Nghiên cứu đặc điểm tổn thương động mạch vành, mối liên quan với microalbumin niệu và một số yếu tố nguy cơ ở bệnh nhân đái tháo đường typ 2

luận văn

Diabetes mellitus with many serious complications withsequelaes sometimes very heavy if not detected early and treatedwell, which should include marcrovascular disease calledatherosclerosis Along with the status artery lesions, a sign appearedvery early in patients with type 2 diabetes is microalbuminuria -status slight increase in urine albumin excretion during routine testsstill result in negative proteinuria Many studies of authors haveshown that microalbuminuria is not only an early sign of diabetickidney disease but also was associated with marcrovascular diseaseand coronary heart disease With the recent advent of Multi SliceComputed Tomography (MSCT) - including 64 slice ComputedTomography - the study of coronary artery system has become muchmore simple

In Vietnam, to date no research about the level of lesioncalcification and coronary atherosclerosis detected by 64-MSCT andbetween them related with microalbuminuria and the other riskfactors in patients with type 2 diabetes Therefore we conducted thisstudy to:

1 Rating characteristic calcifications and atherosclerosis, coronary artery stenosis in patients with type 2 diabetes by 64 slice computed tomography.

2 Understanding the relationship between the degree of calcification and atherosclerosis, coronary artery stenosis on 64 slice computed tomography with microalbuminuria and some risk factors for coronary artery disease in patients with type 2 diabetes

* Epidemiology of coronary heart disease (CHD).

Currently worldwide there are about 40 million people withCHD Each year, about over 5.8 million people with CHD CHD is theleading cause of mortality in cardiovascular disease In 2001 there were7.2 million people died of CHD In Vietnam CHD is increasingdramatically According to the statistics from before 1963, the CHD isvery rare but then CHD began to rise Particularly in Ho Chi Minh City

in 2000 there were 3222 patients with myocardial infarction and 122fatal cases in that

* Coronary heart disease in patients with type 2 diabetes

Through a lot of research in many different centers was foundthat the risk of CHD in patients with type 2 diabetes increased 2-4 timescompared to people without diabetes While the rate of CHD in thegeneral population is 2-4%, this rate in diabetic patients increasedsignificantly to 55% Mortality due to cardiovascular in people type 2diabetes diseases and high up to 2-6 times more than people withoutdiabetes

1.1.2 The pathogenesis of atherosclerosis in patients with type 2 diabetes.

* 4 important disorders in diabetes:

+ Dysfunction of endothelial cells

+ Dysfunction vascular smooth muscle cells

+ Platelet dysfunction

+ Coagulation abnormalities in diabetes

* The deposition of calcium in the coronary arteries:

The calcification in arteries began forming early in the seconddecade of the life, even more soon Calcium phosphate (Hydroxyapatite,

Ca3[-PO4]2-xCa[OH]2) is the main apatite are found in the same plaques

compounds in bone formation and repair Electronic Microscopedetermine the calcium crystal deposition starting from a small amount ofthe artery cells, similar to cartilage Besides, the died foam cells with thelipid core also contribute positively in the deposition of calcium.

1.1.3 Coronary atherosclerotic detection by 64-MSCT.

+ Coronary Artery Calcium Score - CACS:

Agatston score was introduced in 1990, is a traditional method toquantify calcium by computed tomography electron beam This method

is based on the platform of the largest weakening of X-ray or number (measured in HU) and the deposition of calcium

CT-+ Plaque characteristics:

Plaque is evaluated through the identification of structuraldensity Soft plaque ( noncalcification plaque) lower proportion withintravascular contrast agents Hard plaque or calcified plaque whenproportion ≥ 120 HU, even up to > 1000 HU Mixed plaque is theplaque including calcification and noncalcification

A plaque is called straight shaft (or concentric) when plaqueaxis running along the long axis of the vessels on one side of it, butmust not exceed 25% of the lumen diameter Call the misalignment(eccentricity) when the shaft deflect with the axis lumen

Assess coronary artery stenosis on the following factors:location, length of stenosis,% lumen stenosis There are many ways anarrow circuit split but divided into 5 ways depending on the diameter of

Photo 1.2 A noncalcification

plaque MPR

Photo1.3 A mixed plaque MPR

(arrow)

the narrowed lumen, from the 0 (no stenosis) to level IV (completeobstruction) is the most widely used The evaluation of stenosissometimes encounter difficulties especially when high levels of calcium(> 1000 points).

When lumen stenosis <50% diameter stenosis is called

nonsignificant stenosis (or nonobstructive), while ≥ 50% stenosis is called significant stenosis (obstructive).

1.2 MICROALBUMINURIA AND THE RELATED TO CHD IN TYPE 2DIABETES PATIENTS

1 2.1 Overview of microalbuminuria.

Microalbuminuria (MAU) is an excretion of albumin in theurine was higher than normal, at 20-200  g / min or 30-300 mg/24hours, which means a small volume of albumin excretion in the urinewithout being detected by routine testing methods

Clinically, when there appeared MAU means diabetic kidneydisease began to appear Without the active intervention it will graduallyprogress to clinical renal disease (proteinuria) and end-stage renaldisease

1.2.2 Relation between MAU and coronary artery disease.

Photo 1.5 Serve stenosis in middle LCx with the

noncalcification plaque A: 3D image;

B: MIP image;

C: Curved MPR image; D: Hình ảnh QCA

According to Avila, L Lachica and MC Gómez García, themortality rate in patients with type 2 diabetes increases when the MAUappeared ( RR = 1.8) This relationship was found even in subjects withurinary albumin excretion levels below the normal threshold (20 µg /min) Similarly, a study with 1568 people conducted in the U.S showedthat the risk of cardiovascular disease has increased 2.92 times (95% CI

= 1.57 to 5.44, p <0.001) when the excretion of albumin urinary just pass

a very low level in the normal range (≥ 3.9 µg / mg for men or ≥ 7.5 µg /

mg for women - while the diagnosis range to the MAU is 30 - <300 µg /mg)

In summary, through one of the study can be seen that betweenMAU and coronary artery disease in patients with type 2 diabetes have acertain relationship with each other However, there are some authorssuggest that this association is not clear So the study of the relationshipbetween them is really needed to help the clinician with a basis to look at

it more positively about MAU, thereby making timely interventionstrategies

2.2 Patient selection criteria.

* Have been diagnosed with type 2 diabetes currently treated withglucose-lowering drugs

* Diabetes first diagnosed with the WHO 1999 criteria

- Urinary tract infection or other kidney diseases.

- In severe congestive heart failure, liver failure, kidney failure

- Is used to poison the glomerulus

- Pregnant or menstruating

- Diabetes secondary to a medical condition or hormonal

- Being in acute illness such as sepsis, metabolic coma or othercauses, acute coronary syndrome

- History of hypersensitivity to iodine-containing contrast agents

- Irregular rhythm: atrial fibrillation, premature ventricular beats

- Have all bypass surgery, coronary stenting, heart valve replacement,peace macker installed

- Coronary artery calcification score above 1000

CHAPTER 3 RESULT

3.1 GENERAL CHARACTERISTICS OF SUBJECTS.

Table 3.3 Distribution of patients by a some coronary disease risk

Risk factors

Male (n=103)

(1)

Female (n=39)

pressure 142 ± 16 132 ± 22 139 ± 19 > 0,05Systolic

pressure 87 ± 10 81 ± 13 85 ± 11 > 0,05Over

weigh/Obesity 82 79,6 16 41,0 98 69,0 < 0,05 High WHR 76 73,8 12 30,8 88 62,0 < 0,05Dyslipidemia 67 65,0 16 41,0 83 58,5 < 0,05Current smoke 26 25,2 2 5,1 28 19,7 < 0,05Metabolic

syndrom 77 74,8 24 61,5 101 71,1 < 0,05Family historic

- Men have a higher proportion than women on the risk factors:overweight / obesity, abdominal obesity, dyslipidemia and hypertension(p <0,05)

- Percentage of patients with good blood glucose control toachieve the target of HbA1C relatively low

- Percentage of men with coronary atherosclerosis higher than women.

- Percentage of patients while decreasing the number of diseasedsegments increased

- The rate of male patients with 5 or more diseased segments higher than

Table 3.9 Distribution of patients by sex and status stenosis.

Total Male(n=103) Female(n=39)

Chart 3.4 Distribution of patients according to diseased vessel.

Among patients with significant stenosis coronary artery, themajority of patients (62.7%) is one vessel disease

Table 3.12 The prevalence of patients with coronary artery calcification by age.

- The percentage of patients with coronary artery calcification in 60years old and above men than in women (p <0,05).

Chart 3.6 Comparison of average calcification by age group.

- The difference is statistically significant on average CACSbetween age groups CACS average increases with age

Table 3.15 Diagnostic value to obstructive of the coronary arteries by 64-MSCT compared to QCA.

- Sensitivity: 91.8% - Positive predictive value: 91.8%

- Specificity: 98.8% - Negative predictive value: 98.8%3.3 RELATIONSHIP BETWEEN CORONARY ATHEROSCLEROSIS ON64-MSCT AND MICROALBUMINUREA AND SOME SISK FACTORS

Chart 3.8 Relationship between MAU and the prevalence of patients with coronary artery atherosclerosis.

- The percentage of patients with coronary arteryatherosclerosis higher in MAU(+) group than MAU (-) group.

Chart 3.10 Relation between MAU and the number of diseased segment.

- The average diseased segments higher in MAU(+) group than

Proportion of patients with significant stenosis in group MAU(+) higher significantly compared with MAU (-).

Graph 3.2 The correlation between MAU and coronary artery calcification score.

Equation: y = 0.15 x + 35.3 (r = 0.36, 95% CI = 0.12 to 0.19, p <0.001).Calcification score correlated moderately with MAU

Table 3.21 Degree of calcification and coronary atherosclerosis in dyslipidemia patients with or without MAU.

INDEX

Dyslipidemiawithout

MAU (n=46) (1)

Dyslipidemiawith MAU

(n=37) (2)

p (1,2)

Patients with coronary

Number of diseased segment 2,3 ± 1,8 3,4 ± 1,7 < 0,05Length of plaques (mm) 8,4 ± 5,3 15,5 ± 10,4 < 0,05Thickness of plaques (mm) 1,7 ± 0,6 2,1 ± 0,7 > 0.05

- There is a difference between the two groups in terms of thePatients with coronary calcification, Number of diseased segment,Length of plaques, Obstructive.

Chart 3.15 The average calcification in hypertensive patients with or without MAU.

- There are significant differences between the two groups oncoronary artery calcification score average

- The presence of MAU in hypertensive patients withincreased coronary artery calcification score

3.3.2 Relation between coronary atherosclerosis in 64-MSCT with some risk factors for coronary artery disease.

Table 3.26 Association between HbA1C with coronary atherosclerosis.

- The percentage of patients with obstructive and the average ofdiseased segment higher in HbA1C ≥ 7.0% group than in the HbA1C

<7.0% group There is no difference in the proportion of patients withatherosclerosis between 2 groups

Table 3.28 Relation between hypertension and the rate of atherosclerotic subject and the degree of coronary artery stenosis.

Groups

Hypertension(n = 100)

Chart 3.25 Relation between dyslipidemia with coronary artery calcification score.

- The CACS of dyslipidemia group significantly higher thannormal blood lipid group

- Dyslipidemia increases CACS in patients with type 2diabetes

Graph 3.4 The correlation between BMI and coronary artery calcification score.

- Coronary artery calcification score correlated closely withBMI (r=0,52; 95%CI=24,6-43,3; p<0,05)

CHAPER 4

DISCUSSION4.1 Patient characteristics in the study.

The average age of patients in the 6070 age range (67.6 ± 6.9)

-up to 57.7% of patients in this age gro-up Today it was found that type 2diabetes is not only a disease of middle-aged or older people, but alsohas a relatively high proportion of youth and even children

The rate of hypertension in the study was 70.4% (100/142),especially in men is 73.4% The rate of hypertension in the study ismuch higher than the rate of hypertension in the general population Therate of hypertension in the general population of the world in 2000 was26.5%, forecast to rise to 29.2% in 2025

Along with hypertension, dyslipidemia is a metabolic disordercommonly seen in patients with type 2 diabetes Proportion of patientswith dyslipidemia in men with hypertension was 67.1%, in the wholestudy was 58.5% (83/142) A study in Tehran showed that up to 26% -57% of patients with type 2 diabetes have a full CT concentration in theblood is higher than normal, 55 to 66.8% of patients with high TG levelsand special 60 to 72.8% of patients with LDL-C levels higher thannormal[1]

4.2 Status coronary atherosclerosis in 64-MSCT.

Proportion of patients with plaque detected on 64-MSCT in ourstudy is quite high, up to 88% (125/142), higher than some other studies.The average number of vessels with plaque in our study significantlyhigher than some research on people who do not have diabetes

It was found that the occurrence of acute coronary eventsrelated to plaque characteristics rather than the degree of stenosiscausing plaque In these types of plaque, the calcification plaque is themost stable plaque and the risk of embolic complications (due to

peeling, broken, bleeding) is also lowest; then the noncalcificationplaque or less calcification plaque are the opposite.

Rate plaque calcification lower than our study compared with anumber of studies on the general population of subjects contributingagain reiterated by many authors commented that compared: those who

do not have diabetes who have diabetes are at risk of coronary events ishigher, and the risk of death in the first month and in the first year aftercoronary events is higher too

In our study, the percentage of patients with significant stenosiswas 36.6%, males than females (40.8% vs 25.6%, p <0.05) The highest

is among patients smokers (47.2%), lowest in the group with BMI <23(29.6%) Our results equivalent to the results of several studies on manydifferent subjects, including patients without diabetes

4.3 Status coronary artery calcification.

It has been suggested that age and sex are the two mostimportant factors that influence the course of coronary arterycalcification Some research shows that while under the age of 40, therate of coronary artery calcium hoadong sexes are equal (14%) at the age

of 70, the ratio was different between men and women (women: 77 100% and male: 93-100%) In our study, average CACS of men grouphigher than the female group (p <0.05), especially among malesmokers, the proportion of non-significant stenosis among patients withCACS = 0-100 higher than significant stenosis (49.3% compared with28.8%, p <0.05) and vice versa, among patients with CACS = 101 -

-1000, stenosis rate significantly higher than the non-significant stenosis(21.2% compared with 5.5%, p <0,05) Thus increasing calcificationstatus, the level of stenosis also increases

Type 2 diabetes with a variety of disorders associated withincreased blood glucose status and increased blood insulin concentration

as a factor promoting the formation and development of blood vessel