Elsevier

Atherosclerosis

Volume 219, Issue 2, December 2011, Pages 623-629
Atherosclerosis

Qualitative score of systemic arteriosclerosis by vascular ultrasonography as a predictor of coronary artery disease in type 2 diabetes

https://doi.org/10.1016/j.atherosclerosis.2011.08.043Get rights and content

Abstract

Objective

Patients with type 2 diabetes mellitus (T2DM) are at risk of polyvascular comorbidities and poor prognosis. Non-invasive techniques for early prediction of coronary artery disease (CAD) are desirable to prevent cardiovascular events in these patients. The aim of the present study was to investigate the association between CAD and systemic arteriosclerosis by qualitative vascular ultrasonography.

Methods

The study subjects were 102 consecutive outpatients with T2DM [males/females = 60/42, age: mean ± SD 67 ± 9 (range, 40–85) years] evaluated by vascular ultrasonography for arteriosclerosis in the abdominal aorta, carotid, renal, and common iliac arteries. The total number of detected arteriosclerotic vascular lesions in the four arteries was determined. CAD was diagnosed by two cardiologists using either stress electrocardiography, myocardial scintigraphy, multi-detector row computed tomography or coronary angiography.

Results

Multiple arteriosclerotic vascular lesions (>1) were detected in 64 (63%) patients. The total systemic vascular score was significantly higher in patients with CAD than those without (average score 2.7 versus 1.0, p < 0.0001). None of the CAD patients had a total score of 0. Age- and sex-adjusted multiple logistic regression analysis identified total score of ≥2 as the only predictor of CAD (p < 0.001). The sensitivity, specificity, positive and negative predictive values for total systemic vascular score in the prediction of CAD were 98%, 77%, 83%, and 97%, respectively, which were better than those for carotid mean and maximum intima-media thickness.

Conclusion

Non-invasive qualitative evaluation of systemic arteriosclerosis by the total systemic vascular score is potentially useful for the early prediction of CAD in T2DM patients.

Introduction

Patients with type 2 diabetes (T2DM) are at a substantially higher risk of mortality, primarily from cardiovascular disease, than the general population [1]. They can also develop severe polyvascular complications, such as atherosclerosis, cerebrovascular disease (CVD), coronary artery disease (CAD), nephrosclerosis, abdominal aneurysm and peripheral arterial disease (PAD) [2], [3], with a poor prognosis. In this regard, the currently available non-invasive methods do not allow accurate early assessment of systemic arteriosclerosis.

Myocardial ischemia in T2DM patients is often asymptomatic [4] and frequently in an advanced stage when it manifests clinically. Furthermore, diabetics are often at higher risk of new-onset and recurrence of myocardial infarction compared with non-diabetics [5]. The morbidity and mortality of CAD patients with T2DM are also worse than in non-diabetics [5]. Therefore, non-invasive and early prediction of CAD is important in T2DM to prevent cardiovascular events. Previous studies reported that carotid intima-media thickness (IMT) measured by ultrasonography correlates with CAD and cardiovascular events [6], [7]. Although measurement of IMT is a non-invasive and useful method for screening CAD, the cut off values of carotid IMT for identification of CAD are controversial [6], [7].

The aim of the present study was to determine the relation between CAD and systemic arteriosclerosis estimated by qualitative vascular ultrasonography. Specifically, we assessed the utility of the total systemic vascular score, as a non-invasive qualitative index of systemic arteriosclerosis measured by vascular ultrasonography, in the prediction of CAD in T2DM patients.

Section snippets

Participants

The study subjects were 102 consecutive Japanese patients with T2DM who visited the outpatient clinic of the Department of Metabolic Medicine, Osaka University Hospital, between September 2009 and March 2011, and subsequently underwent evaluation for systemic arteriosclerosis by ultrasonography. Table 1 summarizes the profiles of all participants. The Medical Ethics Committee of Osaka University approved this study. All participants were Japanese and each gave a written informed consent. This

Characteristics of diabetic patients

The baseline characteristics of the 102 patients with T2DM are listed in Table 1. The mean age was 67 ± 9 years (range 40–85 years). In the present study, 71% of the patients (n = 73/102) had visceral fat accumulation (estimated visceral fat area; eVFA  100 cm2), based on the Japanese criteria of visceral fat accumulation measured by CT scan [19] and by the bioelectrical impedance analysis method [20], 61% (n = 62/102) had the metabolic syndrome, and 53% (n = 54/102) of patients had CAD.

Evaluation of systemic arteriosclerosis

Fig. 2A shows the

Discussion

The major findings of the present study were: (1) more than 60% of type 2 DM Japanese patients had systemic arteriosclerosis (average duration of diabetes mellitus was 12.8 years), (2) systemic vascular score ≥2 was a significant marker for CAD, and (3) the performance of total systemic vascular score of ≥2 for the diagnosis of CAD was better than the mean and max IMT.

Patients with symptomatic atherothrombosis including those with T2DM have polyvascular diseases (coronary artery disease,

Conflict of interest

The authors declare no conflict of interest.

Funding

This research was supported in part by a Grant-in-Aid for Scientific Research on Innovative Areas No. 22126008 (to T.F. and K.K.)

Contributions

A.H and K.K. recruited the patients, collected and analyzed the data, and wrote the manuscript. K.K. also participated in the concept and design of the study, interpretation of data and reviewed/edited the manuscript. A.H-S. and H.N. recruited and examined the patients, and collected data. T.F. and I.S. contributed to the discussion and wrote the manuscript. All authors read and approved the final version of the manuscript.

Acknowledgements

We are grateful to Dr. Norikazu Maeda for patient enrolment, and Dr. Hiroshi Mastuo, Mrs. Kayoko Asahi and Mr. Tomohiro Kitazawa for help with ultrasonography. We also thank all staff at “Diabetes & Metabolic Station” for the excellent medical care.

References (36)

  • N.A. Roper et al.

    Excess mortality in a population with diabetes and the impact of material deprivation: longitudinal, population based study

    BMJ

    (2001)
  • P.G. Steg et al.

    One-year cardiovascular event rates in outpatients with atherothrombosis

    JAMA

    (2007)
  • S. Nakamura et al.

    The incidence and risk factors of renal artery stenosis in patients with severe carotid artery stenosis

    Hypertens Res

    (2007)
  • F.J. Wackers et al.

    Detection of Ischemia in Asymptomatic Diabetics Investigators Detection of silent myocardial ischemia in asymptomatic diabetic subjects: the DIAD study

    Diabetes Care

    (2004)
  • S.M. Haffner et al.

    Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction

    N Engl J Med

    (1998)
  • D.H. O‘Leary et al.

    Carotid-artery intima and media thickness as a risk factor for myocardial infarction and stroke in older adults

    N Engl J Med

    (1999)
  • M.W. Lorenz et al.

    Prediction of clinical cardiovascular events with carotid intima-media thickness: a systematic review and meta-analysis

    Circulation

    (2007)
  • N. Katakami et al.

    Serum endogenous secretory RAGE level is an independent risk factor for the progression of carotid atherosclerosis in type 1 diabetes

    Atherosclerosis

    (2009)
  • Terminology Diagnostic Criteria Committee, Japan Society of Ultrasonics in Medicine

    Subcommittee for preparing guidelines for ultrasound diagnosis of carotid artery: standard method for ultrasound evaluation of carotid artery lesions

    Jpn J Med Ultrasonics

    (2009)
  • T. Machino-Ohtsuka et al.

    Combined assessment of carotid vulnerable plaque, renal insufficiency, eosinophilia, and hs-CRP for predicting risky aortic plaque of cholesterol crystal embolism

    Circ J

    (2010)
  • T. Zeller et al.

    Color-coded duplex ultrasound for diagnosis of renal artery stenosis and as follow-up examination after revascularization

    Catheter Cardiovasc Interv

    (2008)
  • H.G. Alcorn et al.

    Risk factors for abdominal aortic aneurysms in older adults enrolled in The Cardiovascular Health Study

    Arterioscler Thromb Vasc Biol

    (1996)
  • M.T. Upton et al.

    Detecting abnormalities in left ventricular function during exercise before angina and ST-segment depression

    Circulation

    (1980)
  • W.S. Aronow et al.

    Five year follow-up of double Master's test, maximal treadmill stress test, and resting and postexercise apexcardiogram in asymptomatic persons

    Circulation

    (1975)
  • Y. Inobe et al.

    Role of adenosine in pathogenesis of syndrome X: assessment with coronary hemodynamic measurements and thallium-201 myocardial single-photon emission computed tomography

    J Am Coll Cardiol

    (1996)
  • W.G. Austen et al.

    A reporting system on patients evaluated for coronary artery disease: report of the ad hoc committee for grading of coronary artery disease, Council on Cardiovascular Surgery, American Heart Association

    Circulation

    (1975)
  • M. Ryo et al.

    A new simple method for the measurement of visceral fat accumulation by bioelectrical impedance

    Diabetes Care

    (2005)
  • S. Matsuo et al.

    Collaborators developing the Japanese equation for estimated GFR revised equations for estimated GFR from serum creatinine in Japan

    Am J Kidney Dis

    (2009)
  • Cited by (17)

    • Radial artery intima-media ratio predicts presence of coronary thin-cap fibroatheroma: A frequency domain-optical coherence tomography study

      2013, International Journal of Cardiology
      Citation Excerpt :

      Atherosclerosis is a chronic inflammatory disease involving large and medium-sized arteries [1]. Non-invasive parameters such as ultrasound-detected carotid intimal-medial thickness have been considered as valid tool for early prediction of coronary artery disease [4]. Of note, only few reports have investigated the relations between RA intimal–medial hyperplasia and coronary atherosclerosis [21,22], with only one group concentrating on intimal thickness [23,24].

    • Correlation between serum C1q-adiponectin/total adiponectin ratio and polyvascular lesions detected by vascular ultrasonography in Japanese type 2 diabetics

      2013, Metabolism: Clinical and Experimental
      Citation Excerpt :

      The maximum carotid IMT (Max IMT) and mean IMT of the common carotid artery, and ankle–brachial index (ABI), were measured. Systemic atherosclerosis was assessed by vascular ultrasonography, as reported previously by our group [5]. Briefly, atherosclerosis was evaluated qualitatively by vascular ultrasonography using an ultrasound scanner.

    • High serum S100A8/A9 levels and high cardiovascular complication rate in type 2 diabetics with ultrasonographic low carotid plaque density

      2012, Diabetes Research and Clinical Practice
      Citation Excerpt :

      Fig. 1A shows representative images of carotid plaques with low (left) and high (right) RPD values. Based upon 80% power to detect statistically significant differences (p = 0.05; two-sided), a sample size of at least 29 patients in each group was required to demonstrate (total sample size = 58), according to previous report [22]. Height (cm), weight (kg) (and body mass index [BMI] in kg/m2) and waist circumference (WC) at umbilical level (cm) were measured in the standing position.

    • Metabolic syndrome correlates with polyvascular lesions detected by systemic vascular ultrasonography in Japanese people with type 2 diabetes

      2012, Diabetes Research and Clinical Practice
      Citation Excerpt :

      The study (ADMIT study; UMIN 000002271) subjects were 102 consecutive Japanese patients with T2DM [males/females: 60/42, age (mean ± SD [range]): 67 ± 9 [40–85] years, body mass index (BMI): 25.7 ± 0.4 [19.1–38.5] kg/m2, duration of diabetes mellitus: 12.8 ± 0.9 [1–36] years, HbA1c (NGSP): 7.2 ± 0.1 [5.4–10.6] %], who visited the outpatient clinic of “Diabetes & Metabolic Station”, Osaka University Hospital, between September 2009 and March 2011, and subsequently underwent evaluation for systemic arteriosclerosis by ultrasonography. Description of recruitment and sample characteristics has been published elsewhere [4]. Patients with a previous diagnosis of dyslipidemia or hypertension and receiving drugs for any of these conditions were also included in this study (81% and 64%, respectively).

    View all citing articles on Scopus
    View full text