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Background: Type 2 diabetes Mellitus (T2DM) is associated with cardiac autonomic dysfunction, which is an independent predictor of mortality in chronic diseases. However, whether the coexistence of systemic arterial hypertension (HTN) with DMT2 alters cardiac autonomic modulation remains unknown., Objective: To evaluate the influence of HTN on cardiac autonomic modulation and cardiorespiratory fitness in subjects with DMT2., Methods: 60 patients of both genders were evaluated and allocated to two groups: DMT2 patients (n = 32; 51 ± 7.5 years old) and DMT2 + HTN patients (n = 28; 51 ± 6.9 years old). RR intervals were obtained during rest in supine position. Linear and nonlinear indices of heart rate variability (HRV) were computed using Kubios HRV software. Pulmonary gas exchange was measured breath-by-breath, using a portable telemetric system during maximal incremental exercise testing on a cycle ergometer. Statistical analysis included Shapiro-Wilk test followed by Student's t Test, Pearson correlation and linear regression., Results: We found that patients in the DMT2+HTN group showed lower values of mean RR intervals (801.1 vs 871.5 ms), Shannon entropy (3 vs 3.2) and fractal dimension SD 1 (9.5 vs 14.5), when contrasted with patients in the DMT2 group. Negative correlations were found between some HRV nonlinear indices and exercise capacity indices., Conclusion: HTN negatively affects the cardiac autonomic function in diabetic patients, who are already prone to develop autonomic dysfunction. Strategies are need to improve cardiac autonomic functionality in this population.

Introduction: Metabolic dysregulation is the defining characteristic of type 2 diabetes mellitus (T2DM) and may lead to microvascular complications, specifically retinopathy, nephropathy and neuropathy. Medical treatment and lifestyle interventions targeting risk factors for microvascular complications can yield therapeutic gains, particularly retinopathy and nephropathy. Bariatric/metabolic surgery is superior to the best medical treatment in several randomized controlled trials. Consequently, evidence of the effect of bariatric/metabolic surgery on microvascular complications is now emerging in the literature., Methods: A search of the recent published evidence base on the effects of bariatric/metabolic surgery on microvascular complications reveals further evidence that supports the efficacy of surgery in preventing the incidence and progression of albuminuria and preserving renal functional decline., Discussion: Data on retinopathy are ambivalent representing the potential in some cases for an influence of reactive hypoglycaemia over the retina but the majority of data emphasize that the metabolic control can halt the progression of the eye disease. A significant gap in the literature remains in relation to the effects of surgery on diabetic neuropathy, although some information sheds a light on the benefits secondary to the surgical metabolic control., Conclusion: Overall, although data so far is exciting, there is a pressing need for prospective randomized controlled trials examining long-term microvascular outcomes following bariatric/metabolic surgery in patients with T2DM.

The scope of this article is to estimate the prevalence of microvascular complications of self-reported type 2 diabetes and the association with sociodemographic characteristics, nutritional status, treatment given and time since diagnosis. It involved a cross-sectional study with 318 people with type 2 diabetes living in Maringá in the State of Paraná. A telephone survey of self-reported morbidity was conducted in the months from January to June 2012. For the analysis descriptive statistics, univariate and multiple logistic regression were used. The prevalence of self-reported complications of diabetes was 53.8%, the most frequent being retinopathy (42.8%), followed by peripheral neuropathy (14.5%) and nephropathy (12.9%). The variables associated with the presence of complications were age (p = 0.008), overweight/obesity (p = 0.002), insulin (p < 0.001), insulin use linked to oral antidiabetic drug (p = 0.003) and time since diagnosis (p = 0.013). The prevalence of self-reported microvascular complications for people with diabetes was high, being more frequent among those of more advanced age, with inadequate nutritional status, a delay in diagnosis of the disease and those who were using insulin alone or in combination with oral antidiabetic agents.

Diabetes mellitus (DM) is an independent risk factor for coronary heart disease, stroke, peripheral arterial disease and heart failure, which are the main causes of death in these patients. Moreover, patients with DM and cardiovascular disease have a worse prognosis than nondiabetics, present lower short-term survival, higher risk of recurrence of the disease and a worse response to the treatments proposed. In the last decades, diagnostic and therapeutic progress had already shown benefits concerning cardiovascular risk reduction in these patients, but their absolute mortality risk is still twice that of non-diabetic patients. Because of this, the adoption of intensive treatment, with strict cardiovascular risk factor control, is a priority. The present study presents the main clinical characteristics and also the practical approach for screening, diagnosis and treatment of patients with diabetic macrovascular disease.

The advanced glycation end-products (AGEs) constitute a class of heterogeneous molecules formed by amino-carbonyl reactions of a non-enzymatic nature, which occur at an accelerated rate in the hyperglycemic state of diabetes. Considered important pathogenic mediators of diabetic complications, AGEs are capable of irreversibly modifying the chemical properties and functions of diverse biological structures. In this review, recent data from literature is presented describing the pathways of AGEs formation, their metabolism, the main mechanisms of action of these substances in the triggering of pathological processes associated with diabetes, as well as methods of AGEs determination in biological samples. This text also points to new perspectives in anti-AGE therapies, an example of which is the studies involved with the action of natural compounds of food, which can represent a potential coadjuvant therapy for people with diabetes or other pathologies associated with the degenerative accumulation of AGEs.

Purpose: Check the evolution of type 1(T1) diabetic patients to hypertension and prehypertension and baseline factors related to final blood pressure levels (BP)., Methods: Observational study involving 127 T1 diabetic patients submitted to clinical and laboratory evaluation and followed by for 5 (2.4-9.2) years., Results: From the initially normotensive patients, 21.7% developed prehypertension, 4.7% developed hypertension and 73.6% remained with normal BP. From the prehypertensive patients, 35% returned to normal BP, 50% remained prehypertensive and 15% developed hypertension. The relative risk for hypertension development was 3.2 (0.8-12.3) in the prehypertensive compared to the normotensive group. The prevalence of prehypertension and hypertension increased from 15.7% to 26% and 0.8% to 7% respectively. Levels of serum creatinine predicted final levels of systolic and diastolic BP., Conclusion: It is emphasized the importance of renal function and BP evaluation even when they are in normal range to minimize the deleterious effects of hypertension in the development of nephropathy and cardiovascular disease.

Pancreas and kidney transplants have specific indications, benefits and risks. The procedure has become more common and more often as long-term success has improved and risks have decreased. Compared with a patient being on dialysis, simultaneous pancreas-kidney transplant offers a distinct advantage when it comes to mortality, quality of life and diabetic complications. Since there can be a living-donor kidney transplant,, a possibly similar patient and graft survival by 10 years follow-up, this procedure should be considered. Pancreas after kidney transplants, when successful, can improve microvascular complications compared with kidney transplant alone, but immediate mortality may be higher. Solitary pancreas transplantation can improve the quality of life in selected patients, but it may also increase the immediate risk of mortality due to the complexity of the surgery and the risks of immunosupression. The results of Islet transplantation differ from the higher metabolic performance achieved by whole pancreas allotransplantation and its applicability is limited to selected adult diabetic patients.

The association between type 1 diabetes and coronary heart disease has become very clear since the late 1970. It has been demonstrated that there is an important increased risk in morbidity and mortality caused by coronary artery disease in young adults with type 1 diabetes compared with the non diabetic population. The underlying pathogeneses is still poorly understood. While the role of glycemic control in the development of microvascular disease complication is well established its role in CVD in patients with DM1 remains unclear with epidemiologic studies reporting conflicting data. Recent findings from the DCCT/EDIC showed that prior intensive diabetes treatment during the DCCT was associated with less atherosclerosis, largely because of reduced level of HbA1c during the DCCT. The improvement of glycemic control itself appeared to be particularly effective in younger patients with shorter duration of the disease. Other analyses suggested the glycemia may have a stronger effect on CAD in patients without than in those with albuminúria. Other major determinants of coronary artery disease are the components of metabolic syndrome and the surrogate measure of insulin resistence: eGDR. It is proposed that patients with DM1 should have aggressive medical therapy, risk factor modification and careful monitoring not only of his blood sugar but also of the other processes involved in the atherosclerotic process, mostly the ones with family history of type 2 diabetes.

With the intensive glycemic control in the therapy of type 1 diabetes mellitus (T1DM) patients, cardiovascular disease has been the main cause of mortality. Identification of risk factors, such as dyslipidemia is considered of great importance in terms of avoiding chronic micro and macro vascular complications. The statements for prevention of coronary artery disease in diabetes are generally are related do type 2 diabetes mellitus and little attention is paid to T1DM. Defining therapeutical targets and indications for treatment are more controversial in these patients due to their young ages. The present study aims to emphasize the importance of establishing the diagnosis of dyslipidemia in this group of patients as well as indicate the appropriate and early treatment, in order to reach the targets of treatment and reduce the atherogenic lipid profile.

Cardiovascular disease, which includes coronary heart disease (CHD), cerebrovascular disease (CVD), and peripheral vascular disease (PVD), is the leading cause of mortality in populations, particularly in the diabetic one. Individuals with diabetes have at least a two-fold to four-fold increased risk of having cardiovascular events and a double risk of death compared with age-matched subjects without diabetes. A decline in mortality from CVD has been shown, but decline due to CHD is consistently lower in individuals with diabetes when compared with non-diabetics. The presence of several factors in diabetes leads to high occurrence of CVD such as hyperglycemia, insulin resistance, and classical and non-classical risk factors (systemic hypertension, dyslipidemia, obesity, proinflammatory condition and others). It is possible that the atherogenic role of obesity may be at least in part due to increased adipocyte production of cytokines. Considering the marked association of diabetes and CVD and unfavorable prognosis following an event, it is important to identify who is at high risk and how to screen. The American Heart Association and American Diabetes Association recommend risk stratification using diagnostic tests. However, the challenge is to accurately identify patients without a prior history of an event and those without symptoms strongly suggesting CVD, in whom additional testing would be indicated in order to achieve the most effective prevention. The benefits of glycemic control and the other risk factors have already been shown and justify optimization of the management of this high-risk population, aiming to reduce cardiovascular mortality disease and improve quality of life.

Diabetic microangiopathy is responsible for an important rate of morbidity and mortality related to the disease. Endothelial damage seems to be the triggering factor in the pathogenesis of microvascular complications. Diabetes mellitus and other metabolic diseases are associated to endothelial dysfunction, the most precocious known marker of atherosclerosis. Changes on microvascular reactivity are present in patients with diabetes mellitus, as well as in individuals with risk factors for this disease. Evaluation of endothelial and microvascular functions is possible using different invasive or preferentially non-invasive methods. Adequate control of diabetes mellitus might postpone or perhaps even prevent the microvascular disease. Microvascular dysfunction, when seen only by changes on microvascular reactivity, could be ameliorated with correction of risk factors or drug treatment.

Macroangiopathy is multifactorial. It is more severe and frequent in association with nephropathy in diabetes mellitus (DM), being the first cause of mortality in both types of DM. Nevertheless, it is poorly understood in young patients. We report on 2 young diabetic patients with early-onset coronary disease. Case 1, 40 yo, Caucasian, female, type 2 DM for 21 y: treated with sulphonylureas until 25 y, she was switched to insulin upon becoming pregnant. Preeclampsia ensued, but no premature delivery occurred. Macroproteinuria remained (0.99 g/24 h), and she progressed to renal failure (clearance 52.7 mg/min) (conservative treatment). At age 36, she had an acute myocardial infarction. Severe tri-arterial disease was diagnosed, and coronary bypass grafting (CABG) performed. Case 2, 34 yo, black, female, type 1 DM for 24 y: diagnosed by diabetic ketoacidosis. Due to poor metabolic control (HbA1c chronically above 4 points beyond upper limit for normal) she progressed to microalbuminuria (0.26 g/24 h) at age 22, after pregnancy. Macroproteinuria (1.7 g/24 h) ensued after a second pregnancy. At 31 y, she presented with stable angina. After coronary angiography, CABG was indicated. These two cases of macroangiopathy in patients diagnosed with DM at an early age show acceleration in the development of coronary disease, suggesting aggressive multifactorial approach of related risk factors from the beginning, regardless of its etiology.

Background: Type 2 diabetes (DM2) has been related to the development of macroangiopatic [coronary heart disease (CHD), peripheral vascular disease (PVD) and stroke] and microangiopatic [retinopathy, nephropathy, and distal sensory neuropathy (DSN)] complications. The aims of this study were to analyze prevalence of complications in DM2 patients and to estimate their associated risk factors., Methods: Cross-sectional study, including 927 out patients with DM2 from three medical centers in Rio Grande do Sul: Hospital de Clinicas de Porto Alegre (n = 475), Grupo Hospitalar Conceicao (n = 229) and Hospital Sao Vicente de Paula (n = 223). Of the patients 42% were male, mean age was 59 +/- 10 years and the median known duration of DM2 was 11 (5-43) years. Retinopathy was identified by direct fundoscopy; CHD by WHO questionnaire and/or abnormal ECG and/or perfusion abnormalities on myocardial scintigraphy; DSN by compatible symptoms and absent sensation on 10 g monofilament and/or tune fork; PVD by the presence of claudication and absent foot pulses; stroke by presence of sequels and history; and nephropathy by the urinary albumin excretion rate (>20 microg/min). Hypertension was defined by blood pressure (>140/90 mmHg) and/or use of antihypertensive drugs. Body mass index (BMI, kg/m2) and waist-to-hip ratio (WHR) were calculated., Results: CHD was present in 36% and PVD in 33% of the patients. Among the microvascular, 37% had nephropathy (12% with macroalbuminuria); 48% retinopathy (15% proliferative retinopathy). DSN was present in 36%. Seventy three percent of the patients presented arterial hypertension. Cholesterol levels were >200 mg/dl in 64% and BMI > 30 kg/m2 in 36%. Twenty two percent of patients were smokers and 21% ex-smokers., Conclusion: Diabetic complications are frequent among out patients referring to general hospitals. Almost all patients presented at least one risk factor for cardiovascular disease, justifying the efforts for identification and adequate control.

Introduction: Diabetes is not only a risk factor for coronary artery disease but also influences its presentation and evolution., Objectives: The objective of this work is to define the risk factors, clinical and angiographic characteristics, and evolution of acute coronary syndrome in a population of diabetic patients., Methodology: We studied 521 patients suffering from acute coronary syndrome, consecutively hospitalized in the Cardiology Intensive Care Unit who underwent cardiac catheterization during their hospitalization, in terms of risk factors for coronary disease, pathology (unstable angina versus acute myocardial infarction), coronary morphology, left ventricular function, need for intervention during hospitalization, evolution and complications during one-year follow-up. The characteristics of the diabetic patients with acute coronary syndrome were compared to those of non-diabetic patients., Results: Of the 521 patients suffering from acute coronary syndrome (391 male), 159 (30.5%) were diabetic. The diabetic patients suffering from acute coronary syndrome generally presented fewer risk factors for coronary artery disease, with a lower prevalence of smoking (p < 0.001), greater prevalence of family history of coronary artery disease (p < 0.01), more unstable angina and less acute myocardial infarction (both p < 0.001), than the nondiabetic patients. After the acute coronary syndrome the diabetic patients more frequently presented disease of the left anterior descending artery, left ventricular function was worse and there was a greater need for coronary artery bypass graft surgery and less percutaneous transluminal coronary angioplasty than in the non-diabetic patients (p < 0.05 for all). In terms of evolution, they presented greater complications and more mortality over a year (p < 0.05)., Conclusion: Diabetes constitutes a powerful risk factor for coronary artery disease and its complications, and should therefore be taken into consideration in clinical approaches to this pathology.

Objective: To use published Hypertension Optimal Treatment (HOT) Study data to evaluate changes in cardiovascular mortality in nondiabetic hypertensive patients according to the degree of reduction in their diastolic blood pressure., Methods: In the HOT Study, 18,700 patients from various centers were allocated at random to groups having different objectives of for diastolic blood pressure:

Purpose: To evaluate the left ventricular structure and function and the arterial stiffness in type II diabetic patients., Methods: Thirteen diabetic patients, men and women (age 55 +/- 8 years) were included in the study. None of the patients had any other clinical disorders. Doppler-echocardiography and non-invasive monitoring of arterial blood pressure were performed. All the results were compared to an age and sex matched control group (n = 12)., Results: There were no differences between the groups for diastolic blood pressure, dimensions of cardiac chambers and ventricular systolic and diastolic function indexes. Diabetic patients had increased left ventricular mass index (101 +/- 10 vs 80 +/- 14 g/m2; p < 0.001) and increased arterial stiffness (0.86 +/- 0.26 vs 0.69 +/- 0.19 mmHg/mL; p < 0.05), when compared to control group., Conclusion: Diabetes mellitus is associated to increased systemic arterial stiffness and this may contribute to the adverse effects of diabetes on left ventricular morphology.

We accessed the potential impact of diabetes mellitus and hyperglycemia on early prognosis in a study of 109 cases of CT proved brain infarction. Main end-points of this study were 30-days case-fatality rates and the probability of early discharge or prolonged hospitalization. Proportions of patients exhibiting diverse evolutions were compared by Fisher's test and, when the number of observations permitted, by chi-square test. Diabetes mellitus was diagnosed by history in 15.6% (17 patients). In 86 cases analysed within 72 hours of admission, hyperglycemia (glucose level higher than 110 mg/dL) was detected in 67.4% (including all 14 diabetic patients (35.3% vs 21.7%; p = 0.18), but these patients probably were discharged early less frequently (23.5% vs 51.1%; p = 0.06). Compared to the normoglycemic patients, hyperglycemic patients also fared worse, when considering altogether the early discharge and case fatality rates and the need for prolonged hospitalization (p = 0.06). They also exhibited a nonsignificant increase in early case fatality rate (31% vs 15.4%; p = 0.21) and a markedly reduced chance of obtaining early hospital discharge (37.9% vs 65.4%; p = 0.03). Case fatality rates were maximal in diabetic hyperglycemic patients (42.9%) and seemed intermediate in non-diabetic hyperglycemic patients (27.3%). Considering the three end-points evaluated, the apparent differences between non-diabetic hyper and normoglycemic patients did not reach statistical significance (p = 0.19). These results suggest that both diabetes mellitus and hyperglycemia "per se" have deleterious effects on the clinical evolution of patients with cerebral infarction.(ABSTRACT TRUNCATED AT 250 WORDS)

In non-diabetic patients, the appearance of hyperglycemia in the acute phase of stroke is related to the extension of cellular injury, and hence to the physiologic stress response. In animal models of ischemic insult, the deleterious effects of hyperglycemia depend heavily on the production of lactic acid "via" activation of the glycolytic anaerobic pathway. The abnormal production of lactic acid and consequent tissular acidosis appear mainly in the early post-reperfusion period, or in states of marked but partial reduction of blood flow. A direct reduction of cerebral blood flow and, perhaps, the production of a hyperosmolar state may contribute to worsening of the ischemic injury. In diabetic patients, previous hemorrheologic and microcirculatory changes, and a greater susceptibility to infections may additionally reduce the chances of complete recovery after stroke.

Diabetes Mellitus represents an important public health problem in the most developed industrialized countries. Clinical presentations of diabetes are strongly related to the cardiovascular system, namely, coronary disease and angiopathic renal failure. Diabetes modifies the clinical course of arteriosclerosis by carrying the angiopathic process to a microvascular level, where typical microangiopathic lesions can be observed. The risk of developing atherosclerotic disease is 2-3 fold higher in diabetics than in nondiabetics and arterial hypertension reaches a prevalence of 40 to 80%. Authors analyse Arterial Hypertension in the context of Diabetes putting focus on the underlying pathophysiological mechanisms. Where considering the coronary disease (CD), its high prevalence among the diabetics is also emphasized, which is expressed by an increase of morbidity and mortality when compared to normal subjects. In diabetics not only the incidence of Acute Myocardial Infarction is higher, but also the long term prognosis is more complicated, a reality that the authors try to explain by anatomic and metabolic factors. The association of Diabetes plus hyperlipidemia represents undoubtedly one of the major factors that justify the worsening and progression of CD. Briefly, some interesting points that allow the understanding of this topic are described, pointing the pathogenic differences of types I and II and the clinical implications of their knowledge. Finally, the approach of Diabetes as a cardiovascular risk factor is discussed in a prophylactic perspective.

The different aspects of the etiopathogenesis of arterial hypertension in diabetes mellitus are reviewed. Therapeutic approaches and the several phases of treatment are discussed, with particular emphasis on the most recent developments.