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SphygmoCor
and Diabetes Mellitus
Diabetes increases the risk of heart disease and stroke1, with heart patients, such that each increase of 1 m/s has an 8% increased risk of disease being the leading cause of death. In addition, many people mortality10. Elevated aortic PWV and Aortic Augmentation Index (AIx) have with Type 2 diabetes have co-existing risk factors, such as high blood been shown to be associated with Type 1 and Type 2 diabetes7, 8, 9, 10, 11.
pressure and high cholesterol3, further increasing their cardiovascular Assessment of a cohort of patients in the FIELD (Fenofibrate risk. Diabetes is also associated with long-term complications that Intervention and Event Lowering in Diabetes) Study showed a affect almost every part of the body including heart and vessel significant association between Augmentation Pressure (AP) and AIx disease, kidney failure, stroke, blindness, nerve damage and and carotid IMT, an established marker of atherosclerosis, in Type 2 amputations. The SphygmoCor® system non-invasively provides diabetics, suggesting that arterial stiffness may contribute to the measurements illustrating the progression of macrovascular disease accelerated atherosclerosis in Type 2 diabetes and that measures of driving the patient’s risk of cardiovascular disease, thus providing a central blood pressure and large artery stiffness may be superior to tool for assisting with early identification of high risk patients and other conventional risk factors in determining the presence of subsequent management of the disease.
vascular wall thickening in Type 2 diabetes4. A substudy of the FIELD investigation is ongoing and is expected to provide prospective dataon the predictive values of AP and AIx for cardiovascular morbidity In the United States, 20.8 million people are considered to have and mortality in Type 2 diabetic patients.
diabetes – 7% of the population. This consists of 14.6 million that In previous studies, AP and AIx have also been shown to be strongly have been diagnosed with diabetes and 6.2 million suspected of correlated with carotid IMT and plaque score in diabetic patients12, 13 having diabetes that has not yet been diagnosed2. Each year, and coronary artery disease14, the latter being commonly associated approximately 1.3 million people aged 20 years or older are with diabetes. The CURES (Chennai Urban Rural Epidemiology Study) diagnosed with diabetes and more than 60% of diabetics will die study showed that Type 2 diabetic patients with retinopathy had from heart disease1. Patients with Type 2 diabetes have a 2–7 times significantly higher AIx and IMT values than for those without increased risk of cardiovascular mortality and morbidity4 and patients retinopathy, suggesting an association between early atherosclerosis with Type 1 diabetes also have an increased risk of cardiovascular and diabetic retinopathy in Asian Indians, a high risk group for both disease5. Furthermore, diabetes has been reported to be one of the diabetes and coronary artery disease13.
leading causes of end stage renal disease1 which also carries anincreased risk of cardiovascular disease6.
Children as young as 10 years old with Type 1 diabetes have alsobeen observed to have increased arterial stiffness (AIx) when matched with control subjects15. This highlights the potential for markers ofarterial stiffness such as those available from the SphygmoCor® The increased cardiovascular risk of patients with diabetes remains system for providing additional information for cardiovascular risk largely unexplained. Part of this increased risk relates to cardiovascular stratification and optimisation of therapy in children with conditions risk factors such as hypertension, dyslipidaemia, hyperglycaemia and such as Type 1 diabetes that have a high risk of developing obesity, but some of the increased risk appears to be independent of cardiovascular and non-cardiovascular complications later in life.
these factors and may be different for Type 1 and Type 2 diabetes.
With increased arterial stiffness, central systolic pressure increases Increased arterial stiffness has been associated with both Type 17, 8 resulting in an increase in cardiac workload and therefore myocardial and Type 2 diabetes9, 10, 11, and may be a contributor to the high demand. Increased arterial stiffness can contribute to the development morbidity and mortality. The impact of this increased arterial stiffness and progression of hypertension, left ventricular hypertrophy and on cardiovascular function can be examined by parameters provided dysfunction and decrease in myocardial perfusion. The progression of these conditions is preventable and the use of key central cardiac Peripheral pulse pressure, a surrogate marker for arterial stiffness, function parameters provided by the SphygmoCor® system may assist has been shown to be associated with Type 1 diabetes and compared with this. The SphygmoCor® Pulse Wave Analysis and Pulse Wave with non-diabetics, age related blood pressure increases seem to Velocity Systems allow for assessment of these important parameters shift to a 15–20 year younger age in Type 1 diabetes, suggesting of arterial stiffness, AIx and PWV. Once these conditions have developed, the system may assist with assessment of progressionand the tailoring of drug therapies to the individual patient.
Aortic stiffness, as measured by aortic pulse wave velocity (PWV) hasbeen shown to be an independent predictor of mortality in diabetic SphygmoCor and Diabetes Mellitus
Decreases in arterial stiffness in patients with cardiovascular disease, ascorbic acid has been shown to significantly lower AIx over a 4-week including those with diabetes, have been demonstrated following period in diabetic patients21. The SphygmoCor® system allows the pharmacological interventions, often independent of changes in cuff physician to see the effects of their patient’s treatment regimen BP. Insulin is known to acutely decrease AIx independent of peripheral through changes in the key central cardiac function parameters.
vascular resistance16, 17, however this action is defective in insulin- The SphygmoCor® system provides a clinically valuable cardiovascular resistant obese18, type 118 and type 219 diabetic patients. One study, risk assessment in these high-risk patients, enabling better informed however, has observed an improvement in AIx after six months of treatment and patient management decisions.
insulin therapy20. Among a number of pharmacological interventionsshown to improve arterial stiffness, supplementation with oral 12 Fukui M, Kitagawa Y, Nakamura N, et al. Augmentation of central arterial National Institute of Diabetes and Digestive and Kidney Diseases. National pressure as a marker of atherosclerosis in patients with Type 2 diabetes.
Diabetes Statistics Fact Sheet: general information and national estimates on diabetes in the United States, 2003.
13 Rema M, Deepa R, Mohan V, Ravikumar R. Association of carotid intima- National Institute of Diabetes and Digestive and Kidney Diseases. National media thickness and arterial stiffness with diabetic retinopathy. Diabetes Diabetes Statistics. NIH Publication No 06-3892 November 05.
Williams B. The unique vulnerability of diabetic subjects to hypertensive 14 Weber T, Auer J, O’Rourke MF, et al. Arterial stiffness, wave reflections, and injury. J Hum Hypertens 1999;13:S3-S8.
the risk of coronary artery disease. Circulation 2004;109:184-9.
Westerbacka J, Leinonen E, Salonen JT, et al. Increased augmentation of 15 Haller MJ, Schwartz RF, Samyn M, et al. Radial artery tonometery central blood pressure is associated with increases in carotid intima-media demonstrates arterial stiffness in children with Type 1 diabetes. Diabetes thickness in type 2 diabetic patients. Diabetologia 2005;48:1654- 1662.
5. Ronnback M, Fagerudd J, Forsblom C, et al. Altered age-related blood 16 Westerbacka J, Wilkinson I, Cockcroft J, et al. Diminished wave reflection in pressure pattern in Type 1 diabetes. Circulation 2004;110:1076-1082.
the aorta. A novel physiological action of insulin on large blood vessels.
6. U.S. Renal Data System, USRDS 2004 Annual Data Report: Atlas of End-stage renal disease in the United States. National Institutes of Health, National 17 Westerbacka J, Seppala-Lindroos A and Yki-Jarvinen H. Resistance to acute Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2004.
insulin decreases in large artery stiffness accompanies the insulin resistance Brooks B, Molyneaux L, Yue DK. Augmentation of central arterial pressure in syndrome. J Clin Endocrinol Metab 2001;86:5262-8.
Type 1 diabetes. Diabetes Care 1999;22:1722-1727.
18 Westerbacka J, Uosukainen A, Makimattila S, et al. Insulin-induced decrease Wilkinson IB, MacCallum H, Rooijmans DF, et al. Increased augmentation in large artery stiffness is impaired in uncomplicated Type 1 diabetes index and systolic stress in Type 1 diabetes mellitus. QJM 2000;93:441-8.
mellitus. Hypertension 2000;35:1043-8.
Schram MT, Henry RMA, van Dijk AJM, et al. Increased arterial stiffness in 19 Tamminen M, Westerbacka J, Vehkavaara S, Yki-Jarvinen. Insulin-induced impaired glucose metabolism and Type 2 diabetes. The HOORN study.
decreases in aortic wave reflection and central systolic pressure are impaired in Type 2 diabetes. Diabetes Care 2002;25:2314-9.
10 Cruickshank K, Riste L, Anderson SG, et al. Aortic pulse-wave velocity and its 20 Tamminen MK, Westerbacka J, Vehkavaara S, Yki-Jarvinen H. Insulin therapy relationship to mortality in diabetes and glucose intolerance. Circulation improves insulin actions on glucose and aortic wave reflection in Type 2 diabetic patients. Eur J Clin Invest 2003;33:855-60.
11 Smith A, Karalliedde J, De Angelis L, Goldsmith D, Viberti G. Aortic pulse 21 Mullen BA, Young IS, Fee H, McCance DR. Ascorbic acid reduces blood wave analysis and albuminuria in patients with Type 2 diabetes. J Am Soc pressure and arterial stiffness in Type 2 diabetes. Hypertension AtCor Medical Pty LtdSuite 11, 1059–1063 Victoria Road, West Ryde, NSW 2114, Australia.
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