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Circadian blood pressure variation in patients with type 2 diabetes - relationship to macro- and microvascular subclinical organ damage
Linköping University, Department of Medical and Health Sciences, General Practice. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Primary Health Care in Motala.
Linköping University, Department of Medical and Health Sciences, Internal Medicine. Linköping University, Faculty of Health Sciences.
Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
Linköping University, Department of Medical and Health Sciences, Physiology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.ORCID iD: 0000-0002-9095-403X
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2011 (English)In: Primary Care Diabetes, ISSN 1751-9918, E-ISSN 1878-0210, Vol. 5, no 3, 167-173 p.Article in journal (Refereed) Published
Abstract [en]

Aims

To explore the association between nocturnal blood pressure (BP) dipper status and macro- and microvascular organ damage in type 2 diabetes.

Methods

Cross-sectional data from 663 patients with type 2 diabetes, aged 55–66 years, were analysed. Nurses measured office BP and ambulatory BP during 24 h. Individuals with ≥10% difference in nocturnal systolic blood pressure (SBP) relative to daytime values were defined as dippers. Non-dippers were defined as <10% nocturnal decrease in SBP. Estimated glomerular filtration rate (GFR) was calculated and microalbuminuria was measured by albumin:creatinine ratio (ACR). Aortic pulse wave velocity (PWV) was measured with applanation tonometry over the carotid and femoral arteries.

Results

We identified 433 dippers and 230 subjects with a nocturnal non-dipping pattern. Nocturnal SBP dipping was independently of office SBP associated with decreased PWV (p = 0.008), lower ACR (p = 0.001) and NT-proBNP (p = 0.001) and increased GFR (p < 0.001).

Conclusions

We conclude that diurnal BP variation provides further information about early macro- and microvascular subclinical organ damage that goes beyond standardized office BP measurements in patients with type 2 diabetes.

Place, publisher, year, edition, pages
Elsevier, 2011. Vol. 5, no 3, 167-173 p.
Keyword [en]
Type 2 diabetes mellitus ambulatory blood pressure arterial stiffness microalbuminuria diurnal blood pressure variation
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-75571DOI: 10.1016/j.pcd.2011.04.001ISI: 000304279600004OAI: oai:DiVA.org:liu-75571DiVA: diva2:508322
Note

funding agencies|Medical Research Council of Southeast Sweden||Center for Medical Image Science and Visualization (CMIV)||Linkoping University||GE Healthcare||Swedish Heart-Lung Foundation||Swedish Research Council| 12661 |

Available from: 2012-03-08 Created: 2012-03-08 Last updated: 2017-12-07Bibliographically approved
In thesis
1. Risk factors in type 2 diabetes with emphasis on blood pressure, physical activity and serum vitamin D
Open this publication in new window or tab >>Risk factors in type 2 diabetes with emphasis on blood pressure, physical activity and serum vitamin D
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background

Type 2 diabetes is a common chronic disease with a two-fold increased risk for cardiovascular morbidity and mortality and has an increasing prevalence worldwide. This thesis is based on a study conducted in primary health care in Östergötland and Jönköping, Sweden. The aim of the thesis was to evaluate new risk markers to identify patients with high risk of developing cardiovascular disease in middle-aged men and women with type 2 diabetes.

Methods

Data from the cohort study CArdiovascular Risk in type 2 DIabetes – a Prospective study in Primary care (CARDIPP) was used. In paper III data were also used from CARDIPP-Revisited where all participants in the CARDIPP study were invited four years after the baseline investigation for a re-investigation. In paper IV data were used from CAREFUL which is a control group of 185 subjects without diabetes. The investigation included a standard medical history including data on diabetes duration and on-going medication. Anthropometric data were recorded and both office and ambulatory blood pressure were measured. The patients filled out a detailed questionnaire and physical activity was measured by using waist-mounted pedometers. Pedometer-determined physical activity was classified in four groups: Group 1: <5000 steps/day (‘sedentary’); Group 2: 5000-7499 steps/day (‘low active’); Group 3: 7500-9999 steps/day (‘somewhat active’); Group 4: and ≥10 000 steps/day (‘active’). Blood samples were drawn for routine analyses and also frozen for later analyses. The investigations at the departments of physiology included echocardiography, measurements of the carotid intima-media thickness, applanation tonometry and measurements of  sagittal abdominal diameter.

Results

Paper 1:

Patients with a non-dipping systolic blood pressure pattern showed higher left ventricular mass index and pulse wave velocity (PWV) compared with patients with ≥10% decline in nocturnal systolic blood pressure. Patients with <10% decline in nocturnal systolic blood pressure had higher BMI and sagittal abdominal diameter, lower GFR and higher albumin:creatinine ratio and also higher levels of NT-proBNP than patients with a dipping pattern of the nocturnal blood pressure.

Paper 2:

The number of steps/day were inversely significantly associated with BMI, waist circumference and sagittal abdominal diameter, levels of CRP, levels of interleukin-6 and PWV.

Paper 3:

At the 4-year follow-up the change in PWV (ΔPWV) from baseline was calculated. The group with the lowest steps/day had a significantly higher increase in ΔPWV compared with the group with the highest steps/day. The associations between baseline steps/day and ΔPWV remained after further adjustment in a multivariate linear regression statistically significant (p=0.005). 23% of the variation in the study could be explained by our model. Every 1000 extra steps at baseline reduced the change in ΔPWV by 0.103 m/s between baseline and follow-up.

Paper 4:

Low vitamin D levels were associated with significantly increased risk for premature mortality in men with type 2 diabetes. High levels of parathyroid hormone were associated with significantly increased risk for premature mortality in women with type 2 diabetes. These relationships were still statistically significant also when two other well-established risk markers for mortality, PWV and carotid intima-media thickness, were added to the analyses.

Conclusions

Ambulatory blood pressure recording can by addressing the issue of diurnal blood pressure variation, explore early cardiovascular organ damage and microvascular complications that goes beyond effects of standardised office blood pressure measurements. Pedometer-determined physical activity may serve as a surrogate marker for inflammation and subclinical organ damage in patients with type 2 diabetes. There is novel support for the durable vascular protective role of a high level of daily physical activity, which is independent of BMI and systolic blood pressure. The use of pedometers is feasible in clinical practice and provides objective information not only about physical activity but also the future risk for subclinical organ damage in middle-aged people with type 2 diabetes. Our results indicate that low vitamin D levels in men or high parathyroid hormone levels in women give independent prognostic information of an increased risk for total mortality.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2016. 55 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1507
National Category
Family Medicine Cardiac and Cardiovascular Systems Endocrinology and Diabetes Geriatrics Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:liu:diva-125911 (URN)10.3384/diss.diva-125911 (DOI)978-91-7685-848-6 (ISBN)
Public defence
2016-04-08, Belladonna, ingång 78, Campus US, Linköping, 09:00 (English)
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Supervisors
Available from: 2016-03-08 Created: 2016-03-08 Last updated: 2017-03-27Bibliographically approved

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Jennersjö, Pär E.Wijkman, MagnusWiréhn, Ann-BrittLänne, TosteEngvall, JanNyström, Fredrik H.Östgren, Carl Johan

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Jennersjö, Pär E.Wijkman, MagnusWiréhn, Ann-BrittLänne, TosteEngvall, JanNyström, Fredrik H.Östgren, Carl Johan
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General PracticeFaculty of Health SciencesPrimary Health Care in MotalaInternal MedicineResearch & Development Unit in Local Health CarePhysiologyDepartment of Thoracic and Vascular SurgeryClinical PhysiologyDepartment of Clinical Physiology in LinköpingDepartment of Endocrinology and Gastroenterology UHL
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