Cardiovascular pathology – a factor of the adverse course of diabetic polyneuropathy

Diabetic polyneuropathy (DP) and angiopathy are interdependent processes, as disturbances in the microcirculatory system of peripheral nerves lead to increased axonal damage and is a kind of predictor of polyneuropathy progressing [6]. 80% of deaths from diabetes mellitus (DM) are associated with cardiovascular catastrophes, including coronary heart disease (CHD), stroke and peripheral artery disease [3]. The objective: to analyze the most common cardiovascular pathology (CVP) and show its impact on the course of DP in type I and II DM. Materials and methods. Was clinically examined 101 patient with DP. The examined patients were divided into groups: with DP on the background of type 1 DM (group I) (n=54) and with DP on the background of type II DM (group II) (n=47), and also were divided into subgroups: DP on the background of type I and II DM and existing CVP (including diabetic angiopathy) 82 (82%) (subgroup А) and with the DP on the background of DM type I and II without CVP – 19 (19%) (subgroup В). Patients were examined to determine the neurological status, were performed laboratory and instrumental methods of examination. Static calculation was performed in MS Excel 2003 and in the programme STATISTICA 10. Results. Regarding to the patients of subgroup А and В we noted the natural predominance of trophic disorders, changes in the reflex sphere and sensitivity in subgroup А. Patients of group II more often than in group I had pathology of the cardiovascular system. Hypertension (HT) and CHD in both cases were registered with a high frequency. In subgroup А there was a combination of several nosologies: from the respiratory, urinary, gastroenterological system (1%), urinary and gastroenterological (3%), gastroenterological and endocrine (2%), urinary and endocrine (1%). In subgroup В diseases of urinary and gastroenterological pathology were found in (5%), gastroenterological (5%), endocrine (11%). The examined patients from group I and with the concomitant CVP have lower linear velocity of blood flow (LVBF) on both tibial arteries, patients in group II – have marginally higher LVBF. Analysis of the results of duplex scanning of lower extremity arteries showed a high incidence of stenosis, in particular the anterior tibial arteries (ATA) up to 30–40%, posterior tibial arteries (PTA) up to 40–50% and occlusion (PTA and femoral, popliteal, tibial segment) in individuals of group I. Conclusions. In patients with DP on the background of type I and II DM and available CVP (subgroup А), the clinical manifestations of polyneuropathy were quite pronounced, especially in the field of trophic disorders, because CVP enhances the ischemia of the microsaceous channel of the peripheral nerves. In addition, persons with concomitant CVP have a wide range of another comorbid pathology, which accelerates the onset of DM complications.

Damage to the blood vessels of the lower extremities in DM is the main cause of amputations of the lower extremities, unrelated to physical traumas or road accidents [10].
Diabetic foot is an important problem in economic terms, especially if amputation is the end of long hospital treatment with the patient's discharge home and the need to care for him. The cost of primary treatment is estimated at 7-10 thousand USD [12].
Increased lipid profile indicators in a patient with DM together with hypertension (HT), which predominates in middle-aged and elderly people, contributes to the formation of metabolic syndrome, which can lead to vascular accidents in the future [5].
DP and angiopathy are interdependent processes, as disturbances in the microcirculatory system of peripheral nerves lead to increased axonal damage, and the presence of trophic disorders in DP is accompanied by an inability of the vascular system to adequately deliver nutrients to nerve fibers, which contributes to chronic ischemia and is a kind of predictor of polyneuropathy progressing [6].
Diabetic angiopathies affect almost all organs due to impaired blood supply, and damage to various types of blood vessels leads to a significant deterioration in the course of the disease. The cardiovascular system is most affected. Today we are talking about an epidemic of atherosclerotic complications in patients with type II DM. 80% of deaths from DM are associated with cardiovascular catastrophes, including coronary heart disease (CHD), stroke and peripheral artery disease [3].
The objective: to analyze the most common cardiovascular pathology (CVP) and show its impact on the course of DP in type I and II DM.
The examined patients were divided into groups: with DP on the background of type 1 DM (group I) (n=54) and with DP on the background of type II DM (group II) (n=47). Depending on the presence of CVP, patients were divided into subgroups: DP on the background of type I and II DM and existing CVP (including diabetic angiopathy) 82 (82%) (subgroup А) and with the DP on the background of DM type I and II without CVP -19 (19%) (subgroup В).
Patients were examined to determine the neurological status, were performed laboratory (general blood test, general urine test, biochemical blood test, glycated hemoglobin) and instrumental methods of examination (duplex scanning of the vessels of the lower extremities, electrocardiography (ECG), echocardiography (Echo), electroneuromyography (ENMG). Static calculation was performed in MS Excel 2003 and in the programme for statistical analysis STATISTICA 10.

RESEARCH RESULTS AND DISCUSSION
In subgroup А type I DM was verified in 42 (51%) patients, type II -in 40 (49%), in subgroup В type I DM -in 12 (63%), type II -in 7 (37%). The average data on the age category of patients are shown in Fig. 1.
Regarding to the patients of subgroup А and В we noted the natural predominance of trophic disorders (Table 1), changes in the reflex sphere and sensitivity in subgroup А. Decrease in vibrational sensitivity is present in both subgroups, but in subgroup А the indicators are lower, in particular in the lower extremities (7.18±0,34 s).
In 1 patient of subgroup А was revealed a slight peripheral paresis of both hands, in subgroup В in 1 patient previous changes were combined with slight peripheral paresis of both feet. Manifestations of «diabetic foot» were diagnosed in 12 (15%) patients of subgroup А, and in 6 (8%) amputation of fingers was performed, in subgroup В none of the patients had such complication of DM.
Patients of group II more often than in group I had pathology of the cardiovascular system (Fig. 2). HT and CHD in both cases were registered with a high frequency. In addition to CVP, disorders of the gastrointestinal tract in people with type II DM also dominate (Fig. 3). Gallstone disease (GD), chronic cholecystitis (CC), chronic pancreatitis (CP) and chronic hepatitis (CH) were more commonly diagnosed in both type I and type II DM.
Among transsyndromal comorbidity dominate retinopathy, nephropathy and angiopathy of the lower extremities dominate (Fig. 4), which are more often present in subgroup А.
Lipid profile indicators (Fig. 5, 6) in patients of subgroup А and В are within normal values. In subgroup А the quantity of the scope for all parameters of lipid metabolism is higher, in particular for total cholesterol.
The average rate of glycated hemoglobin (Fig. 7) in patients of group II is significantly higher than in group I, in subgroup В is slightly higher than in А.
In 34 (34%) patients (21 from group I and 13 from group II), was performed duplex vascular scans of the lower extremities.
Linear velocity of blood flow (LVBF) in the anterior (ATA) and posterior tibial (PTA) arteries was within normal range in all examined (table 2).
The examined patients from group I and with the concomitant CVP have lower LVBF on both tibial arteries. The LVBF on the left ATA is quite low -45.45±5.85 sm/s. Regarding to the patients in group II, we observed marginally higher LVBF rates in patients with concomitant CVP. This phenomenon was associated with compensatory acceleration of blood flow in stenosed vessels during the initial stages of atherosclerosis and a wide intake of antiplatelet agents by patients of this sample.
Analysis of the results of duplex scanning of lower extremity arteries (table 3) showed a high incidence of stenosis, in particular ATA up to 30-40%, PTA up to 40-50% and occlusion (PTA and femoral, popliteal, tibial segment) in individuals of group I. According to the literature [9,16], despite hyperlipidemia, it has been proved that in the absence of circulating insulin, such changes in lipid metabolism do not lead to the emergence of a vascular lesion, but the need to increase the dose of insulin is a sensitive indicator of the development of macroangiopathy.