by Richard K. Bernstein, MD, FACE, FACN, CWS
August 2001
Diabetes Care
Diabetes Interview
In a recent issue of Diabetes Care, Schurgin et al. (1) demonstrated a twofold increased prevalence of coronary artery calcification in diabetic patients versus age – and risk-matched nondiabetic patients. This finding suggests two important questions that relate to whether such a finding fully correlates with potential coronary artery stenosis in diabetes patients: 1) does electon beam-computed tomography distinguished between intimal (i.e.,plague) calcification and medical calcification? and 2 if such a distinction is possible, then what fraction of the observed densities in diabetic patients was found to be intimal versus medical?
It has long been known (2) that medical calcification (Moencheberg’s Atherosclerosis [MA]) is ubiquitous among diabetic patients and is possibly unique to diabetes. Primarily, it has been studied in the lower extremities, where it is inevitably associated with neuropathy. I have found no reports that speculate on or demonstrate that the cause of this condition, but I myself have deliberated on it’s etiology for quite some time. For the past 18 years, I have tested 100% of my new diabetic patients (n=~2000) for both postural hypotension and peripheral circulation. For the latter, I have used oscillometry, which not only elucidates distal arterial stenosis by diminished readings and vanishing exercise pulse, but also demonstrates MA by quantitatively bounding pulses far beyond that which is found in nondiabetic patients. I estimate that ~20% of my diabetic patients who have a known duration of diabetes >10 years have a lso postural hypotension, suggesting distalsympathetic neuropathy of large arteries, and virtually all have MA. I propose that MA, which on roentgenography displays segmental (not continuous) calcification, stems from total or partial loss of sympathetic innervation of segments of the muscular tunica media of larger pulsatile arteries. Frequently, the end stage of muscle denervation is muscle atrophy, muscle death, and calcification.
There are only two clinical consequences of MA. First, because the rigid tunica media must be compressed by high-cuff pressure, blood pressure measurement in the lower extremities (as with ultrasonic studies) can be artifactually elevated (2). Second, vascular surgery becomes much more difficult when on must sew through stone (calcified tunica media). MA cannot possibly compromise circulation, as seen in coronary artery stenosis. Therefore, it is important that studies that attempt to use arterial calcification as an estimate of stenosis also isolate MA as a separate and irrelevant entity.
Richard K. Bernstein, MD, FACE, FACN, CWS
From the Peripheral Vascular Disease Clinic, Albert Einstein College of Medicine, Jacobi Medical Center, New York, New York. Address correspondence to Richard K. Bernstein, MD, New York Diabetes Center, 1160 Greacen Point Road, Mamaroneck, NY 10543
Addendum:
After the above comments had been typeset, I came upon a review (3) suggesting a potent role for arterial smooth muscle cells in preventing rupture of vulnerable intimal plaques. Myocardial infarction is not caused by the slow narrowing of coronary arteries but rather by the sudden occlusion of a vessel by ruptured plaque. Apparently the invasion of such friable plaques by proliferating smooth muscle cells is a major factor in transforming vulnerable plaque to stable plaque.
Because MA involves the death of smooth muscle cells, it may well be a significant risk factor – not for stenosis but for occlusion. Thus, MA may not be benign when it is present in coronary arteries.
References
1: Schurgin S, Rich S, Mazzone T: Increased prevalence of significant coronary artery calcification in patients with diabetes. Diabetes Care 24:335-338, 2001
2: Lippman HI: The Foot of the Diabetic in Diabetes Mellitus and Obesity. Blwicher SJ, Brodoff BN, Eds. Williams % Wilkins, Baltimore, MD 1982, p. 723
3: Sobel BE: Is atherosclerosis different in patients with type 2 diabetes? Practical Diabetology 20:12, 2001
