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Singapore Med J 2013; 54(7): 370-376; http://dx.doi.org/10.11622/smedj.2013136
Diabetes mellitus and heart disease
Ambhore A, Teo SG, Poh KK
Correspondence: A/Prof Poh Kian Keong, kian_keong_poh@nuhs.edu.sg
ABSTRACT
Diabetes mellitus is responsible for diverse cardiovascular complications such as accelerated atherosclerosis, increased plaque burden and diffuse coronary lesions. It is also a major risk factor for myocardial infarction, stroke and peripheral vascular disease. Here, we present two cases. The first patient had subtle changes in the ECGs, with severe coronary artery disease requiring coronary artery bypass grafting, while the second had deep T wave inversion in the ECG and was found to have normal coronary arteries and nonischaemic cardiomyopathy. Although ECG failed to show the severity of the disease, it is invaluable as a simple, noninvasive test to aid in diagnosis. Our two cases stress the importance of a high index of suspicion and the low threshold for investigations in the diabetic population.
Keywords: diabetes mellitus, diabetic cardiomyopathy, diffuse coronary artery disease, management, non-ST elevation myocardial infarction
Singapore Med J 2013; 54(7): 370-376; http://dx.doi.org/10.11622/smedj.2013136
REFERENCES
| 1. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care 2004; 27:1047-53. http://dx.doi.org/10.2337/diacare.27.5.1047 | ||||
| 2. Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors. JAMA 2003; 289:76-9. http://dx.doi.org/10.1001/jama.289.1.76 | ||||
| 3. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002; 106:3143-421. | ||||
| 4. Waller BF, Palumbo PJ, Lie JT, Roberts WC. Status of 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 heart disease and comparison to 183 control subjects. Am J Med 1980; 69:498-506. http://dx.doi.org/10.1016/S0149-2918(05)80002-5 | ||||
| 5. Pajunen P, Taskinen MR, Nieminen MS, Syvanne M. Angiographic severity and extent of coronary artery disease in patients with type 1 diabetes mellitus. Am J Cardiol 2000; 86:1080-5. http://dx.doi.org/10.1016/S0002-9149(00)01163-2 | ||||
| 6. Granger CB, Califf RM, Young S, et al, Outcome of patients with diabetes mellitus and acute myocardial infarction treated with thrombolytic agents. The Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) Study group. J Am Coll Cardiol 1993; 21:920-5. http://dx.doi.org/10.1016/0735-1097(93)90348-5 | ||||
| 7. Natali A, Vichi S, Landi P, et al. Coronary atherosclerosis in Type II diabetes: anngiographic findings and clinical outcome. Diabetologia 2000; 43:632-41. http://dx.doi.org/10.1007/s001250051352 | ||||
| 8. Scognamiglio R, Negut C, Ramondo A, Tiengo A, Avogaro A. Detection of coronary artery disease in asymptomatic patients with type 2 diabetes mellitus. J Am Coll Cardiol 2006; 47:65-71. http://dx.doi.org/10.1016/j.jacc.2005.10.008 | ||||
| 9. Canto JG, Shlipak MG, Rogers WJ, et al. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA 2000; 283:3223-9. http://dx.doi.org/10.1001/jama.283.24.3223 | ||||
| 10. Fazzini PF, Prati PL, Rovelli F, et al. Epidemiology of silent myocardial ischemia in asymptomatic middle-aged men (the ECCIS Project). Am J Cardiol 1993; 72:1383-8. http://dx.doi.org/10.1016/0002-9149(93)90184-E | ||||
| 11. Koistinen MJ. Prevalence of asymptomatic myocardial ischaemia in diabetic subjects. BMJ 1990; 301:92-5. http://dx.doi.org/10.1136/bmj.301.6743.92 | ||||
| 12. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation 2007; 116:e148-304. http://dx.doi.org/10.1161/CIRCULATIONAHA.107.181940 | ||||
| 13. Hamm CW, Bassand JP, Agewall S, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011; 32:2999-3054. http://dx.doi.org/10.1093/eurheartj/ehr236 | ||||
| 14. Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. Circuation 2012; 126:2020-35. http://dx.doi.org/10.1161/CIR.0b013e31826e1058 | ||||
| 15. Holmvang L, Clemmensen P, Lindahl B, et al. Quantitative analysis of the admission electrocardiogram identifies patients with unstable coronary artery disease who benefit the most from early invasive treatment. J Am Coll Cardiol 2003; 41:905-15. http://dx.doi.org/10.1016/S0735-1097(02)02970-4 | ||||
| 16. Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA 2000; 284:835-42. http://dx.doi.org/10.1001/jama.284.7.835 | ||||
| 17. Pollack CV Jr, Sites FD, Shofer FS, Sease KL, Hollander JE. Application of the TIMI risk score for unstable angina and non-ST elevation acute coronary syndrome to an unselected emergency department chest pain population. Acad Emerg Med 2006; 13:13-8. http://dx.doi.org/10.1111/j.1553-2712.2006.tb00978.x | ||||
| 18. Boersma E, Pieper KS, Steyerberg EW, et al. Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation. Results from an international trial of 9461 patients. The PURSUIT Investigators. Circulation 2000; 101:2557-67. http://dx.doi.org/10.1161/01.CIR.101.22.2557 | ||||
| 19. Eagle KA, Lim MJ, Dabbous OH, et al. A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry. JAMA 2004; 291:2727-33. http://dx.doi.org/10.1001/jama.291.22.2727 | ||||
| 20. Cohen M, Demers C, Gurfinkel EP, et al. A comparison of lowmolecular-weight heparin with unfractionated heparin for unstable coronary artery disease. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events Study Group. N Engl J Med 1997; 337:447-52. http://dx.doi.org/10.1056/NEJM199708143370702 | ||||
| 21. Antman EM, McCabe CH, Gurfinkel EP, et al. Enoxaparin prevents death and cardiac ischemic events in unstable angina/non-Q-wave myocardial infarction: Results of the Thrombolysis in Myocardial Infarction (TIMI) 11B trial. Circulation 1999; 100:1593-601. http://dx.doi.org/10.1161/01.CIR.100.15.1593 | ||||
| 22. Morrow DA, Antman EM, Snapinn SM, et al. An integrated clinical approach to predicting the benefit of tirofiban in non-ST elevation acute coronary syndromes. Application of the TIMI Risk Score for UA/NSTEMI in PRISM-PLUS. Eur Heart J 2002; 23:223-9. http://dx.doi.org/10.1053/euhj.2001.2738 | ||||
| 23. Cannon CP, Weintraub WS, Demopoulos LA, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 2001; 344:1879-87. http://dx.doi.org/10.1056/NEJM200106213442501 | ||||
| 24. The Bypass Angioplasty Revascularization Investigation (BARI) Investigators.Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease. N Engl J Med 1996; 335:217-25. http://dx.doi.org/10.1056/NEJM199607253350401 | ||||
| 25. Farkouh ME, Domanski M, Sleeper LA, et al. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med 2012; 367:2375-84. http://dx.doi.org/10.1056/NEJMoa1211585 | ||||
| 26. Aguilar D. Management of type 2 diabetes in patients with heart failure. Curr Treat Options Cardiovasc Med 2008; 10:465-75. | ||||
| 27. Saunders J, Mathewkutty S, Drazner MH, McGuire DK. Cardiomyopathy in type 2 diabetes: update on pathophysiological mechanisms. Herz 2008; 33:184-90. | ||||
| 28. Rubler S, Dlugash J, Yuceoglu YZ, et al. New type of cardiomyopathy associated with diabetic glomerulosclerosis. Am J Cardiol 1972; 30:595-602. http://dx.doi.org/10.1016/0002-9149(72)90595-4 | ||||
| 29. Zarich SW, Nesto RW. Diabetic cardiomyopathy. Am Heart J 1989;118(5 Pt 1):1000-12. http://dx.doi.org/10.1016/0002-8703(89)90236-6 | ||||
| 30. Boudina S,Abel ED . Diabetic Cardiomyopathy revisted. Circulation 2007; 115:3213. http://dx.doi.org/10.1161/CIRCULATIONAHA.106.679597 | ||||
| 31. Schilling JD, Mann DL. Diabetic cardiomyopathy bench to bedside. Heart Fail Clin 2012; 8:619-31. http://dx.doi.org/10.1016/j.hfc.2012.06.007 | ||||
| 32. Bella JN, Devereux RB, Roman MJ, et al. Separate and joint effects of systemic hypertension and diabetes mellitus on left ventricular structure and function in American Indians (the Strong Heart Study). Am J Cardiol 2001; 87:1260-5. http://dx.doi.org/10.1016/S0002-9149(01)01516-8 | ||||
| 33. Struthers AD, Morris AD. Screening for and treating left-ventricular abnormalities in diabetes mellitus: a new way of reducing cardiac deaths. Lancet 2002; 359:1430-2. http://dx.doi.org/10.1016/S0140-6736(02)08358-7 | ||||
| 34. Shekelle PG, Rich MW, Morton SC, et al. Efficacy of angiotensin-converting enzyme inhibitors and beta-blockers in the management of left ventricular systolic dysfunction according to race, gender, and diabetic status: a metaanalysis of major clinical trials. J Am Coll Cardiol 2003; 41:1529-38. http://dx.doi.org/10.1016/S0735-1097(03)00262-6 | ||||
| 35. Shindler DM, Kostis JB, Yusuf S, et al. Diabetes mellitus, a predictor of morbidity and mortality in the Studies of Left Ventricular Dysfunction (SOLVD) Trials and Registry. Am J Cardiol 1996; 77:1017-20. http://dx.doi.org/10.1016/S0002-9149(97)89163-1 | ||||
| 36. Moyé LA, Pfeffer MA, Wun CC, et al. Uniformity of captopril benefit in the SAVE Study: subgroup analysis. Survival and Ventricular Enlargement Study. Eur Heart J 1994; 15 Suppl B:2-8; discussion 26-30. | ||||