Journal Of Indian College Of Cardiology

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 9  |  Issue : 2  |  Page : 83--87

The relation between retinopathy grade and coronary artery disease in acute coronary syndrome diabetics


Ahmed Shawky Shereef, Nader T Kandeel 
 Department of Cardiology, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Correspondence Address:
Dr. Ahmed Shawky Shereef
Department of Cardiology, Faculty of Medicine, Zagazig University, Zagazig
Egypt

Abstract

Background: Diabetic retinopathy (DR) was found to be associated with an increased risk for coronary artery disease (CAD). However, there are less data about the relation between the degree of DR and the angiographic severity of CAD. Objective: The objective of the study is to examine the relation between the degree of DR and the angiographic severity of CAD in patients with acute coronary syndrome (ACS). Patients and Methods: Fifty diabetic patients with ACS were enrolled in this study. History, clinical examination, echocardiography, coronary angiography, and fundus examination were done to all patients. According to the degree of DR, patients were classified into two groups: Group I – patients with no or mild nonproliferative (NP) DR (n = 27) and Group II – patients with moderate or severe NP DR or with proliferative DR (n = 23). Results: Population characteristics, risk factors, diabetes duration, insulin use, and echocardiographic measures were comparable in the two groups. Patients in Group II had significantly more number of diseased vessels, more maximum stenosis, and higher Gensini score than those of Group I. There was a significant correlation between the degree of DR and the number of diseased vessels (r = 0.358, P =0.011) and highly significant correlation between the degree of DR and maximum stenosis (r = 0.452, P =0.001) and Gensini score (r = 0.706, P < 0.00001). Conclusion: There is an obvious relation between the degree of DR and angiographic severity of CAD in diabetic patients with ACS. Patients with a higher degree of DR had more severe CAD.



How to cite this article:
Shereef AS, Kandeel NT. The relation between retinopathy grade and coronary artery disease in acute coronary syndrome diabetics.J Indian coll cardiol 2019;9:83-87


How to cite this URL:
Shereef AS, Kandeel NT. The relation between retinopathy grade and coronary artery disease in acute coronary syndrome diabetics. J Indian coll cardiol [serial online] 2019 [cited 2019 Nov 13 ];9:83-87
Available from: http://www.joicc.org/text.asp?2019/9/2/83/267491


Full Text



 Introduction



Coronary artery disease (CAD) is a leading cause of mortality in diabetics.[1],[2],[3] Diabetes confers a risk equivalent to aging by 15 years, and more deaths from diabetes are directly due to CAD than to any other cause.[4] The risk of a myocardial infarction in diabetic patients with no evidence of CAD matches that in patients without diabetes who have had a previous myocardial infarction, supporting the idea of diabetes as a coronary equivalent.[5] While macrovascular disease is the primary pathogenic mechanism underlying CAD in the general population, microvascular disease may play a prominent role in CAD development in diabetics.[6],[7],[8],[9],[10],[11] Diabetic retinopathy (DR) is a specific marker of microvascular disease in diabetics, and the presence of DR was found to be associated with an increased risk of CAD.[12],[13]

Moreover, diabetic patients with CAD and retinopathy were found to be poorer outcome, with higher mortality when compared to those without retinopathy.[14]

However, the relation between the degree of retinopathy and the severity of angiographically detected CAD was not fully investigated.

Our aim was to examine the relation between the degree of DR and the severity of CAD detected by coronary angiography in diabetic patients with acute coronary syndrome (ACS).

 Patients and Methods



This study had been carried out in the Cardiology Department, Faculty of Medicine, Zagazig University, in the period between November 2016 and November 2017.

Fifty diabetic patients who were admitted to the Coronary Care Unit (CCU) of Zagazig University Hospitals with ACS were enrolled in the study. They included 24 males and 26 females, with a mean age of 55.1 ± 8.9 years, including 22 patients with unstable angina pectoris, 23 patients with non-ST-segment elevation myocardial infarction, and 5 patients with ST-segment elevation myocardial infarction.

Our Institutional Review Board had approved the study protocol. After obtaining a written informed consent from every patient, we made the following for them:

Full history takingThorough clinical examinationElectrocardiographyFundus examination.

Fundus examination was done to all patients by an experienced ophthalmologist, unaware to the patients' conditions. The presence of DR and its degree was detected and was graded according to the American Academy of Ophthalmology,[15] as follows:

Grade 0: No retinopathyGrade I: Mild nonproliferative (NP) DRGrade II: Moderate NP-DRGrade III: Severe NP-DRGrade IV: Patients with proliferative DR.

According to the degree of DR, patients were divided into two groups:

Group I: Patients with Group 0 or Group I DR. This group included 27 patients, 12 males and 15 females; their mean age was 54 ± 7.3 yearsGroup II: Patients with Group II, Group III, or Group IV DR. This group included 23 patients, 12 males and 11 females; their mean age was 56.4 ± 10.48 years.

Echocardiography

Standard echocardiographic study was done to every patient. The following measures were taken:

Left ventricular end-diastolic dimension (LVEDD)Left ventricular end-systolic dimension (LVESD)Fraction of shorteningEjection fraction (EF)Mitral valve E-wave velocityMitral valve A-wave velocityE/A ratio

Coronary angiography.

Coronary angiography was done to all patients using retrograde, transfemoral technique.[16] Coronary angiography was done and reviewed by an experienced angiographer, unaware by patients' conditions.

The following were stressed upon:

Number of diseased vesselsSite of lesionsSeverity of stenosis percentage.

Gensini score[17] was calculated for every patient to determine the angiographic severity of CAD. In this score, we give 1 for 25% stenosis, 2 for 50%, 4 for 75%, 8 for 90%, 16 for 99%, and 32 for total occlusion. The score is then multiplied by a factor according to the site of the lesion [Figure 1].{Figure 1}

Statistical analysis

All data were analyzed using the SPSS for Windows package program (Version 20.0, IBM Corp.; Armonk, NY, USA). Differences between patients' group and control group were analyzed using Chi-square test and Student's t-test. Correlations between different variables were investigated by Pearson correlation analysis. P < 0.05 was regarded as being statistically significant.

 Results



We enrolled 50 diabetic patients (24 males and 26 females) in the study. All patients were admitted to the CCU of Zagazig university hospitals with ACS; among them, 27 patients were with Group 0–Group I DR (Group I) and 23 patients were with Group II–Group IV DR (Group II).

As shown in [Table 1], there was no significant difference between the two groups regarding population characteristics, risk factors for CAD, duration of diabetes, or number of patients using insulin.{Table 1}

Furthermore, there was no significant difference between the two groups regarding echocardiographic parameters (LVEDD, LVESD, EF, E-wave, A-wave, or E/A ratio).

Coronary angiographic results showed no significant difference regarding affected vessels or number of diseased vessels.

Maximum coronary stenosis was significantly higher in Group II (84% ±12.56% in Group I, 95.6% ±7.8% in Group II, P = 0.000231). Gensini score was significantly higher in Group II [19 ± 12.97 in Group I, 51 ± 27.98 in Group II, P = 0.0000069, [Table 1].

As shown in [Figure 1]a, there was a significant positive correlation between the grade of DR and number of diseased vessels (r = 0.358, P = 0.011).

There was a highly significant positive correlation between the grade of DR and maximum coronary score [r = 0.452, P = 0.00098, [Figure 1]b and Gensini score [r = 0.706, P < 0.000001, [Figure 1]c.

 Discussion



CAD is the leading cause of death among adult diabetics and accounts for about 3 times as many deaths among diabetic as among nondiabetics.[2] Data of the Framingham Heart Study have shown an increased risk of CAD in diabetics as well as the poor outcome of diabetic CAD patients than nondiabetics.[18]

DR is a common vascular complication in diabetic patients. It occurs in about 19%–30% of adult diabetic patients.[18],[19]

DR was found to be associated with increased risk of CAD and to have a predictive value for CAD events in diabetic patients. Furthermore, CAD patients with DR have poorer outcome, with increased mortality and morbidity.[2],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22]

Diabetic patients with CAD and DR tend to have a poorer prognosis after coronary artery bypass grafting,[23] or after percutaneous coronary intervention with insertion of drug eluting stents,[24] or bare-metal stents.[25]

However, none of these studies evaluated the severity of CAD by coronary angiography, which is the gold standard of the diagnosis of CAD, and its relation to the degree of DR.

In our study, we examined the relation between the degree of DR and the severity of CAD. We used Gensini score[17] to measure CAD severity. Patients with advanced DR had more severe CAD, more stenosis, and higher Gensini score than those with mild or no DR. We also found significant correlations between the degree of DR and number of diseased vessels and maximum stenosis and Gensini score.

Similar results to our study were found by Norgaz et al.[26] However, they did not include patients with ACS, in spite of the great importance of detecting CAD severity in this subset of patients for early risk stratification and plan of management.

However, in our study, there was no significant difference between the two groups regarding the duration of diabetes, blood glucose level, or number of patients using insulin.[27]

Klein et al.[28] reported an association between DR and carotid artery intima-media wall thickness in a cross-sectional study from a population-based cohort of diabetic adults, but they found no association between the severity of DR and atherosclerotic risk factors. We similarly did not observe any relation between the DR and risk factors for CAD.

In a study by Yamamoto et al.,[29] they focused on the nonenzymatic glycation reaction under prolonged hyperglycemia, which results in the formation and accumulation of advanced glycation end-products (AGEs). The interaction of AGEs with the receptor for AGEs (RAGEs) has been implicated in the development of vascular complications.

AGEs play an important role in the accelerated course of atherosclerosis in diabetes mellitus (DM). Wang et al.[30] have demonstrated that the AGEs-RAGEs interaction in vascular smooth muscle cells, in addition to growth factors induced by AGEs, contributes to the stimulatory effect of diabetes on vascular smooth muscle cell proliferation which can accelerate atherosclerosis.

Aso et al.[27] measured the serum concentrations of AGEs in type 2 DM patients and proposed that they were associated with the development of CAD as well as DR and nephropathy.

Therefore, it is reasonable to speculate that there is at least one common pathway in the development of DR and diabetic atherosclerotic lesions.

Limitations of the study

We have evaluated the severity of coronary atherosclerosis by lumen irregularities detected on coronary angiographic images. However, the growth of atherosclerotic plaque that does not protrude into the lumen may result in an underestimation of the CAD severity, which could have been recognized by the use of intravascular ultrasound. However, even by using coronary angiography, the relation with CAD severity and DR was significant.

Clinical implications

According to the results of the present study, the presence of DR, especially if more than Group I, in patients with DM presenting with ACS, was associated with more diffuse and severe CAD. Meanwhile, a fundus examination is a simple, noninvasive, and routinely employed technique used in the follow-up of diabetic patients and may add a role for early risk stratification and management of this, frequently seen, subset of patients.

 Conclusion



Among diabetics with ACS, those with more than mild DR have more diffuse and severe coronary atherosclerosis, compared with diabetics without retinopathy, which cannot be explained by the longer duration or inferior control of the disease. Further studies focusing on the mechanisms of this situation are needed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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