BLOOD-PRESSURE VARIATION AND CARDIOVASCULAR CHANGES IN

DIABETES MELLITUS*

By AMAL~CH3KllAVARTI, m.b. House Physician, Carrrvichael Hospital jor Tropica

Diseases, School of Tropical Medicine, Calcutta

The role of diabetes mellitus in initiating 91 accelerating hypertension and arteriosclerosis has been engaging the attention of the profession for a long time, and numerous clinical studies have been made on the subject. In this papei* observations on the blood-pressure variation and cardiovascular changes in fifty diabetic subjects are reported. Out of 50 patients, 29 were admitted in the

Carmichael Hospital for Tropical Diseases, an(' the

_ remaining 21 were attending the diabetic

clinic attached to the hospital. Forty-three were above the age of 40 and only 7 were females. The racial distribution of the patients was as follows :?

Hindu .. .. .. .. 20 Mohammedan .. ?.. ..14 Jew .. .. .. 9

European or Anglo-Indian .. 6

Ass&mese .. ., 1

The majority of the patients had had' the disease for five years or more. A few had con1"

plications: one came in with a hypertensive cerebral attack, one had a spreading ulcer ovei the -left ankle, one had suffered from epidemic dropsy in the past, and three had associated infections, viz malaria, amcebiasis and a posl~ tive Wassermann.

(a) Blood pressure.?The blood-pressure read- ings of these 50 diabetic patients were compared with those of (i) 50 non-diabetic patients treated in the hospital for various tropical diseases- Very acute cases were left out and only those conforming in age and weight as far as practic- able to the diabetic series, were chosen, and (w those of normal and healthy Indians given by Chopra et al. (1942). From table I it is apparent that (i) the

average systolic and diastolic pressures young diabetic subjects show little variation from those of the non-diabetic: or -normal

July, 1945] DIABETES MELLITUS : CHAKRAVARTI 349

Table I

Showing average systolic and diastolic pressure in different age groups of both diabetic and non-

diabetic patients compared to those of normal individuals

:VSTCLIC PRESSURES

Diabetic patients

94.0

104.0

122.0 96.5

130.1 140.5 136.6 153.1 149.6 142.0

126.8

Non-diabetic patients

110.0 115.4 120.5 113.2 109.3 115.3 124.5 121.5 125.1 109.0 117.3

116.4

Normal men

109.2 111.5 120.0 113.6 118.6 120.4 122.8 126.2 126.4 128.6 130.2

118.7

Diastolic pressures

Diabetic patients

64.0

52.0

84.0 65.0 85.0 86.4 82.4 91.6 81.3 83.0

71.5

Non-diabetic patients

66.0 67.6 70.2 71.8 65.6 57.1 79.4 76.5 78.5 61.0 79.0

70.2

series; after the age of 40, however, they are

definitely higher than the normal or control

figures, and (ii) the mean systolic pressure of diabetic patients for all ages is higher than formal. Moreover, taking systolic and diastolic Pressures above 150 and 90 respectively as in-

dicating hypertension, and below 100 and 70 as indicating hypotension, it is apparent that diabetics show a higher incidence of hyperten- sion (38 per cent) against (12 per cent) in non-

diabetics, and a lower incidence of hypotension (22 per cent) compared to 35 per cent of the non-diabetic group as will be seen from table II.

Table II

Showing percentage incidence of systolic pres- sures, hypertension and hypotension in diabetic

and non-diabetic patients Systolic blood pressure in mm. of Hg.

l^iabetic series -Non-diabetic series

Below 100

12% 16%

100- 140

56% '80%

140- 150

20% 2%

150- 200

20% 2%

Above 200

2% 0%

'

Hyper- tension '

' Hypo-

tension '

(inclusive of diastolic pressure values)

38% 12%

22% 35%

To ascertain whether the blood pressure showed any variation with clinical improvement afld fall in the blood-sugar level, the in-patients ^'ere followed up. It was found that with lruprovement in the diabetic condition in young

patients, who are mostly hypotensive, the blood pressure gradually rises and comes up to normal, whereas in elderly patients with normal tension or hypertension, it remains unaltered or shows a tendency to rise.

Hypertension and diabetes.?Attempts have been made to show hypertension as a cause of diabetes. O'Hare observed that 11 out of 25

hypertensive subjects had low sugar tolerance and concluded that hypertensives have a pre- diabetic inclination. Several theories have been

propounded, stating that hypertension by causing (i) an altered metabolism, (ii) hyper- adrenia or (Hi) arteriosclerosis in the pancreas may give rise to diabetes, but these have failed to stand the test of time.

Diabetes and hypertension.?A larger number of workers have viewed diabetes as a possible serological factor in the causation of hyper- tension. Their opinions are varied and may be grouped as follows :?

(i) Hypertension is not related to diabetes, and in cases of diabetes with hypertension some other co-existent factors are responsible (Rosenbloom, 1922; Adams, 1929; Wilder, 1939; and others). Schwartz (1936) holds that the frequent association of diabetes with

hypertension is due to a higher incidence of

diabetes in females who are very susceptible to hypertension, and in whom endocrine disturb-

ances are very common, and that persistent hyperglycaemia as a cause can be ruled out.

Barach (1942) observed that hypertension is

related to body build. (ii) Hypertension in diabetes is fairly

(Koopman, 1924; Major, 1929; Kramer, 1928;

and others). The two diseases have been

regarded as only stages ofthe same disorder

(Kramer, 1928). O'Hare (1920) holds similar

views. "?

350 THE INDIAN MEDICAL GAZETTE [July, 1945

(in) Hypertension in diabetes is common, but

young patients are mostly hypotensives (Joslin, 1923). The figures obtained for the incidence of hypertension in diabetes mellitus by differ- ent workers are given in the following table :?

Per cent

Major .. ?? .. ... 42.5 Kramer .. .. .. .. 39.0 Schwartz .. .. .. 30.4 Joslin .. .. .. .. 28.0 Katzklin (above 160 mm.) .. .. 25.0 Adams .. .. .. .. 21.9 In our series .. ... .. 38.0

(iv) The kidney has been incriminated as a

cause by some, but nephritis is uncommon in

diabetes, the true picture being one of nephrosis. Recently Allen (1941) has shown that the kidney lesion in diabetes is an intramural glomerulo- sclerosis with appreciable efferent arteriosclerosis, more common in patients with a widespread glomerular lesion, the constriction of the efferent arterioles probably playing an import- ant role. Diabetes and hypotension.?Hypotension has

been mentioned by few and the cause is not clear; perhaps weakness of the heart muscle, due to

slow fatty and glycogenic change and loss of

body weight are responsible. (b) Arteriosclerosis.?In our series of cases,

a detailed study of the arteriosclerotic condition was not possible, but its extent was gauged from palpation of large superficial arteries. It was observed that arteriosclerosis in one or

more of the arteries was present in 29 out of the 50 diabetics (58 per cent), 27 out of these 29 being elderly subjects. In 3, the arteries could not be palpated on account of excessive obesity, and in 18 arteriosclerosis was absent. Of the patients with superficial arteriosclerosis,

the majority had albumen in the urine, some complained of defective vision, and 7 had

slight cardiac symptoms. These had probably some degree of internal sclerosis.

(c) Heart.?Only 7 patients presented cardiac symptoms. Of these, 3 complained of a feeling of breathlessness on exertion, 2

, of occasional palpitation, 1 of palpitation and giddiness and gave history of anginal attack. Examination of the heart, however, revealed no serious defect except that in 5 patients the heart was slightly enlarged outward, and in the patient with anginal history and hypertension the enlarge- ment was considerable. Friedman (1935) found cardiac hypertrophy

in 47 per cent of cases and in only 18 per cent of these was the enlargement more than slight. Quoting Cabbot's figures of cardiac hypertrophy (39 per cent) in diabetic arterio- sclerotic patients, he concluded that cardiac hypertrophy in diabetes cannot be considered of any special significance. In his (Friedman's) series, 19 per cent had cardiac symptoms and only 9 out of 129 patients had anginal attacks. The same view is held by others. In Hepburn and Graham (1928) series, 56 patients out of

123 had an abnormal electrocardiogram at the

beginning of treatment and at the end of treat- ment 15 returned to normal. Unless severe

arteriosclerosis is present, the condition would thus seem to be reversible.

Summary 1. Blood-pressure variation and cardio-

vascular changes in 50 diabetic patients have been studied.

2. It was observed that hypertension and arteriosclerosis are Of common occurrence in

elderly diabetics; young patients usually mani- fest low pressures and with early and successful treatment they are likely to regain tl;eir normal tension.

3. Cardiac abnormalities are infrequent *n

diabetes.

Acknowledgments The writer expresses his gratefulness to Dr. J. ??

Bose, Physician in charge, Diabetes Department, f?r

his valuable suggestions and encouragement, and t? Drs. S. C. Panja, S. Bose, and A. Hossain (colleagues), for their help in carrying out the study.

REFERENCES

Adams, S. F. (1929) .. Amer. J. Med. Sci., 177, 195. Allen, A. C. (1941) .. Arch. Path., 32, 33.

Barach, J. H. (1942) .. West Virginia Med. J., 283

Chopra, R. N., Chopra, Indian Med. Gaz., 77, 21. G. S., and Chopra, I. C. (1942).

Friedman, G. (1935) .. Arch. Intern. Med., 65, 371* Hepburn, J., and Amer. J. Med. Sci., 176, 782. Graham, D. (1928).

Joslin, E. P. (1923) .. Treatment of Diabetes Mellitus. Lea and Febiger' Philadelphia.

Koopman, J. (1924) .. Endocrinology. 8, 340. Kramer, D. W. (1928). Amer. J. Med. Sci., 176, 23. Major, S. G. (1929) .. Arch. Intern. Med., 44, 797- O'Hare, J. P. (1920) .. Amer. J. Med. Sci., 159, 883- Rosenbloom, J. (1922). J. Lab. and Clin. Med-, ''

392. Schwartz, J. (1936) .. New York State J. Med-,

36, 1934. Wilder, R. M. (1939) .. Internat. Clin., 2, 13.