Dapagliflozin and Cardiovascular Outcomes in Type 2 Diabetes

Cardiovascular outcomes of SGLT-2 inhibitors' subtypes in type 2 diabetes; an updated systematic review and meta-analysis of randomized controlled trials

Introduction

The effects of Sodium-glucose cotransporter-2 (SGLT-2) inhibitors on cardiac outcomes, cardiovascular mortality (CVM), and all-cause mortality (ACM) in type 2 diabetes mellitus (T2DM) patients have been reported heterogeneously in different studies.

Methods

PubMed, Scopus, Embase, Cochrane Library, and Scholar databases were searched with relevant MeSH terms from January 1, 2010, to November 14, 2023. The study used Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary outcomes in all trials included the risk of ACM, CVM, hospitalization for heart failure (HHF), myocardial infarction (MI), and cerebrovascular accidents (CVA) in T2DM patients who were treated with one of the SGLT-2 inhibitors. Heterogeneity between studies was evaluated using Cochran's Q and I2 tests. The Egger's test was used to check for publication bias.

Results

Eighteen studies, including 70,830 participants, were included. A pooled estimate showed that SGLT-2 inhibitor treatment was significantly associated with reduced ACM (OR: 0.82, 95% CI: 0.75-0.90, p-value: 0.001, I2: 35.1%), CVM (OR: 0.88, 95% CI: 0.80-0.96, p-value: 0.001, I2: 0%), MI (OR: 0.88, 95% CI: 0.79-0.98, p-value: 0.001, I2: 0%), and HHF (OR: 0.67, 95% CI: 0.58-0.77, p-value: 0.001). SGL-2 inhibitor treatment had no significant relationship with CVA (stroke) (OR: 0.95, 95% CI: 0.8-1.10, p-value: 0.896). Subgroup analysis showed that the effect of SGLT-2 inhibitor treatment on outcomes varied based on the type of SGLT-2 inhibitor.

Conclusion

SGLT-2 inhibitor treatment significantly reduced CVM, ACM, MI, and HHF. Empagliflozin, Canagliflozin, and Dapagliflozin significantly reduced ACM. Canagliflozin was significantly associated with a reduction in CVM. All SGLT-2 inhibitor treatments were associated with a reduction in HHF.

Racial and regional differences in efficacy of sodium-glucose cotransporter 2 inhibitors on cardiorenal outcomes: A systematic review and meta-analysis

BACKGROUND

To investigate the efficacy of SGLT2 inhibitors on multiple cardiorenal outcomes across different racial/ethnic groups and regions.

METHODS

We searched PubMed, Cochrane Library, Web of Science, and Embase databases in April 2024 for a systematic review and meta-analysis. Owing to inconsistencies in the reporting of the racial/ethnic and regional demographics, participants were grouped into three racial groups (Asian, Black, and White) and four regional (Asia, Central/South America, Europe, North America) groups. We compared the efficacy of SGLT2 inhibitors among these racial/ethnic and regional groups by calculating the ratio of hazard ratios (RHR). We evaluated the composite of cardiovascular death or hospitalization for heart failure (HHF), cardiovascular death, HHF, all-cause death, major adverse cardiac events, and cardiorenal composite outcomes.

RESULTS

We included 14 randomized placebo-controlled trials with 94,445 participants. Across the three racial/ethnic groups, SGLT2 inhibitors showed comparable efficacy. Compared with White patients, the efficacy of SGLT2 inhibitors on HHF was more pronounced in Black patients (RHR, 0.64; 95 % confidence interval [CI], 0.44-0.94), and a numerically lower risk was associated with Asian patients (RHR, 0.62; 95 % CI, 0.38-1.01). A consistent reduction in cardiovascular events with SGLT2 inhibitors was observed across all regions, while the efficacy of SGLT2 inhibitors on HHF was more pronounced in Asia than in other regions (RHR, 0.52; 95 % CI, 0.33-0.81).

CONCLUSIONS

SGLT2 inhibitors showed generally consistent efficacy across various racial/ethnic and regional groups, with some differences noted in specific populations. Ensuring adequate representation of diverse populations in clinical trials would be key to addressing healthcare disparities.

Antidiabetic combination therapy and cardiovascular outcomes: An evidence-based approach

Type 2 diabetes mellitus is associated with a 2-4 times increased risk of cardiovascular (CV) disease. Glucagon-like polypeptide-1 receptor agonists (GLP1RA) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) are two important classes of drugs with CV benefits independent of their antihyperglycemic efficacy. The CV outcome trials of both GLP1RA and SGLT2i have demonstrated CV superiority/neutrality concerning major adverse CV events (MACE). While GLP1RAs have exhibited a significant reduction in ischemic stroke and myocardial infarction (MI), SGLT2i have demonstrated a uniformly significant reduction in hospitalization for heart failure (HF) as a class effect. The unique clinical benefits and the distinct but complementary mechanisms of action make the combination of these drugs a mechanistically sound one. Recent meta-analyses suggest an independent and additive benefit of combination therapy of GLP1RA/SGLT2i vs monotherapy. Zhu et al, in a recent issue of the World Journal of Diabetes, demonstrates a numerically lower hazard ratio (HR) for CV outcomes with combination therapy vs monotherapy with either agent, with a reduction in MACE compared to GLP1RA alone [HR = 0.51, 95% confidence interval (CI): 0.16-1.65], or SGLT2i alone (HR = 0.48, 95%CI: 0.15-1.54). The CV death rate was also lower with combination therapy compared to GLP1RA alone (HR = 0.58, 95%CI: 0.08-3.39), or SGLT2i alone (HR = 0.55, 95%CI: 0.07-3.25). Fatal and non-fatal MI and fatal and non-fatal stroke were reduced with combination therapy compared to GLP1RA alone (HR = 0.45, 95%CI: 0.10-2.18 and HR = 0.86, 95%CI: 0.12-6.23, respectively), or SGLT2i alone (HR = 0.44, 95%CI: 0.09-2.10 and HR = 0.74, 95%CI: 0.10-5.47, respectively). Hospitalization for HF was prevented with combination therapy compared to GLP1RA alone (HR = 0.26, 95%CI: 0.03-1.88), or SGLT2i alone (HR = 0.33, 95%CI: 0.04-2.53). They also demonstrated that GLP1RA or SGLT2i monotherapy may not provide significant improvement in CV death and recurrent MI in patients with prior MI or HF, proposing a role for combination therapy in this subgroup. Appropriate patient selection is vital to optimize CV risk reduction as well as the cost-effectiveness of this combination therapy.

Exploration of metformin-based drug combination for mitigating diabetes-associated atherosclerotic diseases

Diabetes mellitus is a substantial global health threat due to its high prevalence and its serious complications. The hyperglycemic state causes damage to vascular endothelial cells and disturbance of lipid metabolism, thus contributing to the development of vascular disorders, especially atherosclerotic diseases. Aggressive glycemic control combined with vascular intervention is critical to the prevention and treatment of diabetes-associated atherosclerosis. It is suggested that metformin should be combined with hypoglycemic agents with proven vascular benefits for treating type 2 diabetes (T2DM) complicated with atherosclerotic diseases. Clinical studies indicates that the preferred combination is metformin with either glucagon-like peptide-1 receptor agonist or sodium/glucose cotransporter-2 inhibitor, which could offer additional vascular benefits and reduce the risk of atherosclerotic complications. Likewise, combination therapy with metformin and hypolipidemic agents has also shown additive effects on glucose control and lipid-lowering in patients with both diabetes and dyslipidemia, whereas extensive clinical trials using atherosclerotic-associated outcomes are required to support the vascular benefits. Moreover, co-administration of metformin with systemic antioxidant or anti-inflammatory therapy may also provide additional vascular benefits as indicated by several animal studies. For instance, a recent study found that additional supplementation of cholecalciferol and taurine enhanced metformin efficacy in controlling diabetes while reducing the risk of associated atherosclerotic complications. However, these potential benefits remain need validation by the evidence from clinical studies. Despite the limitations, such as heterogeneity across different patient populations, and deficiency in long-term outcomes, such efforts can contribute to finding optimal drug combinations to improve the management of T2DM and reduce its atherosclerotic complications.

Fixed dose combination of dapagliflozin, glimepiride and extended-release metformin tablets in patients with type 2 diabetes poorly controlled by metformin and glimepiride: A phase III, open label, randomized clinical study in India

AIM

To evaluate the efficacy and safety of a triple fixed-dose combination (FDC) therapy of dapagliflozin + glimepiride + metformin hydrochloride extended-release (DAPA + GLIM + MET ER) tablets in Indian patients with type 2 diabetes mellitus (T2DM) inadequately controlled by combination of GLIM + MET.

MATERIALS AND METHODS

A phase III, randomized, open-label, active-controlled study was conducted for a maximum 30 weeks (primary treatment [16 weeks]; uptitration [12 weeks] and follow-up [2 weeks]). Eligible patients were randomized in a 1:1 ratio to receive either the FDC of DAPA + GLIM + MET ER or the FDC of GLIM + MET prolonged-release (PR) once-daily. The primary efficacy endpoint was a change in glycated haemoglobin (HbA1c) from baseline to week 16.

RESULTS

The mean reduction in HbA1c from baseline to week 16 was significantly greater with the FDC of DAPA + GLIM + MET ER compared to the FDC of GLIM + MET PR (-1.98% ± 1.01% vs. -1.64% ± 0.86%, p = 0.0047). The mean reduction in HbA1c from baseline to week 12 was significantly greater with the FDC of DAPA + GLIM + MET ER versus dual FDC (p < 0.0001). The proportion of patients achieving HbA1c <7.0% was significantly greater with the FDC of DAPA + GLIM + MET ER versus dual FDC at week 12 (19.1% vs. 6.5%; p = 0.0002) and week 16 (52.6% vs. 36.7%; p = 0.0015). A significant decrease in HbA1c, fasting and post-prandial blood glucose from baseline to weeks 12, 16, and 28 was observed in both arms. The incidence of TEAEs was similar across both arms.

CONCLUSION

This study demonstrated that the FDC of DAPA + GLIM + MET ER tablets once daily was significantly better than dual FDC in achieving glycaemic control in patients with poorly controlled T2DM. Both treatments were well-tolerated.

TRIAL REGISTRATION

CTRI/2022/03/041424, registered on 28 March 2022.

Beyond glycated haemoglobin: Modelling contemporary management of type 2 diabetes with the updated Cardiff model

AIMS

Recommendations on the use of newer type 2 diabetes (T2D) treatments (e.g., SGLT2 inhibitors and GLP-1 receptor agonists [RA]) in contemporary clinical guidelines necessitate a change in how T2D models approach therapy selection and escalation. Dynamic, person-centric clinical decision-making considers factors beyond a patient's HbA1c and glycaemic targets, including cardiovascular (CV) risk, comorbidities and bodyweight. This study aimed to update the existing Cardiff T2D health economic model to reflect modern T2D management and to remain fit-for-purpose in supporting decision-making.

MATERIALS AND METHODS

The Cardiff T2D model's therapy selection/escalation module was updated from a conventional, glucose-centric to a holistic approach. Risk factor progression equations were updated based on UKPDS90; the cardio-kidney-metabolic benefits of SGLT2i and GLP-1 RA were captured via novel risk equations derived from relevant outcomes trial data. The significance of the updates was illustrated by comparing predicted outcomes and costs for a newly diagnosed T2D population between conventional and holistic approaches to disease management, where the latter represents recent treatment guidelines.

RESULTS

A holistic approach to therapy selection/escalation enables early introduction of SGLT2i and GLP-1 RA in modelled pathways in a manner aligned to guidelines and primarily due to elevated CV risk. Compared with a conventional approach, only considering HbA1c, patients experience fewer clinical events and gain additional health benefits.

CONCLUSIONS

Predictions based on a glucose-centric approach to therapy are likely to deviate from real-world observations. A holistic approach is more able to capture the nuances of contemporary clinical practice. T2D modelling must evolve to remain robust and relevant.

Cardiovascular, kidney and safety outcomes with canagliflozin in older adults: A combined analysis from the CANVAS Program and CREDENCE trial

AIM

SGLT2 inhibitors may be underused in older adults with type 2 diabetes due to concerns about safety and tolerability. This pooled analysis of the CANVAS Program and CREDENCE trial examined the efficacy and safety of canagliflozin according to age.

METHODS

Pooled individual participant data from the CANVAS Program (n = 10 142) and CREDENCE trial (n = 4401) were analysed by baseline age (<65 years, 65 to <75 years, and ≥75 years). A range of adjudicated clinical outcomes were assessed, including major adverse cardiovascular events and CKD progression, as well as safety outcomes. Cox proportional hazards models and Fine and Gray competing risk analysis were used.

RESULTS

Among the 14 543 participants, 7927 (54.5%) were <65 years, 5281 (36.3%) were 65 to <75 years and 1335 (9.2%) were ≥75 years. Older participants had higher rates of atherosclerotic cardiovascular disease and heart failure, longer diabetes duration and lower mean eGFR. Reductions in cardiovascular and kidney outcomes with canagliflozin were consistent across age categories (all p trend >0.10), although there was some evidence that effects on cardiovascular death and all-cause death were attenuated with older age (p trend = 0.02 and 0.03, respectively). Although the incidence of adverse events increased with age, effects of canagliflozin on safety outcomes including acute kidney injury, volume depletion, urinary tract infections and hypoglycaemia, were not modified by age (all p trend >0.10).

CONCLUSIONS

In patients with varying degrees of kidney function, canagliflozin reduced cardiovascular and kidney outcomes, regardless of age, with no additional safety concerns identified in older patients.

Identification of plasma proteomic markers underlying polygenic risk of type 2 diabetes and related comorbidities

Genomics can provide insight into the etiology of type 2 diabetes and its comorbidities, but assigning functionality to non-coding variants remains challenging. Polygenic scores, which aggregate variant effects, can uncover mechanisms when paired with molecular data. Here, we test polygenic scores for type 2 diabetes and cardiometabolic comorbidities for associations with 2,922 circulating proteins in the UK Biobank. The genome-wide type 2 diabetes polygenic score associates with 617 proteins, of which 75% also associate with another cardiometabolic score. Partitioned type 2 diabetes scores, which capture distinct disease biology, associate with 342 proteins (20% unique). In this work, we identify key pathways (e.g., complement cascade), potential therapeutic targets (e.g., FAM3D in type 2 diabetes), and biomarkers of diabetic comorbidities (e.g., EFEMP1 and IGFBP2) through causal inference, pathway enrichment, and Cox regression of clinical trial outcomes. Our results are available via an interactive portal ( https://public.cgr.astrazeneca.com/t2d-pgs/v1/ ).

A critical review on SGLT2 inhibitors for diabetes mellitus, renal health, and cardiovascular conditions

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) were originally formulated to reduce blood glucose levels in individuals with diabetes. Recent clinical trials indicate that this compound can be repurposed for other critical conditions. A literature search was performed on PubMed, Scopus, Embase, ProQuest, and Google Scholar, utilizing key terms such as SGLT2i, diabetes, and oxidative stress. SGLT2i has significant beneficial effects not only in cardiovascular disease but also in renal dysfunction. SGLT2i therapy can mitigate critical cardiovascular complications like heart attacks, strokes, mortality rates, and hospitalization duration, as well as delay the necessity for dialysis irrespective of diabetic condition. Evidence supports potential advantages of SGLT2 inhibitors for individuals with renal problems and heart failure, regardless of diabetes status. In addition to diabetic mellitus, this analysis explores the latest updates on SGLT2i and the therapeutic advantages it offers in many renal and cardiovascular diseases (CVDs).

New users of sodium-glucose cotransporter 2 inhibitors are at low risk of incident pancreatic cancer: A nationwide population-based cohort study

AIM

We aimed to investigate whether sodium-glucose cotransporter-2 inhibitors (SGLT2is) are associated with a decreased risk of gastrointestinal (GI) cancers in patients with type 2 diabetes (T2D) compared to other glucose lowering medications (oGLMs).

METHODS

This active-comparator, new-user cohort study used the nationwide National Health Insurance Service database of the Republic of Korea from September 2014 to June 2020. From 79,423 new users of SGLT2is and 294,707 new users of oGLMs, we used a propensity score to match 59,954 from each of these two treatment groups. We calculated hazard ratios (HRs) and 95 % confidence intervals (CIs) for the incidence of GI cancers, encompassing stomach, colorectal, liver, and pancreatic cancers.

RESULTS

During the observation period, there were 814 and 916 GI cancers, and 794 and 1,140 deaths in the SGLT2is and oGLMs treatment groups, respectively. The use of SGLT2is was associated with a statistically significant reduction in the incidence of GI cancers, with an adjusted HR of 0.90 (95 % CI: 0.82 to 0.99). However, only the incidence of pancreatic cancer was significantly lower in SGLT2is users compared to non-users, with an adjusted HR of 0.72 (95 % CI: 0.55 - 0.95). In the entire cohort, the multivariable-adjusted HR for pancreatic cancer was 0.70 (95 % CI: 0.56 to 0.88).

CONCLUSION

For T2D patients, SGLT2i use was associated with a diminished pancreatic cancer risk compared to oGLMs. Future studies should ascertain the potential protective effect of SGLT2is against pancreatic cancer.

Effectiveness of Empagliflozin vs Dapagliflozin for Kidney Outcomes in Type 2 Diabetes

Importance

No large randomized clinical trial has directly compared empagliflozin with dapagliflozin, leaving their comparative effectiveness regarding kidney outcomes unknown.

Objective

To compare kidney outcomes between initiation of empagliflozin vs dapagliflozin in adults with type 2 diabetes who were receiving antihyperglycemic treatment.

Design, Setting, and Participants

This target trial emulation used nationwide, population-based routinely collected Danish health care data to compare initiation of empagliflozin vs dapagliflozin in adults with type 2 diabetes who received antihyperglycemic treatment between June 1, 2014, and October 31, 2020. Data were analyzed from October 2023 to August 2024. Persons were followed up until an outcome, emigration, death, 6 years, or December 31, 2021, whichever occurred first.

Exposure

Initiation of empagliflozin vs dapagliflozin.

Main Outcomes and Measures

Outcomes included acute kidney injury, incident chronic kidney disease (stages G3 to G5 or stage A2 or A3), and progression of chronic kidney disease (≥40% decrease in estimated glomerular filtration rate from baseline). Risks of kidney outcomes were estimated in intention-to-treat and per-protocol analyses using an Aalen-Johansen estimator that adjusted for 56 potential confounders and considered death as a competing event.

Results

A total of 32 819 individuals who initiated treatment with empagliflozin and 17 464 with dapagliflozin were included (median [IQR] age, 63 [54-71] years; 18 872 female individuals [37.5%]; median [IQR] estimated glomerular filtration rate, 88 [73-104] mL/min/1.73 m2). After weighting, all measured covariates were well balanced between the groups. In intention-to-treat analyses, people who initiated treatment with empagliflozin and dapagliflozin exhibited comparable 6-year risks of acute kidney injury (18.2% vs 18.5%; risk ratio, 0.98; 95% CI, 0.91-1.06), chronic kidney disease stages G3 to G5 (11.8% vs 12.1%; risk ratio, 0.97; 95% CI, 0.89-1.05), chronic kidney disease stage A2 or A3 (14.8% vs 14.3%; risk ratio, 1.04; 95% CI, 0.93-1.15), and progression of chronic kidney disease (5.3% vs 5.7%; risk ratio, 0.94; 95% CI, 0.56-1.58). The primary analyses were supported by corresponding per-protocol analyses.

Conclusions and Relevance

The results of this cohort study suggest that people with type 2 diabetes who initiated treatment with empagliflozin and dapagliflozin had comparable long-term kidney outcomes.

Assessing the benefit-risk profile of newer glucose-lowering drugs: A systematic review and network meta-analysis of randomized outcome trials

AIM

To comprehensively evaluate the benefits and risks of glucagon-like peptide-1 receptor agonists (GLP-1RA), dipeptidyl peptidase 4 inhibitors (DPP4i), and sodium-glucose cotransporter 2 inhibitors (SGLT2i).

MATERIALS AND METHODS

A systematic search of PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) from inception to November 2023 to identify randomized cardiovascular and kidney outcome trials that enrolled adults with type 2 diabetes, heart failure, or chronic kidney disease and compared DPP4i, GLP-1RAs, or SGLT2i to placebo. Twenty-one outcomes (e.g., major adverse cardiovascular events [MACE], stroke, and hospitalization for heart failure [HHF]) were assessed. Data were pooled using population-averaged odds ratios (ORs) with 95% CIs.

RESULTS

Twenty-six trials enrolling 198 177 participants were included. GLP-1RAs were most effective in lowering the risks of MACE (OR, 0.85, [95% CI, 0.79 to 0.92]) and stroke (0.84 [0.77, 0.91]), but increased the risk of thyroid cancer (1.58 [1.36, 2.50]). SGLT2i showed the greatest benefits in reducing the risk of HHF (0.68 [0.64, 0.73]) and improving composite renal outcomes (0.67 [0.58, 0.77]), but increased the risk of genital infections (3.11 [2.15, 4.50]). DPP4i were associated with a lower risk of certain psychiatric disorders, Parkinson's disease (0.54 [0.32, 0.92]), and amputation (0.70 [0.86, 0.93]), but an increased risk of neuropathy (1.10 [1.02, 1.18]) and pancreatitis (1.63 [1.40, 1.91]). The weighted origami plot suggested that GLP-1RAs were more suitable for reducing macrovascular and microvascular outcomes, while DPP4i might be better for neurodegenerative diseases and cancer concerns.

CONCLUSIONS

Given the distinct benefit-risk profiles, the selection of glucose-lowering drugs should be individualized based on patient characteristics and risk factors.

Use of SGLT2i Versus DPP-4i as an Add-on Therapy and the Risk of PAD-Related Surgical Events (Amputation, Stent Placement, or Vascular Surgery): A Cohort Study in Veterans With Diabetes

OBJECTIVE

To compare the risk of composite peripheral artery disease (PAD) surgical outcome, including peripheral revascularization and amputation procedures, between new users of sodium-glucose cotransporter 2 inhibitors (SGLT2is) and dipeptidyl peptidase 4 inhibitors (DPP-4is).

RESEARCH DESIGN AND METHODS

This retrospective cohort study of U.S. veterans age ≥18 years with diabetes who received care from the Veterans Health Administration was performed from 1 October 2000 to 31 December 2021. Data were linked to Medicare, Medicaid, and the National Death Index. New use of SGLT2i or DPP-4i medications as an add-on to metformin, sulfonylurea, or insulin treatment alone or in combination was evaluated for an association with PAD surgical procedure for peripheral revascularization and amputation. A Cox proportional hazards model for time-to-PAD event analysis compared the risk of a PAD event between SGLT2is and DPP-4is in a propensity score-weighted cohort with a competing risk of death and allowance for events to occur up to 90 days or 360 days after stopping SGLT2is.

RESULTS

The weighted cohort included 76,072 SGLT2i vs. 75,833 DPP-4i use episodes. The median age was 69 years, HbA1c was 8.4% (interquartile range [IQR] 7.5-9.4%), and the median diabetes duration was 10.1 (IQR 6.6-14.6) years. There were 874 and 780 PAD events among SGLT2i and DPP-4i users, respectively, for an event rate of 11.2 (95% CI 10.5-11.9) and 10.0 (9.4-10.6) per 1,000 person-years (adjusted hazard ratio [aHR] 1.18 [95% CI 1.08-1.29]). When PAD events were allowed for 360 days after SGLT2i use ended, the aHR was 1.16 (95% CI 1.06-1.26).

CONCLUSIONS

SGLT2i as an add-on diabetes therapy was associated with an increased cause-specific hazard of PAD surgeries compared with DPP-4i.

SGLT2 inhibitors: how do they affect the cardiac cells

The first sodium-glucose cotransporter-2 inhibitor (SGLT2I), canagliflozin, was approved by the U.S. Food and Drug Administration for the treatment of type 2 diabetes in 2013. Since then, other members of this drug class (such as dapagliflozin, empagliflozin, and ertugliflozin) have become widely used. Unlike classical antidiabetic agents, these drugs do not interfere with insulin secretion or action, but instead promote renal glucose excretion. Since their approval, many preclinical and clinical studies have been conducted to investigate the diverse effects of SGLT2Is. While originally introduced as antidiabetic agents, the SGLT2Is are now recognized as pillars in the treatment of heart failure and chronic kidney disease, in patients with or without diabetes. The beneficial cardiac effects of this class have been attributed to several mechanisms. Among these, SGLT2Is inhibit fibrosis, hypertrophy, apoptosis, inflammation, and oxidative stress. They regulate mitochondrial function and ion transport, and stimulate autophagy through several underlying mechanisms. This review details the potential effects of SGLT2Is on cardiac cells.

Generalizability and treatment with sodium-glucose co-trasporter-2 inhibitors (SGLT2i) among patients with type 2 diabetes: an assessment using an Italian primary care database

AIMS

This study aimed to assess the proportions of type 2 diabetes (T2D) subjects meeting cardiovascular outcome trials (CVOTs) criteria for sodium-glucose cotransporter-2 inhibitors (SGLT-2i) and estimate SGLT2i utilization, along with associated demographic and clinical characteristics, in a primary care setting.

METHODS

T2D patients in Italy were selected between January 1, 2021, and December 31, 2022, from The Health Improvement Network (THIN®) database. Representativeness was determined by dividing patients meeting key inclusion criteria for four CVOTs (CANVAS, DECLARE-TIMI 58, EMPA-REG OUTCOME, VERTIS-CV) to the total T2D population. Demographic and clinical characteristics of eligible T2D subjects and SGLT2i users were compared, and logistic regression models assessed the likelihood of receiving SGLT2i.

RESULTS

Out of 17,102 T2D patients, 8,828 met eligibility criteria for at least one CVOT. DECLARE-TIMI 58 exhibited the highest representativeness (51.1%), compared to CANVAS (21.1%), EMPA-REG OUTCOME (5.5%), and VERTIS-CV (4.9%) trials. Eligible CVOTs patients were older (74.6 vs. 68.3 years), with a longer disease duration (10.2 vs. 9.7 years), and higher established cardiovascular disease (CVD) prevalence (36.0 vs. 27.3%) compared to SGLT2i users. Less than 10% of eligible T2D patients received SGLT2i. Males (OR: 1.43; 95%CI: 1.24-1.66) were more likely to be prescribed SGLT2i than other antidiabetic drugs, while the elderly (80 + vs. 40-64 years, OR: 0.17; 95% CI: 0.14-0.22) were less likely. Eligible T2D patients with CVD reported an increased likelihood of receiving SGLT2is compared to other antidiabetics.

CONCLUSION

This study highlights significant variability in the proportion of T2D subjects meeting SGLT2i CVOT inclusion criteria, with DECLARE-TIMI-58 being the most represented. Low SGLT2i prescription rates in the Italian primary care setting, along with substantial demographic and clinical differences between SGLT-2i users and T2D eligible patients, emphasize the need for targeted interventions to optimize the use of these medications in primary care settings.

SGLT2 inhibition improves endothelium-independent vasodilatory function in type 2 diabetes: A double-blind, randomized, placebo-controlled crossover trial

AIMS

The objective of this study was to examine the effects of empagliflozin on endothelium-dependent and endothelium-independent vasodilatation and systemic hemodynamic parameters and to assess the role of the nitric oxide (NO) system in patients with type 2 diabetes (T2DM).

MATERIALS AND METHODS

In this double-blind, placebo-controlled cross over trial, patients with T2DM were treated with either empagliflozin 10 mg or matching placebo for 4 weeks. Following a 2-week washout, participants were crossed over to 4 weeks of the opposite treatment. Forearm blood flow (FBF) was measured after each treatment period using venous occlusion plethysmography. Acetylcholine and sodium nitroprusside (SNP) were infused into the brachial artery to assess endothelium-dependent and endothelium-independent vasodilatory function, respectively. Total peripheral resistance, 24-h blood pressure (BP) and biochemical markers of NO activity were measured as well.

RESULTS

Sixteen participants completed the trial. The mean age was 68 ± 8 years, and 69% were male. The SNP response increased by 21% (geometric mean ratio 1.21, 95% CI: 1.09; 1.33) during treatment with empagliflozin compared to placebo (p ≤ 0.001), but not during acetylcholine infusion (p = 0.290). Empagliflozin decreased 24-h systolic BP by 5 mmHg (95% CI: -9; -1 mmHg) (p = 0.015), diastolic BP by 2 mmHg (95% CI: -5; 0 mmHg) (p = 0.029) and systemic vascular resistance by 48 dyn×s/m5 (95% CI: -94; -1 dyn×s/m5) (p = 0.044). Furthermore, empagliflozin reduced plasma levels of nitrite and urinary levels of NOx.

CONCLUSIONS

Empagliflozin improves endothelium-independent vasodilation, reduces vascular resistance and lowers 24-h BP in patients with T2DM, whereas no change in endothelial-dependent vasodilation was observed.

TRIAL REGISTRATION

EU Clinical Trials Register number: 2019-004303-12 (https://www.clinicaltrialsregister.eu/ctr-search/trial/2019-004303-12/DK).

Effects of sodium-glucose cotransporter-2 inhibitors in myocardial infarction patients: A systematic review and meta-analysis

AIMS

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are known to improve cardiovascular outcomes in individuals with heart failure (HF), type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD). However, their efficacy following myocardial infarction (MI) remains unclear.

MATERIALS AND METHODS

A systematic search was conducted using PubMed, Embase, Cochrane Library, Web of Science and ClinicalTrials.gov. Primary outcomes included hospitalization for heart failure (HHF), cardiovascular (CV) death, a composite of HHF or CV death, all-cause death, major cardiovascular events (MACE), recurrent MI, severe arrhythmia, renal injury and stroke. Secondary outcomes targeted improvements in left ventricular ejection fraction (LVEF) and left ventricular end-diastolic volume (LVEDV).

RESULTS

Thirteen studies comprising 22 370 patients were included. Meta-analysis revealed that SGLT2 inhibitors reduced HHF (RR 0.69, 95% CI 0.61 to 0.78, p < 0.001), combined HHF or CV death (RR 0.87, 95% CI 0.77 to 0.99, p = 0.028), all-cause mortality (RR 0.82, 95% CI 0.73 to 0.93, p = 0.002), MACE (RR 0.68, 95% CI 0.53 to 0.88, p = 0.004), recurrent MI (RR 0.81, 95% CI 0.69 to 0.94, p = 0.007), severe arrhythmia (RR 0.54, 95% CI 0.34 to 0.85, p = 0.009) and renal injury (RR 0.68, 95% CI 0.53 to 0.87, p = 0.002). Improvement in LVEF (MD 3.96%, 95% CI 2.52 to 5.40; p < 0.001) and LVEDV (MD -5.52 mL, 95% CI -10.21 to -0.83; p = 0.021) was notably greater in the SGLT2 inhibitors group.

CONCLUSIONS

In post-MI patients, we first found that SGLT2 inhibitors significantly lowered the risk of HHF, combined CV death or HHF, all-cause death, MACE, recurrent MI, severe arrhythmias and renal injury. Additionally, SGLT2 inhibitors improved LVEF and LVEDV.

Real-Life Individual Comparison of Sodium-Glucose Cotransporter-2 Inhibitors in Patients with Heart Failure and Diabetes Mellitus

BACKGROUND

Sodium-glucose cotransporter-2 inhibitors (SGLT2is) are breakthrough agents for the treatment of type 2 diabetes mellitus (T2DM) and heart failure (HF). However, among patients with HF and T2DM, some uncertainty remains about individual comparisons, including dosing.

OBJECTIVES

We aimed to make a real-life individual comparison of SGLT2is among patients with HF and T2DM.

METHODS

This was a subgroup analysis of the Turkish Ministry of Health's National Electronic Database for adult patients with HF (TRends-HF). All-cause mortality (ACM) data up to 7 years were evaluated. Patients with HF and T2DM who were prescribed an SGLT2i were identified, and individual doses of empagliflozin 25 mg, empagliflozin 10 mg, and dapagliflozin 10 mg were compared. For individual comparisons, propensity score-matching analysis was generated as 1:1:1, and disease-modifying therapies (DMTs) for HF were considered.

RESULTS

In the triple-matched cohort, 1-, 5-, and 7-year survival rates were 95%, 81%, and 76% versus 94%, 78%, and 72% versus 94%, 80%, and 75% for empagliflozin 25 mg, empagliflozin 10 mg, and dapagliflozin 10 mg, respectively. Among patients who were on triple DMT for HF, 1-, 5-, and 7-year survival rates were 95%, 78%, and 70% for empagliflozin 25 mg, 95%, 74%, and 66% for empagliflozin 10 mg, and 94%, 77%, and 69% for dapagliflozin, respectively. Annual emergency department visits were slightly lower with empagliflozin 10 mg and dapagliflozin 10 mg than with empagliflozin 25 mg. A greater proportion of patients on dapagliflozin 10 mg did not experience hospitalization during the 7-year follow-up compared with both doses of empagliflozin, albeit with a small effect size.

CONCLUSION

Among patients with HF and T2DM, SGLT2is are instrumental, and empagliflozin 10 mg remains significantly inferior to dapagliflozin 10 mg and empagliflozin 25 mg in terms of 5- and 7-year ACM.

Comparative Effectiveness of Individual Sodium-Glucose Cotransporter 2 Inhibitors

Importance

Evidence on cardiovascular benefits and safety of sodium-glucose cotransporter 2 (SGLT-2) inhibitors is mainly from placebo-controlled trials. Therefore, the comparative effectiveness and safety of individual SGLT-2 inhibitors remain unknown.

Objective

To compare the use of canagliflozin or dapagliflozin with empagliflozin for a composite outcome (myocardial infarction [MI] or stroke), heart failure hospitalization, MI, stroke, all-cause death, and safety outcomes, including diabetic ketoacidosis (DKA), lower-limb amputation, bone fracture, severe urinary tract infection (UTI), and genital infection and whether effects differed by dosage or cardiovascular disease (CVD) history.

Design, Setting, and Participants

This comparative effectiveness study using target trial emulation included adults with type 2 diabetes (T2D) using 3 US claims databases using data from August 2014 through June 2020. The study was conducted from August 2023 to July 2024, with a follow-up period of up to 8 years, and the analysis was completed in July 2024.

Exposures

First dispensing of canagliflozin, dapagliflozin, or empagliflozin without any use of SGLT-2 inhibitors during the prior 365 days.

Main outcomes and measures

Database-specific models were weighted using propensity score matching-weights to adjust for 129 confounders. Hazard ratios and 95% CIs for outcomes were estimated using weighted Cox proportional hazards models. HRs were pooled across databases using a fixed-effect meta-analysis.

Results

: Across the databases, 232 890 patients receiving canagliflozin, 129 881 patients receiving dapagliflozin, and 295 043 patients receiving empagliflozin were identified. Compared with empagliflozin initiators, those receiving canagliflozin or dapagliflozin were less likely to have diabetes-related conditions or a history of CVD at baseline. For MI/stroke risk, both canagliflozin (HR, 0.98; 95% CI, 0.91-1.05) and dapagliflozin (HR, 0.95; 95% CI, 0.89-1.03) were comparable to empagliflozin. For heart failure hospitalization, dapagliflozin initiators had a higher risk (HR, 1.19; 95% CI, 1.02-1.39), particularly at the low dose of 5 mg (HR, 1.30; 95% CI, 1.12-1.50). These findings were consistent across subgroups of CVD history. For safety events, compared with empagliflozin, canagliflozin initiators had a lower risk of genital infections (HR, 0.94; 95% CI, 0.91-0.97) but a higher risk of severe UTIs (HR, 1.13; 95% CI, 1.03-1.24), and dapagliflozin initiators had lower risks of genital infections (HR, 0.92; 95% CI, 0.89-0.95) and DKA (HR, 0.78; 95% CI, 0.68-0.90).

Conclusions and Relevance

This study found that individual SGLT-2 inhibitors demonstrated comparable cardiovascular effectiveness at clinically effective doses, though low-dose dapagliflozin showed a reduced benefit for heart failure hospitalization compared with empagliflozin.

Efficacy and Safety of SGLT-2 Inhibitors in Acute Myocardial Infarction: A Systematic Review and Meta-Analysis

Since there is no specific recommendation of sodium-glucose cotransporter-2 (SGLT-2) inhibitors in acute myocardial infarction (MI), this systematic review and meta-analysis was performed to address this lack of evidence. Scopus, Embase, PubMed, Web of Sciences, and Cochrane Library were searched from inception until May 30, 2024. We used both random and fixed-effects models for data analyses. Odds ratio (OR) and standard means difference (SMD) were performed for binary and continuous variables, respectively. Nine studies including five randomized clinical trials (RCTs) and four observational studies including 15,595 individuals with acute MI were entered. Overall, SGLT-2 inhibitors are significantly associated with a reduction of hospitalization for heart failure (OR, 0.78; 95% CI, 0.63 to 0.97; P =  .02; I2 = 0%) and all-cause mortality (OR, 0.55; 95% CI, 0.38 to 0.81; P =  .002; I2 = 0%) based on the RCTs and observational studies, respectively. SGLT-2 inhibitors also significantly improved the left ventricular ejection fraction (SMD, 0.36; 95% CI, 0.02 to 0.70; P =  .04; I2 = 62%) among RCTs. Further evaluation of these drugs also revealed an acceptable safety profile without any major adverse events. In conclusion, although SGLT-2 inhibitors may have some clinical benefits among acute MI individuals, further RCTs are still needed to provide robust evidence regarding the use of SGLT-2 inhibitors in this setting.

The impact of metformin on kidney disease progression and mortality in diabetic patients using SGLT2 inhibitors: a real-world cohort study

BACKGROUND

Selecting the optimal first-line therapy for type 2 diabetes is essential for achieving glycemic control and providing cardio-renal protection, though the combined benefits of metformin with SGLT2 inhibitors, remain uncertain.

METHODS

This retrospective cohort study analyzed data from Clalit Health Services (2016-2021), to compare outcome in adults with type 2 diabetes treated with SGLT2 inhibitors alone versus in combination with metformin. Propensity score matching was applied to balance baseline characteristics between groups. Primary outcomes were a composite kidney outcome (40% decline in eGFR, or progression to ESRD), and all-cause mortality. Safety outcomes included hospitalizations, acute kidney injury and metabolic acidosis.

RESULTS

The study included 45,545 patients, with 6774 patients in each group following propensity score matching. The median follow-up time was 1166 days. Combination therapy with metformin and SGLT2 inhibitors was associated with significantly reduced risk of all-cause mortality (aHR 0.74, 95% CI 0.64-0.84), and composite kidney outcomes (aHR 0.65 95% CI 0.48-0.87) even after accounting for mortality as a competing risk (aHR 0.67; 95% CI 0.5-0.9). Furthermore, combination therapy was associated with reduced risks of hospitalization (aHR 0.93 95% CI 0.87-0.99), severe acute kidney injury events (aHR 0.72 95% CI 0.54-0.96) and metabolic acidosis events (aHR 0.58 95% CI 0.4-0.83), compared with SGLT2 inhibitors alone.

CONCLUSIONS

Patients receiving combination therapy with metformin and SGLT2 inhibitors showed significantly reduced risks of kidney disease progression and mortality compared to those treated with SGLT2 inhibitors alone. These findings support the use of metformin with SGLT2 inhibitors as a first-line treatment strategy for type 2 diabetes irrespective of glycemic control or cardio-renal risk factors.

2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease."

METHODS

A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease."

METHODS

A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Mitochondrial ferritin inhibition aggravates pacing-induced ventricular arrhythmias after myocardial infarction by promoting cardiomyocyte ferroptosis

BACKGROUND

Post-myocardial infarction ventricular arrhythmias are a leading cause of sudden cardiac death (SCD) following acute myocardial infarction worldwide. Emerging evidence suggests that ferroptosis, an iron-dependent form of cell death, plays a significant role in myocardial infarction damage. While mitochondrial ferritin (FtMt) is known to encapsulate harmful ferrous ions within mitochondria, its role in the development of post-myocardial infarction ventricular arrhythmias (post-MI VAs) is not well understood.

OBJECTIVE

This study aimed to clarify the role and mechanisms by which FtMt-mediated ferroptosis influences susceptibility to post-MI VAs.

METHODS

Mice were subjected to permanent ligation of the left anterior descending artery (LAD) to induce myocardial infarction (MI), followed by intracardiac electrophysiological studies to evaluate their vulnerability to post-MI VAs. Patch-clamp recordings and confocal Ca2+ imaging provided data on neonatal rat ventricular myocytes (NRVMs). We utilized DCFH-DA staining, transmission electron microscopy, and Seahorse analysis to examine the mitochondrial bioenergetics and oxidative phosphorylation in NRVMs.

RESULTS

Ferroptosis was activated in mice post-MI. Inhibiting ferroptosis enhanced cardiac function and reduced the incidence of post-MI VAs. Hypoxia led to electrophysiological dysregulation in NRVMs, which was exacerbated by FtMt inhibition. Specifically, FtMt inhibition under hypoxic conditions further impaired mitochondrial bioenergetics and oxidative phosphorylation, promoting ferroptosis in NRVMs.

CONCLUSION

FtMt plays a crucial protective function in MI by limiting infarct size, decreasing the frequency of ventricular arrhythmias, and inhibiting ferroptosis both in vivo and in vitro. These results suggest that FtMt may be a viable therapeutic target for treating MI.

Lipotoxicity as a therapeutic target in the type 2 diabetic heart

Cardiac lipotoxicity, characterized by excessive lipid accumulation in the cardiac tissue, is a critical contributor to the pathogenesis of diabetic heart. Recent research has highlighted the key mechanisms underlying lipotoxicity, including mitochondrial dysfunction, endoplasmic reticulum stress, inflammation, and cell apoptosis, which ultimately impair the cardiac function. Various therapeutic interventions have been developed to target these pathways, mitigate lipotoxicity, and improve cardiovascular outcomes in diabetic patients. Given the global escalation in the prevalence of diabetes and the urgent demand for effective therapeutic approaches, this review focuses on how targeting cardiac lipotoxicity may be a promising avenue for treating diabetes.

SGLT2i and Cardiovascular Events in Patients With Concomitant Atrial Fibrillation and Diabetes: A TriNetX Cohort Study

AIMS

Sodium-glucose co-transporter 2 inhibitors (SGLT2i) enhance cardiovascular outcomes in individuals with type 2 diabetes mellitus (T2DM). Whether such effects also occur in T2DM patients with atrial fibrillation (AF) remains unknown. We aimed to investigate SGLT2i use on cardiovascular outcomes in patients with concomitant AF and T2DM.

METHODS

Patients with both AF and T2DM were identified from TriNetX, an international electronic medical record. Participants were divided into 2 groups according to their use of SGLT2i, at a 1:1 distribution through propensity score matching (PSM). The hazard ratio (HR) for clinical outcomes was determined using multivariate Cox hazards regression model.

RESULTS

We studied 339 792 patients with AF and T2DM, with 32 945 (9.70%) SGLT2i users. Following PSM, 17 011 patients aged 68.4 ± 7.9 years were included in each group. After a 3-year follow-up, patients treated with SGLT2i showed significantly reduced risks of stroke (adjusted HR: 0.830, P < .001), dementia (adjusted HR: 0.662, P < .001), long-standing persistent AF (adjusted HR: 0.917, P < .001), heart failure (adjusted HR: 0.833, P < .001), and all-cause mortality (adjusted HR: 0.532, P < .001).

CONCLUSION

The use of SGLT2i was associated with reduced risks of stroke, dementia, long-standing persistent AF, heart failure, and mortality in patients with both AF and T2DM. SGLT2i may be considered as a potential first-line therapy for this population.

Glycemic, Cardiorenal, and Weight Implications on Noninsulin Pharmacotherapy for the Management of Type 2 Diabetes

CONTEXT

The incidence of diabetes is growing at an alarming rate globally. Most of these projected individuals will develop type 2 diabetes (T2DM), raising their risk of cardiovascular disease and chronic kidney disease. This mini-review examines current noninsulin and noninjectable pharmacotherapy focused in T2DM, highlighting the effect on glycemic control and importance of cardiovascular and renal outcomes.

EVIDENCE ACQUISITION

We included population level data and searched the PubMed database for recent systematic reviews, meta-analyses, and original research articles.

EVIDENCE SYNTHESIS

There is a pharmacologic menu of noninsulin-based medications for the treatment of diabetes. Through varying mechanisms, all agents ultimately lead to glycemic improvement to varying degrees. Only a select number of agents are shown to improve important clinical cardiovascular and renal outcomes. Of note, sodium-glucose cotransporter-2 inhibitors have improved cardiovascular mortality and time to dialysis in people with diabetes. Likewise, incretin-based therapies have improved important cardiovascular and renal composite outcomes in those with diabetes and cardiovascular disease. As a result, agents with proven cardiovascular and renal benefits should be prioritized based on patient risk.

CONCLUSION

Despite the availability of new medications and technology, published clinical guidelines, and treatment algorithms, most people with diabetes remain above glycemic targets. We encourage clinicians to follow the guidelines and use appropriate medications to lower cardiovascular risk, delay progression of chronic kidney disease, reach glycemic targets, and manage weight.

Reminders EMbedded IN PCI Reports to Optimize Discharge Diabetes Mellitus Care (REMIND-DM): Rationale, Design, and Baseline Characteristics

BACKGROUND

Despite the robust clinical evidence base supporting their role for high-risk patients with type 2 diabetes (T2DM) and concomitant cardiovascular disease, prescription of sodium-glucose co-transporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1RA) remains suboptimal. Clinical encounters occurring in the period post angiography may present a key opportunity to improve implementation in high-risk patients with T2DM.

METHODS

Reminders EMbedded IN PCI Reports to Optimize Discharge Diabetes Mellitus Care (REMIND-DM) is a pragmatic, prospective, cluster randomized quality improvement study in patients with type 2 diabetes undergoing angiography and was run as a quality improvement initiative. Following a 6 month "baseline period", REMIND-DM randomized 23 participating percutaneous coronary intervention (PCI) sites (caring for 7,045 patients over the study period) within the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) quality improvement collaborative to either usual care or a quality improvement intervention consisting of a templated PCI report "reminder" of medication eligibility linked to a decision support tool. Sites were followed for a 6 month "evaluation period." The primary outcome is the new prescription of SGLT2 inhibitor or GLP-1RA among eligible patients at discharge after PCI. To examine the effectiveness of the intervention, primary analyses will be conducted using a difference-in-difference design examining changes in new cardioprotective therapy prescription from baseline to the evaluation periods in both arms.

CONCLUSIONS

The REMIND-DM implementation trial has enrolled a large, high-risk population of patients with T2DM and will determine the effectiveness of a low touch QI intervention within BMC2 implemented in the post-PCI period to improve timely prescription of risk lowering therapies in high-risk patients with T2DM.

Sodium-Glucose Cotransporter-2 Inhibitors and Arrhythmias: A Meta-Analysis of 38 Randomized Controlled Trials

BACKGROUND

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have shown promising results in reducing hospitalizations from heart failure (HF) and cardiovascular mortality. However, their effect on arrhythmia and sudden cardiac death (SCD) is not well established.

OBJECTIVES

The authors sought to evaluate the association between SGLT2i and the risk of arrhythmias and SCD in patients with type 2 diabetes mellitus, HF, or chronic kidney disease.

METHODS

We performed a systematic literature search on PubMed, EMBASE, and Scopus for relevant randomized controlled trials from inception until February 10, 2023. ORs and 95% CIs were pooled using a random effect model.

RESULTS

A total of 38 randomized controlled trials with 88,704 patients (48,435 in the SGLT2i group and 40,269 in the control group) were included in the study. The mean age of patients among SGLT2i and control groups was 56.8 and 56.7 years, respectively. The mean follow-up duration was 1.6 years. Pooled analysis of primary and secondary outcomes showed that SGLT2i significantly reduced the risk of incident atrial arrhythmia (OR: 0.85 [95% CI: 0.75-0.98], P = 0.02), SCD (OR: 0.72 [95% CI: 0.55-0.94], P = 0.02) compared with placebo. However, the risk of ventricular arrhythmia (OR: 1.03 [95% CI: 0.84-1.26], P = 0.77) and cardiac arrest (OR: 0.94 [95% CI: 0.72-1.23] P = 0.67) was comparable between both groups of patients.

CONCLUSIONS

SGLT2i therapy was associated with an overall lower risk of atrial arrythmia and SCD in patients with type 2 diabetes mellitus and/or HF or chronic kidney disease. However, SGLT2i therapy was not associated with a lower risk of ventricular arrhythmia.

Anti-inflammatory Therapies for Ischemic Heart Disease

PURPOSE OF REVIEW

The inclusion of immunomodulatory strategies as supportive therapies in ischemic heart disease (IHD) has garnered significant support over recent years. Several such approaches appear to be unified through their ultimate target, the NLRP3 inflammasome. This review presents a brief update on immunomodulatory strategies in the continuum of conditions constituting ischemic heart disease and emphasising on the seemingly unifying mechanism of NLRP3 activation as well as modulation across these conditions.

RECENT FINDINGS

The NLRP3 inflammasome is a multiprotein complex assembled upon inflammatory stimulation, causing the release of pro-inflammatory cytokines and initiating pyroptosis. The NLRP3 pathway is relevant in inflammatory signalling of cardiac immune cells as well as non-immune cells in the myocardium, including cardiomyocytes, fibroblasts and endothelial cells. In addition to a focus on clinical outcome and efficacy trials of targeting NLRP3-related pathways, the potential connection between immunomodulation in cardiology and the NLRP3 pathway is currently being explored in preclinical trials. Colchicine, cytokine-based approaches and SGLT2 inhibitors have emerged as promising agents. However, the conditions comprising IHD including atherosclerosis, coronary artery disease (CAD), myocardial infarction (MI) and ischemic cardiomyopathy/heart failure (iCMP/HF) are not equally amenable to immunomodulation with the respective drugs. Atherosclerosis, coronary artery disease and ischemic cardiomyopathy are affected by chronic inflammation, but the immunomodulatory approach to acute inflammation in the post-MI setting remains a pharmacological challenge, as detrimental and regenerative effects of myocardial inflammation are initiated in unison. The NLRP3 inflammasome lies at the center of cell mediated inflammation in IHD. Recent trial evidence has highlighted anti-inflammatory effects of colchicine, interleukin-based therapy as well as SGLT2i in IHD and that the respective drugs modulate the NLRP3 inflammasome.

Proteomic and metabolomic profiling reveals the underlying molecular mechanisms in modified alternate-day fasting-mediated protection against Diabetic kidney disease

BACKGROUND

Diabetic kidney disease (DKD) is a leading cause of chronic kidney disease, and while lifestyle interventions like intermittent fasting have shown promise in treating diabetes, the impact of modified alternate-day fasting (MADF) on DKD is not well understood. This study aimed to explore MADF's effects on DKD in db/db mice, a model for the condition, and to investigate its underlying mechanisms.

METHODS

We implemented an MADF regimen in db/db mice on a high-fat diet, measuring blood glucose, body weight, and renal function at various times. After the intervention, we analyzed the proteome and metabolome of renal tissues.

RESULTS

MADF was found to reduce hyperglycemia and slow the pathological progression of DKD in the mice. Proteomic analysis identified 165 proteins that increased and 196 that decreased in the kidneys of db/db mice compared to controls. MADF intervention led to a decrease in 26 of the increased proteins and an increase in 18 of the decreased ones. Notably, many of these proteins, including cathepsin S (CTSS), were related to lysosomes, suggesting a role in renal protection. Metabolomic profiling revealed changes in metabolites associated with inflammation, such as prostaglandin A1, which was downregulated in db/db mice and upregulated with MADF. Western blotting, immunohistochemistry, and immunofluorescence staining confirmed the expression changes of CTSS observed in the proteomic data. Additionally, CTSS expression was found to increase in renal cells exposed to high glucose and palmitic acid.

CONCLUSION

MADF appears to mitigate the progression of DKD, with proteomic evidence pointing to lysosome-related proteins like CTSS as potential mediators of its renal protective effects. These findings indicate that MADF and the inhibition of CTSS could be considered as novel therapeutic strategies for DKD treatment.

Assessing the risk of acute kidney injury associated with a four-drug regimen for heart failure: a ten-year real-world pharmacovigilance analysis based on FAERS events

BACKGROUND

The four-drug regimen for heart failure with reduced ejection fraction (HFrEF) significantly reduces the risks of hospitalization and mortality. To identify key adverse drug events (ADEs) warranting attention with this regimen, we conducted a real-world pharmacovigilance analysis based on the FDA Adverse Event Reporting System (FAERS) events.

RESEARCH DESIGN AND METHODS

We collected ADE reports of the four-drug regimen from FAERS that matched this regimen over a 10-year period. Disproportionality analysis and subgroup analysis were performed using four algorithms. Time-to-onset (TTO) analysis was used to assess the temporal risk patterns of ADE occurrence. Lastly, logistic regression was applied to investigate the relationship-value between patient characteristics and ADEs.

RESULTS

A total of 1,237 cases with 6,580 ADE reports were collected. Disproportionality analysis identified the most frequent ADEs as hypotension, acute kidney injury (AKI), and hyperkalemia. TTO analysis revealed a median TTO of 39 days for all important medical events, and the median TTO for AKI was 28 days, both fitting an early failure curve.

CONCLUSION

In the comprehensive management of HFrEF with the four-drug regimen, in addition to routine monitoring of ADEs such as hypotension and hyperalemia, early-onset AKI should be a particular focus.

"Weekend Warrior" Physical Activity and Adipose Tissue Deposition

BACKGROUND

Attaining guideline-recommended levels of physical activity is associated with substantially lower risk of cardiometabolic diseases.

OBJECTIVES

Although physical activity commonly follows a weekend warrior pattern, in which most moderate-to-vigorous physical activity is concentrated in 1 to 2 days rather than spread more evenly across the week (regular), the effects of activity pattern on imaging-based biomarkers of cardiometabolic health are unknown.

METHODS

We analyzed 17,146 UK Biobank participants who wore accelerometers for 1 week, and later underwent cardiac magnetic resonance imaging. Activity was categorized as inactive, regular, or "weekend warrior". Associations between activity pattern and magnetic resonance imaging-derived visceral adipose tissue (VAT) and epicardial and pericardial adipose tissue (EPAT) were assessed using multiple linear regression adjusted for confounding factors.

RESULTS

Compared to inactive, VAT was progressively lower with weekend warrior (-0.71 L, 95% CI -0.78 to -0.64, P < 0.001) followed by regular activity (-0.96 L, 95% CI -1.04 to -0.88, P < 0.001). Observations were similar for EPAT (weekend warrior activity -2.84 cm2, 95% CI -3.20 to -2.49, P < 0.001; regular activity -3.62 cm2, 95% CI -4.03 to -3.20, P < 0.001). When compared directly, weekend warriors had modestly higher adipose tissue than regular activity (VAT difference 0.25 L, 95% CI 0.17-0.32, P < 0.001; EPAT 0.78 cm2, 95% CI 0.40-1.15, P < 0.001). No differences were observed after adjustment for total moderate-to-vigorous physical activity minutes (VAT 0.07 L, 95% CI -0.01 to 0.14, P = 0.09; EPAT 0.04 cm2, 95% CI -0.35 to 0.43, P = 0.84).

CONCLUSIONS

Guideline-adherent physical activity is associated with favorable quantitative measures of cardiometabolic health, with no differences based on activity pattern for a given activity volume.

Efficacy and prognosis of dapagliflozin in the treatment of patients with acute myocardial infarction complicated with type 2 diabetes in Xining area

Background

The acute myocardial infarction (AMI) is a prevalent and severe cardiovascular disease, characterized by its sudden onset, high mortality rate, and unfavorable prognosis. The presence of type 2 diabetes not only signifies a chronic metabolic disorder, but also serves as a catalyst for various cardiovascular and cerebrovascular ailments such as coronary heart disease and stroke. Xining is situated in a region of middle to high altitude and due to its unique geographical environment, coupled with the population's limited health awareness, unequal medical standards and other factors, there remain some AMI patients who are difficult to diagnose early on. The objective of this study is to investigate the efficacy and prognosis of dapagliflozin in patients with acute myocardial infarction complicated by type 2 diabetes in the Xining region.

Method

analysis on January 1, 2018 to January 1, 2020, in Qinghai province people's hospital of cardiovascular internal medicine hospital treatment of 245 cases of acute myocardial infarction combined the clinical data of patients with type 2 diabetes. The patients were divided into dapagliflozin group and control group according to whether they took dapagliflozin during hospitalization. The basic data, laboratory examination indicators and long-term prognosis of the two groups were observed. Follow-up deadline is December 31, 2023, at the end of follow-up, including the primary endpoint and the secondary endpoint.

Results

245 patients were included in this study, age 34-94, the average age (61-11), 200 cases (81.63%) of men, women, 45 cases (18.37%), dapagliflozin group of men 92 cases (77.97%) and control group, 108 cases (85.04%). Two groups of patients' age, gender, diabetes duration, merge disease, echocardiogram and blood biochemical indexes, had no statistical difference (P > 0.05). There were no significant differences in the number of coronary artery lesions, treatment regimens, cardiovascular and hypoglycemic drugs between the two groups (P > 0.05). However, up to dapagliflozin group of patients after discharge significantly lower than the control group, the incidence of cardiovascular adverse events at dapagliflozin group of 4 cases of heart failure and cardiovascular death in 1 case and control group in heart failure 13 cases, 10 cases of cardiovascular death, cerebral hemorrhage 2 cases died. KaplanMeier survival analysis showed that the primary endpoint of survival was significantly higher in the dapagliflozin group than in the control group (P < 0.05). In addition, the overall survival rate of the dapagliflozin group was significantly higher than that of the control group, and the difference was statistically significant (P < 0.05).

Conclusions

Dapagliflozin is safe and reliable in the treatment of patients with acute myocardial infarction and type 2 diabetes, and can effectively reduce the incidence of cardiovascular events and improve the overall survival rate of patients.

A drug safety evaluation of dapagliflozin for diabetic nephropathies in patients with cardiovascular risk

INTRODUCTION

Diabetic nephropathy is a significant concern for patients with cardiovascular disease. Dapagliflozin, an SGLT2 inhibitor, has emerged as a promising therapeutic approach to managing diabetic nephropathy and reducing cardiovascular risk.

AREAS COVERED

This review encompasses the research and literature search methodology, including clinical trials and real-world evidence, assessing the safety profile of Dapagliflozin in patients with diabetic nephropathy and cardiovascular risk.

EXPERT OPINION

Dapagliflozin, an SGLT2 inhibitor, has redefined patient-centric care by simultaneously improving glycemic control, cardiovascular health, and renal outcomes in individuals with type 2 diabetes, cardiovascular disease, and nephropathy.

The protective effect of sodium-glucose cotransporter-2 inhibitor on left ventricular global longitudinal strain in patients with type 2 diabetes mellitus according to disease duration

Our study aimed to elucidate the impact of sodium-glucose cotransporter-2 inhibitor on left ventricular systolic function using global longitudinal strain in type 2 diabetes mellitus patients and to assess its protective effect depending on disease duration. Type 2 diabetes mellitus patients treated at our institute were included. According to whether sodium-glucose cotransporter-2 inhibitor was used in drug treatment, the patients were divided into SGLT2i group and control group, and propensity score matching was performed. For subgroup analysis, patients were further classified based on disease duration (1-5 years, 5-10 years, and 10-20 years). A total of 256 patients with type 2 diabetes mellitus were enrolled. Significantly better global longitudinal strain results were observed at the 6-month follow-up in the SGLT2i group than those of the control group and its baseline (p < 0.001). A significantly lower proportion of subclinical cardiac dysfunction was observed in the SGLT2i group (p < 0.001). Significantly greater global longitudinal strains were observed in the SGLT2i subgroups compared with control subgroups (p all < 0.05). Furthermore, sodium-glucose cotransporter-2 inhibitor use and epicardial adipose tissue thickness change were independently associated with global longitudinal strain change according to multivariate analysis. Sodium-glucose cotransporter-2 inhibitor significantly improved left ventricular function in type 2 diabetes mellitus patients without cardiovascular complications, regardless of disease duration, with more prominent outcomes observed in patients with early-stage disease.

Comparative cardiovascular effectiveness of glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors in atherosclerotic cardiovascular disease phenotypes: a systematic review and meta-analysis

BACKGROUND

Atherosclerotic cardiovascular disease (ASCVD) encompasses various phenotypes with elevated risks of major adverse cardiovascular events (MACEs). This study aimed to assess the comparative cardiovascular effectiveness of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT2is) across diverse ASCVD phenotypes.

METHODS AND RESULTS

We conducted a systematic review and meta-analysis of randomized controlled trials evaluating GLP-1 RAs or SGLT2is against placebo or standard care in ASCVD patients. Primary outcomes included MACE, defined as cardiovascular mortality, non-fatal myocardial infarction, and non-fatal stroke. Risk ratios (RRs) with 95% confidence interval (CI) were calculated using a random-effects model.Twenty-six trials (151 789 patients) were included. Both GLP-1 RAs and SGLT2is significantly reduced MACE rates in ASCVD patients (RR 0.85; 95% CI 0.80-0.91 for both). GLP-1 RAs showed significant effectiveness in peripheral artery disease (RR 0.86; 95% CI 0.76-0.98) and post-acute cardiovascular events (RR 0.90; 95% CI 0.83-0.97). In ASCVD with heart failure, both drug classes reduced MACE (GLP-1 RAs: RR 0.73; 95% CI 0.63-0.84; SGLT2is: RR 0.86; 95% CI 0.78-0.95). SGLT2is significantly reduced MACE in ASCVD with chronic kidney disease (RR 0.84; 95% CI 0.72-0.99), particularly in severe albuminuria (RR 0.61; 95% CI 0.37-0.99).

CONCLUSION

GLP-1 RAs and SGLT2is exhibit distinct cardiovascular effectiveness profiles across ASCVD phenotypes. GLP-1 RAs show particular benefits in peripheral artery disease and post-acute cardiovascular events, while SGLT2is demonstrate unique advantages in ASCVD with comorbid chronic kidney disease. Both are effective in heart failure. These findings support tailored treatment strategies for diverse ASCVD participants based on specific comorbidities and risk factors.

Outcomes in Atrial Fibrillation Patients with Different Clinical Phenotypes: Insights from the French Population

Background: Atrial fibrillation (AF) patients represent a clinically complex, heterogeneous population comprising multiple homogeneous cohorts. Purpose: We aimed to identify the common clinical phenotypes of AF patients and compare clinical outcomes between these subgroups. Methods: A 1% representative sample of all AF patients hospitalized between 2010 and 2019 was identified from the French national database. Agglomerative hierarchical cluster analysis was performed using Ward's method and squared Euclidian distance to derive the clusters of patients. Cox regression analyses were used to evaluate outcomes including all-cause death, cardiovascular death, non-cardiovascular death, ischemic stroke, hospitalization for heart failure (HF) and composite of ventricular tachycardia, ventricular fibrillation and cardiac arrest (VT/VF/CA) over a mean follow-up period of 2.0 ± 2.3 years. Results: Four clusters were generated from the 12,688 patients included. Cluster 1 (n = 2375) was younger, low cardiovascular disease (CVD)-risk group with a high cancer prevalence. Clusters 2 (n = 6441) and 3 (n = 1639) depicted moderate-risk groups for CVD. Cluster 3 also had the highest degree of frailty and lung disease while Cluster 4 (n = 2233) represented a high-risk cohort for CVD. After adjusting for confounders, with cluster 1 as the reference, cluster 3 had the highest risk of all-cause death, HR 1.24 (1.09-1.41), ARD (10.3%), cardiovascular death, HR 1.56 (1.19-2.06), ARD (3.3%), non-cardiovascular death, HR 1.20 (1.04-1.38), ARD (6.9%), hospitalization for HF, HR 2.07 (1.71-2.50), ARD (9.1%) and VT/VF/CA, HR 1.74 (1.20-2.53), (ARD 1.3%). Conclusions: Four distinct clusters of AF patients were identified, discriminated by the differential presence of comorbidities. Our findings suggest that hospitalized AF patients with moderate CVD risk may have a poorer prognosis compared to hospitalized AF patients with high CVD risk in the presence of lung pathology and frailty. This subgroup of patients may require more stringent management of existing comorbidities such as chronic obstructive pulmonary disease and sleep apnea, alongside their AF.

Advances in Cardiovascular Pharmacotherapy. I. Cardiac Myosin Inhibitors

Hypertrophic cardiomyopathy (HCM) is the most common inherited cardiomyopathy. The disease is characterized by asymmetric left ventricular (LV) remodeling with myocyte disarray and interstitial fibrosis, a hypercontractile state, dynamic subaortic obstruction of the LV outflow tract, impaired LV diastolic function, atrial and ventricular arrhythmias, and sudden cardiac death. HCM occurs as a result of pathological alterations in the cardiac myocyte's chemomechanical cycle, in which an enhanced rate of myosin-actin crossbridge formation and destabilization of the energy-conserving "super-relaxed off-actin state" of myosin play essential roles. For decades, management of HCM has been limited almost exclusively to medications (eg, beta-blockers, calcium channel blockers, disopyramide) and interventions (eg, septal reduction therapy, implanted cardioverter-defibrillator devices) that palliate symptoms, but do not address the disease's underlying causative mechanisms. A new class of cardiovascular medications, cardiac myosin inhibitors, has surged to the forefront of HCM treatment in recent years. These drugs, including mavacamten and aficamten, show great promise to profoundly affect the disease's clinical course. In this article, the authors review the molecular mechanisms of action of cardiac myosin inhibitors, discuss in detail the most recent data from mavacamten and aficamten clinical trials, describe future planned studies designed to address unanswered questions about their clinical utility in HCM phenotypes, and comment on their potential application to patients with other forms of heart failure with preserved ejection fraction. The possible anesthetic implications of mavacamten and aficamten are also discussed because it is highly likely that patients who are treated with these medications will begin to present for perioperative care with increasing regularity.

A sex-disaggregated analysis of the prognostic value of lean type 2 diabetes mellitus in the adult population with acute myocardial infarction

BACKGROUND

Emerging evidence has demonstrated the unfavourable cardiovascular risk of individuals with lean type 2 diabetes mellitus (T2DM). Our study aims to investigate the prognostic value of lean T2DM in patients with acute myocardial infarction (AMI), stratified by sex.

METHODS

The study cohort examines the clinical characteristics and long-term outcomes of individuals with AMI, stratified by four phenotypes based on T2DM and lean body category-lean T2DM, non-lean T2DM, lean non-T2DM and non-lean non-T2DM. The primary outcome was long-term all-cause mortality. Cox regression model was constructed to investigate the associations of lean and non-lean T2DM phenotypes with mortality, adjusted for age, ethnicity, previous AMI, AMI type, chronic kidney disease, angiotensin converting enzyme inhibitor or angiotensin receptor blockers, beta-blockers, and smoking status.

RESULTS

A cohort of 9545 AMI patients was examined, with a mean follow-up duration of 3.4 ± 2.4 years. Majority had the non-lean T2DM phenotype (40.4%), followed by non-lean non-T2DM (29.8%), lean non-T2DM (15.9%), and lean T2DM (13.9%). In the T2DM group, one-quarter was lean (N = 1324), while the vast majority (74.5%) was non-lean. Individuals with lean T2DM tended to be female and older. Patients with lean T2DM had the highest rates of heart failure (23.3%, p < 0.001), cardiogenic shock (9.1%, p = 0.036), and long-term all-cause mortality (32.6%, p < 0.001). Cox regression demonstrated that lean T2DM was an independent predictor of mortality (adjusted hazard ratio [aHR] 1.171, 95% CI 1.040-1.319, p = 0.009) after adjustment. The presence of higher mortality risk following AMI was present in males (aHR 1.201, 95% CI 1.037-1.391, p = 0.015), but not in females (aHR 1.066, 95% CI 0.869-1.308, p = 0.538).

CONCLUSIONS

The lean T2DM phenotype was present in one-quarter of the AMI cohort with T2DM. The lean T2DM phenotype was an independent predictor of long-term mortality following AMI, although this association was stronger in males than in females.

Have SGLT-2 inhibitors DELIVERed an EMPhatic win in heart failure and chronic kidney disease?

INTRODUCTION

Major global guidelines currently recommend sodium-glucose co-transporter-2 inhibitors (SGLT-2i) as the first-line agents in people with type 2 diabetes (T2D) who have either established cardiovascular disease (eCVD), heart failure (HF), or chronic kidney disease (CKD), regardless of baseline glycated hemoglobin. Moreover, SGLT-2i are currently included in guideline-directed medical therapy as one of the pillars for people with HF and CKD, regardless of T2D. These recommendations are based on positive cardio-renal outcomes from several randomized controlled trials (RCTs).

AREAS COVERED

Following an extensive search in electronic databases of PubMed, Google Scholar, and clinicaltrials.gov, we critically analyzed the RCTs that assessed cardio-renal outcome trials of SGLT-2i and put a perspective on how SGLT-2i delivered an emphatic win for people with HF and CKD, with or without T2D.

EXPERT OPINION

From thirteen high-quality RCTS, including five cardiovascular outcome trials, five HF outcome trials, three renal outcome trials, and a pooled meta-analysis, it is evident that SGLT-2i has delivered an emphatic win in people with HF and CKD, with or without T2D, with an acceptable safety profile. Ongoing RCTs shall further enlighten whether SGLT-2i will be effective in polycystic kidney disease, lupus nephritis, vasculitis, end-stage CKD with or without hemodialysis, and renal transplant.

Capturing the Additional Cardiovascular Benefits of SGLT2 Inhibitors and GLP-1 Receptor Agonists Beyond the Control of Traditional Risk Factors in People With Diabetes

OBJECTIVES

This study aimed to quantify the additional cardioprotective effects of sodium-glucose cotransporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) beyond the traditional risk factors control in individuals with type 2 diabetes. This helps calibrate the Building, Relating, Assessing, and Validating Outcomes (BRAVO) diabetes simulation model to capture the total cardiovascular benefits of new diabetes medications accurately.

METHODS

We extracted patient characteristics and treatment efficacy data from 4 cardiovascular outcome trials (CVOTs) of SGLT2is and 4 CVOTs of GLP-1RAs completed before May 2023. Using the BRAVO diabetes simulation model, we translated reductions in traditional risk factors (ie, glycated hemoglobin, systolic blood pressure, low-density lipids, and body mass index) from the newer drugs into risk reductions in cardiovascular outcomes (ie, myocardial infarction [MI], stroke, congestive heart failure [CHF], and mortality), assuming that the drug-associated risk reductions were only driven by traditional risk factors. Then, we compared the simulated risk-factor-driven risk reductions of cardiovascular outcomes with observed risk reductions from the trials and calculated drug-specific incremental benefits (DIB).

RESULTS

After accounting for the cardiovascular effects from traditional risk factors control, SGLT2is was associated with an additional 19% risk reduction in CHF (DIB: 0.81, 95% CI 0.72-0.90). Furthermore, the uncalibrated model predicted a risk reduction in stroke with SGLT2is, which was not observed in CVOTs. This discrepancy highlights the need for an SGLT2i-specific calibrator to align the simulation results with the observed outcomes. In contrast, no additional cardiovascular benefit was associated with GLP-1RAs after controlling for traditional risk factors.

CONCLUSIONS

Our study revealed that SGLT2is could further reduce CHF risk beyond the control of traditional risk factors but may offer additional pathways to offset the overall benefits of traditional risk factor control in stroke risk. No additional cardiovascular benefits were observed for GLP-1RAs beyond traditional risk factor control. The BRAVO model calibration enhances cardiovascular outcome prediction with these newer antidiabetic therapies.

Renal Abscess Associated with SGLT2 Inhibitors Administration in Heart Failure Without Other Previous Risk Factors: A Case Report

Background and Clinical Significance: Renal abscess represents one infectious urological complication with lethal potential. The treatment of this pathology may differ depending on the severity of the symptoms and the size of the infectious collection. Diabetes, immunosuppression, and associated urinary pathologies are most frequently responsible for the development of abscesses. This case report presents the first documented case of a renal abscess associated with Sodium-glucose cotransporter 2 (SGLT2) inhibitors in a person without previous predisposing pathologies. Case Presentation: A 62-year-old patient presented to the emergency department for pain in the right flank, vomiting, and dysuria. The patient's medical history revealed Heart Failure New York Heart Association (NYHA) Class II, Coronary Artery Disease (CAD) with prior angioplasty, and permanent Atrial Fibrillation. No prior urological or immunosuppressive conditions were detected. The Computed Tomography (CT) evaluation confirmed the ultrasound suspicion of a right renal abscess performed in the emergency room. The only risk factor identified was the initiation of SGLT2 inhibitor therapy for cardiac pathology approximately 2 months before. According to the small dimensions and urine culture, the abscess was successfully treated with antibiotic administration in collaboration with the urology department. The infectious process was remitted within 2 weeks. Conclusions: To our knowledge this is the first documented case of a renal abscess associated with SGLT2 inhibitor administration in a person without previous predisposing risk factors. Despite the relatively low incidence of urinary tract infections (UTIs) associated with SGLT2 inhibitors, their widespread use in the treatment of various socially significant conditions highlights the need for both patients and medical specialists to be aware of all potential risks and pay increased attention to these cases.

Clinically approved representative small-molecule drugs for cardiopathy therapy

The application of therapeutic agents for cardiopathy has brought about significant advancements in the treatment of cardiovascular diseases. The intervention of small-molecule drugs has led to substantial reductions in morbidity and mortality rates, along with decreased utilization of healthcare resources. However, current treatment modalities do not exhibit uniform efficacy across all patients, and the emergence of drug resistance poses a significant challenge to further therapeutic efforts. Additionally, chronic administration of these drugs can result in toxicities, adding complexity to long-term management. This review focuses on the application of clinically approved small-molecule drugs for the treatment of cardiopathy, covering major classes such as angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers, β-blockers, and sodium-glucose co-transporter 2 inhibitors. The review provides an in-depth analysis of their synthetic routes, mechanisms of action, and roles in cardiopathy treatment. It also offers perspectives on future directions in the development of next-generation cardioprotective agents, aiming to optimize therapeutic strategies for cardiovascular disease management.

Combination therapy: an upcoming paradigm to improve kidney and cardiovascular outcomes in chronic kidney disease

In this article the authors review recent advances in the treatment of chronic kidney disease (CKD) with diabetes, and summarize evidence supporting combination therapy approaches to improve patient outcomes. Driven by the global rise in diabetes, the worldwide burden of CKD has nearly doubled since the 1990s. People with CKD have notably increased risks for premature cardiovascular disease (heart and blood vessels disease), kidney failure and death. CKD, diabetes, obesity and cardiovascular disease are closely interrelated and share common risk factors. These health conditions therefore comprise what is now known as cardiovascular-kidney-metabolic (CKM) syndrome. Recently approved medications, including sodium-glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1RAs) and the non-steroidal mineralocorticoid receptor antagonist (ns-MRA) finerenone, represent agents capable of reducing metabolic, kidney and cardiovascular risk through complementary mechanisms of action. Current evidence supports use of these therapies in combination. Besides providing additive protective effects, combination therapy may also help reduce side effects. For instance, using an SGLT2 inhibitor in combination with finerenone helps decrease the risk for high potassium levels. Through the multipronged approach, combination therapy allows tailoring treatment for the individual patient characteristics and needs. Several planned and ongoing clinical trials continue to study the benefits of combination therapy in people with CKM syndrome. With building evidence supporting the use of combination therapy, it is crucial to raise awareness of the importance of this treatment approach and develop processes to incorporate new therapies into every day practice to support optimal care and improved outcomes.

ABSTRACT

The global burden of chronic kidney disease (CKD) increased by nearly 90% in the period spanning 1990 to 2016, mostly attributed to an increase in the prevalence of CKD in diabetes. People living with CKD have an elevated lifetime risk for cardiovascular disease (CVD) when compared with the general population, with risk increasing in parallel with albuminuria and kidney function decline. Metabolic disease, CKD and CVD share common risk factors including neurohumoral activation, systemic inflammation and oxidative stress, thus prompting the introduction of a broader construct of cardiovascular-kidney-metabolic (CKM) syndrome. An important rationale for the introduction of this concept are recent and ongoing therapeutic advancements fundamentally changing CKM management. Sodium-glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1RAs) and the non-steroidal mineralocorticoid receptor antagonist (ns-MRA) finerenone have shifted the therapeutic paradigm for patients with CKD and have emerged in rapid succession as cornerstones of guideline-directed medical therapy (GDMT). Recently completed clinical trials of aldosterone synthase inhibitors and endothelin receptor antagonists have additionally reported additive antiproteinuric effects on the background of renin-angiotensin system and SGLT2 inhibition, with acceptable safety profiles. The sum of current evidence from both preclinical and clinical studies support combination therapy in the setting of CKD to achieve additive and potentially synergistic kidney and heart protection by addressing metabolic, hemodynamic, and pro-inflammatory and pro-fibrotic mechanistic pathways. This narrative review will discuss available evidence supporting combination GDMT in CKD with diabetes and additionally discuss ongoing and future trials evaluating the efficacy and safety of combination therapies for CKD with or without diabetes.

Age and Sex Differences in Efficacy of Treatments for Type 2 Diabetes: A Network Meta-Analysis

Importance

Sodium-glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, and dipeptidyl peptidase 4 (DPP4) inhibitors improve hyperglycemia, and SGLT2 inhibitors and GLP-1 receptor agonists reduce the risk of major adverse cardiovascular events (MACEs) among individuals with type 2 diabetes. It is not clear whether efficacy varies by age or sex.

Objective

To assess whether age or sex are associated with differences in the efficacy of SGLT2 inhibitors, GLP-1 receptor agonists, and DPP4 inhibitors.

Data Sources and Study Selection

The MEDLINE and Embase databases and US and Chinese clinical trial registries were searched for articles published from inception to November 2022; in August 2024, the search was updated to capture the trial results. Two reviewers screened for randomized clinical trials of SGLT2 inhibitors, GLP-1 receptor agonists, or DPP4 inhibitors vs a placebo or active comparator in adults with type 2 diabetes.

Data Extraction and Synthesis

Individual participant data and aggregate data were used to estimate age × treatment interactions and sex × treatment interactions in multilevel network meta-regression models.

Main Outcome and Measures

Hemoglobin A1c (HbA1c) and MACEs.

Results

Of the 601 eligible trials identified (592 trials with 309 503 participants reported HbA1c; mean age, 58.9 [SD, 10.8] years; 42.3% were female and 23 trials with 168 489 participants reported MACEs; mean age, 64.0 [SD, 8.6] years; 35.3% were female), individual participant data were obtained for 103 trials (103 reported HbA1c and 6 reported MACEs). The use of SGLT2 inhibitors (vs placebo) was associated with less HbA1c lowering with increasing age for monotherapy (absolute reduction [AR], 0.24% [95% credible interval {CrI}, 0.10% to 0.38%] per 30-year increment in age), for dual therapy (AR, 0.17% [95% CrI, 0.10% to 0.24%]), and for triple therapy (AR, 0.25% [95% CrI, 0.20% to 0.30%]). The use of GLP-1 receptor agonists was associated with greater HbA1c lowering with increasing age for monotherapy (AR, -0.18% [95% CrI, -0.31% to -0.05%] per 30-year increment in age) and for dual therapy (AR, -0.24% [95% CrI, -0.40% to -0.07%]), but not for triple therapy (AR, 0.04% [95% CrI, -0.02% to 0.11%]). The use of DPP4 inhibitors was associated with slightly better HbA1c lowering in older people for dual therapy (AR, -0.09% [95% CrI, -0.15% to -0.03%] per 30-year increment in age), but not for monotherapy (AR, -0.08% [95% CrI, -0.18% to 0.01%]) or triple therapy (AR, -0.01% [95% CrI, -0.06% to 0.05%]). The relative reduction in MACEs with use of SGLT2 inhibitors was greater in older vs younger participants per 30-year increment in age (hazard ratio, 0.76 [95% CrI, 0.62 to 0.93]), and the relative reduction in MACEs with use of GLP-1 receptor agonists was less in older vs younger participants (hazard ratio, 1.47 [95% CrI, 1.07 to 2.02]). There was no consistent evidence for sex × treatment interactions with use of SGLT2 inhibitors and GLP-1 receptor agonists.

Conclusions and Relevance

The SGLT2 inhibitors and GLP-1 receptor agonists were associated with lower risk of MACEs. Analysis of age × treatment interactions suggested that SGLT2 inhibitors were more cardioprotective in older than in younger people despite smaller reductions in HbA1c; GLP-1 receptor agonists were more cardioprotective in younger people.

Dapagliflozin treatment alleviates fatty liver in patients with type 2 diabetes

Non-alcoholic fatty liver disease (NAFLD) is common in patients with type 2 diabetes mellitus (T2DM). The present study evaluated the effect of dapagliflozin on the liver fat content in patients with T2DM and NAFLD. The changes in biochemical data and metabolic parameters were analyzed. Clinical data of patients with T2DM and NAFLD treated by dapagliflozin were retrospectively collected between June 2022 and December 2022. A total of 35 patients, with a mean age of 45.8±2.2 years, consisting of 60.0% male patients, were included in the final analysis. After 20 weeks of dapagliflozin treatment, the parameters of diabetes improved. Plasma glucose and hemoglobin A1C levels significantly decreased (P<0.01), and insulin resistance improved. The change in liver fat content was evaluated by quantitative computed tomography, which revealed a decrease from 16.1±2.2 to 11.2±1.3% after treatment (P<0.01). Liver function (alanine aminotransferase, aspartate aminotransferase and γ-glutamyltransferase levels) also improved. Visceral and subcutaneous fat areas showed a significant decrease after treatment, and there was a more significant reduction in visceral fat area. The factors associated with liver fat content were determined by Pearson's correlation and regression analyses. Pearson's correlation analysis indicated that the post-treatment decrease in liver fat content was positively correlated with the change in body weight (r=0.642, P=0.033), index of homeostasis model assessment-insulin resistance (r=0.670, P=0.048), triglycerides (r=0.627, P=0.039), high sensitivity C-reactive protein (r=0.608, P=0.047) and interleukin (IL)-6 (r=0.604, P=0.049). Linear regression analysis revealed that body weight (β=0.416, P=0.001), IL-6 (β=0.284, P=0.009), triglycerides (β=0.262, P=0.011) and total cholesterol (β=0.388, P=0.001) were independent factors related to liver fat content. In conclusion, dapagliflozin can reduce liver fat in patients with T2DM and NAFLD. The reduction in liver fat is associated with improvement of metabolic parameters and inflammatory cytokines.

[What is new in the management of peripheral arterial occlusive disease and diseases of the aorta? : Highlights of the ESC guidelines 2024]

The European Society of Cardiology (ESC) guidelines on peripheral arterial disease (PAD) and diseases of the aorta published in September 2024 for the first time combine recommendations for both diseases in a joint guideline document. The consolidation of PAD and aorta guidelines follows a holistic approach, which underlines the entirety of the arterial vascular system. This aim is underlined by a specifically introduced recommendation to take the entirety of the circulatory system into account in patients with vascular diseases. The focus in the current ESC guideline document is on a multidisciplinary, patient-centered management of PAD and diseases of the aorta, whereby the prevention and follow-up of patients after therapeutic interventions are emphasized. In PAD the document highlights exercise training and the procedure for patients with chronic wounds as well as risk stratification and hereditary diseases of the aorta.

Nicotinamide n-methyltransferase inhibitor synergizes with sodium-glucose cotransporter 2 inhibitor to protect renal tubular epithelium in experimental models of type 2 diabetes mellitus

AIMS

We aim to explore the potential of nicotinamide n-methyltransferase (NNMT) as a sensitive marker of renal tubular injury and the possibility of an NNMT inhibitor to combine with sodium-glucose cotransporter 2 (SGLT2) inhibitor to protect proximal tubular epithelium in vivo and in vitro model of Type 2 diabetes mellitus (T2DM), respectively.

METHODS

In vivo, immunohistochemical staining, Masson's trichrome staining and Sirius red staining were used to observe the changes of NNMT expression, renal tubular injury and interstitial fibrosis in renal tissue from the db/db mice. Bioinformatic analysis was also conducted to broaden the range of data validation. In vitro, Western Blot and quantitative RT-PCR were used to measure the degree of damage of HK-2 cells.

RESULTS

Our in vivo data showed upregulation of NNMT expression paralleled renal tubular damage and interstitial fibrosis. Our in vitro data revealed both NNMT inhibitors and SGLT2 inhibitors can protect against the injury as assessed by extracellular matrix (ECM) synthesis and profibrotic phenotype transition of HK-2 cells, and the combination of these two agents can further reduce these injuries.

CONCLUSIONS

The present study is the first to show that NNMT is a promising marker of renal tubular injury in diabetic nephropathy (DN) and NNMT inhibitors can synergize with SGLT2 inhibitors to protect HK-2 better. Our findings will provide the insight and pave the way of developing novel therapeutic strategies for chronic renal tubular injury associated with T2DM.

Early combination therapy with SGLT2i and GLP-1 RA or dual GIP/GLP-1 RA in type 2 diabetes

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-Like peptide-1 receptor agonists (GLP-1 RA) are recommended in people with type 2 diabetes (T2D) for glycaemic control and for people with high cardiovascular risk. However, current guidelines do not specifically address the role of initial early combination therapy with SGLT2i and GLP-1 RA or dual gastric inhibitory polypeptide (GIP)/GLP-1 RA, but rather sequential initiation with either in T2D. This review synthesizes the available evidence on the use of SGLT2i and GLP-1-based therapies for T2D and provides a rationale for their combination. The combination of SGLT2i with GLP-1-based therapies addresses complementary pathophysiological mechanisms and enhances efficacy in achieving target haemoglobin A1C (HbA1c) levels. SGLT2i and GLP-1 RA also have been shown to prevent complications of T2D. While both classes reduce adverse cardiorenal events, SGLT2i has a predominant effect on prevention of kidney dysfunction and heart failure, whereas GLP-1 RA has a more marked effect on the risk of atherosclerotic cardiovascular disease. Both drug classes have favourable safety profiles. Finally, weight loss with combination therapy may have disease-modifying effects that may reverse T2D progression. We propose that the combination of SGLT2i with GLP-1 RA or dual GIP/GLP-1 RA should be considered for most patients with T2D who do not have contraindications.