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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 463-467

Albuminuria and its relation to severity of coronary artery disease detected by angiography in type 2 diabetic patients


SYNTAX score Department of Cardiology, Al Azhar University, Cairo, Egypt

Date of Submission10-Jun-2020
Date of Decision22-Jun-2020
Date of Acceptance23-Jun-2020
Date of Web Publication2-Oct-2020

Correspondence Address:
Eman E.A Elwafa
SYNTAX score Department of Cardiology, Al Azhar University, Cairo, Tanta Al Gharbia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjamf.sjamf_70_20

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  Abstract 


Background Diabetes mellitus (DM) is one of the most potent risk factors for coronary artery disease (CAD). Consequently, the diagnosis of CAD in diabetic patients is very important as early as possible. Microalbuminuria is a strong and independent indicator of increased cardiovascular risk among individuals with and without diabetes.
Aim The study aimed to assess the relation between the degree of albuminuria and the angiographic severity of CAD in patients with type 2 DM.
Patients and methods A total of 40 patients with type 2 DM who were referred for elective coronary angiography owing to a suspected CAD were included in the study. Urinary albumin-creatinine ratio (UACR) was calculated for all patients, and the severity of CAD was assessed using the SYNTAX score. All patients were assessed by conventional and 2-D speckle tracking echocardiography.
Results The study population comprised 19 (41.5%) males and 21 (58.5%) females. Their mean age was 53.5±8.7 years. Patients were classified into two groups based on the level of UACR; group 1 included patients with UACR less than 30 mg/g (19 patients), and group 2 included patients with UACR greater than or equal to 30 mg/g (21 patients). The study revealed significantly higher SYNTAX score in patients in group 2 compared with patients in group 1 (P=0.02) and significantly lower left ventricular global longitudinal strain in patients in group 2 compared with patients in group 1 (P=0.016). There was also a weak positive correlation between UACR and SYNTAX score and the duration of DM (r=0.395 and 0.399, respectively).
Conclusion Microalbuminuria can be used as a predictor of the presence and severity of CAD in type II DM.

Keywords: albuminuria, coronary artery diseases, diabetes, SYNTAX score


How to cite this article:
Elwafa EE, Hady BM, Elaziz OH. Albuminuria and its relation to severity of coronary artery disease detected by angiography in type 2 diabetic patients. Sci J Al-Azhar Med Fac Girls 2020;4:463-7

How to cite this URL:
Elwafa EE, Hady BM, Elaziz OH. Albuminuria and its relation to severity of coronary artery disease detected by angiography in type 2 diabetic patients. Sci J Al-Azhar Med Fac Girls [serial online] 2020 [cited 2020 Oct 26];4:463-7. Available from: http://www.sjamf.eg.net/text.asp?2020/4/3/463/296957




  Introduction Top


Diabetes mellitus (DM) is a chronic metabolic disease that has many complications; cardiovascular disease is the most important one. Coronary artery disease (CAD) is a major cause of death in developed and developing countries.

CAD is a multifactorial disorder with several different risk factors. The major and independent risk factors for CAD such as advanced age, male sex, hypertension, DM, cigarette smoking, and dyslipidemia do not entirely explain the variation in cardiovascular disease incidence and mortality between individuals. Therefore, additional risk factors have been proposed to better identify patients potentially at risk of CAD [1].

Many individual new biomarkers have been related to cardiovascular risk, including levels of C-reactive protein, B-type natriuretic peptide, fibrinogen, and homocysteine. Among these new biomarkers is microalbuminuria (MA), which is gaining recognition as a marker of an atherogenesis, owing to its association with several atherosclerotic risk factors and early systemic vascular (endothelial) damage [2],[3].


  Aim Top


The study was conducted to assess the relation between the degree of albuminuria and the angiographic severity of CAD in patients with type 2 DM.


  Patients and methods Top


This was a cross-sectional study that included 40 patients with type 2 DM. Patients were recruited to the study from those referred to the Catheterization Laboratory of Al-Zahraa University Hospital for elective coronary angiography owing to a suspected CAD in the period from November 2018 to June 2019.

Patients with: type 1 DM, patients with estimated glomerular filtration rate less than 60 ml/min/1.73 m2, patients with decompensated liver disease, patients with rheumatic valvular heart diseases, patients with decompensated heart failure, and patients with recent cerebrovascular events (such as brain infarction or hemorrhage) were excluded from the study.

Written informed consent was taken from all participants before enrollment into the study, and the study was approved by the Ethical Committee of Faculty of Medicine for Girls, Al Azhar University.

All enrolled patients were subjected to the following:
  1. Full medical history analysis and clinical examination, with special emphasis on risk factors of CAD, duration, and treatment of DM.
    • Hypertension was defined as systolic blood pressure greater than or equal to 140 mmHg, diastolic blood pressure greater than or equal to 90 mmHg, and/or the use of antihypertensive drugs [4].
    • Patients who had smoked within the previous 6 months of study enrollment were deemed current smokers.
    • The BMI was calculated as the body weight (kg)/the height (m2).
  2. Routine laboratory investigations included the following: complete blood count, serum creatinine, HbA1c, prothrombin time, international normalized ratio, and lipid profile. The estimated glomerular filtration rate was assessed using the Mayo Clinic Quadratic equation which does not underestimate normal GFR as does the Modification of Diet in Renal Disease equation in diabetic patients [5].
  3. Routine 12-lead ECG.
  4. Echocardiographic examination:
    • Transthoracic echocardiography was done for all patients using E-9 GE system, Horton-Norway with multifrequency (2.5–3.5 MHz) matrix probe M3S. Simultaneous ECG physiosignal was displayed with all recorded echo images and loops. All imaging and loops of at least three cardiac cycles were recorded, saved digitally, and retrieved for offline analysis on Echo PAC software version 201 for GE vivid E9 (General Electric Health Care Schenectady, New York, United States). All measurements and evaluation were performed according to the guidelines of American Society of Echocardiography [6].
  5. Measurement of urinary albumin/creatinine ratio:
    • A morning random urine sample was collected from all patients before coronary angiography to measure albumin/creatinine ratio (ACR), which was tested using turbidimetric MA kit (BioSystemsS.A.Costa Brava, Barcelona, Spain).
  6. Coronary angiography was performed for all patients via femoral approach utilizing the standard technique. Coronary lesion was considered significant, if there was greater than or equal to 50% diameter stenosis in greater than or equal to one coronary artery. The severity of CAD was scored on the basis of SYNTAX score. The SYNTAX score is calculated by a computer program consisting of sequential and interactive self-guided questions [7].


Statistical analysis

Statistical analysis was performed using SPSS software version (16 SPSS; SPSS Inc., Chicago, Illinois, USA). Continuous variables were expressed as mean and SD, whereas categorical variables were expressed as numbers and percentages. Comparison of continuous variables among groups was made using the Student t-test and comparison between group 1 and group 2 regarding the number of vessel affected was assessed using χ2 test. Correlation was tested using Pearson’s test. All tests of significance were two tailed, and a P value less than 0.05 was considered statistically significant.


  Results Top


The clinical and demographic data of all patients enrolled in the study are demonstrated in [Table 1].
Table 1 Demographic data of all patients

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The patients were classified into two groups based on the level of urinary albumin-creatinine ratio (UACR):
  1. Group 1 with UACR less than 30 mg/g. It included 19 patients.
  2. Group 2 with UACR more than or equal to 30 mg/g. It included 21 patients.


Comparison between group 1 and group 2 regarding clinical and demographic parameters

The study revealed significant increase in the duration of DM in group 2 compared with group 1; however, there was no statistical significant difference between the two groups regarding other demographic parameters as shown in [Table 2].
Table 2 Comparison between group 1 and group 2 regarding basic demographic and clinical parameters

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Comparison between group 1 and group 2 regarding LV systolic parameters obtained by echocardiography

The study revealed significant decrease in ventricular global longitudinal strain (LVGLS) in group 2 compared with group 1 (P<0.01); however, there was no statistically significant difference between the two groups regarding other parameters, as shown in [Table 3].
Table 3 Comparison between group 1 and group 2 regarding left ventricular systolic parameters

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Comparison between group 1 and group 2 regarding parameters of LV diastolic function obtained by echocardiography

The study revealed significant decrease in Em velocity on mitral valve annulus in group 2 compared with group 1 (P=0.04), whereas no statistical significant difference between the two groups regarding other parameters, as shown in [Table 4].
Table 4 Comparison between group 1 and group 2 regarding parameters of left ventricular diastolic function

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Comparison between group 1 and group 2 regarding SYNTAX score in patients with CAD

The study revealed significant increase in SYNTAX score in group 2 compared with group 1, as shown in [Table 5].
Table 5 Comparison between group 1 and group 2 regarding SYNTAX score in patients with CAD

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Comparison between group 1 and group 2 regarding the number of vessels affected

There was no statistically significant difference between group 1 and group 2 regarding the number of vessel affected in each group; however, the number of patients with two or multivessel affection was higher in group 2 compared with group 1, as shown in [Table 6].
Table 6 Comparison between patients with IHD in group 1 and group 2 regarding number of vessels affected

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Correlation between UACR and other variables in the study

There was a weak positive correlation between UACR and SYNTAX score, and the duration of DM (r=0.395 and 0.399, respectively); however, there was no correlation between urine UACR and other variables examined in the study, as shown in [Table 7] and [Figure 1].
Table 7 Correlation between A/C ratio and other examined variables

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Figure 1 Correlation between A/C ratio and SYNTAX score.

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Correlation between SYNTAX score and other variables in the study

There was a weak positive correlation between SYNTAX score and age (r=0.431); however, there was no correlation between the SYNTAX score and other variables examined in the study, as shown in [Table 8].
Table 8 Correlation between the SYNTAX score and other examined variables

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  Discussion Top


DM is a chronic metabolic disease that has many complications; cardiovascular disease is the most important one. CAD is a major cause of death in developed and developing countries.

In addition to the well-established CAD risk factors, many researchers are trying to find new risk factors to identify patients potentially at risk for CAD. Urinary albumin excretion (UAE) is a marker of endothelial and vascular damage, which could be a predictor for coronary artery atherosclerosis independent of renal function [8].

Although the association between MA and cardiovascular events is well described, few studies had examined the correlation of angiographic severity of CAD with MA. So, the purpose of this study was to evaluate the association between MA and the presence and extent of CAD in type II diabetic patients.

In our study, we found that the duration of DM in group 2 (albuminuric) was significantly longer in comparison with group 1 (nonalbuminuric) (10.42±6.29 and 4.66±2.53, respectively, P<0.000). This result was concordant with the result of Hamed et al. [8], who in their study assessed the relationship between UAE and severity of CAD detected by coronary angiography on 200 diabetic patients in Sohag University Hospital and reported similar results.

However, this result was discordant to the results of El-Awady et al. [9], who in their study done at Al Mansoura University Hospital reported no significant difference between microalbuminuric and normoalbuminuric groups regarding duration of DM.

The study revealed a weak positive correlation between UAC ratio and LVGLS. This result is concordant with the result of Katz et al. [10] in the HyperGEN study, which was conducted to assess the association of low-grade albuminuria with adverse cardiac mechanics on 1894 patients. They reported that MA was positively correlated to decreased LVGLS even in non-HTN and non-diabetic patients.

SYNTAX score was used in our study to assess the severity of CAD. It was significantly higher among patients with MA compared with those without MA (15±12.03 and 9±8.20, respectively, P<0.02). There was also a weak positive correlation between UACR and SYNTAX score (r=0.395).

These results are concordant with the results of Elawady and colleagues; Hamed and colleagues; and ELsawasany and colleagues, who found also significant association between MA and the severity of CAD as assessed by SYNTAX score [8],[9],[11].

Bildirici and colleagues, Guo and colleagues, and Parsa and colleagues, also reported more severe CAD in patient with MA; however, they depended on Gensini score to assess the severity of CAD [12],[13],[14].

Moreover, Rein et al. [15], reported that the prevalence of coronary artery stenosis of greater than or equal to 50% was significantly greater in patients with albuminuria (either microalbuminuria or macroalbuminuria) compared with patients with normoalbuminuria (P<0.001). This association was significant in both patients with and without T2DM.Our study revealed that no statistically significant difference was present between the two groups regarding the number of coronary vessels affected; however, the number of patients with multivessel affection was more in group 2 in comparison with group I. This result is consistent with the result of Reza et al. [16], who studied the relationship of MA and angiographic severity of CAD. They found that triple vessel disease was significantly associated with MA.


  Conclusion Top


Patients with MA have more extensive and severe CAD compared with those without MA. The implementation of this simple assay in clinical routine may influence the aggressiveness of management and ultimately the outcome of the disease.

Study limitations

Our study has some limitations. This is a single-center observational nonrandomized study, with a relatively small group of patients. Therefore, the results need to be validated in larger prospective studies. Moreover, we did not exclude patients with other risk factors for MA and CAD like hypertensive patients, which might affect the overall results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Park HY, Schumock GT, Pickard S, Akhras K. A structured review of the relationship between microalbuminuria and cardiovascular events in patients with diabetes and hypertension. Pharmacotherapy 2003; 23:1611–1616.  Back to cited text no. 1
    
2.
Jia D, Li W, Liu J. Correlation of chronic renal dysfunction and albuminuria with severity of coronary artery lesions in patients with coronary artery disease. Cell Biochem Biophys 2014; 69:55–59.  Back to cited text no. 2
    
3.
Deanfield J, Halcox J, Rabelink T. Endothelial function and dysfunction testing and clinical relevance. Circulation 2007; 115:1285–1295.  Back to cited text no. 3
    
4.
Williams B, Mancia G, Spiering W et al. ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J 2018; 39:1–98.  Back to cited text no. 4
    
5.
Rigalleau V, Lasseur C, Raffaitin C et al. The Mayo Clinic quadratic equation improves the prediction of glomerular filtration rate in diabetic subjects. Nephrol Dial Transplant 2007; 22:813–818.  Back to cited text no. 5
    
6.
Mitchell C, Peter S, Lori A et al. Guidelines for performing a comprehensive transthoracic echocardiographic examination in adults: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr 2019; 32:1–64.  Back to cited text no. 6
    
7.
Garg S, Sarno G, Garcia-Garcia HM et al. A new tool for the risk Stratification of patients with complex coronary artery disease: the clinical SYNTAX score. Circulation 2010; 3:317–326.  Back to cited text no. 7
    
8.
Hamed E, Boghdady A, Shehata H et al. Urinary albumin excretion and severity of coronary artery disease by coronary angiography in patients with type 2 diabetes. Med J Cairo Univ 2018; 86:1995–2000.  Back to cited text no. 8
    
9.
El-Adawy AH, Abdelaziz HM, Eid H et al. Association between albuminuria and severity of coronary artery disease detected by angiography in patients with type 2 diabetes mellitus. Int J Cardiovasc 2017; 6:6.  Back to cited text no. 9
    
10.
Katz H, Aguilar F, Selvaraj S et al. Association of low-grade albuminuria with adverse cardiac mechanics: findings from the hypertension genetic epidemiology network (HyperGEN) study. Circulation 2014; 129:42–50.  Back to cited text no. 10
    
11.
ELsawasany M, ELgendy A, SalahEldeen A et al. Association of albumin to creatinine ratio with severity of coronary artery disease. Egypt J Hosp Med 2019; 74:1251–1259.  Back to cited text no. 11
    
12.
Bildirici U, Ural E, Kilic T et al. Association between documented coronary artery disease and urinary albumin, albumin to creatinine ratio. Med Sci Monit 2010; 16:545–548.  Back to cited text no. 12
    
13.
Guo L, Cheng Y, Wang X et al. Association between microalbuminuria and cardiovascular disease in type 2 diabetes mellitus of the Beijing Han nationality. Acta Diabetol 2012; 49:10–205.  Back to cited text no. 13
    
14.
Parsa AF, Ghadirian L, Kanafi SR et al. Positive correlation between microalbuminuria and severity of coronary artery stenosis in patients with type 2 diabetes mellitus. Acta Med Iran 2013; 51:15–23.  Back to cited text no. 14
    
15.
Rein P, Vonbank A, Saely C, Beer S, Jakovik V, Boenhel C et al. Relation of albuminuria to angiographically determined coronary arterial narrowing in patients with and without type 2 diabetes mellitus and stable or suspected coronary artery disease. Am J Cardiol 2011; 107:1144–1148.  Back to cited text no. 15
    
16.
Reza AS, Zaher A, Ali M. Correlation between microalbuminuria and angiographic severity of coronary artery disease. BMRC Bull 2006; 32:78–86.  Back to cited text no. 16
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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