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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiovascular disease &#40;CVD&#41; is a common complication of diabetes and a major cause of death&#44; permanent disability and resource expenditure&#46; Advances in knowledge and technology&#44; novel treatments and greater accessibility have dramatically changed the overall panorama&#44; with a much more favorable short- and long-term prognosis for people with diabetes and CVD&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">It is interesting to look at how the concept of cardiovascular &#40;CV&#41; risk in diabetes has changed over the last 30 years or so&#46; From CV risk in diabetes being considered equivalent to coronary disease&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> the estimated risk for people with diabetes went to double that of the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> The standpoint now is different&#46; CVD risk in diabetes is strongly related to CV risk factors for ischemic heart disease&#44; but less so for heart failure&#44; for which age is a strong contributor&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Furthermore&#44; other modifiers like duration of diabetes&#44; target organ damage and other diabetes complications &#40;especially nephropathy&#41;&#44; can exponentially increase the risk of progressive and widespread CVD&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Perhaps&#44; at this point&#44; we should start looking at CVD in diabetes in a more comprehensive and wide-ranging way&#46; How should CVD be defined&#63; Should we wait for a person to suffer a major event like myocardial infarction&#44; stroke or amputation&#44; to consider that they have CVD&#63; At that point&#44; it is already too late for many preventive measures and the first window of opportunity is already past&#59; between 13 and 17 years of life have been lost in women and men&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">So&#44; in our view&#44; in the appropriate group of individuals with diabetes &#40;those at very high risk&#41;&#44; it is time to be more proactive in finding subclinical CVD&#44; whether hidden atherosclerosis in different vascular beds or silent myocardial dysfunction&#46; The challenge for most clinicians is to successfully select individuals at sufficient risk to justify a cost-benefit approach&#46; Available risk charts are scarce&#44; unsuitable or untested in general populations&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Imaging modalities and biomarkers are still not totally accepted &#40;despite clear evidence in the case of the former&#41; by the experts who develop practice guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> There is an enormous task to undertake in the coming years&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">This reflection is prompted by the article by Cardoso et al&#46;&#44; on behalf of the PICT2RE investigators&#44; published in this issue of the <span class="elsevierStyleItalic">Journal</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> The paper addresses the prevalence of CVD and CV risk factors among people with diabetes in a hospital setting&#46; The results presented are not surprising&#46; Although the number of patients included in the study is relatively small compared to previously published large registries&#44; its overall findings are in line with what could be expected from a population in hospital care&#44; with longer duration and more severe expression of disease&#46; Obesity was present in a large proportion of participants&#44; as expected&#44; and 80&#37; of the cohort had multiple associated CV risk factors&#44; as is usually found in this type of population&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The prevalence of CVD was relatively high &#40;40&#37;&#41;&#44; but might have been even higher if subclinical disease had been investigated&#46; This contrasts with lower rates observed in general care settings&#44; in which people with milder forms of disease are generally followed&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Importantly&#44; about half of CVD was due to ischemic heart disease and only 21&#46;5&#37; to heart failure&#44; much less than would have been expected&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> This raises questions concerning the inclusion criteria&#46; I believe&#44; since this was a retrospective study&#44; that the only criteria used were clinical&#46; If so&#44; for example&#44; were angina and heart failure symptoms supported by any subsequent tests&#63; Were other etiologies of chest pain or dyspnea sought&#63; The same is true for the diagnosis of peripheral arterial disease and carotid disease&#46; What were the criteria&#63; More than 50&#37; stenosis in a carotid artery&#44; measurement of ankle-brachial index&#44; or lower limb Doppler findings&#63;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Regarding intervention&#44; the results presented are also in line with many other registries&#46; Most patients were treated with several antidiabetic agents &#40;predominantly insulin and metformin&#44; but also about a third with one of the newer therapies&#44; sodium-glucose co-transporter-2 inhibitors or glucagon-like peptide-1 receptor agonists&#41;&#46; In spite of this&#44; metabolic control was clearly suboptimal&#44; with a mean glycated hemoglobin of 7&#46;7&#37;&#44; clearly above the recommended target&#46; There were few hypoglycemic events&#44; perhaps due to the low use of sulfonylureas&#46; On the other hand&#44; hyperglycemic episodes were more frequent&#44; which is in accordance with the inadequate level of metabolic control reported&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Treatment of hypertension and dyslipidemia was also as expected&#46; In general&#44; patients with documented CVD had better control of concomitant CV risk factors&#44; with the exception of lipid control&#46; This seems to indicate a discrepancy between medical advice and the real world&#46; The guidelines are in use everywhere&#44; but control rates&#44; especially for lipids&#44; are well below targets in about 70&#37; of the population&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> What is the problem&#63; It is due to a mix of reasons that include patient adherence&#44; physician inertia&#44; awareness&#44; patient education and deficient team work&#46; A gigantic task for all of us&#44; since these problems have been unresolved for the last 20&#8211;30 years&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">When we look at complications&#44; there is one item that deserves attention&#46; Neuropathy in diabetes is a complex entity&#46; Peripheral neuropathy is responsible for many lower limb amputations and is easily detected with traditional screening methods&#46; By contrast&#44; cardiac autonomic neuropathy &#40;CAN&#41; is more obscure&#44; insidious and difficult to diagnose at the bedside&#46; The reported number of patients with neuropathy &#40;about one quarter&#41; appears to refer only to peripheral neuropathy&#46; We believe a much larger number of patients could have undiagnosed CAN&#44; at different levels of involvement&#46; This can change the perspective&#44; the level of risk and the association with underlying subclinical CVD&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> potentially changing the approach to screening for hidden disease and the prevalence of CVD in this cohort&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Studies of diabetes and CVD in Portuguese patients like this one are welcome&#44; since the findings could be substantially different from populations in other parts of the world&#46; The study published here also reflects how diagnosis&#44; practice and intervention are being carried out in this country&#46; The results are not surprising in general&#44; and are similar to other published registries&#46; The limited number of individuals included &#40;clearly below the number needed for high confidence levels&#41; may to some extent limit the final conclusions to be drawn&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The purpose of the study was to compare a group with previous documented CVD with a follow-up group&#46; The definition of the two groups would therefore seem to be of utmost importance&#46; In this editorial we have underlined the need for more precise definition of CVD in its different clinical and subclinical expressions&#46; It is clear that if we wait for major events&#44; a window of opportunity for prevention is lost and prognosis for survival is significantly impaired&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Our ambition should be to appropriately select who to screen for subclinical disease&#44; to set stricter targets for intervention&#44; and to build global multiteam strategies to improve prognosis&#46; We need to look behind the mirror&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Cardiovascular disease in diabetes: Do we need to look behind the mirror?
Doença cardiovascular na diabetes – precisamos de olhar para trás do espelho?
Pedro Matosa,b
a Cardiologista, Coordenador Departamento Cardiologia, Associação Protectora dos Diabéticos de Portugal (APDP), Lisboa, Portugal
b Cardiologista, Coordenação Imagiologia e Risco CV, Hospital CUF Tejo, Lisboa, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiovascular disease &#40;CVD&#41; is a common complication of diabetes and a major cause of death&#44; permanent disability and resource expenditure&#46; Advances in knowledge and technology&#44; novel treatments and greater accessibility have dramatically changed the overall panorama&#44; with a much more favorable short- and long-term prognosis for people with diabetes and CVD&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">It is interesting to look at how the concept of cardiovascular &#40;CV&#41; risk in diabetes has changed over the last 30 years or so&#46; From CV risk in diabetes being considered equivalent to coronary disease&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> the estimated risk for people with diabetes went to double that of the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> The standpoint now is different&#46; CVD risk in diabetes is strongly related to CV risk factors for ischemic heart disease&#44; but less so for heart failure&#44; for which age is a strong contributor&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Furthermore&#44; other modifiers like duration of diabetes&#44; target organ damage and other diabetes complications &#40;especially nephropathy&#41;&#44; can exponentially increase the risk of progressive and widespread CVD&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Perhaps&#44; at this point&#44; we should start looking at CVD in diabetes in a more comprehensive and wide-ranging way&#46; How should CVD be defined&#63; Should we wait for a person to suffer a major event like myocardial infarction&#44; stroke or amputation&#44; to consider that they have CVD&#63; At that point&#44; it is already too late for many preventive measures and the first window of opportunity is already past&#59; between 13 and 17 years of life have been lost in women and men&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">So&#44; in our view&#44; in the appropriate group of individuals with diabetes &#40;those at very high risk&#41;&#44; it is time to be more proactive in finding subclinical CVD&#44; whether hidden atherosclerosis in different vascular beds or silent myocardial dysfunction&#46; The challenge for most clinicians is to successfully select individuals at sufficient risk to justify a cost-benefit approach&#46; Available risk charts are scarce&#44; unsuitable or untested in general populations&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Imaging modalities and biomarkers are still not totally accepted &#40;despite clear evidence in the case of the former&#41; by the experts who develop practice guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> There is an enormous task to undertake in the coming years&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">This reflection is prompted by the article by Cardoso et al&#46;&#44; on behalf of the PICT2RE investigators&#44; published in this issue of the <span class="elsevierStyleItalic">Journal</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> The paper addresses the prevalence of CVD and CV risk factors among people with diabetes in a hospital setting&#46; The results presented are not surprising&#46; Although the number of patients included in the study is relatively small compared to previously published large registries&#44; its overall findings are in line with what could be expected from a population in hospital care&#44; with longer duration and more severe expression of disease&#46; Obesity was present in a large proportion of participants&#44; as expected&#44; and 80&#37; of the cohort had multiple associated CV risk factors&#44; as is usually found in this type of population&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The prevalence of CVD was relatively high &#40;40&#37;&#41;&#44; but might have been even higher if subclinical disease had been investigated&#46; This contrasts with lower rates observed in general care settings&#44; in which people with milder forms of disease are generally followed&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Importantly&#44; about half of CVD was due to ischemic heart disease and only 21&#46;5&#37; to heart failure&#44; much less than would have been expected&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> This raises questions concerning the inclusion criteria&#46; I believe&#44; since this was a retrospective study&#44; that the only criteria used were clinical&#46; If so&#44; for example&#44; were angina and heart failure symptoms supported by any subsequent tests&#63; Were other etiologies of chest pain or dyspnea sought&#63; The same is true for the diagnosis of peripheral arterial disease and carotid disease&#46; What were the criteria&#63; More than 50&#37; stenosis in a carotid artery&#44; measurement of ankle-brachial index&#44; or lower limb Doppler findings&#63;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Regarding intervention&#44; the results presented are also in line with many other registries&#46; Most patients were treated with several antidiabetic agents &#40;predominantly insulin and metformin&#44; but also about a third with one of the newer therapies&#44; sodium-glucose co-transporter-2 inhibitors or glucagon-like peptide-1 receptor agonists&#41;&#46; In spite of this&#44; metabolic control was clearly suboptimal&#44; with a mean glycated hemoglobin of 7&#46;7&#37;&#44; clearly above the recommended target&#46; There were few hypoglycemic events&#44; perhaps due to the low use of sulfonylureas&#46; On the other hand&#44; hyperglycemic episodes were more frequent&#44; which is in accordance with the inadequate level of metabolic control reported&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Treatment of hypertension and dyslipidemia was also as expected&#46; In general&#44; patients with documented CVD had better control of concomitant CV risk factors&#44; with the exception of lipid control&#46; This seems to indicate a discrepancy between medical advice and the real world&#46; The guidelines are in use everywhere&#44; but control rates&#44; especially for lipids&#44; are well below targets in about 70&#37; of the population&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> What is the problem&#63; It is due to a mix of reasons that include patient adherence&#44; physician inertia&#44; awareness&#44; patient education and deficient team work&#46; A gigantic task for all of us&#44; since these problems have been unresolved for the last 20&#8211;30 years&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">When we look at complications&#44; there is one item that deserves attention&#46; Neuropathy in diabetes is a complex entity&#46; Peripheral neuropathy is responsible for many lower limb amputations and is easily detected with traditional screening methods&#46; By contrast&#44; cardiac autonomic neuropathy &#40;CAN&#41; is more obscure&#44; insidious and difficult to diagnose at the bedside&#46; The reported number of patients with neuropathy &#40;about one quarter&#41; appears to refer only to peripheral neuropathy&#46; We believe a much larger number of patients could have undiagnosed CAN&#44; at different levels of involvement&#46; This can change the perspective&#44; the level of risk and the association with underlying subclinical CVD&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> potentially changing the approach to screening for hidden disease and the prevalence of CVD in this cohort&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Studies of diabetes and CVD in Portuguese patients like this one are welcome&#44; since the findings could be substantially different from populations in other parts of the world&#46; The study published here also reflects how diagnosis&#44; practice and intervention are being carried out in this country&#46; The results are not surprising in general&#44; and are similar to other published registries&#46; The limited number of individuals included &#40;clearly below the number needed for high confidence levels&#41; may to some extent limit the final conclusions to be drawn&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The purpose of the study was to compare a group with previous documented CVD with a follow-up group&#46; The definition of the two groups would therefore seem to be of utmost importance&#46; In this editorial we have underlined the need for more precise definition of CVD in its different clinical and subclinical expressions&#46; It is clear that if we wait for major events&#44; a window of opportunity for prevention is lost and prognosis for survival is significantly impaired&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Our ambition should be to appropriately select who to screen for subclinical disease&#44; to set stricter targets for intervention&#44; and to build global multiteam strategies to improve prognosis&#46; We need to look behind the mirror&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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