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 147,016 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Type 2 diabetes is preceded by long-standing asymptomatic hyperglycaemia. This prediabetic state is characterised by elevated post-prandial hyperglycaemia and yet normal fasting plasma glucose (FPG). The relationship between abnormal circulating glucose levels and the development of long-term diabetic complications became apparent 70 years ago, soon after the introduction of insulin and the prevention of early death due to ketoacidosis. The main issues regarding diabetes and the various target organs throughout the cardiovascular system, including coronary artery disease (CAD), peripheral vascular disease (PVD), increased intima-media thickness (IMT) and stroke, are as follows: CAD causes much of the serious morbidity and mortality in patients with diabetes, who have a 2- to 4-fold increased risk of CAD; epidemiological evidence confirms an association between diabetes and increased prevalence of PVD; and diabetes induces increased IMT and stroke by adversely affecting cerebrovascular circulation including the carotid artery, akin to its effects in the coronary and lower extremity vasculature. In diabetes, FPG and HbA(1C) are the main parameters of glucose metabolism used to monitor and control hyperglycaemia. Recently, particular emphasis has been placed on post-prandial plasma glucose as a parameter in the metabolic assessment of diabetic patients. Therefore, while addressing the question of hyperglycaemia and its relation to cardiovascular morbidity and mortality, we have to look for the possible mechanisms by which diabetic hyperglycaemia causes these complications. Then, we must examine the evidence on how the main parameters of glucose metabolism correlate with cardiovascular complications. This review addresses these issues.
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PMID:Hyperglycaemia and its relation to cardiovascular morbidity and mortality: has it been resolved? 1470 73

Clinically recognized disorders of glucose metabolism include impaired fasting glucose, impaired glucose tolerance (both termed prediabetes), and diabetes mellitus. Type 2 diabetes mellitus affects 6% to 13% of adults in the United States. Among patients with recent stroke, 70% will have known diabetes, occult diabetes (detectable on an oral glucose tolerance test), or prediabetes. Type 2 diabetes mellitus is associated with a two- to six-fold increased risk for first or recurrent ischemic stroke. The mechanisms for the association are myriad and include the effects of hyperglycemia on vascular tissues and coagulation, and aberrations in blood pressure regulation, lipid metabolism, endothelial function, vascular inflammation, lipid metabolism, smooth muscle cell proliferation, and fibrinolysis. The most effective strategies to prevent stroke among people with diabetes include blood pressure control, antiplatelet therapy, and statin therapy. Tight glycemic control is recommended to prevent microvascular disease, but the effect on macrovascular disease, including stroke, has not been proven. Target blood pressure should be less than 130/80. Antiplatelet therapy may be accomplished with 81 to 325 mg of aspirin daily or 75 mg of clopidogrel daily. Statins should be given in dosages effective to reduce low-density lipoprotein cholesterol to less than 100 mg/dL. For glycemic control, first line therapy for most patients is metformin, starting at 500 mg daily. With time, most patients will need two or three oral medications from different classes and many eventually will require insulin therapy. Prevention of diabetes may be best accomplished by identifying those at risk and modifying diet, weight, and exercise habits. Screening for prediabetes and diabetes is appropriate for men and women older than 45 years and all individuals with vascular disease. Insulin resistance and impaired insulin secretion is the major underlying defect in type 2 diabetes mellitus. It also affects 50% of nondiabetic subjects with a recent ischemic stroke. Emerging evidence has linked insulin resistance to the pathophysiologic derangements in type 2 diabetes mellitus that accelerate atherosclerosis. Treatment of insulin resistance with weight loss, exercise, or medication can correct these derangements, and represents a promising approach to stroke prevention.
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PMID:Type 2 Diabetes Mellitus and Insulin Resistance: Stroke Prevention and Management. 1546 22

Prediabetes is associated with a length-dependent polyneuropathy that typically is sensory predominant and painful. A diagnosis of prediabetes should be sought in patients with otherwise idiopathic sensory-predominant neuropathy by doing a 2-hour oral glucose tolerance test. Fasting plasma glucose of 100 to 125 mg/dL or 2-hour glucose 140 to 199 mg/dL (impaired glucose tolerance) constitutes prediabetes. Most patients with neuropathy associated with prediabetes (NAP) are obese and show metabolic manifestations of insulin resistance, including hyperlipidemia and hypertension. Appropriate treatment addresses hyperglycemia, insulin resistance, and neuropathic pain. Professionally administered individualized diet and exercise counseling (modeled on the Diabetes Prevention Program) has been shown to be more effective than glucose-lowering medications in preventing progression from impaired glucose tolerance to diabetes, and is the mainstay of treatment for all patients with NAP. The goals of this therapy should be a 5% to 7% reduction in weight and an increase to 30 minutes of moderate exercise five times weekly. Patients with prediabetes are at increased risk for myocardial infarction, stroke, and peripheral vascular disease. Therefore, risk reduction with control of hypertension and hyperlipidemia is essential. Neuropathic pain troubles nearly every patient with NAP, and often limits aerobic exercise. No trials have specifically addressed the patient population with NAP, and neuropathic pain treatment closely follows recommendations for diabetic neuropathy. Gabapentin, lamotrigine, and tricyclic antidepressants are well-validated first-line therapies. Adjunctive therapy with opioids, nonsteroidal anti-inflammatory drugs often are necessary. Diet and exercise seem to reduce neuropathic pain in patients with NAP.
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PMID:Polyneuropathy with Impaired Glucose Tolerance: Implications for Diagnosis and Therapy. 1561 Jul 5

The metabolic syndrome is a worldwide epidemic, setting the stage for type 2 diabetes and its microvascular complications, and acceleration of macrovascular disease. Insulin resistance, hyperglycemia, dyslipidemia, hypertension, thrombotic disorders and adiposity define the metabolic syndrome and contribute to endothelial dysfunction and, subsequently, to accelerated atherosclerosis. Angiotensin II contributes to the development and progression of cardiovascular and renal endpoints and, as such, angiotensin II receptor blockers and angiotensin-converting enzyme inhibitors demonstrate a protective effect. Ligands for the peroxisome proliferator-activated receptor gamma (PPAR gamma), appear to impact favourably on atherosclerosis through both direct and indirect mechanisms. In humans, these ligands improve endothelial function, attenuate albuminuria and hypertension, and potentially prevent conversion of prediabetes to type 2 diabetes. Statins also have proven benefit in decreasing overall cardiovascular and stroke mortality and morbidity. The combination of angiotensin II blockade, statin therapy and PPAR gamma activation might emerge as an important global therapeutic strategy in the metabolic syndrome and diabetes. Further studies are needed to determine whether they have synergistic effects to protect the vasculature.
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PMID:Metabolic syndrome-interdependence of the cardiovascular and metabolic pathways. 1578 Aug 21

Stroke and peripheral neuropathy are recognized neurological complications of diabetes. Increasing epidemiological evidence also implicates the prediabetic state of impaired glucose tolerance (IGT) as a risk factor for cerebrovascular events and peripheral neuropathy. Data linking IGT to cognitive decline or deficits, however, are less robust. IGT is one component of metabolic syndrome, together with central obesity, hypertension, hypertriglyceridemia and reduced HDL. Each component of metabolic syndrome is an independent risk factor for stroke, but hyperglycemia might be more important than other components in the pathogenesis of neuropathy. Goal-driven diet and exercise regimens, together with pharmacological treatment of hyperlipidemia and hypertension, reduce stroke risk, but the effect of these interventions on neuropathy has not been fully explored.
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PMID:Therapy insight: neurological complications of prediabetes. 1693 64

Chronic hyperglycaemia (e.g. type 2 diabetes mellitus (T2DM) and prediabetes) in humans is associated with an increased risk of cardiovascular (CV) complications, and, vice versa, the presence of CV complications (e.g. myocardial infarction, stroke or intermittent claudication) among patients heightens the risk of T2DM or prediabetes. In both cases (i.e. chronic hyperglycaemia and CV complications), significant diagnostic and treatment challenges resulting from a broad range of factors may serve as barriers to reducing the deleterious societal impact of T2DM and prediabetes. These challenges often include clinicians: failing to intervene early and aggressively enough among patients with T2DM to achieve CV risk factor control; failing to efficaciously identify T2DM patients with already established CV complications; and failing proactively to assess individuals at high risk for T2DM. This review discusses the apparent symbiosis between CV disease and T2DM, with a focus on identifying patients with established T2DM or at risk for T2DM; traditional and novel risk factors and markers for CV disease in T2DM; challenges related to diagnosing CV disease in T2DM; and organization of T2DM care in order to prevent CV complications. These are issues that require attention because identifying patients at high risk for T2DM can halt or reduce their further glycaemic deterioration if addressed properly, and because novel markers and non-invasive tests could be applied in patients with T2DM as a means of detecting and possibly treating unrecognized CV disease in time. Furthermore, several approaches for T2DM care can be effective in controlling the CV risk factors contributing to CV complications.
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PMID:Cardiovascular disease and type 2 diabetes mellitus: a multifaceted symbiosis. 1785 97

At least one fourth of U.S. adults are known to have prediabetes, a condition defined as having impaired fasting glucose (plasma glucose level of 100 to <126 mg/dL after an overnight fast), impaired glucose tolerance (plasma glucose level of 140 to <200 mg/dL after a 2-hour oral glucose tolerance test), or both. Persons with prediabetes are at increased risk for developing type 2 diabetes, heart disease, and stroke. However, lifestyle changes can prevent or delay development of diabetes and its complications among persons with prediabetes. To assess the prevalence of self-reported prediabetes among U.S. adults and the prevalence of activities that can reduce the risk for diabetes, CDC analyzed responses to questions regarding prediabetes asked for the first time in the 2006 National Health Interview Survey. This report summarizes the results of that analysis, which determined that, although at least one fourth of U.S. adults are known to have prediabetes through surveys that included laboratory testing, in 2006, only an estimated 4% of U.S. adults had been told they had prediabetes. Among those who had been told they had prediabetes, 68% had tried to lose or control weight, 55% had increased physical activity or exercise, 60% had reduced dietary fat or calories, and 42% had engaged in all three activities. Persons at greater risk for diabetes should be tested according to published recommendations, and persons with prediabetes should lose or control their weight and increase their physical activity to reduce their risk for developing diabetes.
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PMID:Self-reported prediabetes and risk-reduction activities--United States, 2006. 1898 16

Recent studies support the concept that the retinal vasculature may provide a summary measure of lifetime exposure to the effects of hyperglycemia. Advances in retinal photographic techniques and in image analysis have allowed objective and precise in vivo measurement of retinal vascular changes. In particular, quantitative assessment of retinopathy signs and measurement of retinal vascular caliber have greatly increased our knowledge of early microcirculatory alterations in prediabetes, diabetes, and diabetic micro- and macrovascular complications. Data from recent population-based studies suggest that retinal arteriolar and venular caliber changes reflect different pathophysiologic processes. Retinal arteriolar narrowing, for example, is associated with risk of diabetes and coronary artery disease, whereas retinal venular widening is associated with development and progression of diabetic retinopathy and risk of stroke. Studying these changes offers the potential to improve our understanding of the early pathophysiologic pathways of diabetes development and its complications. Future research will assess the ability of retinal vascular imaging to provide clinically useful prognostic information for patients with diabetes.
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PMID:Retinal vascular changes and diabetic retinopathy. 1964 Mar 40

Numerous studies have linked individual vascular factors to dementia including Alzheimer's disease (AD). We investigated different vascular risk profiles in relation to dementia and AD among very old people. A standardized follow-up procedure was applied three times to a dementia-free cohort (n=1270, age >or= 75) over a nine-year period to detect dementia and AD cases using the DSM-III-R criteria. We examined two vascular risk profiles, which were scored by counting the number of corresponding vascular factors: 1) atherosclerotic profile included systolic pressure >or= 160 mmHg, diabetes/prediabetes, and stroke; and 2) cerebral hypoperfusion profile constituted diastolic pressure < 70 mmHg, pulse pressure < 70 mmHg, and heart failure. Data were analyzed with Cox proportional-hazards models controlling for major potential confounders. During the 6406 person-years of follow-up, 428 subjects developed dementia, including 328 AD cases. All components of vascular profiles were significantly or marginally associated with increased dementia risk. The risk of dementias was increased with increasing score of both risk profiles (p for trend <or= 0.001); subjects with a score >or= 2 in either profile had an approximately twofold-increased risk for dementia and AD. These data suggest that aggregation of atherosclerotic- and hypoperfusion-related vascular factors increases the risk of dementia in very old people. Severe cerebral atherosclerosis and insufficient perfusion are involved in the development of dementia including AD.
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PMID:Vascular risk profiles for dementia and Alzheimer's disease in very old people: a population-based longitudinal study. 2016 87

Current guidelines recommend risk stratification largely based on traditional risk factors such as those in the Framingham Risk Score. We studied the distribution of 12 traditional and non-traditional risk markers (age > or =65 years, male gender, family history of premature coronary heart disease, low-density lipoprotein cholesterol > or =70 mg/dl, high-density lipoprotein cholesterol <40 mg/dl in men and <50 mg/dl in women, systolic blood pressure >130 mm Hg, diabetes mellitus, smoking, C-reactive protein > or =2 mg/L, triglycerides >150 mg/dl, prediabetes defined as a fasting glucose level 100 to 125 mg/dl or hemoglobin A1c >6, and obesity defined as body mass index > or =30 kg/m(2)) in 3,675 patients from the PROVE IT-TIMI 22 trial at 4 months and evaluated the risk of cardiovascular events stratified by the number of risk factors. The median number of risk factors was 5. In individual risk factor subgroups, men, smokers, hypertensives, and patients with increased low-density lipoprotein cholesterol had just that added risk factor compared to their counterparts (median 5 vs 4). In contrast, patients with diabetes, prediabetes, and increased triglycerides, C-reactive protein, or body mass index had not only that, but also another added risk factor (median 6 vs 4). A higher risk factor count was strongly related with increased rate of death, myocardial infarction, unstable angina, stroke, or revascularization, from 0% to 38.6% at 2 years for 0 to > or =9 risk factors (p <0.0001). In conclusion, with the observed "clustering" of risk factors and the link between increasing risk factor count and adverse outcomes in a patient with 1 diagnosed risk factor, a comprehensive review of traditional and novel risk factors is important to fully assess cardiovascular risk.
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PMID:Distribution of traditional and novel risk factors and their relation to subsequent cardiovascular events in patients with acute coronary syndromes (from the PROVE IT-TIMI 22 trial). 2018 6


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