diabetes Control and Complications Trial has shown that, especially in the younger group of patients, significantly higher total cholesterol and triglycerides and lower HDL-cholesterol were observed. Especially in these patients can diet and drug intervention be the most useful in the prevention of cardiovascular disease. These data are consistent with the fact that more sophisticated techniques have previously shown atherogenic changes in the composition of the VLDL-particles and lipoprotein enrichment in apo B. Since these techniques are not easily available in the clinic one has to refer to more classical techniques and the use of above mentioned atherogenic profiles to decide treatment.
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PMID:Atherogenic profiles in insulin-dependent diabetic patients and their treatment. 150 49

The authors report 22 cases of myocardial infarction documented by selective left ventriculography and coronary angiography in women under 45 years of age. The average age in this series was 36 +/- 6.8 years. Two patient groups were identified: Group I (n = 16) with the cardiovascular risk factor of oral contraception (mean age 33.9 +/- 5 years); and Group II (n = 6) comprising older patients (43.8 +/- 1.8 years) with a high prevalence of other risk factors (hyperlipidaemia, hypertension, diabetes). Myocardial infarction tended to be the inaugural event in Group I (9 out of 16 cases, 56.2%) whereas symptoms of effort angina were commonly observed in Group II (5 out of 6 cases, 83.3%). Coronary angiography showed more severe coronary lesions in Group II (score 1.5) than in Group I (score 0.75) in which isolated, single vessel disease mainly affecting the left anterior descending artery or normal coronary angiography was observed. Thrombolytic therapy was performed in 8 patients: percutaneous transluminal angioplasty was performed in 4 patients in the first month with a primary success in 3 cases. Coronary bypass surgery was performed in 1 case. The outcome during follow-up lasting 44.5 +/- 4.2 months was mainly favourable as 15 of the 20 patients had no secondary complications. Nevertheless, 2 patients died in the hospital period (1 from cardiogenic shock and 1 from complications of transluminal coronary angioplasty), 2 patients died less than 1 year after acute myocardial infarction (1 sudden death, 1 cardiogenic shock). Although oral contraception was withdrawn in all cases, many women continued to smoke.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:[Myocardial infarction in young women: apropos of 22 cases. Pathogenic and prognostic approach]. 155 Apr 34

Insulin resistance associated with hyperinsulinemia (metabolic syndrome) emerged in recent years as an important health risk which is present in approximately 25% of the normal population in western industrialized societies. Insulin resistance as assessed for the whole body arises from a reduced glucose utilization of skeletal muscle. If the metabolic syndrome persists over a prolonged period of time, detrimental influences on the cardiovascular system become apparent involving diabetes mellitus, hypertension, and arteriosclerosis. Of particular pathogenic relevance is an unbalanced influence of insulin arising either from a diminished or enhanced insulin action depending on whether the various tissues of the body exhibit a reduced or unchanged insulin sensitivity. Since insulin resistance and hyperinsulinemia appear to be affected by various lifestyle factors, the unique opportunity exists of reducing cardiovascular mortality by correcting this syndrome at a time when degenerative changes have not occurred in the cardiovascular system. Of great importance is the finding that dietary factors can have a modulatory action on insulin sensitivity. In animal experiments, an increased intake of (saturated) fat and refined carbohydrates increased insulin resistance. Since psychosocial distress is expected to be associated with a sustained activation of the sympathoadrenal axis, it is likely also to aggravate the metabolic syndrome. A factor with a beneficial action appears to be physical exercise. In view of the high incidence of cardiovascular diseases, further research on lifestyle factors with an insulin-sensitizing or insulin-desensitizing action is required. Of prime importance is the reevaluation of established dietary recommendations and diets should be designed which take into account the individual cardiovascular risk factor profile.
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PMID:Insulin resistance, hyperinsulinemia, and cardiovascular disease. The need for novel dietary prevention strategies. 159 Jul 42

It is highly probable that the menopause, spontaneous or above all artificially induced, is a cardiovascular risk factor. However, it is less important than other conditions (hypertension, smoking, obesity, diabetes, hypercholesterolemia) with which it is often associated and which it may favourise or worsen. In this respect, hormone replacement therapy is probably beneficial, probably by an action on the arterial endothelium itself, and certainly by opposing the factors which favourise the development of atheroma (metabolic and hemostasis disorders). Its aims and techniques, and hence its cardiovascular consequences, are very different from those of hormonal contraception, with which it must neither be compared nor confused. It would be reasonable, on the basis of these advantages, to extend the indications of post-menopausal hormone replacement therapy to an increasing number of women and for a longer period.
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PMID:[Cardiovascular risk after menopause]. 161 97

Hypertension is one of the primary risk factors for cardiovascular disease, especially coronary artery disease (CAD), cerebrovascular disease, and congestive heart failure. Recent analysis of the numerous prospective clinical trials of the efficacy of antihypertensive therapy performed during the past quarter century has shown that active treatment reduces mortality and cerebrovascular disease but has not prevented CAD. The reason for this paradox--that lowering blood pressure does not reduce CAD mortality or morbidity--is uncertain. During the past several years, it has become clear that hyperinsulinemia and peripheral insulin resistance constitute the link between hypertension, obesity, and non-insulin-dependent diabetes mellitus, three conditions in which the rate of CAD is very high. Other studies have shown that hyperinsulinemia is a potent cardiovascular risk factor. Epidemiologic surveys and retrospective reviews of clinical experience have pointed out the surprising fact that when hypertension and non-insulin-dependent diabetes mellitus occur in the same patient, hypertension is likely to be diagnosed first and the risk of developing diabetes is much higher if antihypertensive drugs (thiazide diuretics or beta-adrenoreceptor blockers) were given. Recently, careful studies have shown that both thiazide diuretic and beta-adrenoreceptor blockers worsen insulin sensitivity, whereas angiotensin converting enzyme inhibitors (captopril) and peripheral alpha 1-blockers (prazosin) improve it and also favorably affect the levels of other atherogenic risk factors. Although it is too early to be certain, this information suggests that, pending the results of long-term clinical trials that measure clinical events, treatment of hypertension might be better able to reduce CAD if it were directed at improving insulin sensitivity. Nonpharmacologic measures that reduce hyperinsulinemia, weight loss, and exercise should be vigorously recommended, and pharmacologic therapy should be aimed at avoiding drugs that worsen insulin sensitivity, as long as blood pressure is successfully reduced.
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PMID:The coronary artery disease paradox: the role of hyperinsulinemia and insulin resistance and implications for therapy. 169 28

Cardiovascular disease, and in particular ischemic heart disease, is the principal cause of morbidity, functional disability, and mortality in patients with non-insulin-dependent (type II) diabetes. The main risk factors for the macrovascular complications of diabetes are dyslipidemia, hypertension, and cigarette smoking. Although degree of hyperglycemia is a risk factor for microvascular complications, it is not a prominent risk factor for macrovascular complications. Nevertheless, there are theoretical reasons for believing that glycemic control could lower cardiovascular risk. For example, glycemic control may both improve clearance and suppress hepatic overproduction of very-low-density lipoprotein. Moreover, there is direct empirical evidence that improved glycemic control can favorably alter lipid profiles in type II diabetic patients. Despite this, the only clinical trial that has assessed cardiovascular mortality as an end point in diabetic subjects (i.e., the University Group Diabetes Program) failed to demonstrate a benefit of glycemic control. In this study, the insulin-variable group, which achieved sustained glycemic control relative to the placebo group, had essentially the same cardiovascular mortality as the latter group. All of the conventional lipid-lowering agents have been shown to produce favorable changes in lipid profiles in diabetic subjects. However, the optimum regimen remains to be defined. Metabolic differences between diabetic and nondiabetic subjects mean that the optimum lipid-lowering regimens for the two categories of patients may differ. For example, nicotinic acid, which is a powerful lipid-altering drug, may worsen glucose intolerance. The characteristic lipid abnormalities in type II diabetic subjects are hypertriglyceridemia and low high-density lipoprotein cholesterol, not hypercholesterolemia. Although the role of hypertriglyceridemia as a cardiovascular risk factor in the general population has been questioned, there is evidence that this lipid abnormality may play a stronger role in diabetic subjects. For all of the above reasons, there is an urgent need for large-scale clinical trials assessing cardiovascular end points and testing various strategies of improving lipid profiles in diabetic subjects, particularly given the fact that all of the current generation of lipid-lowering trials have systematically excluded diabetic patients.
Diabetes Care 1991 Dec
PMID:Dyslipidemia in type II diabetes. Implications for therapeutic intervention. 177 1


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