Relevance of hemostatic risk factors on coronary morphology in patients with diabetes mellitus type 2

  • Thomas W Jax1, 2, 3Email author,

    Affiliated with

    • Ansgar J Peters3,

      Affiliated with

      • Gunnar Plehn4 and

        Affiliated with

        • Frank-Chris Schoebel3

          Affiliated with

          Cardiovascular Diabetology20098:24

          DOI: 10.1186/1475-2840-8-24

          Received: 17 March 2009

          Accepted: 06 May 2009

          Published: 06 May 2009

          Abstract

          Objective

          The influence hemostatitc parameters on the morphological extent and severity of coronary artery disease were studied in patients with and without DM type 2.

          Background

          It is known that patients with diabetes (DM) have abnormal metabolic and hemostatic parameters

          Methods

          Of 150 consecutive patients with angiographically proven coronary artery disease 29 presented with DM. Additionally to parameters of lipid-metabolism fibrinogen, tissue-plasminogenactivator (t-PA), plasminogen-activator-inhibitor (PAI), plasmin-a-antiplasmin (PAP), prothrombin-fragment 1+2 (F1+2), thrombin-antithrombin (TAT), von-willebrand-factor (vWF), platelet factor 4 (PF4), glykomembranproteine 140 (GMP140) and the rheologic parameters plasma viscosity and red blood cell aggregation were evaluated. The extent and severity of CAD was evaluated according to the criteria of the American Heart Association.

          Results

          Patients with DM presented with a higher number of conventional risk factors as compared to non-diabetic patients. Additionally there were significant differences for F1+2, red blood cell aggregation and PAI. Diabetic patients showed a more severe extent of coronary arteriosclerosis, which also could be found more distally. A significant relationship between blood-glucose, thrombocyte-activation (vWF), endogenous fibrinolysis (PAI) and the severity of CAD and a more distal location of stenoses could be found (r = 0.6, p < 0.001).

          Conclusion

          Patients with coronary artery disease and DM type 2 showed marked alterations of metabolic, hemostatic, fibrinolytic and rheologic parameters, which can produce a prothrombogenic state. A direct association of thrombogenic factors on coronary morphology could be shown. This can be the pathophysiologic mechanism of more severe and distal pronounced coronary atherosclerosis in these patients.

          Introduction

          Coronary artery disease is the essential cardiac manifestation of diabetes mellitus type 2 and is responsible for the predominant number of deaths. Early autopsy studies pointed out, that the morphological manifestation of coronary artery disease in patients with diabetes mellitus increases three to four times as compared with non-diabetics [13]. The clinical relevance of these results is documented by an increased incidence of cardiovascular events, and particularly in the "Framingham study" [4] and in the following epidemiological and longitudinal examinations [5, 6]. The influence of diabetes mellitus is statistically independent of other established risk factors for the manifestation of coronary heart disease and is regarded as the risk factor with the highest predictive value for the incidence of cardiovascular complications

          Since coronary thrombosis is essential for the pathogenesis of most acute coronary syndromes [7], the prothrombogenic constellation is probably of importance for the increased cardiovascular event rate among diabetics. Furthermore it seems likely, that subclinical intracoronary thrombi may promote atherosclerotic changes in patients with coronary heart disease [8].

          During the last few years increased attention has been given to the complex metabolic changes associated with diabetes mellitus type 2 and insulin resistance. In this study, metabolic changes associated with diabetes, particularly changes of hemostasis and endogenous fibrinolysis were studied. The importance with regard to the incidence of cardiovascular events for diabetic patients was already proven in large epidemiological studies [914]; the direct association with morphological changes was not assessed yet.

          In the present study we test the hypothesis that a) diabetic patients show a more diffuse form of coronary artery disease with a higher rate of distal stenosis and that b) haemostatic parameters correlate with the extent of coronary atherosclerosis in patients with diabetes mellitus type 2

          Patients, material and methods

          For this study 150 consecutive patients aged between 50 and 65 years, who were scheduled for elective coronary angiography, were recruited at Heinrich-Heine-University, Division of Cardiology. Unstable angina pectoris, acute myocardial infarction within the last six months before inclusion into the study, and prior coronary interventions were exclusion criteria. Furthermore, patients with acute or chronic infections and malignant diseases were excluded. Patients with a diabetes type 1 were not included in the study.

          Definition of cardiovascular risk factors

          Hyperlipidemia was defined as with total cholesterol above 220 mg/dl, as triglycerides above 200 mg/dl, with a positive history of hypercholesterolemia or hypertriglyceridemia and with lipid reducing therapies.

          Diabetes was defined as fasting blood glucose above 126 mg/dl, or antidiabetic therapy. Hypertension was defined as resting blood pressure above 140 mmHg systolic or 90 mmHg diastolic, or with antihypertensive medication. Nicotine consumption was assessed by patient history.

          Coronary Angiography

          In all patients coronary angiograms with imaging of the coronary arteries in different standardised projections were carried out. The degree of coronary artery stenosis was assessed by two experienced, independent examiners. The severity of CAD was defined as coronary 1, 2 or 3 vessel disease corresponding to the number of affected main vessels with hemodynamic relevant stenosis above 50%. Extent of coronary atherosclerosis was determined by a special grading system in accordance with an evaluation system of the American Heart Association [15]. Based on these findings the coronary artery system was divided into 15 segments. The segment with a higher degree of stenosis got a higher score. The sum of these scores was divided by the number of judged segments. The result presents the extent of coronary atherosclerosis. To get information about the distribution pattern of coronary atherosclerosis a proximal score from the proximal segments of coronary main arteries and a distal score from the distal parts of main coronary arteries and vessels of first degree were calculated.

          Laborchemical methods

          Blood samples for the different parameters were taken at the day of cardiac catheterisation between 7:00 and 8:00 am after 30 minutes rest in a lying position. Venous puncture of an antecubital vene was done with a butterfly canula after a maximum venous compression time of 30 seconds and a maximum pressure of 40 mmHg. After decompression the first 4 ml of blood were not used. For parameters of hemostasis and endogenous fibrinolysis vacutainer tubes with 0.129 M Na2 citrat were used. Tubes underwent centrifugation at 2000 g for 15 minutes. The plasma was taken and centrifugated at 2000 g for another 15 minutes. Samples were frozen at -80°C. The samples were analysed immediately after preparation from deeply frozen plasma within three months after sample taking.

          Determination of plasma viscosity and red blood cell aggregation was performed from EDTA tubes within 4 hours after sample taking. Plasmaviscosity was determined by the capillary tube viscosimeter of Rheomed, Aachen (Germany). For determination of red blood cell aggregation an erythrocyte aggregometer (Myrenne, Roetgen, Germany) was used.

          Plasma fibrinogen levels were determined according to method described by Clauss [16]. Prothrombin fragment 1 and 2 were measured by Elisa. Specific activity of AT III was measured by a cinetic test; Protein C and S were measured by coagulometric tests. Determination of Plasminogenactivator inhibitor activity was performed by chromogenic enzymassay. Thrombin-Antithrombin III complex, plasma tissue plasminogenactivator antigen concentration, plasmin a2 antiplasmin and d-dimeres were determined by enzymimmunoassay.

          Obesity indices

          As a calculated index to estimate the extent of Obesity the "body mass index" is clinically established. This index calculates itself by the body weight (kg) being divided by the square of the height (m2). The relationship between waists and hip circumference forms another parameter for the classification of obesity [17]. This quotient was shown to correlate with the visceral fat mass [18].

          Statistical methods

          Statistical analyses were performed using SPSS software (Statistical Package for Social Sciences for Windows; SPSS 12.0, Munich). The results were tested for normal distribution by Kolmogoroff-Smirnoff test. For normally distributed parameters group comparison was made by use of paired and unpaired Student's t-test. Mann-Whitney U-Test was used for non-normally distributed parameters. The Pearson correlation coefficient or the Spearman's rank correlation was used to describe the association between the variables in the study. A stepwise regression model was used to test the relationship of laboratory parameters on morphology. Chi square test was used for comparison of non-continuous data. Statistical significance was defined as p < 0.05.

          Results

          Out of 150 consecutive patients, 28 patients presented with the diagnosis of diabetes mellitus type 2 (19%). Both groups showed a comparable age profile, they were not different with regard to height, however, diabetic patients were heavier, what resulted in a significantly higher "body mass index". Both waist circumference and the "Waist-to hip ratio" calculated from this differed significantly.

          Diabetic patients showed a 20% higher rate of arterial hypertension (table 1). Other conventional risk factors did not differ between the groups (table 1). The laboratory evaluation showed that only HDL cholesterol differed significantly, although the differences for triglycerides are only not significantly different because of the wide standard deviation (table 1). Parameters of glucose metabolism were markedly elevated in diabetic patients, as expected; there was no difference in fasting insulin levels.
          Table 1

          Patient characteristics

           

          all patients

          (n = 150)

          Diabetes mellitus Typ II

          (n = 26)

          control patients

          (n = 122)

          p-value

          age (years)

          58 ± 5

          57 ± 4

          58 ± 5

          0.1158

          hypertension (%)

          62.0%

          85.00%

          57.00%

          0.0076

          hypercholesterinemia (%)

          74.0%

          73.00%

          74.00%

          0.9419

          hypertriglyceridemia(%)

          40.0%

          46.00%

          39.00%

          0.47068

          smoking (%)

          10.0%

          4.00%

          11.00%

          0.28139

          ex-smoking (%)

          75.0%

          81.00%

          74.00%

          0.4543

          history of vascular diesease (%)

          31.0%

          39%

          30.00%

          0.37048

          obesity (%)

          83.0%

          100%

          80.00%

          0.01134

          Hyperurikämie (%)

          20.0%

          12%

          22.00%

          0.26987

          total cholesterol (mg/dl)

          226 ± 42

          225 ± 50

          225 ± 40

          0.5254

          HDL – cholesterol (mg/dl)

          44 ± 13

          37 ± 10

          46 ± 14

          0.0035

          LDL – cholesterol (mg/dl)

          157 ± 39

          159 ± 45

          156 ± 37

          0.9246

          triglycerides (mg/dl)

          210 ± 141

          239 ± 189

          205 ± 130

          0.4681

          lipoprotein (a) (mg/dl)

          20,4 ± 22,5

          16,1 ± 21,9

          20,7 ± 22,1

          0.1302

          uric acid (mg/dl)

          6,3 ± 1,5

          6,4 ± 1,6

          5,6 ± 1,1

          0.0341

          fasting plasma glucose (mg/dl)

          116 ± 51

          197 ± 75

          100 ± 19

          0.0001

          Insuline (mU/l)

          8,8 ± 5,7

          8,7 ± 4,7

          8,8 ± 5,9

          0.7382

          HbA1c (%)

          6,0 ± 1,3

          8,1 ± 1,5

          5,5 ± 0,6

          0.0001

          heigth

          174 ± 6

          173 ± 7

          174 ± 6

          0.4923

          weight (kg)

          83 ± 12

          85 ± 10

          82 ± 12

          0.171

          Body-Mass-Index (kg/m2)

          27,35 ± 3,42

          28,42 ± 2,78

          27,12 ± 3,51

          0.0367

          Waist-to-Hip-Ratio

          0,99 ± 0,07

          1,03 ± 0,07

          0,98 ± 0,07

          0.0035

          waist circumference (cm)

          99 ± 9

          104 ± 9

          100 ± 6

          0.0079

          hip circumference (cm)

          100 ± 6

          100 ± 7

          100 ± 6

          0.6175

          Patients with diabetes mellitus type 2 showed higher values for fibrinogen, the difference, however, was not significant (table 2). Also, prothrombin fragments 1 and 2 as indicators for a thrombin synthesis and a marker for prothrombotic conditions, was elevated in patients with diabetes mellitus, although again, not significantly. Anthrombin III and D-dimer showed no statistical significant differences (table 2). Plasma viscosity and aggregation of erythrocytes as the essential variables influencing microcirculation were higher in patients with diabetes mellitus. Of the markers of fibrinolysis PAI activity was significantly higher in patients with diabetes. Thrombocytic parameters did not differ at all between the two groups.
          Table 2

          Parameters of hemostasis, rheology, fibrinolysis, platelet activation and extent and severity of coronary atherosclerosis

           

          all patients

          Diabetes mellitus Typ II

          control patients

          p-value

           

          (n = 150)

          (n = 26)

          (n = 122)

           

          hemostasis

          fibrinogen (mg/dl)

          282 ± 64

          295 ± 76

          278 ± 61

          0.1618

          prothrombinfragment 1 + 2 (μg/dl)

          0,99 ± 0,52

          1,01 ± 0,55

          0,87 ± 0,37

          0.0622

          D-Dimere (μg/l)

          35 ± 62

          31 ± 43

          36 ± 65

          0.5519

          Thrombin-Antithrombin-Komplex (μg/l)

          7,6 ± 16

          9,6 ± 18,7

          7,3 ± 15,5

          0.5221

          Rheology

          plasma viscosity (mPas)

          1,30 ± 0,09

          1,33 ± 0,09

          1,29 ± 0,09

          0.0933

          erythocyte aggregation M (E)

          6,3 ± 1,8

          7,3 ± 1,9

          6,1 ± 1,8

          0.0026

          erythocyte aggregation M1 (E)

          11,3 ± 2,5

          12,8 ± 2,7

          11,0 ± 2,3

          0.0013

          hematocrit (%)

          43,5 ± 3,1

          42,7 ± 3,7

          43,6 ± 2,9

          0.1537

          fibrinolysis

          tissue-plasminogenaktivator (ng/dl)

          13,47 ± 3,68

          14,18 ± 3,36

          13,30 ± 3,77

          0.4394

          plasminogenactivatorinhibitor (U/ml)

          5,78 ± 3,25

          7,36 ± 3,24

          5,45 ± 3,18

          0.0017

          plasmin-α2-antiplasmin-complex (μg/dl)

          395 ± 152

          378 ± 168

          396 ± 146

          0.4245

          platelet activation

          platelet count (100.000/ml)

          246 ± 71

          265 ± 71

          242 ± 71

          0.1727

          von Willebrand-factor (μg/l)

          94 ± 31

          99 ± 32

          93 ± 30

          0.3661

          plateletfactor 4 (μg/l)

          12,7 ± 18,8

          9,2 ± 10,9

          13,4 ± 20,1

          0.9104

          β-thromboglobulin (μg/l)

          36,68 ± 41,90

          30,07 ± 17,57

          38,28 ± 45,53

          0.7181

          GMP 140 (μg/l)

          96,36 ± 44,69

          94,64 ± 23,41

          96,88 ± 48,26

          0.2773

          Extent and severity of coronary atherosclerosis

          total score

          1,451 ± 0,591

          1,858 ± 0,680

          1,379 ± 0,550

          0.0182

          proximal score

          1,399 ± 0,696

          1,775 ± 1,037

          1,333 ± 0,607

          0.2363

          distal score

          1,457 ± 0,666

          1,874 ± 0,647

          1,388 ± 0,651

          0.0109

          1-vessel CAD

          31.0%

          12.0%

          35.0%

           

          2-vessel CAD

          37.0%

          39.0%

          37.0%

           

          3-vessel CAD

          32.0%

          50.0%

          28.0%

          0.0306

          Patients with diabetes more often presented with 3 vessel disease (table 2). The evaluated coronary score was significantly higher in patients with than without diabetes mellitus. Patients with diabetes especially showed a higher distal score.

          The plasma levels of insulin and HbA1c correlated on the one hand significantly with PAI activity and tPA concentration, on the other hand also with indices of obesity (table 3). Of the parameters of lipid metabolism only triglycerides correlated with insulin. Fasting glucose on the day of coronary angiography strongly correlated with the total and the distally weighted score (R = 0.48, table 3).
          Table 3

          The Pearson correlation coefficient or the Spearman's rank correlations were used to describe the association between the variables in the study.

           

          tPA

          PAI

          cholesterol

          HDL

          LDL

          tg

          fibrinogen

          plasmaviscosity

          insuline

          0.3173

          0.2573

          0.0112

          -0.152

          0.0304

          0.2702

          -0.0011

          0.0444

          0.008

          0.002

          0.896

          0.076

          0.725

          0.001

          0.99

          0.612

          HbA1c

          0.2941

          0.4117

                

          0.016

          0.0001

                

          insuline

          HbA1c

          HDL

          LDL

              

          WHR

          0.2716

          0.2903

          -0.3765

          0.3134

              

          0.033

          0.014

          0.002

          0.009

              

          C-Index

          0.4067

          0.4429

          -0.3539

          0.1792

              

          0.001

          0.0001

          0.004

          0.153

              

          total score

          prox. score

          dist. score

               

          glucose

          0.4872

          0.2097

          0.4769

               

          0.0001

          0.108

          0.4769

               

          Upper line denotes R, lower line the according p-value

          We then calculated a univariant regression model for each of the three coronary scores and parameters of lipid and glucose metabolism, hemostasis and fibrinolysis, platelet activation, rheology, obesity and hypertension. Results are given in table 4. All significant parameters were included into a multivariate, stepwise regression analysis. This analysis revealed the most significant correlation between fasting glucose and all coronary scores but in particular with total and distal score, followed by waist to hip ratio and PAI activity for the distal score and von-willebrand factor for total score (table 4)
          Table 4

          univariant and multivariant (stepwise backward) regression model for each of the three coronary scores and parameters of lipid and glucose metabolism, hemostasis and fibrinolysis, platelet activation, rheology, obesity and hypertension.

           

          total score

           

          distal score

           

          proximal score

          Univariat

          Multivariat

          Univariat

          Multivariat

          Univariant

          R

          p-value

           

          R

          p-value

          p-value

          R

          p-value

          Conventional risk factors

                  

          Total cholesterol (mg/dl)

          0,17099

          0,1665

           

          0,15137

          0,2214

           

          0,12198

          0,3254

          HDL – cholesterol (mg/dl)

          0,1864

          0,134

           

          0,21858

          0,0779

          0,3475

          0,02781

          0,8246

          LDL – cholesterol (mg/dl)

          0,11409

          0,3617

           

          0,08219

          0,5118

           

          0,11332

          0,365

          Triglycerides (mg/dl)

          0,00269

          0,9827

           

          0,00918

          0,9412

           

          0,02211

          0,8591

          Uric acid (mg/dl)

          0,28913

          0,0205

          0,2187

          0,28087

          0,0246

          0,1682

          0,16794

          0,2011

          Plasma glucose (mg/dl)

          0,5456

          0,0001

          0,0001

          0,47045

          0,0001

          0,0001

          0,42108

          0,0005

          Insuline (mU/l)

          0,01736

          0,8943

           

          0,01917

          0,8834

           

          0,10553

          0,4182

          HbA1c (%)

          0,13988

          0,2589

           

          0,14837

          0,2308

           

          0,02186

          0,8606

          Hemostasis

                  

          Fibrinogen (mg/dl)

          0,07329

          0,5556

           

          0,07759

          0,5326

           

          0,03252

          0,7939

          Prothrombinfragment 1+ 2 (μg/l)

          0,05127

          0,6803

           

          0,05278

          0,6715

           

          0,00098

          0,9937

          D-dimers (μg/l)

          0,22375

          0,0687

           

          0,19556

          0,1127

           

          0,19572

          0,1124

          Thrombin-Antithrombin-complex

          0,11095

          0,3714

           

          0,10142

          0,4141

           

          0,07338

          0,5551

          tissue-Plasminogenactivator (ng/dl)

          0,09567

          0,4913

           

          0,07875

          0,5714

           

          0,08

          0,5653

          Plasminogenactivatorinhibitor (U/ml)

          0,22549

          0,0666

          0,1947

          0,25669

          0,036

          0,0407

          0,03477

          0,78

          Plasmin-a2-Antiplasmin-complex (μg/dl)

          0,08721

          0,4828

           

          0,08614

          0,4882

           

          0,05627

          0,6511

          Platelet parameters

                  

          von Willebrand-Factor (μg/l)

          0,3335

          0,0058

          0,013

          0,32558

          0,0072

          0,2661

          0,2229

          0,698

          Platelet factor 4 (μg/l)

          0,00077

          0,9951

           

          0,02395

          0,8486

           

          0,6825

          0,5861

          β-Thromboglobulin (μg/l)

          0,08704

          0,4871

           

          0,05816

          0,6428

           

          0,11954

          0,339

          GMP 140 (μg/l)

          0,11087

          0,3718

           

          0,10535

          0,3962

           

          0,07522

          0,5452

          Rheological parameters

                  

          Plasma viscosity (mPas)

          0,05615

          0,6518

           

          0,07809

          0,5299

           

          0,0132

          0,9156

          Erythrocyte aggregation M (E)

          0,00747

          0,9552

           

          0,02073

          0,8761

           

          0,02058

          0,8771

          Erythrocyte aggregation M1 (E)

          0,02564

          0,8471

           

          0,04427

          0,7392

           

          0,034

          0,7982

          Obesitys-Indices

                  

          BMI (kg/m2)

          0,07228

          0,561

           

          0,06516

          0,6003

           

          0,06279

          0,6137

          WHR

          0,18316

          0,165

           

          0,24149

          0,0654

          0,0003

          0,00075

          0,9955

          Waist (cm)

          0,02086

          0,8799

           

          0,01037

          0,9401

           

          0,05692

          0,6798

          Hip(cm)

          0,00135

          0,9922

           

          0,00294

          0,983

           

          0,02922

          0,8323

          Blood pressure

                  

          systolic (mm Hg)

          0,14903

          0,2287

           

          0,14472

          0,2426

           

          0,10775

          0,3855

          diastolic (mm Hg)

          0,10406

          0,402

           

          0,05629

          0,6509

           

          0,16688

          0,1771

          mean (mm Hg)

          0,1775

          0,1507

           

          0,13861

          0,2633

           

          0,19968

          0,1052

          Discussion

          Coronary morphology in diabetes mellitus

          Although it is well established, that type 2 diabetes is a strong and independent risk factor for the development of atherosclerosis, there is much discussion about a "typical", diabetes related morphology of atherosclerosis. Many clinicians today believe, that diabetic patients present with more extensive atherosclerotic disease than non-diabetics. However, to our knowledge only very few studies confirm these subjective impressions, and these are mostly autopsy based. Early autopsy studies pointed out, that the morphological manifestation of coronary artery disease in patients with diabetes mellitus increases three to four times as compared with non-diabetics [13].

          Here, we present a systematic approach to evaluate the coronary morphology of consecutive patients by angiography with regard to their diabetic status and can confirm this widespread belief. Coronary atherosclerosis can be found in more segments and is generally located more distally. This also confirms the results of a recent study, which could show a higher extent of coronary plaque burden in diabetic patients [19]. Recent studies using intravascular ultrasound (IVUS) to evaluate coronary plaque burden in diabetic patients could show more extensive atherosclerosis [2022]. However, these studies are often technically limited and can not be used to assess distal segments. Nicholls and co-workers assessed IVUS and also quantitative coronary angiography (QCA) and could not find a correlation between diabetes and stenosis severity. However, QCA was only done in segments also evaluated by intravascular ultrasound and did only comprise the most severe stenosis per target vessel [22]. They did find diabetes to be a strong independent predictor of atherosclerotic coronary disease, but the distribution of atherosclerosis within the coronary arteries was not assessed. An analysis of pooled data revealed that coronary artery atherosclerosis in patients with diabetes mellitus is more extensive and accompanied by inadequate compensatory remodelling [23]. Additionally the progression of atheroma was more rapid in patients with diabetes, despite high use of well established and potent therapies. With this in mind angiographic assessment could underestimate the plaque burden. On the other hand recent studies suggest, that a high percentage of cardiac patients present with newly diagnosed type 2 diabetes by use of oral glucose tolerance tests (OGTT) [2426]. OGTT was not part of this protocol; therefore the true rate of diabetes may be underestimated.

          Hemostasis and fibrinolysis in diabetes mellitus

          Type 2 diabetes mellitus, most often being part of a metabolic syndrome is closely associated with obesity, peripheral insulin resistance, arterial hypertension, hypercholesterinemia, hypertriglyceridemia and predisposes for atherosclerosis [27]. Peripheral insulin resistance is strongly associated with atherosclerosis, even after adjusting for other more conventional risk factors [28]. Whether this relation is causal, can only be suspected [28, 29], other authors discussed whether an impaired fibrinolysis could be the link to atherosclerosis [30].

          The changes of hemostasis and endogenous fibrinolysis of diabetic patients in this study correspond with the literature [913, 30], although most often only single parameters were evaluated. These alterations might be responsible for higher atherogenicity and more cardiovascular events in a diabetic population.

          We showed, that plasminogen activator inhibitor activity (PAI) was increased in diabetic patients; this corresponds to other studies [12, 14, 31, 32]. Additionally we found a strong correlation between PAI and insulin levels, which confirms results from experimental studies, where insulin decreased PAI activity in a dose dependent manner [12, 33].

          The potential role of insulin as one of the mechanisms in atherogenesis in diabetic patients has been discussed for 25 years [34]. Results of various prospective studies indicated that elevated plasma insulin levels cause and enhance atherosclerosis [3537]. Diverse diseases associated with hyperinsulinemia show an early and extended manifestation of atherosclerosis [3843]. Several studies proved that elevated insulin levels are accompanied by reduced endogenous fibrinolysis [12, 14, 31]. On the one hand hyperinsulinemia is associated with a decreased t-PA concentration [11], on the other hand it causes an increase of PAI activity [1214, 31].

          The importance of PAI is underlined by a follow up study of men after primary myocardial infarction. Those patients who showed elevated PAI concentrations as a sign of reduced fibrinolysis were at increased risk of reinfarction [44, 45]. High concentrations of von Willebrand factor antigen are supposed to be markers of endothelial lesions and present a procoagulative mechanism due to an enhanced platelet adhesion [46].

          The question remains, how does diabetes mediate its specific effects towards a diabetic specific morphology? Some authors suggest that diabetics undergo invasive evaluation later than others due to their cardiac neuropathy and the resulting lack of symptoms, others, that the impact of the often combined risk factors (e.g. hypertension, high LDL etc.) may trigger an accelerated form of atherosclerosis. This study extends these views by showing a close association between coronary morphology and a diabetic status with alterations of haemostasis and fibrinolysis, especially for distal coronary artery disease. Univariate and multivariate regression analysis revealed a strong relationship between the extent of coronary and especially distal coronary atherosclerosis and fasting glucose, PAI-1 and von-Willebrand-factor.

          Conclusion

          Both parameters of endogenous fibrinolysis and markers of platelet activity showed a relevant association on the extent of coronary atherosclerosis. This association applied to both the total and in particular to the distally weighted coronary atherosclerosis score. Additional predisposing factors were increased uric acid and glucose concentrations as well as the "Waist hip ratio". These changes are part of the "metabolic syndrome" describing obesity, arterial hypertension and typical changes of glucose and lipid metabolism, hemostasis and fibrinolysis.

          The metabolic changes with imbalance of platelet activity, hemostasis and endogenous fibrinolysis, and rheology favour a prothrombotic milieu. These systemic changes may result in an increased, thrombosis driven atherosclerotic process, in part explaining the advanced coronary plaque burden and in particular the more distal pronounced distribution of coronary atherosclerosis in patients with diabetes. More research is needed to elucidate these potential mechanisms and possibly develop a tailored therapy for these diabetes specific mechanisms of atherothrombotic disease.

          Declarations

          Authors’ Affiliations

          (1)
          Profil Institut für Stoffwechselforschung, Division of Cardiometabolic Research
          (2)
          Klinik für Kardiologie, Herzzentrum Wuppertal, Universität Witten-Herdecke
          (3)
          Medizinische Klinik und Poliklinik B (Internal Medicine), Department of Cardiology, Pneumology and Angiology, Heinrich-Heine-University
          (4)
          Klinik für Kardiologie, Marienhospital Herne

          References

          1. Kessler II: Mortality experience of diabetic patients. A twenty-six-year follow-up study. Am J Med. 1971, 51: 715-724. 10.1016/0002-9343(71)90299-3.View ArticlePubMed
          2. Root HF, Bland EF, Gordon WH, White PW: Coronary arteriosclerosis in diabetes mellitus. JAMA. 1939, 118: 27-30.View Article
          3. Stearns S, Schlesinger MJ, Rudy A: Incidence and clinical significance of coronary artery disease in diabetes mellitus. Archives of Internal Medicine. 1947, 80: 463.View ArticlePubMed
          4. Garcia MJ, McNamara PM, Gordon T, Kannel WB: Morbidity and mortality in diabetics in the Framingham population. Sixteen year follow-up study. Diabetes. 1974, 23: 105-111.View ArticlePubMed
          5. Huxley R, Barzi F, Woodward M: Excess risk of fatal coronary heart disease associated with diabetes in men and women: meta-analysis of 37 prospective cohort studies. BMJ. 2006, 332 (7533): 73-8. 10.1136/bmj.38678.389583.7C.PubMed CentralView ArticlePubMed
          6. Kannel WB, McGee DL: Diabetes and cardiovascular disease. The Framingham study. JAMA. 1979, 241: 2035-2038. 10.1001/jama.241.19.2035.View ArticlePubMed
          7. Fuster V, Badimon L, Badimon JJ, Chesebro JH: The pathogenesis of coronary artery disease and the acute coronary syndromes (2). N Engl J Med. 1992, 326: 310-318.View ArticlePubMed
          8. Schoebel FC, Gradaus F, Jax TW, Stiegler HM, Stein DA, Borries M, Kelm M, Strauer BE, Leschke M: Die Bedeutung der Koronarthrombose für die chronsiche Myokardischämie. Z Kardiol. 1997, 86 (Suppl 1): 71-83.PubMed
          9. Thompson SG, Kienast J, Pyke SD, Haverkate F, Loo van de JC: Hemostatic factors and the risk of myocardial infarction or sudden death in patients with angina pectoris. European Concerted Action on Thrombosis and Disabilities Angina Pectoris Study Group [see comments]. N Engl J Med. 1995, 332: 635-641. 10.1056/NEJM199503093321003.View ArticlePubMed
          10. Agewall S, Fagerberg B, Attvall S, Ljungman S, Urbanavicius V, Tengborn L, Wikstrand J: Microalbuminuria, insulin sensitivity and haemostatic factors in non-diabetic treated hypertensive men. Risk Factor Intervention Study Group. J Intern Med. 1995, 237: 195-203.View ArticlePubMed
          11. Eliasson M, Asplund K, Evrin PE, Lindahl B, Lundblad D: Hyperinsulinemia predicts low tissue plasminogen activator activity in a healthy population: the Northern Sweden MONICA Study. Metabolism. 1994, 43: 1579-1586. 10.1016/0026-0495(94)90020-5.View ArticlePubMed
          12. Nordt TK, Sawa H, Fujii S, Sobel BE: Induction of plasminogen activator inhibitor type-1 (PAI-1) by proinsulin and insulin in vivo. Circulation. 1995, 91: 764-770.View ArticlePubMed
          13. Fisher BM, Quin JD, Rumley A, Lennie SE, Small M, MacCuish AC, Lowe GD: Effects of acute insulin-induced hypoglycaemia on haemostasis, fibrinolysis and haemorheology in insulin-dependent diabetic patients and control subjects. Clin Sci Colch. 1991, 80: 525-531.View ArticlePubMed
          14. Auwerx J, Bouillon R, Collen D, Geboers J: Tissue-type plasminogen activator antigen and plasminogen activator inhibitor in diabetes mellitus. Arteriosclerosis. 1988, 8 (1): 68-72.View ArticlePubMed
          15. Austen WG, Edwards JE, Frye RL, Gensini GG, Gott VL, Griffith LS, McGoon DC, Murphy ML, Roe BB: A reporting system on patients evaluated for coronary artery disease. Report of the Ad Hoc Committee for Grading of Coronary Artery Disease, Council on Cardiovascular Surgery, American Heart Association. Circulation. 1975, 51 (Suppl): 5-40.View ArticlePubMed
          16. Clauss A: Gerinnungsphysiologische Schnellmethode zur Bestimmung des Fibrinogens. Acta Haematol. 1957, 17: 237-241. 10.1159/000205234.View ArticlePubMed
          17. Kissebah AH, Vydelingum N, Murray R, Evans D, Hartz A, Kalkhoff RK, Adams PW: Relationship of body fat distribution to metabolic complication of obesity. J Endocrinol Metab. 1982, 54: 254-260.View Article
          18. Ashwell M, Cole TJ, Dixon AK: Obesity: new insights into the anthropometric classification of fat distribution shown by computed tomography. Br Med J. 1985, 290: 1692-1694. 10.1136/bmj.290.6483.1692.View Article
          19. Schukro C, Syeda B, Yahya N, Gessl A, Holy EW, Pichler P, Derntl M, Glogar D: Volumetric intravascular ultrasound imaging to illustrate the extent of coronary plaque burden in type 2 diabetic patients. J Diabetes Complications. 2007, 21 (6): 381-6. 10.1016/j.jdiacomp.2007.06.007.View ArticlePubMed
          20. Larsen JR, Tsunoda T, Tuzcu EM, Schoenhagen P, Brekke M, Arnesen H, Hanssen KF, Nissen SE, Dahl-Jorgensen K: Intracoronary ultrasound examinations reveal significantly more advanced coronary atherosclerosis in people with type 1 diabetes than in age- and sex-matched non-diabetic controls. Diab Vasc Dis Res. 2007, 4 (1): 62-5. 10.3132/dvdr.2007.009.View ArticlePubMed
          21. Nasu K, Tsuchikane E, Katoh O, Fujita H, Surmely JF, Ehara M, Kinoshita Y, Tanaka N, Matsubara T, Asakura Y, Asakura K, Terashima M, Suzuki T: Plaque characterisation by Virtual Histology intravascular ultrasound analysis in patients with type 2 diabetes. Heart. 2008, 94 (4): 429-33. 10.1136/hrt.2007.118950.View ArticlePubMed
          22. Nicholls SJ, Tuzcu EM, Crowe T, Sipahi I, Schoenhagen P, Kapadia S, Hazen SL, Wun CC, Norton M, Ntanios F, Nissen SE: Relationship between cardiovascular risk factors and atherosclerotic disease burden measured by intravascular ultrasound. J Am Coll Cardiol. 2006, 47 (10): 1967-75. 10.1016/j.jacc.2005.12.058.View ArticlePubMed
          23. Nicholls SJ, Tuzcu EM, Kalidindi S, Wolski K, Moon KW, Sipahi I, Schoenhagen P, Nissen SE: Effect of diabetes on progression of coronary atherosclerosis and arterial remodeling: a pooled analysis of 5 intravascular ultrasound trials. J Am Coll Cardio. 2008, 52 (4): 255-62. 10.1016/j.jacc.2008.03.051.View Article
          24. Norhammar A, Tenerz A, Nilsson G, Hamsten A, Efendíc S, Rydén L, Malmberg K: Glucose metabolism in patients with acute myocardial infarction and no previous diagnosis of diabetes mellitus: a prospective study. Lancet. 2002, 359 (9324): 2140-4. 10.1016/S0140-6736(02)09089-X.View ArticlePubMed
          25. Lankisch M, Füth R, Gülker H, Lapp H, Bufe A, Haastert B, Martin S, Rathmann W: Screening for undiagnosed diabetes in patients with acute myocardial infarction. Clin Res Cardiol. 2008, 97 (10): 753-9. 10.1007/s00392-008-0674-5.View ArticlePubMed
          26. Lankisch M, Füth R, Schotes D, Rose B, Lapp H, Rathmann W, Haastert B, Gülker H, Scherbaum WA, Martin S: High prevalence of undiagnosed impaired glucose regulation and diabetes mellitus in patients scheduled for an elective coronary angiography. Clin Res Cardiol. 2006, 95 (2): 80-7. 10.1007/s00392-006-0328-4.View ArticlePubMed
          27. Taegtmeyer H: Insulin resistance and atherosclerosis. Common roots for two common diseases?. Circulation. 1996, 93: 1777-1779.View ArticlePubMed
          28. Howard G, O'Leary DH, Zaccaro D, Haffner S, Rewers M, Hamman R, Selby JV, Saad MF, Savage P, Bergman R: Insulin sensitivity and atherosclerosis. The Insulin Resistance Atherosclerosis Study (IRAS) Investigators [see comments]. Circulation. 1996, 93: 1809-1817.View ArticlePubMed
          29. DeFronzo RA, Ferrannini E: Insulin resistance. A multifaceted syndrome responsible for NIDDM, obesity, hypertension, dyslipidemia, and atherosclerotic cardiovascular disease. Diabetes Care. 1991, 14: 173-194. 10.2337/diacare.14.3.173.View ArticlePubMed
          30. Juhan Vague I, Alessi MC, Vague P: Increased plasma plasminogen activator inhibitor 1 levels. A possible link between insulin resistance and atherothrombosis. Diabetologia. 1991, 34: 457-462. 10.1007/BF00403280.View ArticlePubMed
          31. Juhan Vague I, Alessi MC: Plasminogen activator inhibitor 1 and atherothrombosis. Thromb Haemost. 1993, 70: 138-143.PubMed
          32. Juhan Vague I, Roul C, Alessi MC, Ardissone JP, Heim M, Vague P: Increased plasminogen activator inhibitor activity in non insulin dependent diabetic patients – relationship with plasma insulin. Thromb Haemost. 1989, 61: 370-373.PubMed
          33. McGill JB, Schneider DJ, Arfken CL, Lucore CL, Sobel BE: Factors responsible for impaired fibrinolysis in obese subjects and NIDDM patients. Diabetes. 1994, 43: 104-109. 10.2337/diabetes.43.1.104.View ArticlePubMed
          34. Stout RW: Insulin and atherosclerosis. Lancet. 1969, 2: 327-328. 10.1016/S0140-6736(69)90097-X.View ArticlePubMed
          35. Pyorala K: Diabetes and coronary heart disease. Acta Endocrinol Suppl Copenh. 1985, 272:
          36. Cullen K, Stenhouse NS, Wearne KL, Welborn TA: Multiple regression analysis of risk factors for cardiovascular disease and cancer mortality in Busselton, Western Australia – 13-year study. J Chronic Dis. 1983, 36: 371-377. 10.1016/0021-9681(83)90169-8.View ArticlePubMed
          37. Fontbonne A, Tchobroutsky G, Eschwege E, Richards JL, Claude JR, Rosselin GE: Coronary heart disease mortality risk: plasma insulin level is a more sensitive marker than hypertension or abnormal glucose tolerance in overweight males. The Paris Prospective Study. Int J Obes. 1988, 12: 557-565.PubMed
          38. Swislocki AL, Hoffman BB, Reaven GM: Insulin resistance, glucose intolerance and hyperinsulinemia in patients with hypertension. Am J Hypertens. 1989, 2: 419-423.PubMed
          39. Singer P, Godicke W, Voigt S, Hajdu I, Weiss M: Postprandial hyperinsulinemia in patients with mild essential hypertension. Hypertension. 1985, 7: 182-186.View ArticlePubMed
          40. DeFronzo RA: Insulin secretion, insulin resistance, and obesity. Int J Obes. 1982, 6 (Suppl 1): 73-82.PubMed
          41. Modan M, Halkin H, Almog S, Lusky A, Eshkol A, Shefi M, Shitrit A, Fuchs Z: Hyperinsulinemia. A link between hypertension obesity and glucose intolerance. J Clin Invest. 1985, 75: 809-817. 10.1172/JCI111776.PubMed CentralView ArticlePubMed
          42. Grundy SM: Hypertriglyceridemia: mechanisms, clinical significance, and treatment. Med Clin North Am. 1982, 66: 519-535.PubMed
          43. Orchard TJ, Becker DJ, Bates M, Kuller LH, Drash AL: Plasma insulin and lipoprotein concentrations: an atherogenic association?. Am J Epidemiol. 1983, 118: 326-337.PubMed
          44. Hamsten A, de Faire U, Walldius G, Dahlen G, Szamosi A, Landou C, Blomback M, Wiman B: Plasminogen activator inhibitor in plasma: risk factor for recurrent myocardial infarction. Lancet. 1987, 2: 3-9. 10.1016/S0140-6736(87)93050-9.View ArticlePubMed
          45. Hamsten A, Wiman B, de Faire U, Blomback M: Increased plasma levels of a rapid inhibitor of tissue plasminogen activator in young survivors of myocardial infarction. N Engl J Med. 1985, 313: 1557-1563.View ArticlePubMed
          46. Jansson JH, Nilsson TK, Johnson O: von Willebrand factor in plasma: a novel risk factor for recurrent myocardial infarction and death [see comments]. Br Heart J. 1991, 66: 351-355. 10.1136/hrt.66.5.351.PubMed CentralView ArticlePubMed

          Copyright

          © Jax et al; licensee BioMed Central Ltd. 2009

          This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.