Fasting plasma glucose (FPG) is nowadays routinely measured during early pregnancy to detect preexisting diabetes (FPG ≥ 7 mmol/L). This screening has concomitantly led to identify early intermediate ...hyperglycemia, defined as FPG in the 5.1 to 6.9 mmol/L range, also early gestational diabetes mellitus (eGDM). Early FPG has been associated with poor pregnancy outcomes, but the recommendation by the IADPSG to refer women with eGDM for immediate management is more pragmatic than evidence based. Although eGDM is characterized by insulin resistance and associated with classical risk factors for type 2 diabetes and incident diabetes after delivery, it is not necessarily associated with preexisting prediabetes. FPG ≥ 5.1 mmol/L in early pregnancy is actually poorly predictive of gestational diabetes mellitus diagnosed after 24 weeks of gestation. An alternative threshold should be determined but may vary according to ethnicity, gestational age, and body mass index. Finally, observational data suggest that early management of intermediate hyperglycemia may improve prognosis, through reduced gestational weight gain and potential early introduction of hypoglycemic agents. Considering all these issues, we suggest an algorithm for the management of eGDM based on early FPG levels that would be measured in case of risk factors. Nevertheless, interventional randomized trials are still missing.
Prediabetes is a very prevalent condition associated with an increased risk of developing diabetes and/or other chronic complications, in particular cardiovascular disorders. Early detection is ...therefore mandatory since therapeutic interventions may limit the development of these complications. Diagnosis of prediabetes is currently based on glycemic criteria (fasting plasma glucose (PG), and/or glycemia at 120 min during a 75 g oral glucose tolerance test (OGTT) and/or glycated hemoglobin (HbA1c). Accumulating longitudinal evidence suggests that a 1-hour PG ≥155 mg/dl (8.6 mmol/l) during the OGTT is an earlier marker of prediabetes than fasting PG, 2-h post-load PG, or HbA1c. There is substantial evidence demonstrating that the 1-h post-load PG is a more sensitive predictor of type 2 diabetes, cardiovascular disease, microangiopathy and mortality compared with conventional glucose criteria.
The aim of this review is to highlight the paramount importance of detecting prediabetes early in its pathophysiological course. Accordingly, as recommended by an international panel in a recent petition, 1-h post-load PG could replace current criteria for diagnosing early stages of “prediabetes” before prediabetes evolves as conventionally defined.
In asymptomatic patients with type 2 diabetes (T2D), the prevalence of silent myocardial infarction on routine electrocardiograms is about 4% while for silent myocardial ischemia it is 20–30%. Some ...studies showed that silent myocardial infarction is associated with an increased risk of incident heart failure (HF), whereas no prospective study has ever reported such a risk in patients with silent myocardial ischemia. In patients with HF, however, previously unrecognized coronary artery disease (CAD) often seems to be involved. Brain natriuretic peptide (BNP) and N‑terminal pro-BNP (NT-proBNP) levels represent first-line diagnostic tools for patients with suspected HF and might also serve as biomarkers for silent CAD. Echocardiography provides a detailed report of cardiac alterations that includes changes suggestive of ischemia, heart failure, and left ventricular dysfunction in addition to strong prognostic indices. Diabetic patients with silent myocardial infarction or silent myocardial ischemia should be screened for asymptomatic changes in left ventricular function or structure. In patients with silent CAD, all risk factors need to be better controlled and the choice of antihyperglycemic agents adjusted. In patients with congestive HF and no obvious cause of HF, invasive coronary angiography (or noninvasive computed tomography angiography) should be performed to detect CAD, since the finding of CAD may involve revascularization and requires additional treatments including antiplatelet agents and statins. Future research is needed to examine the cost effectiveness of screening for silent myocardial ischemia as part of HF risk assessment, and to identify preventive therapies to lower the risk of HF among patients with silent myocardial infarction.
Heart rate (HR) predicts cardiovascular morbidity and mortality in individuals either with or without diabetes. In type 2 diabetic patients, cardiac autonomic neuropathy is a risk marker for cardiac ...morbidity and mortality. A major pathogenic potential may be attributed to vagal depression and sympathetic predominance. In this issue of
Diabetologia
, Berkelaar et al (DOI:
10.1007/s00125-013-2848-6
) examined the effects of euglycaemic, and hyperglycaemic clamp with the addition of glucagon-like-peptide-1 (GLP-1) and arginine, on cardiac vagal control in a large number of healthy subjects. After adjustments for age, BMI and insulin sensitivity, insulin associations with HR remained partially intact while those with vagal control disappeared. This suggested that BMI and insulin sensitivity, but not insulin levels, were the main drivers of cardiac vagal control. GLP-1 infusion during hyperglycaemia increased HR and BP and produced a statistically non-significant decrease in measures of cardiac vagal control compared with values before any manipulation of insulin levels. This commentary summarises how, and to what extent, insulin and GLP-1 affect autonomic nervous system activity, HR and BP. More information is needed on the mechanisms through which acute administration of, and long-term treatment with, GLP-1 may affect haemodynamics and autonomic activity in diabetic and obese patients, since this may influence cardiovascular outcomes.
In addition to screening for hyperglycaemia during pregnancy after 24 weeks of gestation (WG), the current guidelines also suggest screening in early pregnancy and referring women with early ...gestational diabetes mellitus (eGDM) or overt diabetes (OD) for immediate care. Our aim was to evaluate this strategy.
This study evaluated, at our hospital (2012–2016), whether the incidence of a predefined composite outcome (preeclampsia, large-for-gestational-age infant, shoulder dystocia) and secondary outcomes was different when women were screened only after 22WG (‘late screening only’) or before 22WG and treated for eGDM or OD if present, with repeat screening after 22WG if absent (‘early ± late screening’).
Early ± late screening (n = 4605, 47.0%) increased between 2012 and 2016 (P < 0.0001) and was associated with more risk factors for GDM than late screening only. Glycaemic status differed in both groups (early ± late screening: eGDM 10.3%, GDM 12.1%, OD 0.9% vs. late screening only: GDM 16.8%, OD 1.2%; P < 0.001), with a higher rate of insulin therapy (8.9% vs. 6.0%; P < 0.001) and less gestational weight gain (11.1 ± 5.4 kg vs. 11.4 ± 5.5 kg; P = 0.013) in the early ± late screening group. Rates of those meeting the composite criterion were similar in both groups 11.6% vs. 12.0%, respectively; odds ratio (OR): 1.040, 95% confidence interval (CI): 0.920–1.176; P = 0.53 and remained comparable after adjusting for Propensity Scores (OR: 1.046, 95% CI: 0.924–1.185; P = 0.4790). Rates for secondary outcomes were also similar in both groups.
While a strategy including early measurement of fasting plasma glucose during pregnancy increases the incidence and care of hyperglycaemia during pregnancy, it may not significantly improve pregnancy outcomes.
A 48-year-old female presented with severe chronic hypothyroidism despite progressively increasing doses of levothyroxine. Poor adherence was suspected based on previous laboratory investigations. A ...low dose thyroxine absorption test using 400 µg of levothyroxine taken orally was performed. FT4 increased by 4.7 pmol/L at 3 hours and 6.6 pmol/L at 5 hours, following ingestion, effectively ruling out malabsorption. Her cardiac hemodynamic profile, measured noninvasively, also improved following levothyroxine intake, further supporting our diagnosis. Poor adherence was successfully managed by implementing twice weekly visits by a registered nurse and an improvement in both thyroid function tests and cardiac parameters was seen at the one-month follow-up visit. We suggest using a lower dose thyroxine absorption test, owing to its efficacy in establishing diagnosis and a safer alternative compared to higher doses in particular in high-risk cardiac patients.
Introduction and aim Findrisk score has been validated for prediction of diabetes risk in many populations. The aim of this study was to examine the value of this score for the detection of ...dysglycemia (impaired fasting glucose and/or glucose intolerance or diabetes) in a high-risk population in Constantine (Algeria). Patients and method We had recruited 397 patients (281 women) with risk factors of diabetes, mean age 50.2 ± 11.7 years. All had fasting glycemia (FG) and oral post charge glycemia (PCG). Findrisk score was calculated. Carotid femoral pulse wave velocity (PWV) was measured by Complior® device. Results FG and PCG were abnormal in 159 and 157 patients, respectively. Dysglycemia was found in 204 patients (51.4%), with diabetes in 17.6% and prediabetes in 33.8% of them. Findrisk score strongly correlated to FG ( r = 0.129, P = 0.01) and PCG ( r = 0.193, P = 10−5 ) but also to systolic ( r = 0.33) and diastolic blood pressure ( r = 0.20), and to PWV ( r = 0.29). Discriminating threshold of this score for predicting dysglycemia was 13. It was significantly associated with prediabetes ( P = 0.001) and dysglycemia ( P = 10−5 ), this association was found in women but not in men. Sensibility and specificity of this score for detecting dysglycemia were 76% and 37%, respectively. Their positive and negative predictive values were 54.7% and 60.7%, respectively. Conclusion FG and PCG detected dysglycemia in similar proportions. Identification of dysglycemia through Findrisk score was validated only in women. The correlation between Findrisk score and PWV suggests that a high score testified also of a high cardiovascular risk in these patients without glycemic abnormality or known cardiovascular history.
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