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SAJDVD: VOLUME 12, ISSUE 2, DECEMBER 2015

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From the Editor’s Desk
Authors: Mahomed, FA
From: South African Journal of Diabetes and Vascular Disease, Vol 12, Issue 2, Dec 2015
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Side effects of statins
Authors: Ramsunder, N
From: South African Journal of Diabetes and Vascular Disease, Vol 12, Issue 2, Dec 2015
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Introduction:The 3-hydroxy 3-methylglutaryl CoA (HMG CoA) reductase inhibitors, also known as statins, were first discovered in 1971 by a Japanese biochemist from the fungus Penicillium citrinum. Lovastatin was the first statin introduced on the market in 1987.
Statins are a widely used group of cholesterol-lowering agents that act by inhibiting the enzyme HMG CoA reductase, which catalyses the rate-limiting step in the biosynthesis of cholesterol.1 They are currently the largest-selling class of pharmaceutical compounds of all time, with six different statins currently available in most parts of the world. With sales in excess of $22 billion per annum, these drugs are taken by hundreds of millions of people around the world to prevent vascular disease.
However these drugs are not without their side effects and it is the purpose of this review to examine some of these side effects. This article will divide these side effects into adverse and beneficial effects.
Understanding dieting
Authors: Naidoo, BM; Martens, A; Adams, GB; Lachman, R; Everson, LA; Jackson, AJ; Tivers, V; Addicott, LB; Walters, E
From: South African Journal of Diabetes and Vascular Disease, Vol 12, Issue 2, Dec 2015
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Background:Globally there is a marked increase in the incidence of obesity. As a society, these increasing rates can be attributed to an increased calorie intake, changes in dietary composition, decreasing levels of physical activity, and the active promotion of food consumption by industry.
On a more personal level, factors that contribute to weight gain for the individual include poor dietary intake and food choices, skipping meals, excessive intake of sugar-containing food and drinks, a lack of exercise and inactivity; psychological factors such as depression, anxiety and stress; biomedical factors such as genetic make-up, disorders of metabolism and medical conditions; use of medication; inflammatory processes; and any factors that may result in reduced mobility.
Overweight and obesity are associated with a higher risk of several related conditions, termed chronic diseases of lifestyle, such as chronic kidney disease, cardiovascular disease, diabetes and hypertension. Data show that most deaths that can be attributed to overweight and obesity are due to a cardiovascular event. Even with aggressive drug therapy to target high blood pressure and cholesterol, increased rates of overweight and obesity are expected to have significant negative health effects and increase the prevalence of diabetes, osteoarthritis, certain types of cancer, major vascular diseases, and sleep apnoea. All of these conditions have the potential to lower the quality of life of an individual.
Weight loss of only five to 10% in obese individuals significantly reduces the above risks. Sustained weight loss of as little as three to 5% is likely to result in clinically significant reductions in triglyceride and blood glucose levels, and the risk of developing type 2 diabetes, and better long-term control of blood glucose levels.
Telomeres and atherosclerosis
Authors: Khan, S; Chuturgoon, AA; Naidoo, DP
From: South African Journal of Diabetes and Vascular Disease, Vol 12, Issue 2, Dec 2015
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Abstract: an extended lifespan, the leading causes of death are atherosclerotic cardiovascular disease and cancer. Experimental and clinical evidence indicates that these age-related disorders are linked through dysregulation of telomere homeostasis. Telomeres are DNA protein structures located at the terminal end of chromosomes and shorten with each cycle of cell replication, thereby reflecting the biological age of an organism. Critically shortened telomeres provoke cellular senescence and apoptosis, impairing the function and viability of a cell. The endothelial cells within atherosclerotic plaques have been shown to display features of cellular senescence. Studies have consistently demonstrated an association between shortened telomere length and coronary artery disease (CAD).
Several of the CAD risk factors and particularly type 2 diabetes are linked to telomere shortening and cellular senescence. Our interest in telomere biology was prompted by the high incidence of premature CAD and diabetes in a subset of our population, and the hypothesis that these conditions are premature-ageing syndromes. The assessment of telomere length may serve as a better predictor of cardiovascular risk and mortality than currently available risk markers, and anti-senescence therapy targeting the telomere complex is emerging as a new strategy in the treatment of atherosclerosis. We review the evidence linking telomere biology to atherosclerosis and discuss methods to preserve telomere length.
Efficacy and safety of sirolimus-eluting stents versus bare-metal stents in coronary artery disease patients with diabetes: a meta-analysis
Authors: Qiao, Y; Bian, Y; Yan, X; Liu, Z; Chen, Y
From: South African Journal of Diabetes and Vascular Disease, Vol 12, Issue 2, Dec 2015
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Objective: To compare by meta-analysis the efficacy and safety of sirolimus-eluting and bare-metal stents in coronary artery disease (CAD) patients with diabetes.
Methods: PubMed, MEDLINE and EMBASE were searched from 1971 to 2012. Data on the efficacy and safety of sirolimus-eluting and bare-metal stents in patients with diabetes were collected. A meta-analysis was then performed on a total of 1 259 CAD patients with diabetes from six studies. The odds ratio (OR) was used for comparison. Subgroup analysis was performed according to the sample size, year of study, subjects’ geographic area and study method.
Results: Compared with those in the bare-metal stent group
(BMS), the subjects in the sirolimus-eluting stent (SES) group had a reduced risk for major cardiac events [OR 0.42, 95% confidence interval (CI): 024–0.74, p < 0.01] and target-lesion revascularisation (OR 0.26, 95% CI: 0.11–0.59, p < 0.01). There was no difference for myocardial infarction (OR 0.92, 95%
CI: 0.61–1.40, p > 0.05) or mortality (OR 1.19, 95% CI: 0.74–1.92, p > 0.05). Subgroup analysis showed a significant difference for overall risk of major cardiac events between SES and BMS when the sample size was ≤ 90 (OR 0.28, 95% CI: 0.16–0.48,
p < 0.01), when it was a randomised control trial (RCT) (OR 0.28, 95% CI: 0.19–0.42, p < 0.01), or when it was performed on European subjects (OR 0.45, 95% CI: 0.27–0.77, p < 0.01). The sensitivity was not different when one study was removed at a time.
Conclusion: Our study confirmed that SES are safer and more effective than BMS in CAD patients with diabetes, as far as major cardiac events are concerned.
Glycaemic, blood pressure and cholesterol control in 25 629 diabetics
Authors: Pinchevsky, Y; Butkow, N; Chirwa, T; Raal, RJ
From: South African Journal of Diabetes and Vascular Disease, Vol 12, Issue 2, Dec 2015
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Objective: To examine and compare the extent to which people with type 2 diabetes (T2DM) are achieving haemoglobin A1c (HbA1c), blood pressure (BP) and LDL cholesterol (LDL-C) treatment targets.
Methods: A review of databases (MEDLINE Ovid, Pubmed and Sabinet) was performed and limited to the following terms: type 2 diabetes mellitus AND guideline AND goal achievement for the years 2009 to 2014 (five years).
Results: A total of 14 studies (25 629 patients) were selected across 19 different countries. An HbA1c level of 7.0% (or less) was achieved by 44.5% of subjects (range 19.2–70.5%), while 35.2% (range 7.4–66.3%) achieved BP of 130/80 mmHg (or less), and 51.4% (range 20.0–82.9%) had an LDL-C level of either 2.5 or 2.6 mmol/l (100 mg/dl or less).
Conclusion: Despite guideline recommendations that lowering of HbA1c, BP and lipids to target levels in T2DM will lead to a reduction in morbidity and mortality rates, we found that control of these risk factors remains sub-optimal, even across different settings.
Prevalence and covariates of electrocardiographic left ventricular hypertrophy in diabetic patients in Tanzania
Authors: Lutale, JJK; thordarson, H; Gulam-Abbas, Z; Vetvik, K; Gerdts, E
From: South African Journal of Diabetes and Vascular Disease, Vol 12, Issue 2, Dec 2015
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Background: Left ventricular hypertrophy (LVH) has been demonstrated to be a powerful predictor of cardiovascular (CV) morbidity and mortality in diabetic as well as hypertensive patients. However, less is known about the prevalence of electrocardiographic LVH (ECG-LVH) and its relation to other CV risk factors in diabetic patients in sub-Saharan Africa. Therefore, the aim was to assess the prevalence of ECG-LVH in diabetic patients in Dar es Salaam, Tanzania, and its relation to other cardiovascular risk factors.
Methods: Two hundred and thirty-seven consecutive patients attending the Muhimbili diabetic clinic were studied. ECG-LVH was diagnosed by Sokolow-Lyon voltage and Cornell voltage-duration product criteria. Q waves, ST-segment deviation, T-wave abnormalities and intraventricular conduction defects were classified by the Minnesota codes. Blood pressure (BP), serum creatinine, cholesterol and triglyceride levels, and HbA1c and urinary albumin and creatinine concentrations were determined.
Results: The prevalence of LVH in patients was 16% by either ECG criteria; 12.2% by Sokolow-Lyon and 5.1% by Cornell product criteria. Patients with LVH had significantly higher systolic and mean BP and pulse pressure, and a higher prevalence of ST-segment abnormalities, T-wave inversion and albuminuria than those without LVH (all p < 0.05). In multivariate logistic regression analysis, systolic BP was the only independent predictor of ECG-LVH. The prevalence of ECG-LVH increased by 15% per 10 mmHg higher systolic BP [OR 1.151 (95% CI 1.009–21.314), p < 0.05]. Clustering of cardiovascular risk factors differed significantly between type 1 and type 2 diabetes patients. On average, type 1 patients had 0.8 and type 2 had 2.2 additional CV risk factors.
Conclusion: ECG-LVH was present in 16% of diabetic patients in Tanzania. Systolic BP was the most important predictor of ECG-LVH. Clustering of CV risks was significantly higher in type 2 than in type 1 diabetics, demonstrating the need for systematic multiple risk-factor assessment in these patients.
Blood pressure response to an exercise treadmill test, and echocardiographic left ventricular geometry in Nigerian normotensive diabetics
Authors: Ajayi, EA; Balogun, MO; Akintomide, OA; Adebayo, RA; Ajayi, OE; Ikem, RT; Ogunyemi, SA; Oyedeji, AT
From: South African Journal of Diabetes and Vascular Disease, Vol 12, Issue 2, Dec 2015
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Objectives: This study evaluated normotensive diabetic patients’ blood pressure response to graded exercise and their echocardiographic pattern of left ventricular geometry.
Methods: A descriptive, cross-sectional, hospital-based study was carried out on 30 normotensive type 2 diabetic patients and 34 controls, aged 30 to 60 years. The outcome measures were to determine the exercise-related variable, blood pressure response, and left ventricular geometry by means of echocardiography.
Results: Nineteen (29.7%) and 11 (17.2%) normotensive diabetic subjects had normal left ventricular geometry and concentric left ventricular remodelling, respectively. None of the subjects had concentric or eccentric left ventricular hypertrophy. On this basis, the normotensive diabetic subjects were divided to two groups: G1 (normal) and G2 (concentric left ventricular remodelling). The groups had comparable mean age, body mass index (BMI), fasting blood glucose (FBG) and two-hour post-prandial blood glucose values, and heart rate, systolic (SBP) and diastolic blood pressure (DBP) at rest. G2 patients had higher mean duration of diabetes than G1 subjects (69.0 ± 9.48 vs 18.7 ± 8.7 months; p = 0.007). Peak systolic blood pressure was significantly higher in G2 than G1 subjects (213.6 ± 20.1 vs 200.0 ± 15.3 mmHg; p = 0.04). Although there was no statistically significant difference in the left ventricular (LV) mass index between the groups, G2 patients had significantly higher relative wall thicknesses than G1 patients (0.53 ± 0.03 vs 0.41 ± 0.04; p < 0.001).
Conclusion: Normotensive diabetic subjects with concentric left ventricular remodelling have increased blood pressure reactivity to exercise. It is probable, as suggested in earlier studies, that increased blood pressure reactivity to exercise is an indicator of target-organ damage, particularly in normotensive diabetics.
Increased relative wall thickness is a marker of subclinical cardiac target-organ damage in African diabetic patients
Authors: Chillo, P; Lwakatare, J; Lutale, J; Gerdts, E
From: South African Journal of Diabetes and Vascular Disease, Vol 12, Issue 2, Dec 2015
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Objective: To assess the prevalence and covariates of abnormal left ventricular (LV) geometry in diabetic outpatients attending Muhimbili National Hospital in Dar es Salaam, Tanzania.
Methods: Echocardiography was performed in 61 type 1 and 123 type 2 diabetes patients. LV hypertrophy was taken as LV mass/height2.7 > 49.2 g/m2.7 in men and > 46.7 g/m2.7 in women. Relative wall thickness (RWT) was calculated as the ratio of LV posterior wall thickness to end-diastolic radius and considered increased if ≥ 0.43. LV geometry was defined
from LV mass index and RWT in combination.
Results: The most common abnormal LV geometries were concentric remodelling in type 1 (30%) and concentric hypertrophy in type 2 (36.7%) diabetes patients. Overall, increased RWT was present in 58% of the patients. In multivariate analyses, higher RWT was independently associated with hypertension, longer isovolumic relaxation time, lower stress-corrected midwall shortening and circumferential endsystolic stress, both in type 1 (multiple R2 = 0.73) and type 2 diabetes patients (multiple R2 = 0.66), both p < 0.001. These associations were independent of gender, LV hypertrophy or renal dysfunction.
Conclusion: Increased RWT is common among diabetic sub-Saharan Africans and is associated with hypertension and LV dysfunction.
Letter to the Editor
From: South African Journal of Diabetes and Vascular Disease, Vol 12, Issue 2, Dec 2015
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