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Table of Contents
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 73-78

Atherogenic index of plasma and left ventricular ejection fraction in newly diagnosed type 2 diabetes mellitus patients

1 Department of Physiology, Raiganj Government Medical College and Hospital, Raiganj, West Bengal, India
2 Department of Physiology, Santiniketan Medical College, Bolpur, West Bengal, India
3 Department of Physiology, Pandit Raghunath Murmu Medical College and Hospital, Sankhabhanga, Odisha, India
4 Department of Physiology, Fakir Mohan Medical College and Hospital, Odisha, India
5 Department of Biochemistry, Fakir Mohan Medical College and Hospital, Odisha, India
6 Department of Medicine, KPC Medical College, Kolkata, West Bengal, India
7 Department of Cardiology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India

Date of Submission16-Mar-2021
Date of Decision25-May-2021
Date of Acceptance04-Jun-2021
Date of Web Publication03-Nov-2021

Correspondence Address:
Dr. Himel Mondal
Department of Physiology, Santiniketan Medical College, Bolpur - 731 204, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/rcm.rcm_16_21

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Background: Atherogenic index of plasma (AIP), a logarithm of ratio of triglycerides and high-density lipoprotein-cholesterol is associated with the risk of cardiovascular diseases. The cardiovascular complication in Type 2 diabetes is often assessed by the left ventricular ejection fraction (LVEF). Aim: This study aimed to observe and to find any correlation between LVEF and AIP in newly diagnosed Type 2 diabetes mellitus patients. Materials and Methods: In this cross-sectional observational study, we recruited 140 (male 81, female 59) newly diagnosed Type 2 diabetes mellitus patients from a tertiary care hospital. Plasma lipids were measured from venous blood after 12-h fasting. The LVEF was measured by echocardiography. Data were presented as mean, standard deviation, and statistically tested by Chi-square and Pearson correlation coefficient in IBM SPSS Statistics 20. Results: The mean age of the participants was 53.95 ± 11.63 years (male 53.85 ± 11.12 years, female 54.08 ± 12.39 years, unpaired t-test P = 0.91). The mean LVEF was 0.59 ± 0.06 and 0.6 ± 0.05 (unpaired t-test P = 0.17) in males and females, respectively. The AIP was 0.57 ± 0.07 and 0.57 ± 0.07 (unpaired t-test P = 0.97) in males and females, respectively. There was a negative correlation (r = −0.56, P < 0.001) between LVEF and AIP. Conclusion: Newly diagnosed type 2 diabetes mellitus patients showed a high AIP. Hence, serum lipid profile may be tested early in these patients. Patients with a higher AIP may have lower LVEF. Hence, diabetic patients with a high AIP may be screened for LVEF periodically for early detection and management of heart failure.

Keywords: Cholesterol, diabetes mellitus, heart failure, lipoproteins, stroke volume, ventricular function

How to cite this article:
Mondal S, Mondal H, Samantaray R, Das D, Biri SK, Naskar A, Jana S. Atherogenic index of plasma and left ventricular ejection fraction in newly diagnosed type 2 diabetes mellitus patients. Res Cardiovasc Med 2021;10:73-8

How to cite this URL:
Mondal S, Mondal H, Samantaray R, Das D, Biri SK, Naskar A, Jana S. Atherogenic index of plasma and left ventricular ejection fraction in newly diagnosed type 2 diabetes mellitus patients. Res Cardiovasc Med [serial online] 2021 [cited 2023 Feb 7];10:73-8. Available from: https://www.rcvmonline.com/text.asp?2021/10/3/73/329842

  Introduction Top

The worldwide prevalence of diabetes mellitus is rising in an alarming rate. This chronic disease, over time, causes damage to the several system of the body.[1] Cardiovascular complications with a high risk of heart failure are common in diabetes mellitus patients.[2] The heart failure is one of the most common causes of hospitalization; increased mortality, and morbidity in diabetic patients worldwide.[3],[4],[5],[6] Detection of heart failure at an early stage is beneficial for proper management of the patient.[7] Left ventricular ejection fraction (LVEF) indicates the systolic function of the heart and is an important parameter for the diagnosis and prognosis of the heart failure.[8]

The treatment modalities of diabetes mellitus for low- and middle-income countries include control of blood glucose, control of blood pressure, and foot care. However, this basic treatment may be coupled with other cost-saving interventions such as screening for retinopathy, control of blood lipids, and screening of kidney diseases.[1] The detrimental effect of deranged serum lipid profile is an established fact. Atherogenic index of plasma (AIP), a logarithm of ratio of triglycerides (TG) and high-density lipoprotein-cholesterol Close the bracket to make it (HDL-C) is an index for plasma atherogenicity and is associated with higher cardiovascular diseases in Type 2 diabetes mellitus patients.[9],[10] The increased level of TG and cholesterol in blood affects the left ventricular function.[11] Low-density lipoprotein – cholesterol (LDL-C) is negatively correlated with LVEF.[12] In contrast, a higher HDL-C is associated with a lower risk of coronary artery diseases (CAD).[13] Hence, often the LDL-C is called as “bad” cholesterol and HDL-C is called as “good” cholesterol.[14]

The AIP has been found to be strongly correlated with CAD.[15] In diabetic patients, the heart failure may occur both due to the CAD and abnormal metabolism due to poor glycaemic control.[7] In this context, our research question was if there is any correlation between AIP and LVEF in Type 2 diabetes mellitus patients without any acute complication.

With this research question, we aimed to conduct this study to observe the serum lipid profile in newly diagnosed type 2 diabetes mellitus patients and to calculate the risk of atherogenicity in them. Then to observe the LVEF in the same sample and find any correlation between AIP and LVEF. The finding would help us to understand if the lipid profile is to be tested at an early stage when the diabetes mellitus is first diagnosed and if AIP can help to identify lower LVEF among the patients.

  Materials and Methods Top


This study was conducted after getting permission from the Institutional Ethics Committee. All the research participants were briefed about the study aim and protocol. All of them were adult (age >18 years) and provided written consent for voluntary participation in the study. We further confirm that the study was conducted in accordance with the Declaration of Helsinki, updated in 2013.

Minimum sample size calculation

As there is no similar study found with similar patient characteristics, after reviewing available literature,[12] we expected a correlation coefficient of −0.323 between LVEF and LDL-C. With this assumption, and two-sided α = 0.05 and β = 0.1 (power of the study 90%), the minimum sample size of the study was 97.[16] However, we aimed to recruit more participants according to available time and permissible resource.


Patients were first briefed about the aim and protocol of the study. They were fully explained about the benefit and risk for participating in the study. They were then informed that their voluntary participation may be withdrawn without stating any reason at any moment. After the counseling, willing patients signed the informed consent form. They were then instructed about the time and venue of the LVEF and blood test.

Settings and sample

This study was conducted in a government-run tertiary care hospital situated in the eastern part of India. Patients attending general medicine outpatient department for the treatment of type 2 diabetes mellitus were recruited for this study as a convenience sample. The inclusion criteria were as follows: Providing written consent for participation, age ≥18 years, newly diagnosed diabetes mellitus 2. The exclusion criteria were as follows: Any family history of CAD, history or presence of hypertension (blood pressure ≥130/80 mm of Hg),[17] history of smoking or currently smoking, treatment with lipid-lowering drugs, and presence of any acute illness (either related or not related to diabetes). This strict exclusion criteria were set to reduce bias as smoking, hypertension, or family history of CAD are risk factors for CAD in patients and it may contribute to the development of lower LVEF.


Recruited subjects were measured for height on a portable stadiometer to the nearest 1 mm. During the measurement, the participants stand on the stadiometer platform with head on the Frankfurt plane, without any shoes or socks, and with hill approximated. The height was measured after a normal expiration. The weight was measured on the same session by a digital weighing scale with 100 g sensitivity.

Left ventricular ejection fraction measurement

LVEF was measured by echocardiography. No special laboratory preparation was suggested to the participants. A single cardiologist with >5 years' experience in measuring the LVEF measured the chamber volume by transthoracic two-dimensional echocardiography with Modified Simpson's rule. The cardiologist was not involved in this study and was not aware about the lipid status of the patient. The ejection fraction was calculated from the following formula:[18]

Ejection fraction = (End diastolic volume − End systolic volume)/End diastolic volume

The brief procedure of measurement of LVEF by echocardiography can be found in the article by Foley et al.[19] For generating receiver operating curve, we considered ≥55% (0.55) ejection fraction as normal and <55% as risk category.[20] There are various types of classification of LVEF; however, many of the clinicians use the following criteria-normal 50%–70%, borderline 41%–49%, reduced ≤40%.[20],[21]

Blood tests

Participants were instructed to have light meal at night and appear to the institutional central laboratory next day with a status of 12-h fasting. Participants were allowed to take water in these 12-h fasting. They were also instructed to bring their usual breakfast along with them. On the test day, after explaining the process of blood testing, and taking a confirmatory verbal consent, venous blood was collected from a peripheral vein (ante-cubital vein preferred) maintaining proper ascetic precautions. The blood was collected in commercial vaccutainer and transported immediately for testing. The participants were allowed to have breakfast and after 2 h, blood was collected for postprandial blood sugar.

We used the following reference values to categorize participants according to risk.


We considered normal TG <150 mg/dL and ≥150 mg/dL as risk category. Accepted range is as follows – normal <150 mg/dL, mild hypertriglyceridemia 150–499 mg/dL, moderate hypertriglyceridemia 500–886 mg/dL, and severe hypertriglyceridemia >886 mg/dL.[22]

Low-density lipoprotein-cholesterol

We considered low risk LDL-C ≤129 mg/dL and ≥130 mg/dL as risk category. The accepted range is as follows: Optimal <100 mg/dL, above optimal 100–129 mg/dL, borderline high 130–159 mg/dL, high 160–189 mg/dL, and very high >190 mg/dL.[22]

High density lipoprotein–cholesterol

We considered <40 mg/dL as risk category and ≥40 mg/dL as low risk category.[23]

Atherogenic index of plasma

We considered an AIP <0.11 as normal and ≥0.11 as at risk.[24]

Statistical analysis

We used Microsoft Excel® 2010 to store the study data, IBM SPSS Statistics 20 (IBM Corp; Armonk, NY, USA) and GraphPad Prism 6.01 (San Diego, CA, USA) for statistical analysis and visualization of data. For all the statistical tests, we used α =0.05. We expressed the variables in mean, median, standard deviation, and range wherever applicable. The parameters between female and male were compared statistically by unpaired t-test. Pearson correlation coefficient was used to find the correlation among different parameters. Multiple regression analysis was conducted to find age, BMI, and lipid parameters (AIP, TG, HDL-C, and LDL-C) as a predictor variable for LVEF.

  Results Top

A total of 140 participants comprised the sample of the study. Among them, 59 (42.14%) was female. The mean age was 53.95 ± 11.63 years (male 53.85 ± 11.12 years, female 54.08 ± 12.39 years, unpaired t-test P = 0.91). Participants' distributions according to demographics are shown in [Table 1]. The majority of the participants were secondary educated, obese, married, in the age group of 40–50 years, and living in urban area.
Table 1: Research participants' characteristics

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Overall and sex wise measured serum lipid parameters are shown in [Table 2]. There was no gender difference in any parameter.

Serum lipid profile according to risk of developing cardiovascular disease is shown in [Table 3]. According to AIP, all the participants were in risk category. According to LDL-C, 97.14% of the sample was in the risk group.
Table 2: Measured parameters in research participants

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Table 3: Risk of cardiovascular disease according to lipid profile

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Among the sample, 30 (21.43%) showed less than normal LVEF. The LVEF showed no gender difference [P = 0.17, [Table 2]].

There was a statistically significant negative correlation (r = −0.56, P < 0.0001) between AIP and LVEF. TG and LDL-C also showed negative correlation with LVEF. In contrast, HDL-C showed a positive correlation [Table 4].
Table 4: Correlation of left ventricular ejection fraction with serum lipids and atherogenic index of plasma

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Receiver operating characteristic curve for AIP as a tool to detect low LVEF in newly diagnosed type 2 diabetes patients is shown in [Figure 1]. In this analysis, there was 30 (21.43%) low LVEF and 110 (78.57%) normal LVEF. The area under the curve (AUC) was 0.86 (P < 0.001, 95% confidence interval = 0.79–0.93). The AUC and the position of the curve toward the left-hand border and then the top border suggest that AIP may be considered as a good tool to detect low LVEF.
Figure 1: Receiver operating characteristic curve for atherogenic index of plasma as a tool to detect low left ventricular ejection fraction in newly diagnosed Type 2 diabetes patients

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  Discussion Top

We found that, although the risk of developing cardiovascular diseases was different according to TG, HDL-C, and LDL-C level, the AIP was high among all the newly diagnosed type 2 diabetes mellitus patients. This finding suggests that a newly diagnosed diabetes patient may be screened for lipid profile at an early date, if feasible. The World Health Organization suggests that measuring lipid profiles in diabetes mellitus is “cost-saving interventions.”[1]

Our study sample was apparently healthy. We excluded patients with hypertension, smoking, with family history of CAD to reduce bias in the study. In apparently healthy newly diagnosed type 2 diabetes mellitus patients showed a negative correlation between AIP and LVEF. This indicates that a higher AIP may indicate a lower functioning status of the left heart. TG and LDL-C showed a negative correlation, and HDL-C showed a positive correlation with LVEF. However, the correlation coefficient was the highest with AIP.

A study by da Luz et al. found that TG/HDL-C is associated with higher chances of CAD in nondiabetic patients from Turkey.[15] In the current study, we found a negative correlation of TG/HDL-C with the ejection fraction in diabetic patients. Hence, despite the glycaemic status, a high atherogenic index may be treated as a risk factor for cardiovascular complications and these patients may be suggested lipid lowering drugs.

Liu et al. found that a higher TC is associated with higher ejection fraction in patients of heart failure due to CAD.[25] Zhao et al. also reported that a higher TC and HDL-C helps in better recovery of patients from heart failure due to CAD.[26] In both the study, the sample was recruited from heart failure patients. TC is composed of LDL-C and HDL-C. A relatively higher HDL-C in TC is obviously a favourable finding. In our study, we found that HDL-C is positively correlated with LVEF. However, we recruited apparently healthy diabetic patients.

Female and male of this study showed no difference in lipid profile parameters. Majority of the subjects had poorly controlled diabetes mellitus as evident from the FBS and HbA1c levels. In addition, the lipid profile was also deranged from the normal range. The high AIP in the sample indicates a significant risk (indicated by the ratio >3) for heart disease.[22] However, the LVEF was not impaired in the patients. Hence, the presence of risk factors does not indicate presence of abnormality immediately. However, dyslipidemia should be controlled by statins or lifestyle modification, especially in diabetes patients as it increases cardiovascular disease risks.[23] It has been found that in India, the urban population has more atherogenic dyslipidemia.[27] Hence, special care should be taken to detect dyslipidemia in the urban population.

This study has several limitations. Although the study was conducted after calculating minimum sample size, higher sample size could give us more generalizable result. The sample was taken from a tertiary care hospital in Eastern India. Sample from multiple states could further extend the result to all Indian population. However, this study may be taken as the reference study for any further study on similar subject. Although we excluded patients with any acute diseases, hypertension, smoking, and with any family history of CAD, presence of any other undetected bias may be still there.

  Conclusion Top

Newly diagnosed Type 2 diabetes mellitus patients from a tertiary care hospital in Eastern India showed a high atherogenic index. Along with TG and LDL-C, AIP showed a negative correlation with LVEF. Hence, serum lipid profile may be tested early in newly diagnosed diabetic patients to start appropriate therapy. Patients with a high AIP may be screened for LVEF periodically, if feasible, for early detection and initiation of management of heart failure.

Ethical clearance

This study was approved by the Institutional Ethics Committee (REF/06/IEC, Dated 24/07/2019).

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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