Quantitative Comparison of Angiographic Characteristics of Coronary Artery Disease in Patients With Noninsulin-Dependent Diabetes Mellitus Compared With Matched Nondiabetic Control Subjects

doi:10.1016/S0002-9149(97)00420-7

The American Journal of Cardiology

Volume 80, Issue 5, 1 September 1997, Pages 550-556

https://doi.org/10.1016/S0002-9149(97)00420-7 Get rights and content

Abstract

The angiographic characteristics of coronary artery disease (CAD) in noninsulin-dependent diabetes mellitus (NIDDM) patients were studied by quantitative coronary angiography (QCA). Fifty-seven consecutive NIDDM patients undergoing clinically indicated elective coronary angiography and 57 nondiabetic coronary artery disease (CAD) patients were individually matched for sex, age, and body mass index. Technically adequate coronary angiograms, available for 55 subjects in each group, were analyzed with third-generation QCA software. To evaluate the anatomic severity and extent of CAD, several QCA-derived parameters were incorporated into indexes describing various per-patient features of CAD. These measures reflect CAD severity, extent, and overall “atheroma burden,” and were calculated separately for different coronary segments (i.e., left main, proximal, mid, and distal segments), for the different coronary arterial territories (i.e., left main, left anterior descending, left circumflex, and right), and for the entire coronary tree. No significant differences were found between the NIDDM and nondiabetic groups (global severity index, 51 ± 14 vs 54 ± 13, p = NS; global extent index, 34 ± 13 vs 32 ± 12, p = NS; global atheroma burden index, 27 ± 16 vs 24 ± 12, p = NS). We also found no between-group differences in proximal, mid, or distal segments, in separate vessel territories, or in left ventricular function. Our data suggest that CAD patients, with and without NIDDM, who have similar symptoms at a given age, have similar severity and extent of CAD.

Section snippets

Patients and Control Subjects

The study included 57 consecutive NIDDM patients undergoing clinically indicated elective coronary angiography at Helsinki University Central Hospital between September 1989 and February 1992. All patients, aged ≤65 years, had previously diagnosed diabetes fullfilling the World Health Organization criteria[7] for NIDDM and were found to have ≥1 major coronary branch with ≥50% severe diameter stenosis according to visual estimation by the attending cardiologist. Fifty men and 7 women were

Results

Characteristics of study groups are outlined in Table 1. Two of 57 patients or their matched controls were exluded from the study because of poor image quality. Therefore, each of the final study groups included 48 male and 7 female matched subjects. Because of the matching, the groups were well balanced for age and body mass index. Twelve of the NIDDM patients were treated by diet only, 33 were on oral hypoglycemic therapy, and 2 on a combined insulin and oral regimen. Insulin as the only

Discussion

This study focused on the angiographic characteristics of coronary atherosclerosis and left ventricular function in diabetic men and women who underwent coronary angiography in our hospital because of symptomatic CAD. The patients were carefully selected to represent noninsulin-dependent (type 2) diabetes; thus, although some of our patients were treated with insulin, this was due to secondary failure of dietary and oral therapy. In all cases diabetes had been diagnosed after the age of 35 and

References (29)

RI Hamby et al.
Reappraisal of the role of the diabetic state in coronary artery disease
Chest
(1976)
BF Waller et al.
Status of the coronary arteries at necropsy in diabetes mellitus with onset after age 30 years. Analysis of 229 diabetic patients with and without clinical evidence of coronary disease and comparison to 183 control subjects
Am J Med
(1980)
VJ Vigorita et al.
Absence of correlation between coronary arterial atherosclerosis and severity or duration of diabetes mellitus of adult onset
Am J Cardiol
(1980)
JS Hochman et al.
The distribution of atherosclerotic lesions in the coronary arterial tree: relation to cardiac risk factors
Am Heart J
(1988)
PMJ Van der Zwet et al.
A new approach for the quantification of complex lesion morphology: the gradient field transform; basic principles and validation results
J Am Coll Cardiol
(1994)
RL Kirkeeide et al.
Assessment of coronary stenoses by myocardial imaging during pharmacologic coronary vasodilation. VII. Validation of coronary flow reserve as a single integrated functional measure of stenosis severity reflecting all its geometric dimensions
J Am Coll Cardiol
(1986)
GG Gensini
A more meaningful scoring system for determining the severity of coronary artery disease
Am J Cardiol
(1983)
CJ Slager et al.
Quantitative assessment of regional left ventricular motion using endocardial landmarks
J Am Coll Cardiol
(1986)
RF Bradley et al.
Coronary heart disease in the diabetic patient
Med Clin North Am
(1965)
RM Jacoby et al.
Acute myocardial infarction in the diabetic patient: pathophysiology, clinical course and prognosis
J Am Coll Cardiol
(1992)

RW Nesto et al.

Asymptomatic myocardial ischemia in diabetic patients

Am J Med

(1986)

BF Uretsky et al.

Symptomatic myocardial infarction without chest pain: prevalence and clinical course

Am J Cardiol

(1977)

P Valsania et al.

Severity of coronary artery disease in young patients with insulin-dependent diabetes mellitus

Am Heart J

(1991)

AC Dortimer et al.

Diffuse coronary artery disease in diabetic patients: fact or fiction?

Circulation

(1978)

Cited by (65)

Relationship between Syntax Score and prognostic localization of coronary artery lesions with conventional risk factors, plasma profile markers, and carotid atherosclerosis (CAPP Study 2)
2018, International Journal of Cardiology
Citation Excerpt :
In agreement with our results, Krishhaswami et al. [39] reported that the severity of CAD was not related to diabetes, hypertension, dyslipidemia, and smoking. Similarly, Pajunen et al. [40] did not find any difference in terms of severity and extent of CAD in diabetic and nondiabetic patients. Our hypothesis is that once CAD is triggered, it seems to no longer fulfill the criterion of factorial proportion.
Data concerning the relationship between cardiovascular risk factors, plasmatic markers, carotid disease and extent of coronary lesions are lacking.
To evaluate the role of cardiovascular risk factors, plasmatic levels of high sensitivity C-reactive protein (hs-CRP), fibrinogen, lipoprotein(a), and carotid plaque extension in predicting the severity of coronary artery disease (CAD).
We analyzed 574 subjects undergoing first coronary angiography. For angiographic analysis, we used the Syntax Score and we defined the prognostic localization of CAD as a critical stenosis of the left main and/or proximal segment of left anterior descending artery. Levels of hs-CRP > 3 mg/L, lipoprotein(a) plasma levels > 30 mg/dL and plasma fibrinogen > 300 mg/dL were considered critical. Significant carotid disease (SCD) was defined by the presence of lesions producing a 50% diameter stenosis with a peak systolic velocity > 125 cm/s. A mean carotid intima media thickness (IMT) > 0.9 mm was considered abnormal.
In the adjusted analysis the presence of SCD was found to be an independent predictor of high Syntax Score (p < 0.001), while high fibrinogen levels were independently associated with the presence of CAD in prognostic localization (p = 0.04). In the sub-group of patients without SCD, IMT > 0.9 mm was found to be an independent predictor of the presence of CAD (p < 0.001).
SCD strongly predicts high Syntax Score, while IMT shows excellent positive predictive value for the presence of CAD. In addition, high plasma fibrinogen levels are associated with coronary stenoses in prognostic localization.
Elevated glycated albumin and reduced endogenous secretory receptor for advanced glycation endproducts levels in serum predict major adverse cardio-cerebral events in patients with type 2 diabetes and stable coronary artery disease
2015, International Journal of Cardiology
Glycated albumin (GA) and the endogenous secretory receptor for advanced glycation endproducts (esRAGE) may modulate risk related to atherosclerosis. We tested the hypothesis that elevated GA and reduced esRAGE in serum are associated with adverse clinical outcomes in patients with type 2 diabetes and stable coronary artery disease (CAD).
We determined GA and esRAGE serum levels in 576 consecutive patients with type 2 diabetes and stable CAD undergoing sirolimus-eluting stent (SES)-PCI. The primary endpoint was the incidence of major adverse cardio-cerebral events (MACCE) including cardiac death, non-fatal myocardial infarction, and non-fatal stroke during a 2-year follow-up. The secondary endpoint was the occurrence of clinically driven repeat revascularization during a 2-year follow-up. The prognostic value of GA and esRAGE was determined with the Cox-proportional hazard model after adjustment for covariates.
A total 40 patients (6.9%) experienced MACCE, and 108 (18.8%) patients underwent repeat coronary revascularization during the follow-up. Serum GA (HR = 1.22, 95% CI 1.16–1.28; HR = 1.15, 95% CI 1.11–1.19, respectively; for both p < 0.001) and esRAGE (HR = 0.60, 95% CI 0.40–0.87; HR = 0.75, 95% CI 0.61–0.92, respectively; for both p < 0.01) levels remained independent predictors of the primary and secondary endpoints after adjustment for possible confounders.
Serum GA and esRAGE are novel predictors of long-term clinical outcomes in patients with type 2 diabetes and stable CAD. Increased serum GA and decreased esRAGE are associated with a poor prognosis in such patients.
An intravascular ultrasound appraisal of atherosclerotic plaque distribution in diseased coronary arteries
2012, American Heart Journal
Citation Excerpt :
In 2 IVUS studies, diabetes mellitus was an independent predictor of plaque burden; however, these studies were done in major epicardial arteries either preintervention or as part of progression/regression studies.10,11 Using quantitative coronary angiography, Pajunen et al12,13 reported that type 1 but not non–insulin-dependent diabetic patients had greater global severity, global extent, and global atheroma burden than did nondiabetic “control” subjects. Patients with type 1 diabetes had more distal disease, a finding that was especially true in women.
The assumption that atherosclerosis accumulates in the proximal coronary arteries and that distal segments are spared has yet to be systematically shown in vivo.
We used intravascular ultrasound to analyze complete proximal, mid, and distal segments from 75 diseased left anterior descending arteries (LADs) and 61 diseased right coronary arteries (RCAs) (including either the posterolateral [PLA; n = 38] or posterior descending artery [PDA; n = 23]) to document that distal coronary arteries are more often free of disease vs proximal vessels. External elastic membrane, lumen, and plaque and media areas were measured every 0.4 mm (median), and plaque burden (plaque and media/external elastic membrane) and percentage of normal (plaque and media thickness <0.3 mm) cross sections/segment were determined.
Left anterior descending artery plaque was heaviest in proximal and mid segments, diminishing significantly in distal segments; plaque burden was 46% ± 9% in proximal, 39% ± 8% in mid, and 31% ± 9% in distal LAD (P < .0001), with 93% (median) of distal LAD cross sections being normal compared with 21% of mid and 0% of proximal cross sections (P < .0001). Right coronary artery plaque gradient was less pronounced vs the LAD; plaque burden was 37% ± 13% in proximal, 40% ± 10% in mid, and 36% ± 10% in distal RCA, followed by 31% ± 11% in PDA and 33% ± 10% in PLA. This was supported by the median percentage of normal cross sections/segment: 0% proximal, 0% mid, and 23% distal RCA sections plus 100% PDA and 48% PLA sections.
Intravascular ultrasound data indicated a proximal-to-distal LAD plaque gradient; significant disease was uncommon in the distal LAD. Conversely, the proximal-to-distal RCA plaque gradient was less distinct than the LAD, although disease in the PDA was still reduced compared with proximal segments.
Relation of coronary artery plaque location to extent of coronary artery disease studied by computed tomographic angiography
2010, Journal of Cardiovascular Computed Tomography
Distal coronary artery disease (CAD) is less amenable to surgery or stenting compared with proximal disease. However, little is known about the epidemiology of distal versus proximal CAD.
We determined the prevalence and factors associated with proximal, mid, and distally located plaque in the left anterior descending, left circumflex, and right coronary arteries in 418 subjects without prior CAD history who underwent coronary computed tomographic angiography for symptoms or stress test results. Clinical characteristics and coronary artery calcium (CAC) scores were also determined.
Most subjects (88%) had plaque, but only 18% of plaques were associated with stenosis >50%. In subjects with single-vessel plaque, only 7% had distal plaque, whereas 75% had proximal plaque. With 3-vessel plaque, 70% had distal and 100% had proximal plaques. Of subjects with a single location of plaque along a vessel, most had proximal plaque (69%); isolated distal-vessel plaque was rare (2%). Distal plaque was dominantly found in association with both proximal and mid plaque (88%). After multivariable adjustment for demographics, traditional, and nontraditional risk factors, both increasing number of vessels with plaque and clinically significant CAC scores were independently associated with higher odds of distal plaque, whereas associations of traditional risk factors were weaker. Distal plaque was independently associated with stenosis > 50%.
These data support the concept that early lesions are most often proximal and that CAC scoring may be a poor screening tool for detecting proximal disease. Furthermore, distal lesions are more associated with advanced disease than with traditional cardiovascular risk factors.
Increased glycated albumin and decreased esRAGE levels are related to angiographic severity and extent of coronary artery disease in patients with type 2 diabetes
2009, Atherosclerosis
This cross-sectional study aimed at evaluating the possible association of serum levels of glycated albumin (GA) and endogenous secretory RAGE (esRAGE) with angiographically significant coronary artery disease (CAD) in patients with type 2 diabetes mellitus (T2DM) and non-diabetic patients.
Serum levels of GA, esRAGE, and inflammatory markers were measured in 1320 patients undergoing coronary angiography from three large districts in Shanghai. Patients were divided into four groups based on the presence/absence of T2DM and of significant CAD (diameter stenosis ≥70%).
Serum levels of GA, high-sensitivity C-reactive protein (hsCRP), tumor necrosis factor (TNF)-α and interleukin (IL)-6 were significantly higher and, in contrast, serum esRAGE levels were lower in patients with both T2DM and significant CAD than in all other groups (all P < 0.01), whereas there were no significant differences in GA and esRAGE levels between non-diabetic patients with CAD and those without. Serum GA and esRAGE levels correlated with angiographic CAD severity (P = 0.031 and P = 0.001), extent (both P < 0.001) and number of diseased coronary arteries (both P < 0.001) in diabetic CAD patients. At multivariable regression analysis, male gender, age, hypertension, cigarette smoking, HDL-C, lipoprotein (a), GA, esRAGE, hsCRP and TNF-α were all independent determinants of significant CAD in diabetic patients. Moreover, male gender, age, hypertension, lipoprotein (a), GA and esRAGE remained independently associated with three-vessel disease.
Patients with T2DM and CAD feature elevated serum GA and decreased serum esRAGE levels. Here serum GA and esRAGE levels are associated with angiographic extent and severity of CAD.
Baseline Coronary Angiographic Findings in the Bypass Angioplasty Revascularization Investigation 2 Diabetes Trial (BARI 2D)
2009, American Journal of Cardiology
Citation Excerpt :
This trial and the core angiographic data are exclusively devoted to patients with T2DM. Most previous studies have been comparisons between patients with T2DM and matched controls or patients with T2DM and those without T2DM with risk factor adjustment and have focused on angiographic or anatomic comparisons rather than examining the association of risk factors with coronary disease in patients with T2DM per se.5,6 One study comparing 55 patients with T2DM with matched controls found that atherosclerotic burden in patients with T2DM was independently and directly related to age and to the level of intermediate-density lipoprotein cholesterol and inversely to the level of high-density lipoprotein.7
This report describes the baseline angiographic findings in the Bypass Angioplasty Revascularization Investigation (BARI) 2 Diabetes (BARI 2D) trial, a randomized study that was initiated after the original BARI trial (BARI 1). Unlike BARI 1, which compared coronary artery bypass graft surgery with coronary angioplasty (percutaneous coronary intervention) in patients with and without diabetes, BARI 2D is investigating early versus deferred revascularization as needed in selected patients with type 2 diabetes mellitus and significant stable coronary artery disease (CAD). This analysis included 1,773 patients without previous procedures. The intended mode of revascularization, percutaneous coronary intervention or coronary artery bypass graft surgery, was specified before randomization. Angiographic findings in those randomized to revascularization versus medical treatment were similar. Overall, the mean number of lesions ≥20% diameter stenosis was 4.6 ± 2.3, and the myocardial jeopardy index was 46 ± 24%. Patients selected for the coronary artery bypass graft stratum had a higher mean number of lesions ≥20% diameter stenosis (5.7 vs 4.0, p <0.0001) and a higher myocardial jeopardy index (61% vs 38%, p <0.0001) than those selected for the percutaneous coronary intervention stratum. Female gender, black race, and higher body mass index were associated with less extensive CAD, whereas a history of hypertension, age at entry, low-density lipoprotein cholesterol, and ankle-brachial index ≤0.9 were associated with more extensive CAD. In conclusion, BARI 2D patients, who by design have mild or no symptoms, demonstrate considerable variation in the extent of CAD and amount of jeopardized myocardium. Coronary arteriographic findings are consistent with the intent of the design of BARI 2D. Certain baseline and clinical features were associated with the extent of disease and myocardial jeopardy.

View all citing articles on Scopus

View full text

Coronary Artery DiseaseQuantitative Comparison of Angiographic Characteristics of Coronary Artery Disease in Patients With Noninsulin-Dependent Diabetes Mellitus Compared With Matched Nondiabetic Control Subjects

Abstract

Section snippets

Patients and Control Subjects

Results

Discussion

Chest

Am J Med

Am J Cardiol

Am Heart J

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Med Clin North Am

J Am Coll Cardiol

Am J Med

Am J Cardiol

Am Heart J

Diffuse coronary artery disease in diabetic patients: fact or fiction?

Circulation

Coronary Artery Disease
Quantitative Comparison of Angiographic Characteristics of Coronary Artery Disease in Patients With Noninsulin-Dependent Diabetes Mellitus Compared With Matched Nondiabetic Control Subjects