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NVVC voorjaarscongres, Amsterdam April 2008

NVVC voorjaarscongres, Amsterdam April 2008. Arterial Stiffness in Diabetes and the Metabolic Syndrome - a pathway to cardiovascular disease -. Isabel Ferreira, PhD Dept. of Internal Medicine Dept. Clinical Epidemiology & MTA University Hospital Maastricht. PP=104 mmHg!.

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NVVC voorjaarscongres, Amsterdam April 2008

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  1. NVVC voorjaarscongres, Amsterdam April 2008 Arterial Stiffness in Diabetes and the Metabolic Syndrome - a pathway to cardiovascular disease - Isabel Ferreira, PhD Dept. of Internal Medicine Dept. Clinical Epidemiology & MTA University Hospital Maastricht

  2. PP=104 mmHg! NVVC voorjaarscongres, Amsterdam April 2008 Arterial stiffness - the clinical problem • Mrs T • At the of 70 yrs: • Duration of diabetes 12 yrs; • BMI = 28 Kg/m2 • HbA1c = 7.1% • blood pressure 172/68 mmHg • 5 antihypertensives • At the age of 72: • myocardial infarction and heart failure; • Died at the age of 74 (stroke) Stehouwer CD et al, Diabetologia 2008

  3. NVVC voorjaarscongres, Amsterdam April 2008 Pulse pressure and risk of Coronary Heart Disease (Framingham Study) Franklin SS et al, Circulation 1999

  4. NVVC voorjaarscongres, Amsterdam April 2008 Arterial Stiffness – Concepts Viscoelastic properties of arteries ~ cushioning of pulsatile pressure Stiffness volume per pressure pulse wave velocity and earlier return of reflected wave systolic pressure  but diastolic pressure  PULSE PRESSURE  SBP  left ventricular hypertrophy; stroke  DBP   diastolic coronary perfusion

  5. NVVC voorjaarscongres, Amsterdam April 2008 Arterial Stiffness – Concepts Viscoelastic properties of arteries ~ cushioning of pulsatile pressure Stiffness volume per pressure pulse wave velocity and earlier return of reflected wave systolic pressure  but diastolic pressure  PULSE PRESSURE  SBP  left ventricular hypertrophy; stroke  DBP   diastolic coronary perfusion

  6. NVVC voorjaarscongres, Amsterdam April 2008 • Estimates of (local) arterial stiffness – volume per pressure Ultrasonography - WTS Distensibility Coefficient DC=(2D.D+D2)/P.D2 The fractional change in vessel diameter for a given change in transmural pressure – elastic properties Young’s Elastic Modulus Einc=D/(IMT*DC) - Intrinsic elastic properties Note: local P was calculated by calibration of the distension waveforms Method described by Van Bortel et al, J Hypertens 2001 Adapted from Brands et al. Eur J Ultrasound 1999

  7. Arterial Stiffness Reflected wave NVVC voorjaarscongres, Amsterdam April 2008 • Estimates of (regional) arterial stiffness – pulse wave velocity Forward wave PWV = L/t(m/s) young healthy PWV=5m/s older/diabetic PWV=12m/s Pressure sensors, tonometry, WTS Laurent, S et al, Eur Heart J 2006

  8. NVVC voorjaarscongres, Amsterdam April 2008 • Estimates of pulse wave reflection – augmentation index (AIx) applanation tonometry AIx = P2-P1/PP (%) Stehouwer CD et al, Diabetologia 2008

  9. PP=104 mmHg! NVVC voorjaarscongres, Amsterdam April 2008 Arterial stiffness - the clinical problem • Mrs T • At the of 70 yrs: • Duration of diabetes 12 yrs; • BMI = 28 Kg/m2 • blood pressure 172/68 mmHg • 5 antihypertensives • At the age of 72: • myocardial infarction and heart failure; • Died at the age of 74 (stroke) Stehouwer CD et al, Diabetologia 2008

  10. NVVC voorjaarscongres, Amsterdam April 2008 Pulse Pressure and incident CVD - Type 1 Diabetes The EURODIAB Study N = 3250, mean age = 33 yrs Median follow-up duration, 7.4 yrs 163 incident CV events RR (95%CI) Per 10 mmHg increase in BP variable Schram et at, J Hypertension 2003

  11. NVVC voorjaarscongres, Amsterdam April 2008 Pulse Pressure increases with age in young Type 1 Diabetics …especially in those with microangiopathy ‘Accelerated Arterial Ageing’ Schram et at, J Hypertension 2003

  12. <42 mmHg 42-50 mmHg 51-61 mmHg >=61 mmHg NVVC voorjaarscongres, Amsterdam April 2008 Pulse Pressure and incident CVD - Type 2 Diabetes The Hoorn Study N = 2484 (208 DM2), mean age = 61 yrs Median follow-up duration, 8.8 yrs 150 incident CV events (34 among DM2) Schram et at, J Hypertension 2002

  13. NVVC voorjaarscongres, Amsterdam April 2008 Pulse Pressure increases with age in Type 2 Diabetic vs. non-diabetic individuals ‘Accelerated Arterial Ageing’ Schram et at, J Hypertension 2002

  14. IGM DM2 NVVC voorjaarscongres, Amsterdam April 2008 Arterial stiffness is increased in type 2 Diabetic but also in those with impaired glucose metabolism The Hoorn Study N = 278 NGM, 168 IGM, 301 DM2 mean age = 697 yrs ‘Early phenomenon…’ Henry et al, Circulation 2003

  15. NVVC voorjaarscongres, Amsterdam April 2008 Arterial stiffness is increased in type 2 Diabetics …especially in those with microangiopathy The Hoorn Study N = 278 NGM, 168 IGM, 301 DM2, mean age = 697 yrs P<0.05 Alb/kreat mg/mmol Carotid DC according to levels ofalbuminuria P<0.05 0 Hermans et al, J Am Soc Nephrol 2007

  16. NVVC voorjaarscongres, Amsterdam April 2008 Arterial stiffness is increased in young subjects with the Metabolic Syndrome (MetS) 10.4% 12.6% Amsterdam Growth and Health Longitudinal Study N=364, mean age 361.6 yrs 30.8% 46.2% 0 RFs 1 RF 2 RFs >=3 RFs (MetS) Ferreira et al, Arch Intern Med 2005

  17. NVVC voorjaarscongres, Amsterdam April 2008 Arterial stiffness is increased in young subjects with the Metabolic Syndrome (MetS) Northern Ireland Young Hearts Project N=313, age 22-25 yrs Ferreira et at, J Hypertension 2007

  18. NVVC voorjaarscongres, Amsterdam April 2008

  19. NVVC voorjaarscongres, Amsterdam April 2008 In conclusion,… • Diabetes is a disease of accelerated arterial ageing as shown by stiffer arteries and consequent steeper increases in pulse pressure with ageing • Arterial stiffening may thus explain, at least in part, the increased CVD observed in diabetes and the metabolic syndrome

  20. Thank you for your attention! also on behalf of… dr. Mark Hermans dr. Ronald M Henry dr. Miranda Schram prof. dr. Coen DA Stehouwer University Hospital Maastricht, The Netherlands

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