normal ejection fraction in type-2 diabetes mellitus. Patients with Diabetes Mellitus Type-2, Hypertension: BP³140/90 (with or without …
Original Article
ASSOCIATION OF HYPERTENSION AND DIASTOLIC DYSFUNCTION WITH TYPE-2 DIABETES MELLITUS
SM Sohail Ashraf1, Fasia Basir2 ABSTRACT Objective: To evaluate the prevalence of hypertension and diastolic dysfunction LVDD with normal ejection fraction in type-2 diabetes mellitus Method: Two hundred twelve diabetic patients 98 females and 114 males from January 2005 to June 2006 were enrolled in this study Their ages ranged from 35 to 65 years with mean age of 55 years Patients with Diabetes Mellitus Type-2, Hypertension: BP140/90 with or without medication Body Mass Index30, Waist-Hip ratio090 Left Ventricular Diastolic Dysfunction LVDD and Serum Triglyceride and HDL Cholesterol were included Result: Out of 212 patients, 10449 were found to be hypertensive both systolic and diastolic and 12 patients 56 were found to be suffering from isolated systolic hypertension Hence total number of hypertensive patients was 116 546 Thirty two patients were found to be suffering from diastolic dysfunction Conclusion: Hypertension and Diabetes are interlinked and show how micro and macrovascular complications of diabetes are increased when two conditions occur together The LVDD is much more
prevalent than previously suggested in patients with type-2 diabetes mellitus Hence LVDD is an early marker of diabetic cardiomyopathy KEYWORDS: Diabetes Mellitus Type-2, Hypertension, Diastolic dysfunction
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INTRODUCTION Diabetes Mellitus is a cardiovascular disease Two out of three diabetic patients die of cardiovascular disease or its complications1 According to the international diabetic federation the number of diabetic patients worldwide was estimated as 150 million in 2000, a figure that is said to rise to 300 million in 20252 The
1 Dr SM Sohail Ashraf DTCD,MCPS,MD Assistant professor of Medicine 2 Dr Fasia Basir FCPS Associate professor of Medicine 1-2: Ziauddin Medical University Hospital Kemari Campus Karachi - Pakistan Correspondence Dr SM Sohail Ashraf, D-87/1, Block 7, Gulshan-e-Iqbal, Karachi - Pakistan E-mail: drsohailashraf@gmailcom Received for Publication: Accepted: September 7, 2006 December 27, 2006 wwwpjmscompk
implications are enormous, both in terms of personal suffering and cost to health-care systems, which are increasingly faced with treating the serious macro-vascular complications of diabetes mellitus
Hypertension frequently co exists with diabetes, there is an increased prevalence of hypertension among diabetic patients 3 but there is also high propensity among hypertensive patients to develop type-2 diabetes 4,5 When occurring together the two disease entities appear to aggravate one another worsening both the diabetes and cardiovascular end points6 Data from UK Prospective Diabetes Study UKPDS revealed that every 10mmHg reduction in the level of systolic BP is associated with a nearly 12 lower incidence in myocardial infarction, down to a systolic BP level of 120mmHg7 Progressive lower diastolic BP also reduces CV risk progressively The Hyper-
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Hypertension, diastolic dysfunction type-2 diabetes
tension Optimal Treatment HOT trial showed that number of major cardiovascular events dropped in line with increasing astringent target diastolic BP-target8 These findings are reflected in the BP-target for diabetic patients of 130/80mm of Hg as now recommended by European Society of Hypertension,9 JNC7 report10 and American Diabetes Association11 Hypertension is the most important preventable cause of premature death in various countries The
ASCOT study AngloScandanavian Cardiac Outcomes Trial demonstrated both control of blood pressure and reduction in risk of strokes, heart attacks and other related diseases such as diabetes12 Regarding diastolic dysfunction the most common feature of diabetic heart is abnormal early left-ventricular diastolic filling, suggesting reduced compliance or prolonged relaxation13 because diabetes affect diastolic functions before systolic function,14 left ventricular diastolic dysfunction may be an early marker of diabetic cardiomyopathy Hypertension is also associated with impaired diastolic filling15 PATIENTS AND METHODS A total of 212 patients 98 females and 114 males of Diabetes Mellitus, 35 to 65 years of age mean age was 55 years, from Ziauddin Medical University Hospital and its consultation clinic Kaemari Campus were enrolled in this study during January 2005 to June 2006 Prevalence of Hypertension and left ventricular diastolic dysfunction was carried out by means of cross-sectional study and all the patients were selected on random sample basis The inclusion criteria was: Diabetes Mellitus Type-2, Hypertension: BP 140/90 mm Hg with or without medication Body Mass Index30
Waist-Hip ratio090 Diastolic Dysfunction Normal Systolic function LV ejection fraction 50 no segmental wall motion abnormalities and no evidence of significant coronary valvular, infiltrative pericardial or pulmonary disease and serum Triglyceride and HDL Cholesterol Patient on insulin therapy, those with history of angina pectoris or myocardial
infarction, Diabetic complications like Nephropathy, Neuropathy, and Retinopathy as well as valvular and congenital heart disease were excluded BP was measured with a random zero mercury sphygmanometer The mean of 6 measurements 3 while lying and 3 while standing of systolic and diastolic BP was used on different occasions As regards the assessment for obesity, BMI was calculated as weight in Kgs divided by the square of height in meters Waist circumference was calculated as an average of 2 measurements taken after inspiration and expiration at the mid-point of the lowest rib and iliac crest Waist-Hip ratio was defined as waist-girth divided by the hip-circumference measured at greater trochanter For assessment of blood sugar, HbA1c and dyslipidaemia, the patients were asked to fast 12 to 14 hours Then the blood samples were analysed The
reading of fasting blood glucose level, serum triglyceride, HDL, LDL Cholesterol plasma glucose concentration were measured by a glucose oxidase method and HbA1C was measured by an affinity binding assay, serum cholesterol, triglyceride and HDL were analyzed enzymatically The reading of fasting blood glucose level, serum triglyceride, HDL, LDL cholesterol and HbA1c were recorded For the assessment of effect on the CV system, ECG, chest X-ray and echocardiography were carried out Echocardiography was recorded by means of a 2-dimensional, M-mode and Doppler method Patients were examined on the left lateral decubitus position using standard parasternal, short axis and apical views Left ventricular diastolic dysfunction LVDD was evaluated All Doppler measurements were assessed at the end of expiration From the transmitted recording, the measurements were carried out Peak E- velocity in cms/ sec Peak early transmitted filling velocity during early diastole Peak A velocity in cms/sec peak transmitted Atrial filling Velocity during late diastole and declaration time in milliseconds Time elapsed between peak E-velocity and the point where the extrapolation of
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the declaration slope of the E-velocity crosses the zero base line No subject had echocardiographically detectable regional wall motion abnormalities and each subject had normal ejection fractions All the cardiac valves were examined to rule out significant valvular disease RESULT A total of 212 patients were screened and diagnosed with DM Type-2, their mean fasting blood sugar level was 140mg/dl On average basis HBA1C was proved to be 8 Their mean age was calculated as 55 years Mean duration of DM was 10 years Out of 212 patients, 10449 patients were found to be hypertensive both systolic and diastolic and 1256 patients were suffering from systolic hypertension Thus there were 116 hypertensive patients 546 Among them both systolic and diastolic hypertension, there were 58 males and 46 females Among systolic hypertensive patients 7 were males and 5 were females Serum Cholesterol was increased by 220mg/ dl mean Serum Trigyceride was found to be
Table-I: Characteristic of 212 diabetic patients Age in years mean Male Female Hypertension BMI Kg/m2 mean Fasting blood sugar mean HbA1C mean Blood cholesterol mean Blood triglycerides mean HDL mean
Waist-hip ratio Note: SD Standard deviation
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Table-II: Hypertension and diastolic dysfunction ratio in Diabetes Mellitus Sex Total No of patients n212 Male Female 114 98 Hypertension n116 65 57 51 52 Diastolic dysfunction n32 20175 12122
P-Value 0468 0283
55 SD6 114 98 116547 30 SD28 140m/dL SD129 8 SD095 220mg/dL SD2040 210mg/dL SD195 44mg/dL SD78 092 SD006
210mg/dl mean Overall Body Mass Index was found to be 30 and waist-hip ratio was 092 Diastolic dysfunction was carried out by means of 2-D 2 Dimensional colored Doppler, and M-Mode echocardiography was performed Only 3215 patients had shown isolated diastolic dysfunction having ejection fraction 50 There were no ECG changes in the heart All chest X-rays of patients were normal, so patients had Diabetes Mellitus Type-2 hypertension and diastolic dysfunction Thirty two out of 212 patients showed diastolic dysfunction with normal ejection fraction; subjects with impaired relaxation showed lower E-wave velocity compared with subjects with normal diastolic function A-wave velocity was higher in patients with impaired relaxation compared with patients with normal diastolic
dysfunction Hence E:A ratio showed an inverse proportion or less than one Most cases of diastolic dysfunction with normal ejection fraction were found in elderly age groups There was no correlation between the E:A ratio and lipid profile, E:A ratio and HbA1C, E:A ratio and fasting blood glucose, E:A ratio and fasting blood glucose, E:A ratio and left ventricular mass
Table-III: Involvement of different age groups Ages yrs 35-45 46-55 56-65 Total Diabetes Mellitus 20 94 98 212 Hypertension 6 52 58 116 Diastolic dysfunction 2 13 17 32
Hypertension, diastolic dysfunction type-2 diabetes
DISCUSSION According to the WHO estimates, there were 52 million Diabetics in the year 2000 and it will be 139 million by the year 2030 Pakistan is 6th in the world ranking16 Hence according to the DCCT and UKPDS, poor HbA1C control will be progressively worsening complications Every 1 decrease in mean HbA1C yields significant reduction in complications17 Hypertension is a common finding in patients with type-2 diabetes mellitus, when present it is an ominous sign that double the already elevated risk of future cardiovascular events Lowering BP has repeatedly shown to benefit hypertensive diabetic
patients in terms of both macro and micro vascular disease The fact that anti-hypertensive treatment reduces diabetic and CV end points in diabetes underlines the necessity to integrate rigorous BP control with glycaemic control in the management of diabetes In this study 212 diabetes mellitus patients were selected, out of which 116 patients 546 proved to be hypertensive Among them 12 patients were those who had systolic hypertension They belonged to 60 years of age FRAMINGHAM study revealed that on long term follow-up stroke and CHD are respectively 4 and 5 times more common in patients with systolic hypertension18 Both JNCVII and WHO: International Society of Hypertension sub-committee guidelines have strongly recommended treating systolic hypertension at 140mm Hg or even lower in diabetics This isolated systolic hypertension is due to arterial stiffness, which results in an increased PWV pulse wave velocity and therefore reflects high pulse pressure There is a doubling of cardiovascular events when hypertension and diabetes mellitus coexist19 With each disease patient has abnormalities in central and peripheral characteristics of cardiovascular structure and function that
precedes the clinical manifestation of cardiovascular disease, including increased left ventricular mass and wall thickness, left ventricular diastolic filling abnormalities impaired
endothelial functions and increased arterial stiffness The most common feature of the diabetic heart is abnormal early left ventricular diastolic filling, suggesting reduced compliance and prolonged relaxation13 Diabetes affects diastolic function before systolic function; left ventricular diastolic dysfunction LVDD may be an early marker of diabetic cardiomyopathy Hypertension is also associated with impaired diastolic filling20 In our study there were 32 cases of diastolic dysfunction with EF 50 This study shows inverse EA ratio, prolonged relaxation of left ventricle during M-Mode, 2-D and Doppler echocardiography though the number is small but it signifies alarming situation of diabetic heart in adults without any myocardial ischemia, congestive cardiac failure and any valvular heart disease As the age increases, there is a decrease in EA ratio This progression of LVDD with aging seems markedly accelerated by diabetes Hence increasing numbers of cases are found in elderly people in this study
Therefore LVDD can occur in individuals with wellcontrolled diabetes and without vascular complication This diabetic cardiomyopathy may happen due to arterial stiffness, inflammation, obesity and endothelial dysfunction21 CONCLUSION The evidence described clearly shows how closely Diabetes and hypertension are interlinked and how micro and macro vascular complications of Diabetes increase when the two conditions co-exist The LVDD is much more prevalent than previously thought in patients with type 2 Diabetes Mellitus who are free of clinically detectable heart disease Hence this study unmasks the significant number of LVDD For prevention one should adopt life style modifications to control blood sugar level and a Dietary Approach to Stop Hypertension DASH eating plans22 diet rich in fruits, vegetables and low fat dietary products with a reduced content of saturated and total fat
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