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 124,988 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

In patients with type II diabetes mellitus, the prevalence of hypertension is increased as much as twofold over that in the nondiabetic population. Hypertension in diabetic patients increases the risk and accelerates the course of development of cardiac disease, stroke, peripheral vascular disease, retinopathy, and nephropathy. Despite the importance of hypertension in type II diabetics, the basic mechanisms that initiate and sustain hypertension in these patients are poorly understood. Contributing factors discussed in this review include the following: obesity, insulin resistance, hyperinsulinemia, genetic factors, and abnormalities of cellular cation homeostasis. Also discussed are the features of hypertension in type II diabetic individuals which are reminiscent of the hemodynamic abnormalities characterizing hypertension in the elderly, including increased vascular reactivity and increased atherosclerotic vascular disease. Recent evidence has shown that insulin resistance and hyperinsulinemia exist in as many as 50 to 70% of adult nonobese individuals with untreated hypertension. These observations strongly suggest that the disease known as hypertension is characterized by fundamental abnormalities of metabolism as well as by hemodynamic alterations. This review discusses the mechanisms by which hyperinsulinemia and/or insulin resistance may lead to hypertension. Elevated levels of triglycerides in plasma and suppressed high-density lipoprotein cholesterol concentrations are often observed in hypertensive individuals. These elevations may result, in part, from hyperinsulinemia and/or insulin resistance. Information will be presented suggesting that subtle abnormalities of carbohydrate metabolism that exist in patients with hypertension may contribute to the accelerated cardiovascular disease that accompanies the hypertension state. This review also addresses both special concerns about metabolic consequences of antihypertensive therapy in hypertensive patients with subtle carbohydrate intolerance as well as those in hypertensive patients with overt diabetes.
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PMID:Relationship between hypertension and subtle and overt abnormalities of carbohydrate metabolism. 1698 76

Fistula use for dialysis is less frequent among obese than non-obese patients. This discrepancy may be due to a lower rate of fistula placement in obese patients, a higher primary failure rate (fistulas that are never usable for dialysis), or a higher secondary failure rate (fistulas that fail after being used successfully for dialysis). Using a prospective, computerized vascular access database, we identified all patients receiving a first fistula or graft at our institution during a 2-year period. The access outcomes were compared between obese (body mass index (BMI) >or=30 kg/m2) and non-obese (BMI<30 kg/m2) patients. Fistula placement was equally likely between obese and non-obese patients (47.4 vs 47.1%). The primary failure rate of fistulas was similar in both groups (46 vs 41%, P=0.45). Among those fistulas that were usable for dialysis, the secondary survival was worse in obese patients (hazard ratio 2.74; 95% confidence interval (CI), 1.48-7.90; P=0.004). Secondary fistula survival in obese vs non-obese patients was 68 vs 92% at 1 year, 59 vs 78% at 2 years, and 47 vs 70% at 3 years. On multiple variable survival analysis with age, sex, race, diabetes, coronary artery disease, peripheral vascular disease, fistula location, surgeon, and obesity in the model, obesity was the only significant factor predicting secondary fistula failure (hazards ratio 2.93; 95% CI, 1.44-5.93; P=0.004). In conclusion, long-term fistula survival is worse in obese than non-obese patients, owing to a higher secondary failure rate.
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PMID:Impact of obesity on arteriovenous fistula outcomes in dialysis patients. 1742 18

Over the past decade, the frequency of use of enhanced external counterpulsation (EECP) has increased in patients with angina, irrespective of medical therapy and coronary revascularization status. Many patients referred for EECP have one or more comorbidities that could affect this treatment's efficacy, safety, or both. By use of data from more than 8,000 patients enrolled in the International EECP Patient Registry, we provide practical guidelines for the selection and treatment of patients. We have focused on considerations for patients who have one or more of the following characteristics: age older than 75 years, diabetes, obesity, heart failure, and peripheral vascular disease. We have also reviewed outcomes and treatment recommendations for individuals with poor diastolic augmentation during treatment, for those with atrial fibrillation or pacemakers, and for those receiving anticoagulation therapy. Lastly, we examined relevant data regarding extended courses of EECP, repeat therapy, or both. While clinical studies have demonstrated the usefulness of EECP in selected patients, these guidelines permit recommendations for the extended application of this important treatment to subsets of patients excluded from clinical trials.
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PMID:Primer: practical approach to the selection of patients for and application of EECP. 1706 67

Diabetes mellitus is associated with a greater risk of developing atherosclerosis and its complications: myocardial infarction, stroke and peripheral vascular disease. In patients with diabetes, atherosclerosis represents a complex multifactorial disease with increased lesion progression and severity compared to the nondiabetic population. Several risk factors have been proposed to explain the increased risk of cardiovascular disease with diabetes. They include: hyperglycemia, hypertension, dyslipidemia, obesity and other factors. It is difficult to precisely establish the elements leading to diabetes-accelerated atherosclerosis by means of epidemiological studies because all these factors coexist in diabetic patients. Then, management of atherosclerosis in diabetes is a multifactorial process involving nonpharmacological interventions like exercise, diet control, and pharmacological therapy directed at hypertension, hyperglycemia, and dyslipidemia.
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PMID:[Guidelines for the management of atherosclerotic diseases in diabetes mellitus]. 1708 99

Obesity is a widespread problem, particularly in the cardiovascular disease population. Obese patients have a lower incidence of cardiovascular mortality after elective percutaneous coronary interventions (PCIs); however, there is a paucity of data in the acute myocardial infarction (AMI) setting. This study investigated the effects of body mass index (BMI) on outcomes after percutaneous coronary revascularization in patients with AMI. Patients were categorized into 3 groups based on their BMI, i.e., normal, overweight, or obese. Most patients undergoing primary PCI for AMI (70%) were overweight or obese. Obese patients were significantly younger and more often diabetic, hypertensive, and hyperlipidemic compared with other groups. Angiographically, there was no difference in presence of multivessel disease, final Thrombolysis In Myocardial Infarction grade 3 flow, and presence of thrombus or dissection. Mortality was significantly lower in the hospital at 6 and 12 months in the obese group. Multivariate analysis demonstrated age>70 years, final Thrombolysis In Myocardial Infarction grade<3 flow, history of peripheral vascular disease, and ejection fraction to be the strongest predictors of mortality at 12 months. In conclusion, our data show that obese patients with AMI have a lower risk for in-hospital, 6-month, and 12-month mortality and cardiovascular events than patients with a normal BMI.
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PMID:Impact of body mass index on outcomes after percutaneous coronary intervention in patients with acute myocardial infarction. 1739 81

Cardiovascular disease, which includes coronary heart disease (CHD), cerebrovascular disease (CVD), and peripheral vascular disease (PVD), is the leading cause of mortality in populations, particularly in the diabetic one. Individuals with diabetes have at least a two-fold to four-fold increased risk of having cardiovascular events and a double risk of death compared with age-matched subjects without diabetes. A decline in mortality from CVD has been shown, but decline due to CHD is consistently lower in individuals with diabetes when compared with non-diabetics. The presence of several factors in diabetes leads to high occurrence of CVD such as hyperglycemia, insulin resistance, and classical and non-classical risk factors (systemic hypertension, dyslipidemia, obesity, proinflammatory condition and others). It is possible that the atherogenic role of obesity may be at least in part due to increased adipocyte production of cytokines. Considering the marked association of diabetes and CVD and unfavorable prognosis following an event, it is important to identify who is at high risk and how to screen. The American Heart Association and American Diabetes Association recommend risk stratification using diagnostic tests. However, the challenge is to accurately identify patients without a prior history of an event and those without symptoms strongly suggesting CVD, in whom additional testing would be indicated in order to achieve the most effective prevention. The benefits of glycemic control and the other risk factors have already been shown and justify optimization of the management of this high-risk population, aiming to reduce cardiovascular mortality disease and improve quality of life.
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PMID:[Cardiovascular disease in diabetes mellitus: classical and non-classical risk factors]. 1750 32

Cardiovascular disease (CVD), which includes coronary heart, cerebrovascular, and peripheral vascular disease, is the leading cause of death in the United States and most developed countries, accounting for about 50% of all deaths. The major risk factors include obesity and its consequences, dyslipidemia, hypertension, insulin resistance leading to diabetes, and cigarette smoking. In developing countries, CVD will become the leading cause of death due to alarming increases in obesity, sedentary lifestyles, cigarette smoking, and improvements in prevention and treatment of malnutrition and infection. Compared with nonschizophrenics, patients with schizophrenia have a 20% shorter life expectancy (i.e., from 76 to 61 years). In general populations, about 1% die from suicide compared with about 10% among patients with schizophrenia (relative risk = 10). For CVD, the corresponding figures are 50% and about 75% (relative risk = 1.5). In patients with schizophrenia, however, CVD occurs more frequently and accounts for more premature deaths than suicide. Patients with schizophrenia have alarmingly higher rates of obesity, dyslipidemia, hypertension, diabetes, and cigarette smoking than nonschizophrenic individuals in the general population. Compounding these data, patients with schizophrenia have less access to medical care, consume less medical care, and are less compliant. Primary prevention strategies should include the choice of antipsychotic drug regimens that do not adversely affect the major risk factors for CVD.
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PMID:Increasing global burden of cardiovascular disease in general populations and patients with schizophrenia. 1753 93

The growing incidence and prevalence of the overweight/obese condition across developed economies worldwide has an enormous impact on increasing the risk for the development of impaired glycemic control or insulin resistance and ultimately peripheral vascular disease (PVD) in afflicted individuals. This places an enormous economic and social burden on these societies, in terms of additional health care costs and lost productivity and through a reduction in the quality of life of the individual owing, in part, to the progressive PVD. Characterized by an inability of the vascular systems to adequately perfuse tissues and organs relative to their metabolic demand, PVD is in part a function of a structural remodeling of the microvascular networks such that the density of microvessel and capillaries within tissues is reduced below that under normal conditions, with the potential for profound negative impacts on the processes of mass transport and exchange. The review discusses the severity of the obesity "epidemic" from the perspective of PVD and the effects of the development of the obese, insulin-resistant condition on tissue/organ microvessel density. Additional material is reviewed that addresses ameliorative treatments, primarily exercise training, on blunting microvessel loss in the obese, insulin-resistant individual, and on potential mechanistic contributors that warrant considerable future investigation.
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PMID:Obesity, insulin resistance, and microvessel density. 1761 2

During the last two decades, various Doppler methods have been successfully used to screen patients with significant cerebral and peripheral vascular disease. In general terms, the principal advantages of Doppler ultrasound techniques in the evaluation of atherosclerotic lesions are that they: 1) are noninvasive, 2) are nontraumatic, 3) are relatively inexpensive, 4) provide anatomical and physiological data, and 5) provide direct and dynamic measurements. Nevertheless, the general limitations of the techniques are of equal importance: 1) the techniques are difficult in some subjects due to obesity and anatomical variations; 2) the technique cannot examine tissues surrounded by air or bone; 3) the techniques require operator skill and a thorough knowledge of human anatomy and cardiovascular dynamics; 4) the techniques have finite spatial resolutions which may compromise the important measurement of vessel diameter, ulceration, and percent stenosis; and 5) the techniques have finite velocity measuring capabilities which may compromise some measurements of highly disturbed blood velocities outside the range of 2-200 cm/sec. As clinical demands for the early diagnosis and quantification of vascular lesions increased, improvements in Doppler ultrasonics and spectra analysis significantly increased the technical and clinical capabilities of existing simple, inexpensive instruments. Presently, both anatomical and physiological images along with quantitative Doppler spectra from superficial and deep-lying vessels can be obtained. Consequently, the ability of new expensive imaging equipment to quantitate atherosclerotic lesions using spectral analysis techniques compares favorably with the interpretational precision of standard invasive or intravenous digital angiography.
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PMID:Quantitative evaluation of atherosclerosis using Doppler ultrasound. 1823 60

Arteriovenous fistulae (AVF) are widely regarded as the preferred vascular access in hemodialysis patients due to their primary patency and patient survival benefits. While the obesity paradox has been associated with improved cardiovascular morbidity and all-cause mortality in dialysis patients, its long-term vascular access outcomes are less clear. Recent literature has suggested that obese patients may have increased early and late fistula failure. The purpose of this study was to explore the relationships between obesity and vascular access outcomes. We performed a retrospective cohort analysis using the USRDS DMMS Wave 2 data set. All incident dialysis patients as of January 1, 1996, over the age of 18, receiving only hemodialysis as mode of renal replacement therapy were eligible for inclusion. Among other variables, data collected for the DMMS Wave 2 included: type and location of vascular access, AVF maturity, vascular access revision, and failure. Logistic regression analyses were used to examine the relationships between obesity and vascular access outcomes, adjusting for important covariates. In all, 1486 hemodialysis patients were included. Using body mass index (BMI) <30 kg/m(2) as reference, obesity did not emerge as a factor in predicting vascular access revisions or failures. An increased risk of AVF failure to mature was found only in the highest BMI quartile (>or=35 kg/m(2)) (aOR 3.66 [95% CI 1.27-10.55], p = 0.017). Peripheral vascular disease was independently associated with an increased risk of AVF failure (aOR 2.78 [95% CI 1.01-7.63], p = 0.047) and arteriovenous graft (AVG) failure (aOR 1.65 [95% CI 1.03-2.64], p = 0.036). Obesity was not associated with increased AVF or AVG revision rates or failure and only associated with poorer AVF maturity at highest BMI quartile. We conclude that obesity should not preclude placement of AVF as vascular access of choice, except in the very obese where assessment should be individually based.
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PMID:Obesity as a predictor of vascular access outcomes: analysis of the USRDS DMMS Wave II study. 1839 5


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