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The ankle-brachial Index should be included in the routine caring of subjects with type 2 diabetes
Submit responseDear Sir,
With great interest we have read the first paper from the “In the Clinic” section devoted to type 2 diabetes mellitus. We would like to make some comments regarding the screening of diabetes complications and specifically referring to the peripheral arterial disease (PAD). For evaluating cardiovascular complications in type 2 diabetes, one of the measures proposed, is to examine peripheral pulses at each visit (i.e. quarterly). However, this examination is not sensitive enough to detect PAD in type 2 diabetes (1). PAD is considered a coronary heart disease risk equivalent and, subsequently, a tight control of classical cardiovascular risk factors is recommended (2, 3). Most subjects with PAD are asymptomatic (i.e. do not have typical intermittent claudication or ischaemic signs) (2, 3) (4), specially if they have diabetes, interfering with the detection of PAD. Nevertheless, asymptomatic PAD implicates a similar relative risk of cardiovascular mortality as symptomatic PAD (4). The fact that patients with PAD frequently do not have any other clinical manifestation of cardiovascular disease, mainly coronary heart disease or stroke, further complicates the identification of these subjects, as having a very high cardiovascular risk (4).
Recently, a Consensus Statement from the American Diabetes Association, recommended increasing the detection of PAD through the determination of the ankle-brachial index -ABI- in all diabetic patients older than 50 years of age and those younger than 50, who have other classical cardiovascular risk factor or a diabetes > 10 years’ evolution (1). Similar recommendations have been made by other guidelines (2, 3). Compared with the assessment of pulses, the ABI has been found to be more accurate for detecting PAD (sensitivity of 95 % and especificity of 100 %, against angiographically confirmed PAD) (1). The implementation of ABI for detecting PAD (mainly asymptomatic PAD) would assist in identifying and treating subjects with type 2 diabetes mellitus and a very high risk of subsequent cardiovascular events, who otherwise will remain underdiagnosed and undertreated (1). ABI is underutilized in routine clinical practices, PAD remains underdiagnosed and the awareness of the importance of treating in PAD as a coronary heart disease equivalent, is low among physicians (5), partially because of the ABI determination is time-consuming and is usually non-reimbursable. Including the ABI determination as part of the recommendations for routine caring of subjects with type 2 diabetes mellitus, could facilitate its implementation in the usual care of these subjects in the future.
References
1. American Diabetes Association. Peripheral arterial disease in people with diabetes. Diabetes Care. 2003;26:3333-41.[PMID: 14633825]
2. Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation. 2006;113:e463-654.[PMID: 16549646]
3. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(1 Suppl):S1-S75.[PMID: 17140820]
4. Newman AB, Shemanski L, Manolio TA, Cushman M, Mittelmark M, Polak JF, et al. Ankle-arm index as a predictor of cardiovascular disease and mortality in the Cardiovascular Health Study. The Cardiovascular Health Study Group. Arterioscler Thromb Vasc Biol. 1999;19:538-45. [PMID: 10073955]
5. Hirsch AT, Criqui MH, Treat-Jacobson D, Regensteiner JG, Creager MA, Olin JW, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 2001;286:1317-24.[PMID: 11560536]
Conflict of Interest:
JMGC received an unrestricted grant from Bristol-Myers-Squibb (Spain) to assess the prevalence of PAD using the ABI determination in subjects with type 2 diabetes mellitus.
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Diabetes Quality Indicators
Submit responseThe debut In the Clinic issue on type 2 diabetes is very informative, and does well to describe related quality indicators (1), which extend beyond the traditional ‘ABCs of diabetes’(2). These indicators can be summarized for action under the first six letters of the alphabet:
‘A’ for (hemoglobin) A1c and (urinary micro-) albumin;
‘B’ for blood pressure;
‘C’ for cholesterol and cigarette cessation;
‘D’ for diet;
‘E’ for exercise and eye care; and
‘F’ for foot care.
This simple mnemonic can aid process improvement in primary care clinics.
1. Type 2 Diabetes. Ann Intern Med. 2007;146(1):ITC-1-.
2. Kemp TM, Barr EL, Zimmet PZ, et al. Glucose, lipid, and blood pressure control in Australian adults with type 2 diabetes: the 1999-2000 AusDiab. Diabetes Care. 2005;28(6):1490-2.
Conflict of Interest:
None declared
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Great new feature!
Submit responseDear Sir,
You have welcomed the new year with a truly useful new feature added to Annals. The practicing physician often finds himself unable to keep up with the large amount of new data generated by clinical trials. While the academician may devote the time necessary to assess study quality and scientific rigour, the average busy physician would far rather read a concise overview of the clinical implications of published literature for application in his practice.
This new series will go a long way in bridging the gap between clinical research and clinical practice. Type 2 diabetes is an especially topical theme for the first article. Thank you.
Conflict of Interest:
None declared
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About the etiology of type 2 diabetes
Submit responseDear editor.
I wish to comment about the etiology of type 2 diabetes mellitus(DM).In base to surgical observations after omental transplantation on the optic chiasma,carotid bifurcation and anterior perforate space,on 3 patients with type 2 DM,Alzheimer`s disease,arterial hypertension and stroke(1);I believe that,type 2 DM is caused by progressive ischemia in the anterior hypothalamic nuclei,due to atherosclerosis at the supraclinoid carotids.Thus,atheromatous plaques can provoke stenosis or occlusion in the mouths of the arterior perforating arteries;because,in contrast to this,its revascularization can normalize or reduce the circulating glucose levels,and without antidiabetic medication(1,2).
But,the arcuate nucleus is the first in suffer lesion, between 25 to 30 years of age,and thus,the decline of growth hormone in blood,increase the incidence of obesity and the aging process.
References.
1-Rafael H.hypothalamic ischemia and metabolic syndrome.Med Sci Monit.2006;12(9):LE 17-18. www.medscimonit.com 2-Rafael H.disfunciòn hipotalàmica y sindrome metabòlico. Rev Fac Med UNAM 2006;49(6):262-263 (letter )
www.medigraphic.com
Conflict of Interest:
No competing interests