Summary
Background
Although diabetes is associated with a high cardiovascular risk, very little information is available about diabetic patients enrolled in cardiac rehabilitation (CR).
Aims
To analyse the characteristics of diabetic patients and diabetes care in CR.
Methods
From the database of 700 patients enrolled in CR during a 29-month period, we analysed data from all patients with glucose metabolism disorders ( n = 105) and 210 matched normoglycaemic patients.
Results
A total of 105 patients with glucose metabolism disorders (type 1 diabetes, n = 5; type 2 diabetes, n = 84; impaired fasting glucose, n = 16) were enrolled in a CR programme (15% of whole population). Fifteen per cent of patients with type 2 diabetes and all patients with impaired fasting glucose were diagnosed during CR. These 105 patients were older and had a higher body mass index, a larger waist circumference, higher fasting blood glucose and triglyceride concentrations and lower low-density lipoprotein cholesterol concentrations than non-diabetic patients; they also had higher rates of hypertension ( P = 0.001) and dyslipidaemia ( P = 0.02). They were more frequently referred to CR for peripheral artery disease ( P = 0.001), coronary heart disease + peripheral artery disease ( P = 0.007) and primary prevention ( P = 0.009). The intervention of a diabetologist was needed for 42.6% of patients because of uncontrolled or newly diagnosed diabetes.
Conclusion
In the present study, we showed that (1) the proportion of patients with diabetes in CR is lower than expected, (2) many glucose metabolism disorders are diagnosed during CR, (3) patients with glucose metabolism disorders show a more severe cardiovascular risk profile than normoglycemic patients, and (4) the intervention of a diabetologist is needed during CR for many patients with diabetes.
Résumé
Contexte
Bien que le diabète soit associé à un risque cardiovasculaire élevé, la situation des patients diabétiques en réadaptation cardiaque (RC) reste mal connue.
Objectif
Analyser les caractéristiques des patients diabétiques et la prise en charge du diabète en RC.
Méthodes
À partir d’une base de données de 700 patients admis en RC au cours d’une période de 29 mois, nous avons étudié les données de tous les patients avec anomalies du métabolisme glucidique ( n = 105) et de 210 patients normoglycémiques appariés.
Résultats
105 patients avec anomalies du métabolisme glucidique (5 diabète de type 1, 84 diabète de type 2, 16 hyperglycémies à jeun non diabétiques) ont été admis en CR, soit 15 % de l’ensemble de la population. Quinze pour cent des diabètes de type 2 et toutes les hyperglycémies à jeun non diabétiques ont été diagnostiqués en RC. Ces 105 patients étaient plus âgés, plus hypertendus et présentaient des valeurs plus élevées de BMI, tour de taille, glycémie à jeun, triglycérides et des valeurs plus basses de LDL-cholestérol comparés aux patients non diabétiques. Ils étaient plus fréquemment admis en RC pour artériopathie des membres inférieurs (AMI) ( p = 0,001), coronaropathie + AMI ( p = 0,007) ou prévention primaire ( p = 0,009). Pour 42,6 % des patients, l’intervention d’un diabétologue fut nécessaire en raison de mauvais contrôle du diabète ou de découverte de diabète.
Conclusion
Notre étude montre que : (1) la proportion des patients diabétiques en RC est plus faible qu’attendu ; (2) Plusieurs anomalies du métabolisme glucidique sont diagnostiquées au cours de la RC ; (3) les patients avec anomalies du métabolisme glucidique admis en RC ont profil cardiovasculaire plus sévère que les non diabétiques ; et (4) que l’intervention d’un diabétologue au cours de la RC est nécessaire pour de nombreux patients diabétiques.
Background
Diabetic patients are at increased risk of coronary heart disease, heart failure and stroke. Cardiovascular disease in diabetic patients is also more severe, with significantly higher rates of morbidity and mortality compared to cardiovascular patients without diabetes . Several studies have clearly shown that cardiac rehabilitation (CR) significantly reduces cardiovascular morbidity and mortality and improves quality of life . The first meta-analyses clearly demonstrated that CR after myocardial infarction significantly reduced cardiovascular morbidity and mortality . This clear beneficial effect of CR on overall mortality and cardiovascular mortality was confirmed subsequently by several clinical trials and meta-analyses . The cardiovascular mortality rate in patients who underwent CR with exercise training after myocardial infarction was found to be 20–26% lower than in those who did not have CR . Long-term reductions in cardiovascular mortality and total mortality after CR were confirmed by Hedbäck et al., who showed a 26.7% reduction in total mortality and a 27.1% reduction in cardiovascular mortality over a 10-year period . Hence, CR programmes are recognized as an integral part of the care strategy for patients with coronary heart disease, heart failure, cardiac surgery and peripheral artery disease, and CR is a level A recommendation in patients with coronary heart disease .
CR is strongly recommended for both primary and secondary prevention in patients with type 2 diabetes because of their high cardiovascular risk. However, little is known about diabetic patients who undergo CR. For instance, it is not clearly known whether diabetic patients referred for CR are representative of all diabetic individuals and whether there are differences compared with non-diabetic patients referred for CR. In addition, there are no data on glycaemic control during CR, and the percentage of patients who are referred to a diabetologist for uncontrolled diabetes is unknown. This lack of knowledge prompted us to perform a retrospective study to analyse the characteristics of diabetic patients enrolled in CR, including clinical and biological features, cardiovascular complications, other diabetes-related complications, indications for CR, diabetes care in CR and situations in which referral to a diabetologist was needed.
Methods
Patients
From the database of the 700 patients enrolled in a comprehensive CR programme in a CR centre (clinique des Rosiers, Dijon) from September 2008 to February 2011, we retrospectively reviewed data from all patients with diabetes or fasting hyperglycaemia ( n = 105). In addition, for each patient with a glucose metabolism disorder (diabetes or fasting hyperglycaemia), we selected, by drawing lots, two normoglycaemic patients enrolled in the same CR programme during the same month, in order to have a randomized control group of 210 individuals.
All of the patients were enrolled in an outpatient CR programme consisting of 20 physical training sessions, an individualized educational programme (nutrition, management and control of cardiovascular risk factors to reach the goals of secondary prevention, stress management, smoking cessation), psychological support, and help with occupational and work reintegration.
During the programme, all patients had a regular cardiac follow-up (once a week), to assess cardiac treatment, patient motivation and cardiovascular risks factors, and to supervise training sessions. A multidisciplinary meeting was held each week. Diabetic patients had a careful follow-up that included blood glucose monitoring during training sessions, modifications of antidiabetic treatments when needed, a specific group educational course and nutritional counselling.
Data collection
For all of the patients, we collected baseline clinical and biological characteristics, indications for CR and cardiovascular risk factors (hypertension, smoking, dyslipidaemia). Patients were considered dyslipidaemic when plasma low-density lipoprotein (LDL)-cholesterol or triglyceride concentrations were above the recommended target or when they were taking hypolipidaemic agents. Data on diabetes, including type of diabetes, duration of diabetes, treatment, complications and need to be referred to a diabetologist during the CR programme, were also collected.
Coronary heart disease was defined as the occurrence of an acute coronary event (ACE), angina pectoris, the presence of coronary artery occlusion on the coronary angiogram, percutaneous coronary intervention with stent placement, or coronary artery bypass surgery. Peripheral artery disease was defined as the presence of intermittent claudication, a history of limb artery surgery, or an abnormal lower limb Doppler ultrasound scan.
Statistical analysis
Data are expressed as mean ± standard deviations for quantitative variables and as percentages for qualitative variables. The two populations were compared using the Chi 2 test for qualitative variables and Student’s t test for quantitative variables. A P value < 0.05 was considered statistically significant. Statistical calculations were performed using the SPSS software package (Chicago, IL, USA).
Results
Clinical and biological characteristics and cardiovascular risk factors
During the 29-month study period, 105 patients with glucose metabolism disorders (22 women and 83 men) were enrolled in the CR programme. This number represented 15% of the whole population ( n = 700) enrolled in CR during the same period.
The 105 patients with glucose metabolism disorders included five patients with type 1 diabetes (5%), 84 patients with type 2 diabetes (80%) and 16 patients with impaired fasting glucose (15%). Among the 84 patients with type 2 diabetes, 13 were diagnosed with type 2 diabetes (15%) during the CR. All of the patients with impaired fasting glucose were diagnosed during the CR. Among the 105 patients with glucose metabolism disorders, 29 (27.6%) were diagnosed during the CR.
The 105 patients with glucose metabolism disorders were compared with 210 normoglycaemic patients (54 women and 156 men) enrolled in the CR programme, during the same period (ratio 1:2). The main characteristics of the patients with glucose metabolism disorders and normoglycaemic patients are shown in Table 1 . Patients with glucose metabolism disorders were older than normoglycaemic patients (63.31 ± 12.38 vs. 60.92 ± 9.87 years; P = 0.038) and had a higher body mass index and waist circumference. They also had higher fasting blood glucose and triglyceride concentrations, lower LDL-cholesterol concentrations and a more severe cardiovascular risk profile, with a greater proportion of patients with hypertension ( P = 0.001) and dyslipidaemia ( P = 0.02). Patients with glucose metabolism disorders had a lower baseline cycloergometer workload than normoglycaemic patients.
| Normoglycaemic patients ( n = 210) | Patients with glucose metabolism disorders ( n = 105) | P | |
|---|---|---|---|
| Age (years) | 60.92 ± 9.87 | 63.31 ± 12.38 | 0.038 |
| Men | 156 (74.3) | 83 (79.0) | 0.35 |
| Weight (kg) | 78.97 ± 15.61 | 87.53 ± 15.10 | < 0.001 |
| Height (cm) | 168.94 ± 14.18 | 169.21 ± 9.85 | 0.86 |
| BMI (kg/m 2 ) | 28.53 ± 13.38 | 29.96 ± 5.01 | 0.29 |
| Waist circumference (cm) | 97.96 ± 11.25 | 107.25 ± 13.25 | < 0.001 |
| Fasting blood glucose (mmol/L) | 5.27 ± 0.50 | 7.49 ± 2.11 | < 0.001 |
| Total cholesterol (mmol/L) | 4.26 ± 1.11 | 4.13 ± 1.08 | 0.37 |
| LDL-cholesterol (mmol/L) | 2.43 ± 0.95 | 2.17 ± 0.77 | 0.01 |
| HDL-cholesterol (mmol/L) | 1.21 ± 0.36 | 1.14 ± 0.28 | 0.10 |
| Triglycerides (mmol/L) | 1.37 ± 0.70 | 1.92 ± 1.86 | 0.005 |
| Creatinine (μmol/L) | 92.75 ± 47.61 | 88.61 ± 22.38 | 0.40 |
| Hypertension | 124 (59) | 82 (78) | 0.001 |
| Dyslipidaemia | 180 (86) | 99 (94) | 0.02 |
| Tobacco smoking | 50 (24) | 23 (22) | 0.71 |
| Statin treatment | 201 (96) | 100 (95) | 0.85 |
| ACEI/ARB treatment | 184 (88) | 95 (90) | 0.45 |
| Beta-blocker treatment | 176 (84) | 87 (83) | 0.83 |
| Antiplatelet agent treatment | 210 (100) | 105 (100) | 1 |
| Cycloergometer peak workload (W) | 94 ± 32 | 83 ± 28 | 0.002 |
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