- SHORT COMMUNICATION
Impact of diabetes mellitus on the dimensions of normal atherosclerosis-free coronary arteries
Jarosław Skowroński1, Gary S Mintz2, Ilona Michałowska1, Emilia Szudejko1, Min Jae Cha3, Cezary Kępka1, Mariusz Kruk1, Jacek Kwieciński1, Łukasz Kalińczuk1, Zbigniew Chmielak1, Adam Witkowski1, Michał Ciszewski1, Sang-Wook Kim3, Jerzy Pręgowski1
1National Institute of Cardiology, Warszawa, Poland
2Cardiovascular Research Foundation, New York, United States of America
3Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Korea
Correspondence to:
Jarosław Skowroński, MD, PhD,
National Institute of Cardiology,
Alpejska 42, 04–628 Warszawa, Poland,
phone: +48 22 3434127,
e-mail: jskowronski@ikard.pl
Copyright by the Author(s), 2021
Kardiol Pol. 2021; 79 (5): 566–568; DOI: 10.33963/KP.15941
Received: February 8, 2021
Revision accepted: March 22, 2021
Published online: March 26, 2021
INTRODUCTION
In diabetic patients the coronary arteries appear angiographically smaller [1–5]. This is typically seen in the reference segments and may influence stent size selection. The possible explanations for this appearance in diabetics include: (1) more diffuse disease, (2) less pronounced remodeling, or (3) authentically smaller vessel size. The aim of our study was to use coronary computed tomography angiography (CCTA) in order to compare the dimensions of normal coronary arteries in patients with and without diabetes mellitus.
METHODS
The current study is a subgroup analysis of a larger study focused on the anatomy of normal coronary arteries [6]. The study conduct complied with the Helsinki Declaration and was performed with agreement of institutional review board. Written consent was not required due to the retrospective character of the study. Demographic characteristics and patient risk factors were collected retrospectively by hospital chart review. The risk factor definitions have been described previously [6]. Patients with diabetes mellitus were case-control matched in a 1:3 ratio with non-diabetics, exactly according to sex and coronary dominance pattern and within 0.1 m2 maximal allowance of freedom for body surface area (BSA) calculated with the Du-Bois formula [7].
In all patients CCTA was performed after administration of sublingual nitroglycerin (0.8 mg). If necessary, intravenous boluses of metoprolol were given to reduce heart rate below 75 bpm. The CCTA studies were performed with the use of a dual-source computed tomography scanner (Somatom Definiton; Siemens Healthcare, Forchheim, Germany) as described previously [6].
The normal coronary artery was defined by CCTA as free of any calcification and detectable atherosclerosis. CCTA measurements were performed by a single reader at a dedicated workstation (Syngovia software, Siemens, Forchheim, Germany). The coronary artery dominance pattern and segmentation were defined according to the SYNTAX study criteria [8]. The distal coronary segments were excluded from the analysis. Lumen diameters (LD) and lumen areas (LA) were measured in all coronary segments. Mean values were computed using minimal and maximal dimension and then were used for the analyses.
The statistical analyses were performed with MedCalc 9.3.8.0 (MedCalc, Marierkerke, Belgium). The categorical data are presented as numbers and percentages and analyzed with the χ2 test. The Shapiro-Wilk test was performed to assess the normality of data distribution. Continuous variables are presented as mean and standard deviation and compared with the t-test, or in the case of non-parametric distribution median with first and third quartile and compared with the Mann–Whitney U test. The Spearman test was used for the correlation analysis.
RESULTS AND DISCUSSION
The population of 201 consecutive subjects without CCTA-detected coronary atherosclerosis was described previously in an article focused on the influence of sex and coronary artery dominance pattern on the coronary segments dimensions [6]. Overall, in the current sub-analysis, there were 14 (7%) diabetic patients (4 males, mean [SD] age 58 [6] years) and 42 matched control subjects (12 males, mean [SD] age 51 [12] years). All diabetic patients had type 2 diabetes and were on oral antidiabetic medication (8 patients treated with metformin, 1 patient with glyclaside, 2 patients with inhibitors of dipeptidyl peptidase-4), except for 2 patients treated with insulin and 1 patient with newly diagnosed diabetes with diet-controlled disease. The median duration of diagnosed diabetes was 5.5 years (Q1 = 2; Q3 = 9 years). Diabetic patients were older (58 [6] years vs 51 [12] years; P = 0.046), more often had arterial hypertension (100% vs 62%; P = 0.005), and their mean (SD) body mass index was higher (31.9 [5.6] kg/m2 vs 27.9 [3.3] kg/m2; P = 0.002). There were no differences in any coronary segments with regards to the LA or LD comparing the two groups (Table 1).
Table 1. Comparison of lumen area and diameter in diabetic and control subjects
|
Segment |
Diabetic group (n = 14) |
Control group (n = 42) |
P value |
|
LMCA LA, mm2, median (IQR) |
21.7 (19.6–27.1) |
21.3 (17.4–28.3) |
0.64 |
|
LMCA LD, mm, mean (IQR) |
5.4 (0.6) |
5.3 (0.8) |
0.60 |
|
Prox LAD LA, mm2, median (IQR) |
11.8 (10.1–13,9) |
11.5 (9.8-14.4) |
0.81 |
|
Prox LAD LD, mm, median (IQR) |
3.9 (3.6–4.2) |
3.9 (3.6–4.3) |
0.87 |
|
Mid LAD LA, mm2, mean (SD) |
7.3 (2.5) |
6.9 (2.1) |
0.53 |
|
Mid LAD LD, mm, mean (SD) |
2.9 (0.5) |
2.9 (0.5) |
0.57 |
|
OM LA, mm2 median, (IQR) |
3.6 (2.9–4.0) |
2.9 (2.4–3.9) |
0.19 |
|
OM LD, mm, mean (SD) |
2.0 (0.3) |
1.8 (0.3) |
0.14 |
|
IM LA, mm2, median (IQR) |
2.0 (1.9–4.2) |
3.3 (2.2–4.1) |
0.33 |
|
IM LD, mm, median (IQR) |
1.5 (1.4–2.1) |
1.9 (1.6–2.1) |
0.31 |
|
Prox LCX LA, mm2, mean (SD) |
12.6 (4.2) |
10.4 (4.1) |
0.09 |
|
Prox LCX LD, mm, mean (SD) |
3.9 (0.7) |
3.6 (0.7) |
0.09 |
|
Mid LCX LA, mm2, mean (SD) |
12.9 (4.3) |
10.7 (4.1) |
0.44 |
|
Mid LCX LD, mm, mean (SD) |
4.0 (0.7) |
3.7 (0.7) |
0.45 |
|
Prox RCA LA, mm2, mean (SD) |
13.1 (4.6) |
12.5 (4.2) |
0.66 |
|
Prox RCA LD, mm, mean (SD) |
4.0 (0.6) |
3.9 (0.7) |
0.68 |
|
Mid RCA LA, mm2, mean (SD) |
11.1 (4.9) |
9.4 (4.1) |
0.20 |
|
Mid RCA LD, mm, mean (SD) |
3.7 (0.9) |
3.4 (0.8) |
0.26 |
Abbreviations: IM, intermediate artery; LA, lumen area; LAD, left anterior descending coronary artery; LCx, left circumflex coronary artery; LD, lumen diameter; LMCA, left main coronary artery; mid, middle; OM, obtuse marginal branch; IQR, interquartile range; prox, proximal; RCA, right coronary artery; SD, standard deviation
We did not find any correlation between the duration of diabetes and coronary dimensions including the left main coronary artery LA (r = -0.2; P = 0.48) and LD (r = -0.3; P = 0.38) and proximal right coronary artery LA (r = -0.5; P = 0.13) and LD (r = -0.5; P = 0.16).
Interobserver variability for appropriate measurements was reported previously [6].
The main finding of our study is that diabetes mellitus per se does not influence the dimensions of coronary arteries in the absence of atherosclerosis.
The coronary arteries in diabetics with coronary artery disease (CAD) appear angiographically smaller than in CAD patients without diabetes [1–5]. By excluding any influence of diabetes mellitus on non-atherosclerotic coronary artery dimensions, the most probable explanations for this finding are either more diffuse atherosclerosis in diabetics or impairment of compensatory remodeling.
Coronary angiography can identify reduction of lumen size, but cannot explain its pathophysiological background. Moseri et al. [1] found that angiographically normal coronary arteries in diabetic patients were smaller as compared with matched controls. The authors claimed that their findings represented the earliest phase of CAD. However, invasive angiography cannot exclude mild atherosclerotic lesions that can be identified by CCTA.
Coronary stenoses develop either due to plaque accumulation that outstrips the capacity of the coronary artery to adapt (limitation of positive remodeling) or due to inadequate or negative vessel remodeling with limited plaque accumulation. These two processes can be visualized with intravascular ultrasound (IVUS) studies or non-invasively with CCTA. Vavuranakis et al. [5] showed with IVUS that compensatory vessel response to atherosclerosis is impaired in diabetic patients which may explain earlier and accelerated disease progression. Jansen et al. [4] found blunted remodeling response to atherosclerosis accumulation in reference segments of diabetic subjects. A pooled analysis of 5 prospective IVUS studies showed inadequate compensatory remodeling in diabetics, especially insulin-dependent subjects [9]. Typically, the development of type 2 diabetes mellitus is proceeded by several years of hyperinsulinemia [10]. Moreover, the diagnosis of type 2 diabetes is usually delayed by 2 years and 7% of patients are unaware of the disease for up to 7 years [11]. In response to insulin, the smooth muscle proliferates; and the amount of fibrous tissue increases which together with endothelial dysfunction may impact the ability of the arterial wall to expand [12]. However, it has been unclear whether negative remodeling (i.e. vessel shrinkage) in diabetic patients may occur independently and prior to the plaque accumulation. The results of the current study of diabetic patients without any plaque accumulation suggest that negative remodeling does proceed the plaque formation and that the reduction of luminal diameters only begins with the start of plaque accumulation.
All the diabetics and control patients routinely received sublingual nitroglycerin prior to CCTA. It is possible that the size of coronary arteries in diabetic patients was smaller at baseline, due to lower levels of nitric oxide mediated vasodilation (i.e.. endothelial dysfunction) [13].
The current study has some limitations. The study is retrospective, and the population is small. However, diabetes is one of the strongest risk factors of the CAD and the diabetic patients with coronary tree virtually free from atherosclerosis are not common. The median duration of diabetes was 5.5 years. However, as stated above the prediabetic state and even undiagnosed diabetes could have been present for much longer period.
Article information
Conflict of interest: None declared.
Open access: This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially. For commercial use, please contact the journal office at kardiologiapolska@ptkardio.pl.
How to cite: Skowroński J, Mintz GS, Michałowska I, et al. Impact of diabetes mellitus on the dimensions of normal atherosclerosis-free coronary arteries. Kardiol Pol. 2021; 79(5): 566–568, doi: 10.33963/KP.15941.
REFERENCES
- 1. Mosseri M, Nahir M, Rozenman Y, et al. Diffuse narrowing of coronary arteries in diabetic patients: the earliest phase of coronary artery disease. Cardiology. 1998; 89(2): 103–110, doi: 10.1159/000006764, indexed in Pubmed: 9524010.
- 2. Melidonis A, Dimopoulos V, Lempidakis E, et al. Angiographic study of coronary artery disease in diabetic patients in comparison with nondiabetic patients. Angiology. 1999; 50(12): 997–1006, doi: 10.1177/000331979905001205, indexed in Pubmed: 10609766.
- 3. Gui MH, Qin GY, Ning G, et al. The comparison of coronary angiographic profiles between diabetic and nondiabetic patients with coronary artery disease in a Chinese population. Diabetes Res Clin Pract. 2009; 85(2): 213–219, doi: 10.1016/j.diabres.2009.05.010, indexed in Pubmed: 19501926.
- 4. Jensen LO, Thayssen P, Mintz GS, et al. Comparison of intravascular ultrasound and angiographic assessment of coronary reference segment size in patients with type 2 diabetes mellitus. Am J Cardiol. 2008; 101(5): 590–595, doi: 10.1016/j.amjcard.2007.10.020, indexed in Pubmed: 18308004.
- 5. Vavuranakis M, Stefanadis C, Toutouzas K, et al. Impaired compensatory coronary artery enlargement in atherosclerosis contributes to the development of coronary artery stenosis in diabetic patients. An in vivo intravascular ultrasound study. Eur Heart J. 1997; 18(7): 1090–1094, doi: 10.1093/oxfordjournals.eurheartj.a015402, indexed in Pubmed: 9243141.
- 6. Skowronski J, Pregowski J, Mintz GS, et al. Measurements of lumen areas and diameters of proximal and middle coronary artery segments in subjects without coronary atherosclerosis. Am J Cardiol. 2018; 121(8): 917–923, doi: 10.1016/j.amjcard.2018.01.002, indexed in Pubmed: 29452689.
- 7. DuBois D, DuBois EF. A formula to estimate the approximate surface area if height and weight be known. Arch Intern Med. 1916; 17: 863–871.
- 8. Sianos G, Morel MA, Kappetein AP, et al. The SYNTAX score: an angiographic tool grading the complexity of coronary artery disease. EuroIntervention. 2005; 1(2): 219–227, indexed in Pubmed: 19758907.
- 9. Nicholls SJ, Tuzcu EM, Kalidindi S, et al. Effect of diabetes on progression of coronary atherosclerosis and arterial remodeling: a pooled analysis of 5 intravascular ultrasound trials. J Am Coll Cardiol. 2008; 52(4): 255–262, doi: 10.1016/j.jacc.2008.03.051, indexed in Pubmed: 18634979.
- 10. Ramlo-Halsted BA, Edelman SV. The natural history of type 2 diabetes. Implications for clinical practice. Prim Care. 1999; 26(4): 771–789, doi: 10.1016/s0095-4543(05)70130-5, indexed in Pubmed: 10523459.
- 11. Samuels TA, Cohen D, Brancati FL, et al. Delayed diagnosis of incident type 2 diabetes mellitus in the ARIC study. Am J Manag Care. 2006; 12(12): 717–724, indexed in Pubmed: 17149994.
- 12. Nigro J, Osman N, Dart AM, et al. Insulin resistance and atherosclerosis. Endocr Rev. 2006; 27(3): 242–259, doi: 10.1210/er.2005-0007, indexed in Pubmed: 16492903.
- 13. Kibel A, Selthofer-Relatic K, Drenjancevic I, et al. Coronary microvascular dysfunction in diabetes mellitus. J Int Med Res. 2017; 45(6): 1901–1929, doi: 10.1177/0300060516675504, indexed in Pubmed: 28643578.
