Elsevier

American Heart Journal

Volume 147, Issue 6, June 2004, Pages 1017-1023
American Heart Journal

Clinical investigations: acute ischemic heart disease
Coronary flow reserve abnormalities in patients with diabetes mellitus who have end-stage renal disease and normal epicardial coronary arteries

https://doi.org/10.1016/j.ahj.2003.07.029Get rights and content

Abstract

Background

Diabetic nephropathy is associated with increased cardiovascular events. Coronary atherosclerosis is responsible for many of these events, but other mechanisms such as impaired flow reserve may be involved. The purpose of this study was to define the prevalence and mechanism of abnormal coronary velocity reserve (CVR) in patients with diabetes mellitus who have nephropathy and a normal coronary artery.

Methods

Patients undergoing catheterization for clinical purposes were enrolled. CVR was measured with a Doppler ultrasound scanning wire in a normal coronary in 32 patients without diabetes mellitus, 11 patients with diabetes mellitus who did not have renal failure, and 21 patients with diabetes mellitus who had nephropathy. A CVR <2.0 was considered to be abnormal.

Results

Patients with diabetes mellitus who had renal failure had a higher incidence of hypertension and left ventricular hypertrophy. The average peak velocity (APV) at baseline was higher in patients with diabetes mellitus who had renal failure. At peak hyperemia, APV increased in all 3 groups, with no difference between groups. The mean CVR for patients without diabetes was 2.8 ± 0.8 and was not different from that in patients with diabetes mellitus who did not have renal failure (2.7 ± 0.7), but was lower than that in patients with diabetes mellitus who had renal failure (1.6 ± 0.5; P < 0.001). Abnormal CVR was observed in 9% of patients without diabetes mellitus, 18% of patients with diabetes mellitus who did not have renal failure, and 57% of patients with diabetes mellitus who had renal failure, and abnormal CVR was caused by an elevation of baseline APV in 66% of these cases. The baseline heart rate and the presence of diabetes mellitus with renal failure were independent predictors of abnormal CVR by multivariable analysis.

Conclusions

Patients with diabetic nephropathy have abnormalities in CVR in the absence of angiographically evident coronary disease.

Section snippets

Patient inclusion

The Human Investigations Committee approved the protocol, and all patients gave informed consent. Patients with an ejection fraction >50% who were referred for coronary angiography with at least 1 major coronary artery appearing “normal” were enrolled. An artery was defined as “normal” when it appeared smooth, with no lumen irregularities. Noncritical stenoses, defined as lesions with <50% lumen narrowing, in other coronaries were permitted. Patients with conditions known to impair CFR

Clinical characteristics

Clinical characteristics are shown in Table I. There was no difference in the age, proportion of men, or the prevalence of hyperlipidemia in the 3 groups. The hematocrit level was lower in patients with diabetes who had renal failure than in the other groups. There was a higher proportion of patients with noncritical disease in other arteries in the nondiabetic group and in the diabetic without renal failure group, as compared with the diabetic with renal failure group. The incidence of both

Discussion

In this study, diminished CVR was observed in asymptomatic patients with diabetes mellitus who had nephropathy and an angiographically normal coronary artery. Patients with diabetes mellitus who did not have renal failure had a CVR similar to that of patients without diabetes mellitus. With multivariable analysis, diabetes with renal failure was independently associated with the presence of abnormal CVR. These data suggest that in the absence of end-organ damage, diabetes mellitus alone does

References (33)

  • H Laine et al.

    Early impairment of coronary flow reserve in young men with borderline hypertension

    J Am Coll Cardiol

    (1998)
  • A.D Baron

    Vascular reactivity

    Am J Cardiol

    (1999)
  • R.N Foley et al.

    Clinical epidemiology of cardiovascular disease in chronic renal failure

    Am J Kidney Dis

    (1998)
  • S Aakhus et al.

    Cardiovascular morbidity and risk factors in renal transplant patients

    Nephrol Dial Transplant

    (1999)
  • K Lin et al.

    Pre-transplant cardiac testing for kidney-pancreas transplant candidates and association with cardiac outcomes

    Clin Transplantation

    (2001)
  • B.E Strauer et al.

    Evidence for reduced coronary flow reserve in patients with insulin-dependent diabetesa possible cause for diabetic heart disease in man

    Exp Clin Endocrinol Diabetes

    (1997)

    • Cited by (0)

    View full text
    Copyright © 2004 Elsevier Inc. All rights reserved.