Diabetes mellitus type 2 and angina pectoris : novel insights in diagnosis, prognosis and treatment Wiersma, J.J.

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1 UvA-DARE (Digital Academic Repository) Diabetes mellitus type 2 and angina pectoris : novel insights in diagnosis, prognosis and treatment Wiersma, J.J. Link to publication Citation for published version (APA): Wiersma, J. J. (2008). Diabetes mellitus type 2 and angina pectoris : novel insights in diagnosis, prognosis and treatment General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. UvA-DARE is a service provided by the library of the University of Amsterdam ( Download date: 25 Jan 2019

2 C h a p t e r 7 The procoagulant state of patients with type 2 diabetes mellitus in relation to myocardial ischemia Jacobijne J Wiersma Joost CM Meijers Thijs CB Wielenga Hein J Verberne Arne WJH Dielis Henri MH Spronk Hugo ten Cate Jan J Piek Jan GP Tijssen Mieke D Trip Submitted Proefschrift Wiersma.indb :59:06

3 Abstract 106 Background A prothrombotic state is present in diabetes mellitus and this state potentially contributes to the pathogenesis of atherosclerosis in these patients. The aim of this study was to assess the relation between this prothrombotic state and the presence of myocardial ischemia in type 2 diabetic patients with mild symptoms of angina pectoris. Methods A total of 282 patients with diabetes mellitus type 2 and stable angina pectoris underwent myocardial perfusion scintigraphy (MPS). Levels of von Willebrand factor (vwf), D-dimer, prothrombin fragment 1+2 (F1+2), thrombin activatable fibrinolysis inhibitor (TAFI) and parameters related to thrombin generation (i.e. endogenous thrombin potential [ETP] peak height and lag time) were determined before MPS and related to the presence of myocardial ischemia. Results Myocardial ischemia on MPS was present in 141 (50%) patients. These ischemic patients had significantly higher levels of vwf compared with patients without ischemia: (141% (IQR ) vs.126% (IQR ), p-value 0.03). Increase of vwf was an independent predictor of the presence of myocardial ischemia (OR per 1% increase, 95%CI , p<0.05). No significant relation was found between levels of D-dimer, prothrombin fragment 1+2, or TAFI and the presence of myocardial ischemia. Furthermore, normalized levels of thrombin generation (peak height and ETP) measured at 1pM tissue factor, were increased in diabetic patients, respectively 282% (±140%) and 161% (±60%). Conclusion Diabetics exhibit a procoagulant state as demonstrated by an increased thrombin generation. Limited evidence was provided in this study that this prothrombotic state contributes to the pathogenesis of coronary artery disease defined as perfusion defects on MPS. A moderate increase in vwf was observed in diabetic patients with evidence of myocardial ischemia on MPS. Proefschrift Wiersma.indb :59:06

4 Introduction Type 2 diabetic patients have a higher incidence of atherosclerosis and related thrombosis which leads to an increased morbidity and mortality from coronary artery disease (CAD); 75% of diabetics will die a cardiac death 1. In addition, diabetics have an increased risk of acute coronary syndromes and a worse prognosis afterwards 2. Early recognition of CAD and subsequent adequate anti-anginal treatment and cardiac risk reduction may decrease these cardiac complications. There is substantial laboratory evidence of a prothrombotic state in diabetes mellitus, manifested by impaired fibrinolysis, hypercoagulability and increased platelet aggregation. It is speculated that this prothrombotic state plays a role in the pathogenesis of CAD in these diabetics 3-7. Furthermore, it is thought that this prothrombotic state is not only related to the occurrence of acute cardiac events but are also involved in the initiation and progression of atherosclerotic lesions While studies have focused on different hemostatic markers as an expression of this prothrombotic state in relation to diabetes, none have focused on the association of this prothrombotic state and the presence and early diagnosis of myocardial ischemia in diabetic patients. Therefore the main purpose of the present study was to investigate the possible relation between the presence of regional myocardial ischemia and markers of a prothrombotic state in diabetic patients. The study was conducted in type 2 diabetic patients with stable angina pectoris (Canadian Cardiovascular Society (CCS) I-II/IV) who underwent a myocardial perfusion scintigraphy (MPS). The markers selected for this study were located in different parts of the coagulation/fibrinolysis pathway. Von Willebrand factor (vwf) mediates platelet adhesion, acts as a carrier for coagulation factor VIII, and is considered a reliable marker of endothelial dysfunction 11. D-dimer, a fibrin degradation product, is a marker of not only thrombin generation (coagulation) but also of crosslinked fibrin turnover by plasmin (fibrinolysis) 12. Prothrombin fragments 1+2 (F1+2) are released when thrombin is formed from its precursor prothrombin and thus reflects activation of coagulation 13. Thrombin Activatable Fibrinolysis Inhibitor (TAFI) is a proenzyme that is activated by thrombin during coagulation. Activated TAFI suppresses fibrinolysis by preventing the binding of the fibrinolytic components plasminogen and tissue type plasminogen activator, and thereby limits plasmin formation 14. And finally the in vitro total plasma coagulation potential was investigated in this group of patients by assessing thrombin generation. In this test, coagulation in a plasma sample is activated by tissue factor and thrombin formation is followed in real-time, thereby enabling measurement of the coagulation potential of plasma. The assay reflects the Chapter Coagulation and myocardial ischemia in diabetics Proefschrift Wiersma.indb :59:06

5 balance between pro- and anticoagulant proteins, instead of focusing on a single parameter as described above 15, Methods Setting The study population consisted of consecutive type 2 diabetic patients with mild anginal complaints (CCS class I-II/IV) who had been screened for inclusion in the randomized multicenter MERIDIAN (Multicenter trial of Elective Revascularization in patients with DIabetese mellitus and mild ANginal symptoms) trial 17. The patients were recruited from the Cardiology and Internal Medicine out-patient clinics in 20 Dutch hospitals. All patients underwent initial clinical and laboratory evaluation, followed by a MPS. The study complied with the Declaration of Helsinki. The medical ethical committees of the participating centers approved the protocol and all patients gave written informed consent. Patient population Patients, aged 30 years, with mild, stable ( two months) complaints of angina pectoris (CCS class I-II/IV) were eligible for screening. Type 2 diabetes mellitus was defined as the presence of one or more of the following: fasting glucose of >7.0 or non-fasting of >11.0 mmol/l in two samples on two separate days, treatment with oral antidiabetic medication, treatment with oral medication combined with insulin, or onset of insulin treatment at age 50 years. Exclusion criteria were 1) percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in the preceding six months; 2) unstable angina pectoris (UAP) (CCS III-IV/IV) or MI in the preceding two months; 3) severe hypertension (systolic blood pressure 180 mmhg or diastolic blood pressure 100 mmhg, after treatment); 4) body weight >120 kg; 5) heart failure or ejection fraction <35%, as measured by echocardiography or gated MPS; 6) known valvular disease; 7) known severe cardiomyopathy; 8) plasma creatinine level >250 μmol/l; 9) prescription of coumarin derivatives. Myocardial perfusion scintigraphy and image analysis Stress and rest myocardial perfusion scintigraphy (with single-photon emission computed tomography (SPECT)) were performed with 99m Tc labeled perfusion tracers Proefschrift Wiersma.indb :59:06

6 (Tetrofosmin or sesta-mibi) or 201 Thallium according to the guidelines of the American Society of Nuclear Cardiology 18. Symptom limited exercise (bicycle or treadmill ergometry) was the preferred stress modality. Pharmacological vasodilatory stress with adenosine or dipyridamole was applied if there was insufficient increase of heart rate (<85% age predicted maximal heart-rate) during physical exercise, in the presence of a left bundle branch block, or if the anti-anginal medication had not been discontinued beforehand. Dobutamine stress testing was performed in patients with a contra-indication for adenosine or dipyridamole. Nuclear medicine physicians semi-quantitatively analyzed the images by use of 17 myocardial segments. Segments were scored with a 5-point scoring system (0=normal; 1= equivocal; 2=moderate reduction; 3=severe reduction; 4= absent activity). Summed stress score (SSS) and summed rest score (SRS) were obtained by adding the scores of all segments of respectively stress and rest images. The summed difference score (SDS) was calculated by subtracting the SRS from the SSS. Reversible myocardial perfusion defects were defined as SDS 3, these defects are indicative for myocardial ischemia and will be referred to as myocardial ischemia. Fixed defects were defined as a SRS-score of 3, these defects are indicative for scar tissue and therefore will be referred to as scar tissue; mixed defects were defined as both SDS 3 and SRS-score of 3. Chapter Coagulation and myocardial ischemia in diabetics Biochemical analysis Fasting blood samples were collected before MPS and were centrifuged without delay (< 1 hour) and stored at 70 C until further analysis. Measurements of prothrombin fragment F1+2 (Dade Behring, Marburg, Germany), D-dimers (Diagnostica Stago, Asnières-sur-Seine, France), and von Willebrand factor antigen (antibodies from Dako, Glostrup, Denmark) were performed by ELISA. TAFI activity levels were determined with a chromogenic assay (Pefakit TAFI, Pentapharm LTD, Basel, Switzerland) by converting TAFI into its active form and subsequently measuring the carboxypeptidase activity. Measurements were run on a BCS coagulation analyser (Dade Behring Inc.,Marburg, Germany). Normal levels of vwf were between 50 and 150%, of F1+2 between 53 and 271 pmol/l and of TAFI between 64 and 125%. Levels of D-dimers were considered normal when below 400 µg/l. Thrombin generation in tissue factor (TF)-triggered platelet-poor plasma was measured with the Calibrated Automated Thrombogram (CAT) method (Thrombinoscope BV, Maastricht, The Netherlands). Measurements were conducted on 80 μl plasma with final concentrations of 5 or 1 pm TF (Thrombinoscope BV) and 4 μm phospholipids. Thrombin Calibrator Proefschrift Wiersma.indb :59:06

7 110 was obtained from Thrombinoscope BV. Fluorescence was read in a Fluoroskan Ascent reader (Thermo Labsystems OY, Helsinki, Finland) equipped with a 390/460 filter set and thrombin generation curves were calculated with the Thrombinoscope software (Thrombinoscope BV). Three parameters were derived from the thrombin generation curves: endogenous thrombin potential (ETP; area under the curve), peak height and lag time. Lag time was defined as the time to reach one-sixth of the peak height. Validation of the CAT method in our laboratory showed normalization of non-timedependent parameters to be mandatory to obtain acceptable inter-assay variations (data not shown). Intra-assay variations for normalized parameters are typically below 6%, inter-assay variations below 8% 19. Therefore, each thrombin generation measurement includes normal pooled plasma and both the ETP and peak height values are expressed as the ratio of value patient /value normal pooled plasma. Statistical analysis Data are presented as number of patients (%), mean (standard deviation (SD)) or as median (interquartile range (IQR)). Continuous variables were compared by Student s unpaired t test or Mann-Whitney test; categorical variables were compared by χ 2 or Fisher s exact test where appropriate. Von Willebrand factor, prothrombin fragment 1+2 and D-dimer had a skewed distribution, in tables we show untransformed medians and corresponding interquartile range. Spearman correlation coefficients were calculated to assess evidence of association between vwf levels and the following parameters: age, hs-crp, leukocyte count, systolic blood pressure, years of diabetes mellitus, and body mass index (BMI). Binary logistic regression analysis was performed to assess the additional value of vwf in the prediction of myocardial ischemia on MPS. First adjustment was performed for male gender, anti-anginal medication, previous MI but no revascularization and the absence of statin therapy (previously described as predictors of myocardial ischemia in this population). Secondly, the model was also adjusted for all other cardiac risk factors (systolic blood pressure, hypertension, hypercholesterolemia and smoking). Finally, the model was also adjusted for markers of inflammation CRP and leucocytes and the coagulation markers D-dimer, F1+2 and TAFI 20. Criterion for entry of variables into the logistic regression analysis was set on p 0.2. Statistical analyses were performed using SPSS software (version , Chicago, Illinois, USA). P<0.05 was considered statistically significant. Proefschrift Wiersma.indb :59:06

8 Results In 282 patients out of the 329 participants of the MERIDIAN trial blood samples were available. Blood samples of the remaining 47 patients were incomplete, missing or haemolytic. No differences were found between baseline characteristics of patients with and those without available blood samples. Patients were more often male, over 60 years old and the majority was overweight (table 1). Approximately 50% had a previous Table 1. Patient characteristics All patients, n=282 Patient Male gender 183 (65) Age (years) 65 (9) BMI (kg/m2) 29.3 (4.4) Risk factors Smoking or previous smoking 145 (51) Hypertension 155 (55) Hyperlipidemia 178 (63) Family history of CAD 102 (36) History of CAD 134 (48) Years of DM 6.6 ( ) Medication Aspirin 236 (84) Statin 209 (74) 2 anti-anginal drugs 192 (68) Insulin 106 (38) Laboratory Leucocytes (10E9/L) 7.2 ( ) hs-crp (mg/l) 2.14 ( ) HbA1c (mmol/l) 7.4 ( ) HDL (mmol/l) 1.2 ( ) LDL (mmol/l) 2.53 (0.8) Triglycerides (mmol/l) 1.6 ( ) vwf (%) 134 ( ) F1+2 (pmol/l) 225 ( ) D-dimer (μg/l) 437 ( ) TAFI (%) 98 (87-111) In vitro thrombin generation 1pM TF ETP (%) 161 (60) 1pM TF peak height (%) 282 (140) 1pM TF lag time (min) 6.6 (3.5) 5pM TF ETP (%) 105 (30) 5pM TF peak height (%) 127 (50) 5pM TF lag time (min) 3.0 (1.8) Table 1. Baseline characteristics. Values are presented as number (percentage), as mean (standard deviation) or median (IQR). In vitro thrombin generation: ETP and peak height are normalized values, expressed as the ratio of valuepatient/valuenormal pooled plasma. BMI= body mass index; CAD= coronary artery disease; DM=diabetes mellitus; TF= tissue factor; ETP=endogenous thrombin potential. Chapter Coagulation and myocardial ischemia in diabetics Proefschrift Wiersma.indb :59:06

9 112 Table 2. Association of coagulation/fibrinolysis markers and perfusion defects on MPS no defects (SDS<3 / SRS<3) n=83 any defect SDS 3/SRS 3 n=199 myocardial ischemia (SDS 3 n=144 no myocardial ischemia (SDS<3) n=138 vwf (n=272) 127 ( ) 135 ( ) 141 ( )* 126 (99-168) F1+2 (n=275) 225 ( ) 225 ( ) 235 ( ) 223 ( ) D-dimer (n=281) 387 ( ) 445 ( ) 444 ( ) 436 ( ) TAFI (n=281) 100 (18) 99 (17) 100 (17) 99 (18) In vitro thrombin generation Stimulation with 1pM TF ETP (%) 160 (54) 164 (59) 162 (62) 163 (53) peak height (%) 275 ( (140) 281 (144) 286 (133) lag time (min) 6.8 (3.6) 6.5 (3.2) 6.7 (3.5) 6.4 (3.1) Stimulation with 5pM TF ETP (%) 106 (28) 106 (30) 106 (32) 106 (27) peak height (%) 124 (37) 129 (57) 122 (46) 134 (57) lag time (min) 3.2 (2.0) 2.9 (1.8) 3.0 (1.7) 3.0 (1.8) Table 2. Association of laboratory outcomes with MPS outcome. Values are presented as mean (standard deviation) or median (IQR).* Significant difference in vwf between patients with and without myocardial ischemia, p<0.03. In vitro thrombin generation: ETP and peak height are history of CAD defined as previous MI, PCI or CABG. Of these, 27 patients (10%) had a previous history of MI and no history of any revascularization, 48 (17%) patients had no history of MI but had undergone revascularization for anginal complaints, and 59 (21%) patients had both. The majority of patients already had prescriptions for aspirin, lipid lowering therapy and/or blood pressure lowering medication. The median duration of diabetes mellitus was 6.6 years with a median level of HbA1c of 7.4 mmol/l (IQR ) and 40% of patients needed insulin to control their hyperglycemia. Median levels of Von Willebrand factor, F1+2 and mean levels of TAFI were in the normal range, median levels of D-dimer were slightly above normal (table 1). Furthermore, levels of inflammation markers hs-crp and leukocytes, as well as levels of cholesterol, LDL and HDL were in the normal range (table 1). Thrombin generation parameters determined at 1 pm tissue factor (TF) and 5 pm TF are depicted in table 1. Thrombin generation in plasmas of patients triggered with 5 pm TF was comparable to the overall coagulation observed for healthy volunteers. Analysis with 1 pm TF showed increased increased peak height (282% ± 140%) and ETP (161% ± 60%) compared to healthy volunteers (peak height: 99% ± 38% and ETP: 103% ± 21%) and normal pool plasma (defined as 100% for all parameters) values 21. Furthermore, at 1 pm TF the lag times Proefschrift Wiersma.indb :59:07

10 scarred tissue (SRS 3) n=133 no scarred tissue (SRS<3) n= (92-173) 137 ( ) 239 ( ) 216 ( ) 471 ( ) 426 ( ) 98 (17) 100 (18) 165 (56) 161 (62) 294 (132) 274 (143) 6.1 (2.7) 6.9 (4.1) 105 (26) 106 (33) 133 (58) 123 (46) 2.8 (1.5) 3.1 (2.0) normalized values, expressed as the ratio of valuepatient/valuenormal pooled plasma.. vwf= von Willebrand factor; F1+2=prothrombin fragment 1+; TAFI=thrombin Activatable Fibrinolysis Inhibitor; TF= tissue factor; ETP=endogenous thrombin potential were prolonged by almost 2 min to 6.64 (±3.5) min compared to healthy subjects (4.0 min ± 0.64[ ]). Chapter Coagulation and myocardial ischemia in diabetics Myocardial perfusion scintigraphy In total 176 patients (62%) adequately performed an exercise-test, in 100 patients (36%) vasodilatory stress was applied, and in 6 patients (2%) dobutamine stress test was performed. Semi-quantitative scores are presented in table 2. MPS outcome of in total 199 patients suggested the presence of coronary artery disease: 144 patients had myocardial ischemia. Of these 144 patients, 78 also had scar tissue, indicative of a previous myocardial infarction. Finally, in 55 patients only signs of a previous myocardial infarction.were present Association between MPS results and coagulation and fibrinolysis markers Associations between any perfusion abnormality, myocardial ischemia and scar tissue with laboratory outcomes are depicted in table 2. Median levels of vwf were significantly higher in diabetic patients with myocardial ischemia on MPS compared with diabetics without myocardial ischemia (141% (IQR ) vs.126% (IQR ), p-value 0.03), although median values were within the normal range. This relationship remained Proefschrift Wiersma.indb :59:07

11 Table 3. Multivariate models of the value of vwf for the prediction of myocardial ischemia OR 95%CI p-value Univariate analysis ( ) < Multivariate analysis Model ( ) <0.02 male gender, statin therapy, 2 anti-anginal drugs and MI (no revascularization) Model ( ) <0.02 Model 1 plus age>65, history of hypertension, BMI and hypercholesterolemia Model 3 Model 2 plus hs-crp, leucocytes, D-dimer, F1+2 and TAFI ( ) <0.05 Table 3. Multivariate logistic regression model. OR= odds ratio; CI= confidence interval; hs-crp= high sensitive C-reactive protein. present when using the upper limit of normal of vwf as cut-off value (>150%): 57 (41%) of patients with myocardial ischemia vs. 40 (30%) patients without myocardial ischemia had vwf levels above the normal range of 150%, p<0.05. In relation to the presence of scar tissue, no significant relation was found with levels of vwf. No significant differences were observed for any of the other markers in relation to myocardial ischemia or scarred tissue, nor for the parameters for endogenous thrombin generation (table 2). These non-significant findings were consistent using upper limit of normal value, 75 th and 90 th percentile of the total group as cut-off value of these markers. Von Willebrand factor No correlation was found between vwf and hs-crp, leukocyte count, years of diabetes and body mass index. vwf was modestly correlated with age (Spearman s rho 0.23, P < 0.001). Univariate logistic regression with vwf as a continuous variable for the prediction of myocardial ischemia on MPS resulted in an unadjusted odds ratio (OR) of per 1% increase of vwf ( ), p<0.02. After adjustment for the known clinical predictors for myocardial ischemia in this population, vwf remained an independent predictor of myocardial ischemia (OR ( ), p<0.02) (table 3). Furthermore, after adjustment of all other potential cardiac risk factors and after adjustment of inflammation and markers of coagulation and fibrinolysis, a significant association remained present (OR ( ), p<0.02 and OR ( ), p<0.05 respectively). Proefschrift Wiersma.indb :59:07

12 Discussion The prothrombotic state in blood is considered to be a pivotal player in the pathogenesis of atherosclerosis in diabetic patients. This state is characterized by a combination of an enhanced coagulation activity, chronic platelet activation, and decreased fibrinolysis. Although it is tempting to associate a prothrombotic state with the enhanced risk of coronary artery disease in these subjects, there has been no published evidence of such an association. In our population of diabetic patients with mild anginal complaints, we found evidence of a procoagulant state by increased thrombin generation at low tissue factor levels as indicated by both an increased peak height and ETP. However, a relation between a prothrombotic condition and the presence of myocardial ischemia did not emerge except for a slight increase in levels of vwf in those patients with myocardial ischemia compared with those without myocardial ischemia. No significant relation was found between levels of D-dimer, which were slightly elevated above the normal range, prothrombin fragment 1+2, TAFI or thrombin generation indices and myocardial ischemia. Procoagulant state of diabetes mellitus Based on our findings we can conclude that the studied diabetic patients are in a procoagulant state indicated by an increased thrombin-forming capacity. Previous studies have concluded that hyperglycemia and diabetes mellitus are related to increased levels of trombin-antithrombin (TAT), tissue factor procoagulant activity and enhanced procoagulant factors VII and VIII, which in concert may accelerate coagulation However, to our knowledge no specific studies have addressed overall coagulation tendency as measured by in vitro thrombin generation assay in diabetes. Based on our observations that after stimulation with 1pM tissue factor, parameters of thrombin generation peak height and ETP were increased, we conclude that especially activation of the intrinsic pathway including factors VIII and IX is enhanced. This finding was independent of the presence or absence of myocardial perfusion abnormalities, suggesting that it is related to the presence of diabetes mellitus. The observed prolonged lag times are suggestive of increased tissue factor pathway inhibitor (TFPI) levels. Indeed, elevated TFPI activity has been demonstrated in patients with insulin-dependent diabetes mellitus and at low levels of TF the factor VIIa:Xa pathway is more rapidly inhibited in favour of the factor IX and VIII route 25. Chapter Coagulation and myocardial ischemia in diabetics Proefschrift Wiersma.indb :59:07

13 116 Von Willebrand factor, coronary artery disease and diabetes mellitus As mentioned above, a positive association between vwf and diabetes mellitus and insulin resistance has been established years ago 26. Other associations have been described between vwf and low-grade inflammation, age, genetic factors (ABO bloodgroup), and several hormones 27. In our population, we could only confirm a positive association with age, but a relation with low grade inflammation (hs-crp and leukocyte count) could not be established. Unfortunately, information on ABO blood group, insulin resistance and levels of vasopressin and epinephrin were not obtained in our population. A relationship between vwf and incidence of CAD has been described in studies with different patient populations. Based on these previous studies, it can be concluded that the relation is rather weak in the general population, but becomes stronger in high risk populations such as patients with diabetes mellitus Our results extend these findings to diabetic patients with stable angina pectoris, in whom we found higher levels of vwf in relation to myocardial ischemia. However, the precise role of vwf in the development of myocardial ischemia is unclear. Whether increased levels of vwf in diabetics result in increased thrombus formation due to increased platelet aggregation, or whether they reflect an alteration in endothelial function remains unclear. Based on the lack of association with hs-crp and leucocyte count, it seems unlikely that vwf acts through a mechanism of low grade inflammation 28. Although levels of vwf were significantly higher in patients with myocardial ischemia, median levels remained within normal range; however, the interquartile range exceeded the upper limit of normal. Furthermore, with an OR of only per 1% increase in vwf, the predictive value for the presence of myocardial ischemia is limited. Other coagulation or fibrinolysis markers, coronary artery disease and diabetes mellitus Increased levels of D-dimer, F1+2 as well as TAFI as markers of a prothrombotic state are found in different diabetic populations, and positive associations were observed with D-dimer, F1+2 and coronary artery disease TAFI has been linked to the process of endothelial damage in diabetics 38. However, in our study, which is the first to analyze the relation of these markers with the presence of myocardial ischemia in diabetic patients, no significant relations were present between these markers and perfusion abnormalities on MPS. Causes for this absent relation with myocardial ischemia might be found within the population studied: patients were included with varying glycemic control and cholesterol levels, with and without overt coronary artery Proefschrift Wiersma.indb :59:07

14 disease, suggesting a varying extent of both insulin resistance and the development of atherosclerotic lesions, ranging from endothelial dysfunction to multiple atherosclerotic plaques. The presence and severity of the prothrombotic state might be influenced by these patient characteristics, although the positive association of vwf contradict this possible explanation. Finally, statin therapy is known to decrease levels of D-dimer and F1+2, and the prevalence of statin therapy was rather high in this population 39, 40. Conclusions Based on these findings we can conclude that diabetic patients with mild anginal complaints are in a procoagulant state and possess an increased thrombin-forming capacity, mainly via the pathway including factor VIII and IX. The hypothesis that a prothrombotic state in diabetics is related to the pathogenesis of coronary artery disease, could only be validated by an increase in vwf in the diabetic patients with evidence of myocardial ischemia on MPS. However, the clinical utility of vwf for diagnosis of ischemia in this patient population is limited. Chapter Coagulation and myocardial ischemia in diabetics Proefschrift Wiersma.indb :59:07

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17 (40) Sommeijer DW, MacGillavry MR, Meijers JCM, Van Zanten AP, Reitsma PH, Cate HT. Anti- Inflammatory and Anticoagulant Effects of Pravastatin in Patients With Type 2 Diabetes. Diabetes Care 2004 February 1;27(2): Proefschrift Wiersma.indb :59:07