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Diabetic heart disease (DHD) is one of the most important contemporary management problems confronting the entire diabetic management team. DHD is multifactorial and multifaceted. The three major problems are: coronary artery disease (CAD), autonomic cardiac denervation and a specific heart muscle disease in diabetes (diabetic cardiomyopathy). Various other ancillary problems include obesity, hypertension, lipid aberrations and rheological alterations etc. CAD and diabetes mellitus (DM) have a greater association; the disease is more severe, sets in early and has many atypical features including painless, silent onset, delayed arrival at intensive coronary care unit, increased incidence of pump failure and arrhythmias and high case fatality rate. Autonomic cardiac denervation is an important and a common companion of diabetic peripheral neuropathy and has serious repercussions in DHD. Simple, sensitive screening tests may identify such a group so as to exercise caution in management. Various clinical (non-invasive, invasive and autopsy) and experimental studies provide evidence for the existence of a specific diabetic heart muscle disease comprising of small vessel disease and metabolic aberrations. Recent advances in literature and our own experience are reviewed. The practical management aspects of each facet, such as maintenance of high index of suspicion, early diagnosis and referral, close monitoring, role of rigid blood glucose control and specific role of each member of the diabetic team is outlined. The possible preventative strategies are discussed.
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PMID:Diabetic heart disease--current problems and their management. 268 Nov 39

Serum high density lipoproteins (HDL) are a protective factor against atherosclerosis. Many epidemiological studies show a strong inverse relationship between serum HDL-cholesterol (HDL-C) and the likelihood of developing coronary artery disease (CAD). HDL-C levels appear to be a stronger predictive factor for CAD than serum total or low density lipoprotein cholesterol (LDL-C) levels. In the presence of high HDL-C levels, the development of CAD is unlikely even in persons with increased total or LDL-C. Conversely, subjects with low serum levels of HDL-C are at increased risk even if their total and LDL-C is within the "desirable" range. A number of studies have also shown that increasing HDL-C levels is associated with both primary and secondary prevention of atherosclerosis. HDL-C levels should be estimated in individuals with family and/or personal history of premature atherosclerosis, even if they have normal total cholesterol. Only the current problems with the accuracy and precision of the serum HDL-C assay prevent it from being the single most important test for assessment of the lipid risk factors for CAD. The most frequent causes of low HDL-C are smoking, obesity, and hypertriglyceridemia. Treatment of low HDL-C includes removal of these factors, and if this is ineffective, use of drugs. Gemfibrozil and niacin are most effective in raising serum HDL-C, although a number of other medications can markedly improve the total:HDL-C ratio.
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PMID:The clinical significance of serum high density lipoproteins. 269 72

Cardiovascular disorders pose a major health problem for industrialized societies in terms of excess morbidity and mortality. Hypertension (HT) is a major risk factor for coronary heart disease (CHD) and cerebrovascular disease. The impact of psychosocial factors, personality traits, genetic-behavioral interactions, sodium sensitivity, obesity, insulin metabolism, and psychophysiology on HT status is discussed. An understanding of pathophysiologic processes is needed to provide a better basis for risk factor reduction and other aspects of treatment. The study of myocardial ischemia appears to provide an important link between the development of coronary artery disease and the occurrence of CHD. Further studies are needed to assess the clinical significance of stress-induced myocardial ischemia as well as whether mental stress is predictive of future CHD. Associations have been made between behavioral risk factors and CHD, but the exact nature of the relationship remains to be clarified. Hostility has been identified as an important aspect of coronary-prone behavior, but considerable research will have to be completed before a comprehensive understanding of coronary-prone behavior and the manner in which it has an impact on disease can be fully understood.
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PMID:Biobehavioral aspects of cardiovascular disease: progress and prospects. 270 Mar 41

Differences in the importance of risk factors according to the anatomic location of coronary artery disease (CAD) were assessed in 4722 men and 1069 women who underwent arteriography. Examined characteristics included total and high-density lipoprotein (HDL)-cholesterol, triglycerides, obesity, smoking, alcohol consumption, diabetes, and hypertension. Of these risk factors, the ratio of total to HDL-cholesterol showed the highest correlation with the overall severity of CAD (r = 0.24, men; r = 0.38, women); in contrast, its relation to left main (LM) disease was much lower (r = 0.10, men; r = 0.08 women) than were correlations with stenotic disease in the left anterior descending, circumflex, and right coronary arteries. Other risk factors also showed weaker associations with LM disease than with stenoses in other vessels, and none was related to increased LM disease after controlling for disease in other vessels. For example, as compared with men who had no significant CAD, those with 1-, 2-, and 3-vessel disease had mean increases in total cholesterol of 12, 18, and 19 mg/dl, respectively. In contrast, after adjusting for disease in other vessels, LM disease (present in 293 men) was associated with only a 4 mg/dl increase in mean cholesterol levels (P = 0.20). These results indicate that the relation of risk factors to CAD differs according to the location of the stenotic disease, and that LM disease is poorly predicted by the standard risk factors.
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PMID:Risk factors and the anatomic distribution of coronary artery disease. 271 65

A prospective study correlated coronary risk factors with new coronary events in 192 elderly men and 516 elderly women, mean age 82 +/- 8 years. Follow-up was 41 +/- 6 months (range 24-44). Coronary events (myocardial infarction, primary ventricular fibrillation, and sudden cardiac death) occurred in 64 of 192 men (33%) and in 149 of 516 women (29%), P not significant. Using univariate analysis, significant risk factors for coronary events were antecedent coronary artery disease, cigarette smoking, hypertension, diabetes mellitus, serum total cholesterol (TC) greater than or equal to 200 mg/dL and greater than or equal to 250 mg/dL, serum high-density lipoprotein cholesterol (HDL-C) less than 35 mg/dL, and serum TC/HDL-C greater than or equal to 6.5 in men and women, and obesity in women. Using multivariate analysis, significant risk factors for coronary events were age, antecedent coronary artery disease, cigarette smoking, hypertension, diabetes mellitus, and serum TC in men and women and serum HDL-C and serum triglycerides in women. Using univariate analysis, significant risk factors for coronary events in men and women with antecedent coronary artery disease were cigarette smoking, diabetes mellitus, serum TC greater than or equal to 250 mg/dL, and serum TC/HDL-C greater than or equal to 6.5. Using multivariate analysis, significant risk factors for coronary events in men and women with antecedent coronary artery disease were age, cigarette smoking, diabetes mellitus, serum TC, serum HDL-C, and serum triglycerides.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:41-month follow-up of risk factors correlated with new coronary events in 708 elderly patients. 271 56

The fibrinogen and orosomucoid levels in plasma were studied in 249 patients within 24 h after admission to the coronary care unit because of suspected unstable coronary artery disease (CAD), i.e. unstable angina pectoris or non-Q-wave myocardial infarction (MI). Of these patients, 127 were considered to have unstable CAD either because of symptoms and signs of coronary insufficiency at a pre-discharge exercise test (n = 66) or because of the development of a probable or definite non-Q-wave MI (n = 61). The other chest pain patients without objective signs of myocardial ischaemia constituted the control group. A diagnosis of unstable CAD, and the occurrence of obesity or current smoking contributed independently to elevated fibrinogen and orosomucoid levels. In patients with non-Q-wave MI both the fibrinogen and orosomucoid levels were high regardless of obesity and smoking, indicating myocardial necrosis as a prominent cause for the elevation of these acute phase reactants. Obesity and smoking seemed to influence the metabolism of fibrinogen and orosomucoid and change their basal level and/or exaggerate their response to inflammatory stimuli. The increased fibrinogen level in unstable CAD might reflect a hypercoagulable state that contributes toward a progression of coronary lesions.
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PMID:Plasma fibrinogen in unstable coronary artery disease. 272 17

Clinical experience of diagnostic and interventional procedures, including cardiac surgery, indicates a greater prevalence of coronary heart disease in white men than in other race-gender groups. Studies of children and young adults in the Bogalusa Heart Study have provided evidence that might account for this race-gender contrast. A variety of anthropometric and metabolic parameters influencing serum lipid and lipoprotein levels places white boys and young white men selectively at high risk for the development of atherosclerotic coronary artery disease. Obesity and greater central body fat, subtle aberrations in carbohydrate-lipid metabolic relations and variability in sex hormone profiles appear to underlie a trend to adverse lipoprotein changes in white men. A lower high-density lipoprotein cholesterol level and apolipoprotein A-l at puberty and a dramatic increase of low-density lipoprotein cholesterol are seen in young white men; such adverse changes identify them to be at greater risk. It is noteworthy that children whose fathers had myocardial infarction tend to be white. These children also have relatively high ratios of apolipoprotein B/apolipoprotein A-l and apolipoprotein B/low-density lipoprotein cholesterol. Studies of risk factors in children emphasize their importance in the early natural history of coronary artery disease. These findings show the need for beginning prevention of adult heart disease in childhood.
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PMID:Insight into a bad omen for white men: coronary artery disease--the Bogalusa Heart Study. 275 97

In order to assess the relationship between obesity and serum lipids, a homogenous group of adult men and premenopausal women is assessed for body mass index, body fat distribution reflected by the waist/hip ratio (WHR), serum lipid parameters and apolipoproteins. Body fat distribution is distinguished in an abdominal and gluteal-femoral type using a cut-off point of 1.00 for the ratio of waist-to-hips girth for men. In women the cut-off value is considered as 0.80 but was also evaluated when considered as 0.85. In the next step tertiles for WHR are created to show a graded relationship between WHR and lipoprotein fraction. The results indicate that WHR is an important determinant for most atherosclerosis-related lipids and apoproteins: in both men (P less than 0.05) and women (P less than 0.005) WHR is significantly correlated with apolipoprotein B. Using multiple regression analysis, in women WHR seems to be the most important dependent variable, where body mass index is not significantly contributing to the explained variance. In men, however, besides WHR age is the most significant variable, although age distribution is similar in men and women. Using tertiles of WHR, we show a clear graded relationship with most lipids and lipoproteins; this gives additionally an argument to confirm that in women WHR = 0.80 is the most accurate cut-off value for abdominal obesity. This study demonstrates that both obese men and women with an abdominal fat mass distribution show a lipid and apoprotein profile that is less favorable than that seen in gluteal-femoral obese subjects insofar as the risk of coronary artery disease is concerned.
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PMID:Apolipoprotein concentrations in obese subjects with upper and lower body fat mass distribution. 276 78

Coagulation plays an important role in the pathogenesis of coronary artery disease. Therefore, reversing a tendency to thrombosis may be an avenue for its prevention. Because of an association between obesity and high levels of several coagulation factors, the effect of weight loss on coagulation factors VII and X was investigated among subjects taking part in a 3-month weight loss study. At baseline, both coagulation factors were correlated with age, Quetelet's index, total cholesterol and triglycerides. During the diet period, the subjects lost an average of 3.5 kg at 1 month and 4.2 kg at 3 months, whereas lipoproteins changed in only minor ways. In the group as a whole, factor VII and X both decreased at 1 month but returned to or exceeded the baseline levels despite continued weight loss at 3 months. Although changes in weight, serum total cholesterol and triglycerides were correlated with the changes in the factors during the first month, during months 2 and 3 these correlations remained substantial only for triglycerides. Multiple regression analysis indicated that changes in weight, cholesterol and triglycerides could not explain the decreasing and increasing pattern in factors VII and X. These data suggest that weight itself does not explain the association between obesity and factors VII and X, and that weight loss does not effectively decrease the levels of these factors.
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PMID:Effect of weight loss on coagulation factors VII and X. 277 96

Unlike coronary artery disease, peripheral atherosclerosis is considered to be infrequent in heterozygous familial hypercholesterolaemia. The authors studied 20 consecutive asymptomatic familial hypercholesterolaemic patients and an age- and sex-matched control group of consecutive normolipidaemic and asymptomatic patients admitted to the hospital for elective non-vascular surgery. The patients and the controls were studied non-invasively by measuring the ankle-arm systolic blood pressure ratio at rest. Peripheral atherosclerosis was common in this study population in contrast to the control group: an abnormal (less than 0.97) pressure ratio was found in 13 patients (65%) in the study group but in only one person in the control group. Eight out of 20 patients had coronary artery disease, and seven of them had an asymptomatic concomitant peripheral artery disease. Neither the classical risk factors, i.e. age, smoking, obesity, hypertension and glucose intolerance, nor serum lipid or lipoprotein status or the parameters of cholesterol metabolism correlated with peripheral atherosclerosis. It is concluded that atherosclerosis in familial hypercholesterolaemia is a multilevel disease that frequently affects also the peripheral arteries.
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PMID:Peripheral atherosclerosis in familial hypercholesterolaemia. 278 75


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