| Background: At present,there is a lack of research on the factors affecting the occurrence of postural blood pressure changes(PBPC)in patients with type 2 diabetes mellitus(T2DM),and the influence of PBPC on the risk of cardiovascular and cerebrovascular diseases(CCD)in patients with diabetes autonomic neuropathy(DAN)remains to be studied.Objective: To study the influencing factors of PBPC in patients with T2 DM and to evaluate the predictive value of PBPC in the occurrence of major adverse cardiovascular and cerebrovascular events(MACCE)in patients with DAN.Methods: Consecutive patients with T2 DM who were treated in the endocrine clinic and inpatient department of the Second Affiliated Hospital of Nanchang University from June 2015 to August 2015 were included.According to the value of PBPC,patients were divided into three groups: orthostatic hypotension(OH),orthostatic hypertension(OHT)and normal orthostatic blood pressure changes(NOR).The differences and influencing factors between groups were studied by pairwise comparison.LASSO regression was used to screen variables and multivariate binary Logistic regression analysis was used to study the influencing factors.The patients with DAN were selected for follow-up study,and the relationship between PBPC and MACCE risk was evaluated using restricted cubic spline(RCS).The model was established by multivariate Cox regression analysis,and the best prediction model was shown by Nomogram chart.Results: We collected a total of 291 patients with T2 DM,of which 55 were OH(19%),62 were OHT(21%),and 174 were NOR(60%).Compared with NOR group,OH group had poorer renal function(OH vs NOR:BUN 6.5 vs 5.51,P=0.021;Scr 79.7 vs 65.5, P=0.031;Alb 62.6 vs 30.7,P=0.001),lower left ventricular ejection fraction(LVEF)(62 vs 64,P=0.004)and higher proportion and higher proportion of autonomic neuropathy(AN)(SSR:78.2 vs 54,P=0.002);LVEF was a protective factor for OH(OR:0.92,95%CI:0.863-0.981,P=0.011)and AN was a risk factor(OR:3.152,95%CI:1.277-7.776,P=0.013).Compared with NOR group,OHT group has a higher proportion of AN(OHT vs NOR:SSR 75.8 vs 54,P=0.004),and AN was a risk factor for OHT(OR:2.345,95%CI:1.193-4.606,P=0.013).Compared with OHT group,OH group had poorer renal function(OH vs OHT:BUN 6.5 vs 5.65,P=0.057;Scr 79.3 vs 64.3,P=0.031;Alb 62.2 vs 33.6,P=0.011),lower LVEF(65 vs 62,P=0.001)and higher serum homocysteine(Hcy)concentration(13.2 vs 10.7,P=0.019);when OHT was defined as the target event,LVEF was a risk factor(OR:1.089,95%CI:1.007-1.178,P=0.034)and Hcy was a protective factor(OR:0.911,95%CI:0.836-0.993,P=0.033).186 DAN patients were followed up for 5 years,with an average follow-up time of 48 months.67 patients(36%)had MACCE endpoint events as we defined.The 5-year MACCE incidence was the highest in the OHT group(58.3%),followed by the OH group(38.6%)and the lowest in the NOR group(23.4%).The change of postural systolic blood pressure(p SBP)showed a U-shaped curve with the risk of major adverse cerebrovascular events(MABE)(P for non-linear=0.001),a J-shaped curve with the risk of major adverse cardiovascular events(MACE)(P for overall<0.0001),and a U-shaped curve with the risk of MACCE(P for non-linear<0.0001).There was no correlation between postural diastolic blood pressure(p DBP)and the risk of MACCE.After adjusted for the effects of age,Hcy and glycosylated hemoglobin(Hb Alc),the incidence of 5-year MACCE was the highest in DAN patients whose p SBP increased more than 20 mm Hg(HR 4.47,95%CI [2.36-8.47],P<0.001,Power=0.98),followed by decreased more than 20 mm Hg(HR 2.22,95%CI [1.11-4.41],P=0.02,Power=0.46).The risk of OHT group was higher than that of NOR group(HR 2.74,95%CI [1.55-4.83],P<0.001,Power=0.93),but there was no difference between OH group and NOR group(HR 1.49,95%CI [0.79-2.84],P=0.22,Power=0.38).The model including p SBP has the best predictive ability(C-index:0.728;Brier Score:0.108;IDI [95%CI]:0.102 [0.017,0.176],P<0.01;NRI [95%CI]:0.314[0.068,0.466],P<0.01).Conclusion: The prevalence rate of OHT in patients with T2 DM was slightly higher than that of OH.The renal function of OH group significantly worse than that of OHT group and NOR people.the occurrence of OH was related to the deterioration of renal function.LVEF was a risk factor for OHT and a protective factor for OH,and Hcy was a risk factor for OH and a protective factor for OHT.There was a U-shaped curve relationship between p SBP and 5-year MACCE risk,and it had good predictive value. |
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