Silent myocardial ischemia and related risk factors in patients with type 2 diabetes mellitus

Öz

Objectives: The aim of this study was to investigate the frequency of silent myocardial ischemia (SMI) in patients with Type 2 diabetes mellitus (DM) who do not have isch­emic cardiac disease. Materials and Methods: To examine the relationship between ischemic cardiac disease and related factors such as blood pressure, lipid profile, smoking, gender, family history, body mass index (BMI), microalbuminuria, hsCRP, 150 diabetic patients who have never had any known coroner artery disease, exertional or rest dyspnea and labored breathing, aged between 35 and 70 years were included. Effort testing (treadmill) were performed to examine the existence of SMI. Results: Effort testing gave positive result for SMI in 20 patients and negative in 130 patients. Coronary angiog­raphy was performed in 20 patients with positive effort testing results. The frequency of SMI was found as %13.3 by effort testing. The frequency of SMI (including non-crit­ical patients) was %10.6 (16 patients) by using coronary angiography, which 13(8.6%) had critical and 3(2%) had non-critical coronary stenosis. No significant differences were found in age, gender, diabetic duration, trigliserid, HDL- cholesterol, blood pressure, BMI and hsCRP levels between positive and negative SMI patients with Type 2 DM. Conclusion: We determined that high LDL-Cholesterol and HbA1c and existence of microalbuminuria indicated significant SMI risk for patients with Type 2 DM.

Anahtar Kelimeler

• Diabetes mellitus, silent myocardial isch­emia, lipoproteins, electrocardiography

Tip 2 diyabetes mellituslu hastalarda sessiz miyokard iskemisi ve ilişkili risk faktörleri

Öz

Amaç: İskemik kalp hastalığı olmayan Tip 2 diyabetes mellituslu (DM) hastalarda sessiz miyokardiyal iskemisi (SMI) sıklığını araştırmak amaçlandı. Gereç ve Yöntem: Diyabetik hastalardaki kan basıncı, li­pid profili, sigara kullanımı, cinsiyet, aile öyküsü, vücut kit­le indeksi (VKİ), mikroalbüminüri, duyarlı C-reaktif protein (hsCRP) düzeyleri ölçülerek, efor testi sonuçları ile ilişkisi araştırıldı. önceden bilinen koroner arter hastalığı bulun­mayan, efor veya istirahat dispnesi tanımlamayan, 35-70 yaş arası ve kan basıncı 140/80 mmHg\'nın altında olan, 150 diyabetik hasta çalışmaya alındı. Bu hastalara sessiz miyokard iskemisi sıklığını araştırmak üzere efor testi ya­pıldı ve test pozitif çıkanlara anjiyografi uygulandı. Bulgular: Efor testi yapılan hastalardan 20\'sinde (%13.3) efor testi sonucunda miyokard iskemisi saptanırken, 130 (%87.7) hastada test sonucu negatif bulundu. Efor testi pozitif olan 20 hastaya iskemiyi doğrulamak için koroner anjiyografi yapıldı. Anjiyografi sonucunda 13 (%8.6) has­tada koroner arter darlığı, 3 (%2) hastada ise kritik olma­yan darlık saptandı. Böylece toplam olarak 16 (%10.6) hastada miyokard iskemisi saptandı. Tip 2 DM\'li sessiz iskemi pozitif ve negatif olan hastalar arasında yaş, cinsiyet, diyabet süresi, trigliserid, HDL-K, kan basıncı, VKİ ve hsCRP değerleri arasında anlamlı fark saptanmadı. Sonuç: Tip 2 DM\'li hastalarda yüksek LDL-K, kötü glisemik kontrol (yüksek HbA1c) ve mikroalbüminürinin bulunması sessiz iskemi açısından anlamlı risk oluşturmaktadır.

Anahtar Kelimeler

• Diyabetes mellitus, sessiz miyokar­diyal iskemi, lipoproteinler, vücut kitle indeksi, elektrokar­diyografi

Kaynakça

1. Lochen ML. The Tromso study: the prevalence of exercise-in- duced silent miyocardial ischemia and relation the risk factors for coronary heart disease in apparently healthy population. Eur Heart J 1992; 13: 728-731.
2. Lubaszewski W, Kawecka-Jaszcz K, Czarnecka D, Rajzer M, Stochmal A. Silent miyocardial ischemia in patients with es- sential arterial hypertension and non-insulin dependent diabetes mellitus. J Hum Hypertens 1999; 13: 309-313
3. Diagnosis and classification of diabetes mellitus. By Diabetes Care 27: 5-10, 2004
4. Jacoby RM, Nesto RW. Acute myocardial infarction in the dia- betic patient: pathophysiology, clinical course and prognosis. J Am Coll Cardiol 20:736-744, 1992
5. Herlitz J, Malmberg K, Karlson BW, Ryden L, Hjalmarson A. Mortality and morbidity during a five-year follow-up of diabetics with myocardial infarction. Acta Med Scand 224:31-38, 1988
6. Haffner SM. Cor. heart dis. in patients with diabetes. N Engl J Med 342:1040-1042, 2000
7. Lochen ML. The Tromso study: the prevalence of exercise-in- duced silent myocardial ischemia and relation the risc factors for coronary heart disease in apparently healthy population. Eur Heart J 13:728-731, 1992
8. Lubaszewski W, Kawecka-Jaszcz K, Czarnecka D, Rajzer M, Stochmal A. Silent myocardial ischemia in patients with essen- tial arterial hypertension and non- insulin dependent diabetes mellitus. J Hum Hypertens 13:309-313, 1999

9. Cohn PF. Silent myocardial ischemia. Ann Intern Med 109:312- 317, 1988
10. Detrana R, Gianrossi R, Frocclicher U. The diagnostic accuracy of the exercise electrocardiogram: A metaanalysis of 22 years of research. P.Cardiovasc Dis 32:173-206, 1989
11. DeLuca AJ, Saulle LN, Aronow WS, Ravipati G, Weiss MB. Prevalence of silent myocardial ischemia in persons with diabe- tes mellitus or impaired glucose intolerance and association of hemoglobin A c with prevalence of silent myocardial ischemia. Am J Cardiol 95(12):1472-4, 2005
12. Fleg JL, Gerstenbliyh G, Zonderman AB, et al. Prevalence and prognosis significance of exercise-induced silent myocardial ischemia detected by thallium scintigraphy and electrocardi- ography in asymptomatic volunteers. Circulation 81:428- 436, 1990
13. Inoguchi T, Yamashita T, Umeda F, Mihara H, Nakagaki O, Taka- da K, Kawano T, Murao H, Doi T, Nawata H. High incidence of silent myocardial ischemia in elderly patients with non-insulin dependent diabetes mellitus. Diabetes Res Clin Pract 47:42-45, 2000
14. Liebow IM, Hellerstein HK, Miller M. Atherosclerotic heart dis- ease in diabetes mellitus. Am J Med 18:438-447, 1955
15. Hambly RI, Sherman L, Mehta J, Aintablian A. Reappraisal of the role of the diabetic state in coronary artery disease. Chest 70:251-7, 1976
16. Milan Study on Atherosclerosis and Diabetes (MISAD Group) Prevalence of unrecognised silent myocardial ischemia and its association with atherosclerotic risk factors in non-insulin de- pendent diabetes mellitus. Am J Cardiol 79:134-139, 1997
17. Gokcel A, Aydin M, Yalcin F, Yapar AF, Ertorer ME, Ozsahin AK, Muderrisoglu H, Aktas A, Guvener N, Akbaba M. Silent coronary artery disease in patients with type 2 diabetes mellitus. Acta Diabetol 40:176-180, 2003
18. Naka M, Hiramatsu K, Aizawa T, Momose A, Yoshizawa K, Shigematsu S, Ishihara F, Niwa A, Yamada T. Silent myocardial ischemia in patients with non-insulin dependent diabetes melli- tus as judged by treadmill exercise testing and coronary angiog- raphy. Am Heart J 123:46-53, 1992
19. Janand-Delenne B, Savin B, Habib G, Bory M, Vague P, Lass- mann V. Silent myocardial ischemia in patients with diabetes: who to screen. Diabetes Care, 22:1396-1400, 1999
20. Sargin H, Ozisik M, Ozisik NC, Seven O, Orbay E, Gozu H, Sargin M, Tekce M, Yayla A. The prevalence of silent ischemia in Turkish patients with type 2 diabetes mellitus. Tohoku J Exp Med 205:351-355, 2005
21. Faglia E, Fabrizio F, Patrizia C, Felice P, et al. Cardiac events in 735 type 2 diabetic patients who underwent screening for un- known asymptomatic coronary heart disease. 5-year follow-up report from the Milan Study on Atherosclerosis and Diabetes (MiSAD). Diabetes Care 25:2032-2036, 2002
22. Milan Study on atherosclerosis and diabetes (MiSAD) group. Prevalence of unrecognized silent myocardial ischemia and its association with atherosclerotic risk factors in noninsulin-depen- dent diabetes mellitus. Am J Cardiol 1997;79:134-9.
23. Karam JH. Diabetes Mellitus Perspectives on Therapy: ndocronil Metab. Clin North Am, 1992; 21:199-219
24. Abraira C, Colwell JA, Nuttall FQ, et al. For the Veterans Affairs Cooperative Study on Glycemic Control and Complications in type 2 diabetes (VA CSDM) Group: Cardiovascular events and correlates in the Veterans Affairs Diabetes Feasibility Trial. Arch Intern Med. 157:181-88, 1997
25. UK Prospective Diabetes Study Group: Tight blood pressure con- trol and risk of macrovasculer and microvasculer complications in type 2 diabetes (UKPDS 38). BMJ 1998; 317: 703-713.
26. Gerstei HC, Mann JF, Yi Q, Zinman B, et al. Microalbuminuria and risk of cardiovascular events, death and heart failure in dia- betic and nondiabetic individuals. JAMA 2001; 286: 421-6.
27. Taskıran M, Rasmussen B, et al. Urinary albumin excretion in hospitalize patients with acute myocardial infarctus. Scand Car- diovasc J 1998; 32: 163-6
28. Ford ES. Body mass index, diabetes and C reactive protein among US adults. Diabetes Care 1999; 22:1971-7