Ankle Brachial Index in Patients with Diabetes Mellitus Vs Non-diabetics Background: Diabetes Mellitus is a syndrome of abnormal metabolism and hyperglycemia, leading to micro-vascular and macro vascular complications. Atherosclerosis, amongst macro-vascular complications is the leading cause of stroke, ischemic heart disease and peripheral vascular disease.
Objective: To compare Ankle Brachial Index in Diabetics and Non-diabetics.Methods: A comparative study of 100 patients, amongst which 50 were diabetic and rest non-diabetic, was carried out in medical ward 6 of PIMS, Islamabad by measuring Ankle Brachial Index with doppler device. Results: Out of 100 patients 36 had abnormal (less than 1.0) Ankle Brachial Index; amongst them 86% were diabetic and 14 % were non-diabetic. Chi square test value was significant (p 0.003). Previous blood sugar record at presentation was also roughly assessed which showed increasing number of patients with abnormal ABI, with increasing range of hyperglycemia (p <0.05). Conclusion: Tendency of decreased Ankle Brachial Index was noted with diabetes and increased range of hyperglycemia, which shows a significant association of diabetes with peripheral vascular disorder. Keywords: Ankle brachial index, Diabetic vasculopathy IntroductionDiabetes mellitus is a syndrome with disordered metabolism and inappropriate hyperglycemia due to deficient insulin secretion, insulin resistance or combination of both. Hyperglycemia is an independent risk factor for progression of disease and manifestation of its complications, which involve both large and small blood vessels. Diabetes mellitus predisposes to atherosclerosis of blood vessels, which by hindrance of blood flow may lead to macro-vascular complications, e.g. ischemic heart disease, stroke and peripheral vascular disease. Persistent microalbuminuria observed in 15-20% of diabetic patients is a risk marker for macro- as well as micro-vascular complications. Evidence suggests a common pathogenetic mechanism for microalbuminuria and premature atherosclerosis, so microalbuminuria can be considered as indicator for all types of vascular complications.1 Similarly longitudinal studies have shown that rising plasma prorenin levels also predict the development of diabetic vasculopathy.2 A large body of evidence supports the possible role of genetics in determining the expression of the ischemic vascular phenotype in diabetic patients, mainly derived from studies in ethnic groups or in first-degree relatives of diabetic patients and from association studies with genetic polymorphisms. Neglecting the polygenic susceptibility factors for macro vascular complications of diabetes is difficult, since diabetes itself has multifactorial inheritance. 3 Peripheral vascular disease is very significant complication in which there occurs circulatory insufficiency leading to clinical symptomatology of claudication, Ischemic limb pains, gangrenes and ulcers. Mechanisms for vascular disease in diabetes include the pathologic effects of advanced glycation end product accumulation, impaired vasodilatory response attributable to nitric oxide inhibition, smooth muscle cell dysfunction, overproduction of endothelial growth factors, chronic inflammation, hemodynamic dysregulation, impaired fibrinolytic ability, and enhanced platelet aggregation. Vasoactive hormones, such as angiotensin II and endothelin, are potent stimulators of cytokines with recent studies showing that inhibitors of these vasoactive hormone pathways may confer organ protection in diabetes by inhibition of growth factor expression. Glucose-dependent factors, such as the formation of advanced glycation end products that interact with specific receptors and lead to overexpression of a range of cytokines, may play an important role in diabetic vascular complications including atherosclerosis. It is likely that the effects of inhibitors of this pathway such as aminoguanidine on cytokine production may play a pivotal role in mediating the renal, retinal, and vasoprotective effects observed with this agent in experimental diabetes. It is anticipated that the advent of specific inhibitors of cytokine formation or action will provide new approaches for the prevention and treatment of diabetic vascular complications. |
Yasir Mehmood Malik* Jamal Zafar** Shajee Siddiqui***
*Postgraduate Trainee **Professor ***Assistant Professor Department of Medicine Pakistan Institute of Medical Sciences Islamabad It is becoming increasingly important for physical therapists to be aware of diabetes-related vascular complications as more patients present with insulin resistance and diabetes. The opportunities for effective physical therapy interventions (such as exercise) are significant.4 Ankle Brachial Index (ABI) is a non-invasive tool to check the degree of peripheral vessels involvement. This has already been worked upon and found as significant indicator of dementia, cognitive impairment and cardiovascular pathologies, by Sir Jacquline F and coworkers.5 Takahiro Nakano and assistants claimed a strong relationship between acute ischemic stroke and atherosclerotic process, by measuring Ankle Brachial Index (ABI) of patients. They commit a decreased ABI may be a risk factor to ischemic stroke.6 This study was conducted to look into the frequency of peripheral vascular disorder, in terms of Ankle brachial Index in Type II Diabetics and compare it with that of healthy controls. Materials and MethodsThis study was conducted in the department of General Medicine (Medical Ward-6), Pakistan Institute of Medical Sciences, Islamabad, over a period of one year (January -Dec 2007). One hundred patients were randomly selected. Amongst them 50 were patients of diabetes mellitus and rest were non-diabetics (controls). Systolic blood pressure at brachial and Dorsalis pedis artery was recorded with a Doppler device, to ensure accuracy and then Ankle brachial index was calculated. Patients with 7 years duration of Diabetes were taken as inclusion criteria and Hyperlipidemia and Hypertension were taken as confounding factors. They were given significance in relation to glycemic control and systemic compilations. Patients with vasculitis, malignancy, deep venous thrombosis, valvular heart disease, nephrotic syndrome, gross edema, limb amputation, Raynaud’s phenomenon and patients on ergot alkaloid or sympathomimetics were excluded to see pure effect of atherosclerotic process on blood vessels, caused by diabetes. Ankle brachial index value equal or above 1.0 was considered normal in operational definition and below it was taken as abnormal. After collection of data we analyzed it in SPSS version 11 and Chi-square test was applied, as it was a comparative study Results Amongst 100 cases included in the study (both patients and controls), the mean age at time of examination was 43 years (ranging 14 – 83 years with SD=18.024). Ankle Brachial Index (ranging from 0.8 – 1.4 with Mean 1.03 and SD = 0.137) in 36 patients was abnormal, amongst which 86% patients were diabetic and 14% non-diabetic (p=0.003), as shown in Fig 1. There were so many males and females patients, unevenly distributed in diabetic and non-diabetic groups and in both groups many patients had Ankle Brachial Index below normal value. In gender distribution out of 57 males 15 had decreased Ankle Brachial Index (26.3%) and out of 43 females 21 had abnormal ABI (48.8%), which depicts abnormal ABI was more in female group. For Complete Abstract on your email Pls. Contact Chief Editor APIMS |