Glucagon-like Peptide-1 analogues and delipidation of coronary atheroma in statin-treated type 2 diabetic patients with coronary artery disease: The prespecified sub-analysis of the OPTIMAL randomized clinical trial

Background and aims

Randomized clinical trials have demonstrated the ability of glucagon-like peptide-1 analogues (GLP-1RAs) to reduce atherosclerotic cardiovascular disease events in patients with type 2 diabetes (T2D). How GLP-1RAs modulate diabetic atherosclerosis remains to be determined yet.

Methods

The OPTIMAL study was a prospective randomized controlled study to compare the efficacy of 48-week continuous glucose monitoring- and HbA1c-guided glycemic control on near infrared spectroscopty (NIRS)/intravascular ultrasound (IVUS)-derived plaque measures in 94 statin-treated patients with T2D (jRCT1052180152, UMIN000036721). Of these, 78 patients with evaluable serial NIRS/IVUS images were analyzed to compare plaque measures between those treated with (n = 16) and without GLP-1RAs (n = 72).

Results

All patients received a statin, and on-treatment LDL-C levels were similar between the groups (66.9 ± 11.6 vs. 68.1 ± 23.2 mg/dL, p = 0.84). Patients receiving GLP-1RAs demonstrated a greater reduction of HbA1c [-1.0 (-1.4 to -0.5) vs. -0.4 (-0.6 to -0.2)%, p = 0.02] and were less likely to demonstrate a glucose level >180 mg/dL [-7.5 (-14.9 to -0.1) vs. 1.1 (-2.0 - 4.2)%, p = 0.04], accompanied by a significant decrease in remnant cholesterol levels [-3.8 (-6.3 to -1.3) vs. -0.1 (-0.8 - 1.1)mg/dL, p = 0.008]. On NIRS/IVUS imaging analysis, the change in percent atheroma volume did not differ between the groups (-0.9 ± 0.25 vs. -0.2 ± 0.2%, p = 0.23). However, GLP-1RA treated patients demonstrated a greater frequency of maxLCBI4mm regression (85.6 ± 0.1 vs. 42.0 ± 0.6%, p = 0.01). Multivariate analysis demonstrated that the GLP-1RA use was independently associated with maxLCBI4mm regression (odds ratio = 4.41, 95%CI = 1.19-16.30, p = 0.02).

Conclusions

In statin-treated patients with T2D and CAD, GLP-1RAs produced favourable changes in lipidic plaque materials, consistent with its stabilization.

Continuous glucose monitoring for the routine care of type 2 diabetes mellitus

Although continuous glucose monitoring (CGM) devices are now considered the standard of care for people with type 1 diabetes mellitus, the uptake among people with type 2 diabetes mellitus (T2DM) has been slower and is focused on those receiving intensive insulin therapy. However, increasing evidence now supports the inclusion of CGM in the routine care of people with T2DM who are on basal insulin-only regimens or are managed with other medications. Expanding CGM to these groups could minimize hypoglycaemia while allowing efficient adaptation and escalation of therapies. Increasing evidence from randomized controlled trials and observational studies indicates that CGM is of clinical value in people with T2DM on non-intensive treatment regimens. If further studies confirm this finding, CGM could soon become a part of routine care for T2DM. In this Perspective we explore the potential benefits of widening the application of CGM in T2DM, along with the challenges that must be overcome for the evidence-based benefits of this technology to be delivered for all people with T2DM.

Glycemic variability assessed using continuous glucose monitoring in individuals without diabetes and associations with cardiometabolic risk markers: A systematic review and meta-analysis

BACKGROUND & AIMS

Continuous glucose monitoring (CGM) provides data on short-term glycemic variability (GV). GV is associated with adverse outcomes in individuals with diabetes. Whether GV is associated with cardiometabolic risk in individuals without diabetes is unclear. We systematically reviewed the literature to assess whether GV is associated with cardiometabolic risk markers or outcomes in individuals without diabetes.

METHODS

Searches were performed in PubMed/Medline, Embase and Cochrane from inception through April 2022. Two researchers were involved in study selection, data extraction and quality assessment. Studies evaluating GV using CGM for ≥24 h were included. Studies in populations with acute and/or critical illness were excluded. Both narrative synthesis and meta-analyzes were performed, depending on outcome.

RESULTS

Seventy-one studies were included; the majority were cross-sectional. Multiple measures of GV are higher in individuals with compared to without prediabetes and GV appears to be inversely associated with beta cell function. In contrast, GV is not clearly associated with insulin sensitivity, fatty liver disease, adiposity, blood lipids, blood pressure or oxidative stress. However, GV may be positively associated with the degree of atherosclerosis and cardiovascular events in individuals with coronary disease.

CONCLUSION

GV is elevated in prediabetes, potentially related to beta cell dysfunction, but less clearly associated with obesity or traditional risk factors. GV is associated with coronary atherosclerosis development and may predict cardiovascular events and type 2 diabetes. Prospective studies are warranted, investigating the predictive power of GV in relation to incident disease. GV may be an important risk measure also in individuals without diabetes.

Comparative effects of fixed-dose mitiglinide/voglibose combination and glimepiride on vascular endothelial function and glycemic variability in patients with type 2 diabetes: A randomized controlled trial

INTRODUCTION

The aim of this study was to compare the effects of mitiglinide/voglibose with those of glimepiride on glycemic variability and vascular endothelial function in patients with type 2 diabetes.

MATERIALS AND METHODS

It was a multicenter, open-label, randomized, crossover study. Hospitalized patients received either mitiglinide/voglibose (three times daily administration of 10 mg mitiglinide and 0.2 mg voglibose) or glimepiride (once-daily 2 mg) in random order, each for 5 days. The reactive hyperemia index (RHI) and the mean amplitude of glycemic excursions (MAGE) were measured as co-primary endpoints using reactive hyperemia peripheral arterial tonometry and continuous glucose monitoring.

RESULTS

The analysis included 30 patients (15 in each group). The RHI was 1.670 ± 0.369 during treatment with mitiglinide/voglibose and 1.716 ± 0.492 during treatment with glimepiride, with no significant difference between the two. MAGE was significantly lower in the mitiglinide/voglibose group (47.6 ± 18.5 mg/dL) than in the glimepiride group (100.6 ± 32.2 mg/dL). Although the mean blood glucose levels over the entire 24 h period were comparable between the two groups, the use of mitiglinide/voglibose was associated with a lower standard deviation of mean glucose, coefficient of variation, and mean postprandial glucose excursion compared with glimepiride. The time below range (<70 mg/dL) and the time above range (>180, >200, and 250 mg/dL) were lower in the mitiglinide/voglibose group, while the time in range (70-180 mg/dL) was higher.

CONCLUSIONS

In our short-duration randomized crossover study, although not impacting vascular endothelial function, mitiglinide/voglibose demonstrated potential benefits in reducing glycemic variability, postprandial hyperglycemia, and hypoglycemia in patients with type 2 diabetes.

Effect of 24 h glucose fluctuations on 30-day and 1-year mortality in patients with acute myocardial infarction: an analysis from the MIMIC-III database

Background

It is recognized that patients' blood glucose fluctuates over time during acute disease episodes, especially during the outbreak of cardiovascular events, regardless of the presence of an abnormal blood glucose profile prior to admission to the hospital. Glucose fluctuations in patients with acute myocardial infarction (AMI) in the intensive care unit (ICU) are currently not adequately monitored and studied. We focused on blood glucose fluctuation values within 24 h of admission to assess their association with 30-day and 1-year mortality.

Methods

Data of patients with AMI aged 18 years or older from the Critical Care Medical Information Marketplace database III V1.4 were available for analysis in this research. Glucose data were obtained by measurement. A total of 390 of them were treated with PCI. The principal consequence was 30-day and 1-year mortality in patients with AMI. The effect of different glucose fluctuations within 24 h of admission on mortality was predicted by constructing a multivariate Cox regression model with four model adjustments and Kaplan-Meier survival curves. Additionally, we performed curve-fitting analyses to show the correlation between blood glucose fluctuations and risk of death.

Results

We selected 1,699 AMI patients into our study through screening. The included population was categorized into three groups based on the tertiles of blood glucose fluctuation values within 24 h of admission to the ICU. The three groups were <25 mg/dl, 25-88 mg/dl and >88 mg/dl. By cox regression analysis, the group with the highest blood glucose fluctuation values (>88 mg/dl) had the most significant increase in 30-day and 1-year mortality after excluding confounding factors (30-day mortality adjusted HR = 2.11; 95% CI = 1.49-2.98 p < 0.001; 1-year mortality adjusted HR = 1.83; 95% CI = 1.40-2.39 p < 0.001). As demonstrated by the Kaplan-Meier survival curves, the group with the greatest fluctuations in blood glucose has the worst 30-day and 1-year prognosis.

Conclusions

The extent of glucose fluctuations in patients with AMI in the first 24 h after ICU admission is an essential predictor as to 30-day as well as 1-year mortality. When blood glucose fluctuates more than 88 mg/dl within 24 h, mortality increases significantly with the range of blood glucose fluctuations.

Short-term glucose variability as a determinant of the healing rate of diabetic foot ulcer: A retrospective study

BACKGROUND

The aim of this study was to describe the clinical characteristics of people with diabetic foot ulcer (DFU) according to glucose variability (GV) and to investigate the relationship between GV and DFU outcome in a population with type 2 diabetes (T2D) and DFU.

METHODS

This is a retrospective study of 300 individuals aged 64.3 years (181 males) treated for DFU in a tertiary-care center with a regular follow-up for 6 months. Laboratory measurements and clinical assessments were collected at baseline. According to the coefficient of variation (CV) cut-off (≥36%), people were divided into two groups (low and high GV).

RESULTS

Compared with low GV group (n = 245), high GV group (n = 55) had significant longer duration of diabetes [low vs high GV, mean ± Standard Deviation (SD), 17.8 ± 11.8 vs 22.4 ± 10.8, P = 0.012], higher levels of glycated haemoglobin [median (IQR), 7.4 (6.6, 8.8) vs 8.2 (7.0, 9.6), P = 0.010] and urinary albumin excretion [25.2 (11.9, 77.0) vs 48.0 (23.2, 106.0), P = 0.031]. Moreover, 10 days self-monitoring of blood glucose-derived glycemic metrics were significantly different between groups. No differences among clinical features were found. The multiple logistic regression analysis identified CV and SD as negative predictors of healing.

CONCLUSIONS

In a population of people with T2D and DFU treated in a tertiary-care center, individuals with high GV had a 3-fold higher risk of healing failure, as compared with those with low GV. CV and SD were related to poor healing within 6 months follow-up.

Research progress on the association between glycemic variability index derived from CGM and cardiovascular disease complications

Currently, glycated hemoglobin A1c (HbA1c) has been widely used to assess the glycemic control of patients with diabetes. However, HbA1c has certain limitations in describing both short-term and long-term glycemic control. To more accurately evaluate the glycemic control of diabetes patients, the continuous glucose monitoring (CGM) technology has emerged. CGM technology can provide robust data on short-term glycemic control and introduce new monitoring parameters such as time in range, time above range, and time below range as indicators of glycemic fluctuation. These indicators are used to describe the changes in glycemic control after interventions in clinical research or treatment modifications in diabetes patient care. Recent studies both domestically and internationally have shown that these indicators are not only associated with microvascular complications of diabetes mellitus but also closely related to cardiovascular disease complications and prognosis. Therefore, this article aims to comprehensively review the association between CGM-based glycemic parameters and cardiovascular disease complications by analyzing a large number of domestic and international literature. The purpose is to provide scientific evidence and guidance for the standardized application of these indicators in clinical practice, in order to better evaluate the glycemic control of diabetes patients and prevent the occurrence of cardiovascular disease complications. This research will contribute to improving the quality of life for diabetes patients and provide important references for clinical decision-making.

Enhancement of Ambulatory Glucose Profile for Decision Assistance and Treatment Adjustments

The ambulatory glucose profile (AGP) lacks sufficient statistical metrics and insightful graphs; indeed, it is missing important information on the temporal patterns of glucose variations. The AGP graph is difficult to interpret due to the overlapping metrics and fluctuations in glucose levels over 14 days. The objective of this proposed work is to overcome these challenges, specifically the lack of insightful information and difficulty in interpreting AGP graphs, to create a platform for decision assistance. The present work proposes 20 findings built from decision rules that were developed from a combination of AGP metrics and additional statistical metrics, which have the potential to identify patterns and insightful information on hyperglycemia and hypoglycemia. The "CGM Trace" webpage was developed, in which insightful metrics and graphical representations can be used to make inferences regarding the glucose data of any user. However, doctors (endocrinologists) can access the "Findings" tab for a summarized presentation of their patients' glycemic control. The findings were implemented for 67 patients' data, in which the data of 15 patients were collected from a clinical study and the data of 52 patients were gathered from a public dataset. The findings were validated by means of MANOVA (multivariate analysis of variance), wherein a p value of < 0.05 was obtained, depicting a strong significant correlation between the findings and the metrics. The proposed work from "CGM Trace" offers a deeper understanding of the CGM data, enhancing AGP reports for doctors to make treatment adjustments based on insightful information and hidden patterns for better diabetic management.

Association between perioperative glucose profiles assessed by the continuous glucose monitoring (CGM) system and prognosis in patients with ST-segment elevation myocardial infarction (STEMI): protocol for a cohort study

INTRODUCTION

ST-segment elevation myocardial infarction (STEMI) presents a serious cardiovascular condition requiring prompt intervention. Dysglycaemia has been identified as a significant risk factor impacting STEMI prognosis. However, limited research has focused on comprehensively examining the association between glucose dynamics during the perioperative period and patient outcomes. This study aims to address this gap by leveraging continuous glucose monitoring (CGM) technology to gain real-time insights into glucose fluctuations and their potential impact on STEMI prognosis.

METHODS AND ANALYSIS

This is a multicentre, prospective, 3-year follow-up cohort study. Between May 2023 and May 2024, 550 eligible STEM patients who underwent percutaneous coronary intervention are expected to be recruited. Using the CGM system, continuous glucose levels will be collected throughout the perioperative phase. Key clinical parameters, including cardiac biomarkers, angiographic findings and major adverse cardiovascular events, will be assessed in relation to glucose profile.

ETHICS AND DISSEMINATION

The study was approved by the Medical Research Ethics Committee of The First Affiliated Hospital of University of Science and Technology of China and will be conducted in accordance with the moral, ethical and scientific principles of the Declaration of Helsinki. Written informed consent will be obtained from all participants before any study-related procedures are implemented. Study results will be disseminated through conferences and peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

ChiCTR2300069662.

Role of the Adrenal Medulla in Hypoglycaemia-Associated Autonomic Failure-A Diabetic Perspective

Hypoglycaemia-associated autonomic failure (HAAF) is characterised by an impairment in adrenal medullary and neurogenic symptom responses following episodes of recurrent hypoglycaemia. Here, we review the status quo of research related to the regulatory mechanisms of the adrenal medulla in its response to single and recurrent hypoglycaemia in both diabetic and non-diabetic subjects with particular focus given to catecholamine synthesis, enzymatic activity, and the impact of adrenal medullary peptides. Short-term post-transcriptional modifications, particularly phosphorylation at specific residues of tyrosine hydroxylase (TH), play a key role in the regulation of catecholamine synthesis. While the effects of recurrent hypoglycaemia on catecholamine synthetic enzymes remain inconsistent, long-term changes in TH protein expression suggest species-specific responses. Adrenomedullary peptides such as neuropeptide Y (NPY), galanin, and proenkephalin exhibit altered gene and protein expression in response to hypoglycaemia, suggesting a potential role in the modulation of catecholamine secretion. Of note is NPY, since its antagonism has been shown to prevent reductions in TH protein expression. This review highlights the need for further investigation into the molecular mechanisms involved in the adrenal medullary response to hypoglycaemia. Despite advancements in our understanding of HAAF in non-diabetic rodents, a reliable diabetic rodent model of HAAF remains a challenge.

Experimental pharmacological approaches to reverse impaired awareness of hypoglycemia-a review

The colossal global burden of diabetes management is compounded by the serious complication of hypoglycemia. Protective physiologic hormonal and neurogenic counterregulatory responses to hypoglycemia are essential to preserve glucose homeostasis and avert serious morbidity. With recurrent exposure to hypoglycemic episodes over time, these counterregulatory responses to hypoglycemia can diminish, resulting in an impaired awareness of hypoglycemia (IAH). IAH is characterized by sudden neuroglycopenia rather than preceding cautionary autonomic symptoms. IAH increases the risk of subsequent sudden and severe hypoglycemic episodes in patients with diabetes. The postulated causative mechanisms behind IAH are complex and varied. It is therefore challenging to identify a single effective therapeutic strategy. In this review, we closely examine the efficacy and feasibility of a myriad of pharmaceutical interventions in preventing and treating IAH as described in clinical and preclinical studies. Pharmaceutical agents outlined include N-acetyl cysteine, GABA A receptor blockers, opioid receptor antagonists, AMP activated protein kinase agonists, potassium channel openers, dehydroepiandrosterone, metoclopramide, antiadrenergic agents, antidiabetic agents and glucagon.

Baseline high-sensitivity C-reactive protein and glycosylated hemoglobinA1c predict adverse outcomes in patients with chronic coronary syndromes undergoing percutaneous coronary intervention

Introduction

This study explored the ability of high-sensitivity C-reactive protein (hs-CRP) and glycosylated hemoglobin A1c (HbA1c) to predict adverse cardiac and cerebrovascular outcomes in patients with chronic coronary syndromes (CCS) undergoing percutaneous coronary intervention (PCI).

Methods

In total, 4083 consecutive patients with CCS undergoing PCI were investigated throughout 2013 at a single center. The primary endpoint was all-cause death at the 5-year follow-up. Hs-CRP and HbA1c data were collected on admission.

Results

The highest quartile of hs-CRP had a significantly increased the risk of all-cause death, with an adjusted HR of 1.747 (95 % CI 1.066-2.863), while, there was no difference in all-cause death among the groups of HbA1c after adjustment, with an adjusted HR of 1.383 (95 % CI 0.716-2.674). The highest quartiles for hs-CRP and HbA1c in the study population had a significantly increased risk of major adverse cardiac and cerebrovascular events (MACCE), with an adjusted hazard ratios (HR) of 1.263 (95 % confidence intervals [CI] 1.032-1.545) for hs-CRP and an adjusted HR of 1.417 (95 % CI 1.091-1.840) for HbA1c. Remarkably, the incidence of all-cause death and that of MACCE were significantly increased when both hs-CRP and HbA1c were elevated (HR 1.971, 95 % CI 1.079-3.601, P = 0.027 and HR 1.560, 95 % CI 1.191-2.042), P = 0.001, respectively). Addition of hs-CRP and HbA1c to conventional risk factors significantly improved prediction of the risk of all cause death (net reclassification index 0.492, P < 0.001; integrated discrimination improvement 0.007, P = 0.011) and MACCE (net reclassification index 0.160, P < 0.001; integrated discrimination improvement 0.006, P < 0.001).

Conclusions

Hs-CRP and HbA1c can serve as independent predictors of MACCE in patients with CCS undergoing PCI. Furthermore, a combination of hs-CRP and HbA1c could predict all cause death and MACCE better than each component individually.

Comparison of Effects of Injectable Semaglutide and Dulaglutide on Oxidative Stress and Glucose Variability in Patients with Type 2 Diabetes Mellitus: A Prospective Preliminary Study

INTRODUCTION

Recent trials have shown that glucagon-like peptide-1 receptor agonists considerably reduce atherosclerotic cardiovascular disease in patients with type 2 diabetes mellitus (T2DM). Oxidative stress, a surrogate marker of cardiovascular risk, is associated with glucose variability. However, to the best of our knowledge, no studies have compared the effects of injectable semaglutide and dulaglutide therapies on oxidative stress and glucose variability assessed via continuous glucose monitoring (CGM). This study aimed to analyze and compare the effects of semaglutide and dulaglutide therapies on oxidative stress and glucose variability as assessed through CGM.

METHODS

This is an open-label, multicenter, randomized, prospective, parallel-group comparison study. Overall, 37 patients with T2DM treated with dulaglutide for at least 12 weeks were randomized into two groups: one receiving continuous dulaglutide therapy (n = 19) and one receiving injectable semaglutide therapy (n = 18) groups. The coprimary endpoints were changes in the results of the diacron-reactive oxygen metabolites test, an oxidative stress marker, and CGM-evaluated glucose variability after 24 weeks. The secondary endpoint was changes in the Diabetes Treatment Satisfaction Questionnaire (DTSQ) scores.

RESULTS

Switching to semaglutide therapy was better than continuous dulaglutide therapy in reducing oxidative stress, glucose variability, and glycated hemoglobin levels. Conversely, continuous dulaglutide therapy was better than semaglutide therapy in terms of DTSQ scores for "Convenience" and "Recommend."

CONCLUSION

Injectable semaglutide therapy may be more effective than dulaglutide therapy in ameliorating oxidative stress and regulating glucose metabolism, including glucose variability, in patients with T2DM, while dulaglutide therapy may be more effective in terms of treatment satisfaction.

CLINICAL TRIAL REGISTRATION

UMIN-CRT ID: UMIN000042670 (registered 7 December 2020).

Glycemic variability: Measurement, target, impact on complications of diabetes and does it really matter?

Over the past two decades, there has been continuous advancement in the accuracy and complexity of continuous glucose monitoring devices. Continuous glucose monitoring provides valuable insights into blood glucose dynamics, and can record glucose fluctuations accurately and completely. Glycemic variability (GV) is a straightforward measure of the extent to which a patient's blood glucose levels fluctuate between high peaks and low nadirs. Many studies have investigated the relationship between GV and complications, primarily in the context of type 2 diabetes. Nevertheless, the exact contribution of GV to the development of diabetes complications remains unclear. In this literature review, we aimed to summarize the existing evidence regarding the measurement, target level, pathophysiological mechanisms relating GV and tissue damage, and population-based studies of GV and diabetes complications. Additionally, we introduce novel methods for measuring GV, and discuss several unresolved issues of GV. In the future, more longitudinal studies and trials are required to confirm the exact role of GV in the development of diabetes complications.

Mitigating iftar-related glycemic excursions in adolescents and young adults with type 1 diabetes on MiniMed™ 780G advanced hybrid closed loop system: a randomized clinical trial for adjunctive oral vildagliptin therapy during Ramadan fasting

BACKGROUND

Ramadan Iftar meal typically causes glucose excursions. Dipeptidyl peptidase-4 inhibitors increase glucagon-like peptide-1 and thus, decrease blood glucose levels with low risk of hypoglycemia.

AIM

To investigate the efficacy and safety of vildagliptin as an add-on therapy on glucose excursions of Iftar Ramadan meals among adolescents and young adults with type 1 diabetes mellitus (T1DM) using advanced hybrid closed-loop (AHCL) treatment.

METHODS

Fifty T1DM patients on MiniMed™ 780G AHCL were randomly assigned either to receive vildagliptin (50 mg tablet) with iftar meal during Ramadan month or not. All participants received pre-meal insulin bolus based on insulin-to-carbohydrate ratio (ICR) for each meal constitution.

RESULTS

Vildagliptin offered blunting of post-meal glucose surges (mean difference - 30.3 mg/dL [- 1.7 mmol/L] versus - 2.9 mg/dL [- 0.2 mmol/L] in control group; p < 0.001) together with concomitant exceptional euglycemia with time in range (TIR) significantly increased at end of Ramadan in intervention group from 77.8 ± 9.6% to 84.7 ± 8.3% (p = 0.016) and time above range (180-250 mg/dL) decreased from 13.6 ± 5.1% to 9.7 ± 3.6% (p = 0.003) without increasing hypoglycemia. A significant reduction was observed in automated daily correction boluses and total bolus dose by 23.9% and 16.3% (p = 0.015 and p < 0.023, respectively) with less aggressive ICR settings within intervention group at end of Ramadan. Coefficient of variation was improved from 37.0 ± 9.4% to 31.8 ± 7.1%; p = 0.035). No severe hypoglycemia or diabetic ketoacidosis were reported.

CONCLUSION

Adjunctive vildagliptin treatment mitigated postprandial hyperglycemia compared with pre-meal bolus alone. Vildagliptin significantly increased TIR while reducing glycemic variability without compromising safety. Trial registration This trial was registered under ClinicalTrials.gov Identifier no. NCT06021119.

Continuous glucose monitoring-derived time in range and CV are associated with altered tissue characteristics of the carotid artery wall in people with type 2 diabetes

AIMS/HYPOTHESIS

Previous studies have suggested that glucose variability may accelerate atherosclerosis progression in people with type 2 diabetes. Current guidelines recommend assessing glycaemic control using continuous glucose monitoring (CGM), which provides a comprehensive glycaemic profile to supplement HbA1c measurement. However, the association between CGM-derived metrics and atherosclerosis progression is not entirely clear.

METHODS

This exploratory study used baseline data and data obtained after 104 weeks from an ongoing prospective, multicentre, observational study. Six hundred study participants with type 2 diabetes and no apparent history of symptomatic cardiovascular disease underwent CGM and ultrasonographic atherosclerosis measurements of the carotid arteries, including the intima-media thickness (IMT) and grey-scale median (GSM), at baseline and 104 weeks. Non-invasive ultrasonic tissue characterisation of the carotid artery wall or plaque using the GSM reflects vascular composition. Multivariate regression models were used to analyse the association between CGM-derived indices, mainly time in range (TIR) and CV, and changes in carotid atherosclerosis index values.

RESULTS

Over the 104-week study period, there were modest increases in mean IMT (from 0.759±0.153 to 0.773±0.152 mm, p<0.001) and thickened-lesion GSM (from 43.5±19.5 to 53.9±23.5 units, p<0.001), but no significant changes in common carotid artery maximum-IMT (from 1.109±0.442 to 1.116±0.469 mm, p=0.453) or mean GSM (from 48.7±19.3 to 49.8±20.8 units, p=0.092). In a linear regression model with adjustment for possible atherosclerotic risk factors, including HbA1c, TIR and CV at baseline were significantly associated with the annual change in mean GSM (regression coefficient per 10% increase in TIR 0.52; 95% CI 0.06, 0.98; Hochberg-adjusted p value 0.038; regression coefficient per 1% increase in CV -0.12; 95% CI -0.22, -0.02; Hochberg-adjusted p value 0.038). TIR and CV at baseline were also significantly associated with the annual change in thickened-lesion GSM (regression coefficient per 10% increase in TIR 0.95; 95% CI 0.12, 1.79; Hochberg-adjusted p value 0.038; regression coefficient per 1% increase in CV -0.19; 95% CI -0.36, -0.01; Hochberg-adjusted p value 0.038). Participants who achieved target CGM-derived metrics at baseline, as proposed by an international consensus, showed significant annual changes in mean GSM compared with those who did not (0.94±6.88 vs -0.21±6.19 units/year, p=0.007).

CONCLUSIONS/INTERPRETATION

TIR and CV were significantly associated with changes in the tissue characteristics of the carotid artery wall.

TRIAL REGISTRATION

University Hospital Medical Information Network Clinical Trials Registry, number UMIN000032325.

A Consensus Statement for Continuous Glucose Monitoring Metrics for Inpatient Clinical Trials

Diabetes Technology Society organized an expert consensus panel to develop metrics for research in the use of continuous glucose monitors (CGMs) in a hospital setting. The experts met virtually in small groups both before and after an April 13, 2023 virtual meeting of the entire panel. The goal of the panel was to develop consensus definitions in anticipation of greater use of CGMs in hospital settings in the future. Establishment of consensus definitions of inpatient analytical metrics will be easier to compare outcomes between studies. Panelists defined terms related to 10 dimensions of measurements related to the use of CGMs including (1) hospital hypoglycemia, (2) hospital hyperglycemia, (3) hospital time in range, (4) hospital glycemic variability, (5) hospital glycemia risk index, (6) accuracy of CGM devices and reference methods for CGMs in the hospital, (7) meaningful time blocks for hospital glycemic goals, (8) hospital CGM data sufficiency, (9) using CGM data for insulin dosing, and (10) miscellaneous factors. The panelists voted on 51 proposed recommendations. Based on the panel vote, 51 recommendations were classified as either strong (43) or mild (8). Additional research is needed on CGM performance in the hospital. This consensus report is intended to support that type of research intended to improve outcomes for hospitalized people with diabetes.

Current and future therapies to treat impaired awareness of hypoglycemia

In order to achieve optimal glycemic control, intensive insulin regimes are needed for individuals with Type 1 Diabetes (T1D) and insulin-dependent Type 2 Diabetes (T2D). Unfortunately, intensive glycemic control often results in insulin-induced hypoglycemia. Moreover, recurrent episodes of hypoglycemia result in both the loss of the characteristic warning symptoms associated with hypoglycemia and an attenuated counterregulatory hormone responses. The blunting of warning symptoms is known as impaired awareness of hypoglycemia (IAH). Together, IAH and the loss of the hormonal response is termed hypoglycemia associated autonomic failure (HAAF). IAH is prevalent in up to 25% in people with T1D and up to 10% in people with T2D. IAH and HAAF increase the risk of severe hypoglycemia 6-fold and 25-fold, respectively. To reduce this risk for severe hypoglycemia, multiple different therapeutic approaches are being explored that could improve awareness of hypoglycemia. Current therapies to improve awareness of hypoglycemia include patient education and psychoeducation, the use of novel glycemic control technology, pancreas/islet transplantation, and drug therapy. This review examines both existing therapies and potential therapies that are in pre-clinical testing. Novel treatments that improve awareness of hypoglycemia, via improving the counterregulatory hormone responses or improving hypoglycemic symptom recognition, would also shed light on the possible neurological mechanisms that lead to the development of IAH. To reduce the risk of severe hypoglycemia in people with diabetes, elucidating the mechanism behind IAH, as well as developing targeted therapies is currently an unmet need for those that suffer from IAH.

Long-term glycemic variability predicts compromised development of heart failure with improved ejection fraction: a cohort study

Background

A substantial portion of heart failure (HF) patients adherent to guideline-directed medical therapies have experienced improved ejection fraction (EF), termed HFimpEF. Glycemic variability (GV) has emerged as a critical cardiometabolic factor. However, the relation between long-term GV and the incidence of HFimpEF is still unclear.

Methods

A total of 591 hospitalized HF patients with reduced EF (HFrEF, EF≤ 40%) admitted from January 2013 to December 2020 were consecutively enrolled. Repeat echocardiograms were performed at baseline and after around 12 months. The incidence of HFimpEF, defined as (1) an absolute EF improvement ≥10% and (2) a second EF > 40% and its association with long-term fasting plasma glucose (FPG) variability were analyzed.

Results

During a mean follow-up of 12.2 ± 0.6 months, 218 (42.0%) patients developed HFimpEF. Multivariate analysis showed FPG variability was independently associated with the incidence of HFimpEF after adjustment for baseline HbA1c, mean FPG during follow-up and other traditional risk factors (odds ratio [OR] for highest vs. lowest quartile of CV of FPG: 0.487 [95% CI 0.257~0.910]). Evaluation of GV by alternative measures yielded similar results. Subgroup analysis revealed that long-term GV was associated with HFimpEF irrespective of glycemic levels and diabetic conditions.

Conclusions

This study reveals that greater FPG variability is associated with compromised development of HFimpEF. A more stable control of glycemic levels might provide favorable effects on myocardial functional recovery in HF patients even without diabetes.

Glucose metabolism profile recorded by flash glucose monitoring system in patients with hypopituitarism during prednisone replacement

BACKGROUND

Commonly used glucocorticoids replacement regimens in patients with hypopituitarism have difficulty mimicking physiological cortisol rhythms and are usually accompanied by risks of over-treatment, with adverse effects on glucose metabolism. Disorders associated with glucose metabolism are established risk factors of cardiovascular events, one of the life-threatening ramifications.

AIM

To investigate the glycometabolism profile in patients with hypopituitarism receiving prednisone (Pred) replacement, and to clarify the impacts of different Pred doses on glycometabolism and consequent adverse cardiovascular outcomes.

METHODS

Twenty patients with hypopituitarism receiving Pred replacement [patient group (PG)] and 20 normal controls (NCs) were recruited. A flash glucose monitoring system was used to record continuous glucose levels during the day, which provided information on glucose-target-rate, glucose variability (GV), period glucose level, and hypoglycemia occurrence at certain periods. Islet β-cell function was also assessed. Based on the administered Pred dose per day, the PG was then regrouped into Pred > 5 mg/d and Pred ≤ 5 mg/d subgroups. Comparative analysis was carried out between the PG and NCs.

RESULTS

Significantly altered glucose metabolism profiles were identified in the PG. This includes significant reductions in glucose-target-rate and nocturnal glucose level, along with elevations in GV, hypoglycemia occurrence and postprandial glucose level, when compared with those in NCs. Subgroup analysis indicated more significant glucose metabolism impairment in the Pred > 5 mg/d group, including significantly decreased glucose-target-rate and nocturnal glucose level, along with increased GV, hypoglycemia occurrence, and postprandial glucose level. With regard to islet β-cell function, PG showed significant difference in homeostasis model assessment (HOMA)-β compared with that of NCs; a notable difference in HOMA-β was identified in Pred > 5 mg/d group when compared with those of NCs; as for Pred ≤ 5 mg/d group, significant differences were found in HOMA-β, and fasting glucose/insulin ratio when compared with NCs.

CONCLUSION

Our results demonstrated that Pred replacement disrupted glycometabolic homeostasis in patients with hypopituitarism. A Pred dose of > 5 mg/d seemed to cause more adverse effects on glycometabolism than a dose of ≤ 5 mg/d. Comprehensive and accurate evaluation is necessary to consider a suitable Pred replacement regimen, wherein, flash glucose monitoring system is a kind of promising and reliable assessment device. The present data allows us to thoroughly examine our modern treatment standards, especially in difficult cases such as hormonal replacement mimicking delicate natural cycles, in conditions such as diabetes mellitus that are rapidly growing in worldwide prevalence.

Correlation Analysis and Diagnostic Value of Serum Homocysteine, Cystatin C and Uric Acid Levels with the Severity of Coronary Artery Stenosis in Patients with Coronary Heart Disease

Background

Coronary angiography (CAG) is an invasive examination with high risks and costs and various complications may occur. It is necessary to find a diagnostic method, non-invasiveness, inexpensive with low risk. This study aims to analyze the correlation between the levels of serum homocysteine (Hcy), cystatin C (Cys C) and uric acid (UA) and Gensini score in patients with coronary heart disease (CHD) and assess their diagnostic value for CHD.

Methods

A retrospective analysis was conducted on 1412 patients underwent CAG from October 2019 to December 2021, and we conducted this study from January to July 2022. A total of 765 patients with CHD confirmed by CAG were selected as the research group, while 647 patients revealed as non-obstructive stenosis by CAG as the control group. The serum Hcy, Cys C and UA levels were detected and the correlation between Gensini score and variables was analyzed. The receiver-operating characteristic (ROC) curve was performed to assess the diagnostic value of the Hcy, Cys C and UA for CHD.

Results

The serum Hcy, Cys C and UA levels in the research group were higher as compared with the control group (p<0.05). Spearman correlation and multivariate linear regression analysis showed that there was a significantly positive correlation between Gensini score and serum Hcy, Cys C and UA levels (p<0.05). The ROC curve analysis presented the combined Hcy and Cys C with UA having the highest specificity of diagnostic value for CHD (area under the curve (AUC)=0.768, 95% CI 0.706-0.823, specificity = 72.34%, sensitivity = 67.88%, Youden Index = 0.4022).

Conclusion

The serum Hcy, Cys C and UA levels in patients with CHD were significantly increased, positive correlation with Gensini score. The combined Hcy and Cys C with UA could be used to assess the severity of coronary artery stenosis and provide predictive and early intervention treatment values for CHD and a new way of diagnosing CHD, which is cheap, safe, effective and deserving of clinical application.

Intensified glycemic control by HbA1c for patients with coronary heart disease and Type 2 diabetes: a review of findings and conclusions

The occurrence and development of coronary heart disease (CHD) are closely linked to fluctuations in blood glucose levels. While the efficacy of intensified treatment guided by HbA1c levels remains uncertain for individuals with diabetes and CHD, this review summarizes the findings and conclusions regarding HbA1c in the context of CHD. Our review showed a curvilinear correlation between regulated level of HbA1c and therapeutic effectiveness of intensified glycemic control among patients with type 2 diabetes and coronary heart disease. It is necessary to optimize the dynamic monitoring indicators of HbA1c, combine genetic profiles, haptoglobin phenotypes for example and select more suitable hypoglycemic drugs to establish more appropriate glucose-controlling guideline for patients with CHD at different stage of diabetes.

Cardiovascular disease in type 1 diabetes, an underestimated danger: Epidemiological and pathophysiological data

Cardiovascular disease (CV) is a common complication of type 1 diabetes (T1D) and a leading cause of death. T1D patients are more likely to develop CV disease (CVD) early in life and show a reduction of life expectancy of at least 11 years. Patients with a young age of T1D onset have a substantially higher CV risk. The reasons for increased atherosclerosis in T1D patients are not entirely explained. In addition to the typical CV risk factors, long-term hyperglycemia has a significant impact by inducing oxidative stress, vascular inflammation, monocyte adhesion, arterial wall thickening and endothelial dysfunction. Additionally, CVD in T1D is also associated with nephropathy. However, CVD risk is still significantly increased in T1D patients, in good glycemic control without additional CV risk factors, indicating the involvement of supplementary potential factors. By increasing oxidative stress, vascular inflammation, and endothelial dysfunction, hypoglycemia and glucose variability may exacerbate CVD. Moreover, significant qualitative and functional abnormalities of lipoproteins are present in even well-controlled T1D patients and are likely to play a role in the development of atherosclerosis and the promotion of CVD. According to recent research, immune system dysfunction, which is typical of auto-immune T1D, may also promote CVD, likely via inflammatory pathways. In addition, T1D patients who are overweight or obese exhibit an additional CV risk due to pathophysiological mechanisms that are similar to those seen in T2D.

Time in Range Estimation in Patients with Type 2 Diabetes is Improved by Incorporating Fasting and Postprandial Glucose Levels

INTRODUCTION

Time in range (TIR) as assessed by continuous glucose monitoring (CGM) measures an individual's glucose fluctuations within set limits in a time period and is increasingly used together with HbA1c in patients with diabetes. HbA1c indicates the average glucose concentration but provides no information on glucose fluctuation. However, before CGM becomes available for patients with type 2 diabetes (T2D) worldwide, especially in developing nations, fasting plasma glucose (FPG) and postprandial plasma glucose (PPG) are still the common biomarkers used for monitoring diabetes conditions. We investigated the importance of FPG and PPG to glucose fluctuation in patients with T2D. We used machine learning to provide a new estimate of TIR based on the HbA1c, together with FPG and PPG.

METHODS

This study included 399 patients with T2D. (1) Univariate and (2) multivariate linear regression models and (3) random forest regression models were developed to predict the TIR. Subgroup analysis was performed in the newly diagnosed T2D population to explore and optimize the prediction model for patients with different disease history.

RESULTS

Regression analysis suggests that FPG was strongly linked to minimum glucose, while PPG was strongly correlated with maximum glucose. After FPG and PPG were incorporated into the multivariate linear regression model, the prediction performance of TIR was improved compared with the univariate correlation between HbA1c and TIR, and the correlation coefficient (95% CI) increased from 0.62 (0.59, 0.65) to 0.73 (0.72, 0.75) (p < 0.001). The random forest model significantly outperformed the linear model (p < 0.001) in predicting TIR through FPG, PPG and HbA1c, with a stronger correlation coefficient 0.79 (0.79, 0.80).

CONCLUSIONS

The results offered a comprehensive understanding of glucose fluctuations through FPG and PPG compared to HbA1c alone. Our novel TIR prediction model based on random forest regression with FPG, PPG, and HbA1c provides a better prediction performance than the univariate model with solely HbA1c. The results indicate a nonlinear relationship between TIR and glycaemic parameters. Our results suggest that machine learning may have the potential to be used in developing better models for understanding patients' disease status and providing necessary interventions for glycaemic control.

Ghrelin does not impact the blunted counterregulatory response to recurrent hypoglycemia in mice

Introduction

Recurrent episodes of insulin-induced hypoglycemia in patients with diabetes mellitus can result in hypoglycemia-associated autonomic failure (HAAF), which is characterized by a compromised response to hypoglycemia by counterregulatory hormones (counterregulatory response; CRR) and hypoglycemia unawareness. HAAF is a leading cause of morbidity in diabetes and often hinders optimal regulation of blood glucose levels. Yet, the molecular pathways underlying HAAF remain incompletely described. We previously reported that in mice, ghrelin is permissive for the usual CRR to insulin-induced hypoglycemia. Here, we tested the hypothesis that attenuated release of ghrelin both results from HAAF and contributes to HAAF.

Methods

C57BL/6N mice, ghrelin-knockout (KO) + control mice, and GhIRKO (ghrelin cell-selective insulin receptor knockout) + control mice were randomized to one of three treatment groups: a "Euglycemia" group was injected with saline and remained euglycemic; a 1X hypoglycemia ("1X Hypo") group underwent a single episode of insulin-induced hypoglycemia; a recurrent hypoglycemia ("Recurrent Hypo") group underwent repeated episodes of insulin-induced hypoglycemia over five successive days.

Results

Recurrent hypoglycemia exaggerated the reduction in blood glucose (by ~30%) and attenuated the elevations in plasma levels of the CRR hormones glucagon (by 64.5%) and epinephrine (by 52.9%) in C57BL/6N mice compared to a single hypoglycemic episode. Yet, plasma ghrelin was equivalently reduced in "1X Hypo" and "Recurrent Hypo" C57BL/6N mice. Ghrelin-KO mice exhibited neither exaggerated hypoglycemia in response to recurrent hypoglycemia, nor any additional attenuation in CRR hormone levels compared to wild-type littermates. Also, in response to recurrent hypoglycemia, GhIRKO mice exhibited nearly identical blood glucose and plasma CRR hormone levels as littermates with intact insulin receptor expression (floxed-IR mice), despite higher plasma ghrelin in GhIRKO mice.

Conclusions

These data suggest that the usual reduction of plasma ghrelin due to insulin-induced hypoglycemia is unaltered by recurrent hypoglycemia and that ghrelin does not impact blood glucose or the blunted CRR hormone responses during recurrent hypoglycemia.

Association of hyperglycemia ratio and ventricular arrhythmia in critically ill patients admitted to the intensive care unit

INTRODUCTION

The relationship between relative hyperglycemia and ventricular arrhythmia (VA) in critically ill patients admitted to intensive care units (ICU) remains unclear. This study aims to investigate the association between stress hyperglycemia ratio (SHR) and VA in this population.

METHODS

This retrospective and observational study analyzed data from 4324 critically ill patients admitted to the ICU, obtained from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. The SHR was calculated as the highest blood glucose level during the first 24 h of ICU admission divided by the admission blood glucose level. Based on the optimal cut-off values under the receiver operating characteristic curve, patients were stratified into high SHR (≥ 1.31) and low SHR (< 1.31) group. To investigate the impact of diabetes mellitus (DM) on the outcome, patients were stratified as low SHR/DM; low SHR/non-DM; high SHR/DM, and high SHR/non-DM. Restricted cubic spline (RCS) and logistic regression analysis were performed to analyze the relationship between SHR and VA.

RESULTS

A total of 4,324 critically ill patients were included in this retrospective and observational study. The incidence of VA was higher in the high SHR group. Multiple-adjusted RCS revealed a "J-shaped" correlation between SHR and VA morbidity. The logistic regression model demonstrated that high SHR was associated with VA. The high SHR/non-DM group had a higher risk of VA than other groups stratified based on SHR and DM. Subgroup analysis showed that high SHR was associated with an increased risk of VA in patients with coronary artery disease.

CONCLUSION

High SHR is an independent risk factor and has potential as a biomarker of higher VT/VF risk in ICU-admitted patients.

HbA1c is a predictive factor of severe coronary stenosis and major adverse cardiovascular events in patients with both type 2 diabetes and coronary heart disease

BACKGROUND

Coronary heart disease (CHD) is not only a macrovascular complication of type 2 diabetes mellitus (T2DM). Cardiovascular disease (CVD) is one of the leading causes of mortality among individuals with T2DM. Reducing the risk of adverse cardiovascular events (MACE) is crucial for the management of patients with CHD. This study aimed to investigate the effect of glycemic control on CHD severity and 3-point MACE (3p-MACE) risk in patients with T2DM and CHD.

METHODS

681 patients with both T2DM and CHD throughout October 2017 and October 2021 who were hospitalized in the second affiliated hospital of Nanchang university were included. A total of 300 patients were eventually enrolled in this retrospective cohort research. The severity of CHD in these patients was assessed, and the primary outcome during follow-up was recorded, with the primary result being the 3-point major adverse cardiovascular event (3p-MACE). The correlation between baseline glycated hemoglobin A1c (b-HbA1c) and the severity of CHD was evaluated by logistic regression analysis. The effect of b-HbA1c and follow-up HbA1c (f-HbA1c) levels on the risk of 3p-MACE were investigated by cox regression analysis.

RESULTS

b-HbA1c was positively correlated with the severity of CHD (r = 0.207, p = 0.001), and patients with b-HbA1c > 9% were more likely to have severe CHD. The HRs for b-HbA1c and f-HbA1c on the risk of 3p-MACE were 1.24 (95% CI 0.94-1.64, p = 0.123) and 1.32 (95% CI 1.02-1.72, p = 0.036), respectively. Patients with f-HbA1c   ≥8.6% had a higher risk of 3p-MACE than f-HbA1c < 8.6% (HR = 1.79, 95% CI 1.16-2.79, p = 0.009).

CONCLUSION

In patients with both T2DM and CHD, b-HbA1c was an independent predictive factor of severe CHD. f-HbA1c was an independent predictive factor of 3p-MACE. Having the f-HbA1c below 8.6% significantly reduced the risk of 3p-MACE.

Increased Two-Hour Post-Load Plasma Glucose Fluctuation Corresponds with Worse Clinical Prognoses among Acute Ischemic Stroke Patients without a History of Diabetes Mellitus

INTRODUCTION

This study aimed to evaluate the relationship between 2-h post-load minus fasting plasma glucose (2hPG-FPG) and 1-year clinical outcomes, such as death, stroke recurrence, and modified Rankin Scale (mRS) ≥2-3 among acute ischemic stroke (AIS) patients without diabetes mellitus (DM) history.

METHODS

1,214 AIS patients without DM history, obtained from ACROSS-China, were divided into 4 quartiles, based on 2hPG-FPG measurements obtained 14 days post-admission. Four models were constructed using multivariate Cox and logistic regression analyses, based on the inclusion of age, gender, trial of ORG 10172 in acute stroke treatment, NIH Stroke Scale scores (model 1), plus 10 other clinical parameters (model 2), plus newly diagnosed DM (NDDM) post-admission (model 3), plus 2hPG and FPG (model 4). Associations found from those 4 models between 2hPG-FPG and 1-year clinical outcomes were confirmed via stratification, multiplicative interaction, sensitivity, and restricted cubic spline analyses.

RESULTS

The highest quartile of 2hPG-FPG, after adjusting for variables, such as stroke severity (model 2), was independently associated with death, stroke recurrence, and mRS ≥2-3 (odds ratio [OR] = 3.95, 2.96, 4.15, and 4.83, respectively, all p < 0.0001). Increased 2hPG-FPG remained independently associated with mRS ≥2-3 in models 3-4, as well as increased mRS ≥2 under stratification analyses among both non-NDDM and NDDM patients.

CONCLUSION

2hPG-FPG is a relatively specific indicator of poorer 1-year clinical prognoses among AIS patients, independent of NDDM, 2hPG, and FPG post-hospital admission. Therefore, the oral glucose tolerance test could be a useful approach for detecting a higher likelihood for developing poorer prognoses among patients without DM history.

Eating Vegetables First Regardless of Eating Speed Has a Significant Reducing Effect on Postprandial Blood Glucose and Insulin in Young Healthy Women: Randomized Controlled Cross-Over Study

People with fast eating habits have been reported to have an increased risk of diabetes and obesity. To explore whether the speed of eating a test meal (tomato, broccoli, fried fish, and boiled white rice) influences postprandial blood glucose, insulin, triglyceride, and free fatty acid levels, 18 young, healthy women consumed a 671 kcal breakfast at fast speed (10 min) and slow speed (20 min) with vegetables first and slow speed (20 min) with carbohydrate first on three separate days. This study was conducted using a within-participants cross-over design in which all participants consumed identical meals of three different eating speeds and food orders. Significant ameliorations of both fast and slow eating with vegetables first regimen on postprandial blood glucose and insulin levels at 30 and 60 min were observed compared with those of slow eating with carbohydrates first. In addition, the standard deviation, large amplitude of excursion, and incremental area under the curve for blood glucose and insulin in both fast and slow eating with vegetables first were all significantly lower than those of slow eating with carbohydrate first. Interestingly, there was no significant difference between fast and slow eating on postprandial blood glucose and insulin levels as long as vegetables were consumed first, although postprandial blood glucose at 30 min was significantly lower in slow eating with vegetables first than that of fast eating with the same food order. These results suggest that food order with vegetables first and carbohydrate last ameliorates postprandial blood glucose and insulin concentrations even if the meal was consumed at fast speed.

Long-Term Risk of Cardiovascular Disease Among Type 2 Diabetes Patients According to Average and Visit-to-Visit Variations of HbA1c Levels During the First 3 Years of Diabetes Diagnosis

BACKGROUND

It remains unclear whether a combination of glycemic variability and glycated hemoglobin (HbA1c) status leads to a higher incidence of cardiovascular disease (CVD). Therefore, to investigate CVD risk according to the glucose control status during early diabetes, we examined visit-to-visit HbA1c variability among patients with type 2 diabetes (T2DM).

METHODS

In this 9-year retrospective study, we measured HbA1c levels at each visit and tracked the change in HbA1c levels for 3 years after the first presentation (observation window) in newly diagnosed T2DM patients. We later assessed the occurrence of CVD in the last 3 years (target outcome window) of the study period after allowing a 3-year buffering window. The HbA1c variability score (HVS; divided into quartiles, HVS_Q1-4) was used to determine visit-to-visit HbA1c variability.

RESULTS

Among 4,817 enrolled T2DM patients, the mean HbA1c level was < 7% for the first 3 years. The group with the lowest HVS had the lowest rate of CVD (9.4%; 104/1,109 patients). The highest incidence of CVD of 26.7% (8/30 patients) was found in HVS [≥ 9.0%]_Q3, which was significantly higher than that in HVS [6.0-6.9%]_Q1 (P = 0.006), HVS [6.0-6.9%]_Q2 (P = 0.013), HVS [6.0-6.9%]_Q3 (P = 0.018), and HVS [7.0-7.9%]_Q3 (P = 0.040).

CONCLUSION

To our knowledge, this is the first long-term study to analyze the importance of both HbA1c change and visit-to-visit HbA1c variability during outpatient visits within the first 3 years. Lowering glucose levels during early diabetes may be more critical than reducing visit-to-visit HbA1c variability.

Data-Driven Identification of Long-Term Glycemia Clusters and Their Individualized Predictors in Finnish Patients with Type 2 Diabetes

Purpose

To gain an understanding of the heterogeneous group of type 2 diabetes (T2D) patients, we aimed to identify patients with the homogenous long-term HbA1c trajectories and to predict the trajectory membership for each patient using explainable machine learning methods and different clinical-, treatment-, and socio-economic-related predictors.

Patients and Methods

Electronic health records data covering primary and specialized healthcare on 9631 patients having T2D diagnosis were extracted from the North Karelia region, Finland. Six-year HbA1c trajectories were examined with growth mixture models. Linear discriminant analysis and neural networks were applied to predict the trajectory membership individually.

Results

Three HbA1c trajectories were distinguished over six years: "stable, adequate" (86.5%), "improving, but inadequate" (7.3%), and "fluctuating, inadequate" (6.2%) glycemic control. Prior glucose levels, duration of T2D, use of insulin only, use of insulin together with some oral antidiabetic medications, and use of only metformin were the most important predictors for the long-term treatment balance. The prediction model had a balanced accuracy of 85% and a receiving operating characteristic area under the curve of 91%, indicating high performance. Moreover, the results based on SHAP (Shapley additive explanations) values show that it is possible to explain the outcomes of machine learning methods at the population and individual levels.

Conclusion

Heterogeneity in long-term glycemic control can be predicted with confidence by utilizing information from previous HbA1c levels, fasting plasma glucose, duration of T2D, and use of antidiabetic medications. In future, the expected development of HbA1c could be predicted based on the patient's unique risk factors offering a practical tool for clinicians to support treatment planning.

The stress hyperglycemia ratio improves the predictive ability of the GRACE score for in-hospital mortality in patients with acute myocardial infarction

BACKGROUND

The Global Registry of Acute Coronary Events (GRACE) score is a powerful tool used to predict in-hospital mortality after acute myocardial infarction (AMI) and does not include a glycometabolism-related index. We investigated whether the addition of the stress hyperglycemia ratio (SHR) provides incremental prognostic value in addition to the GRACE score.

METHODS

A retrospective cohort of 613 AMI patients was enrolled in the present analyses. The patients were stratified according to the primary endpoint (in-hospital mortality) and the tertiles of the SHR.

RESULTS

During hospitalization, 40 patients reached the primary endpoint, which was more frequently observed in patients with a higher SHR. The SHR, but not admission blood glucose (ABG), adjusted for the GRACE score independently predicted in-hospital mortality [odds ratio 2.5861; 95% confidence interval (CI), 1.3910-4.8080; P = 0.0027]. The adjustment of the GRACE score by the SHR improved the predictive ability for in-hospital death (an increase in the C-statistic value from 0.787 to 0.814; net reclassification improvement, 0.6717, 95% CI 0.3665-0.977, P < 0.01; integrated discrimination improvement, 0.028, 95% CI 0.0066-0.0493, P = 0.01028). The likelihood ratio test showed that the SHR significantly improved the prognostic models, including the GRACE score. Adding the SHR to the GRACE score presented a larger net benefit across the range of in-hospital mortality risk than the GRACE score alone.

CONCLUSION

The SHR, but not the ABG, is an independent predictor of in-hospital mortality after AMI even after adjusting for the GRACE score. The SHR improves the predictability and clinical usefulness of prognostic models containing the GRACE score.

Short-term Glycemic Variability and Its Association With Macrovascular and Microvascular Complications in Patients With Diabetes

The introduction of continuous glucose monitoring inaugurated a new era in clinical practice by shifting the characterization of glycemic control from HbA1c to novel metrics. The one that gained widespread attention over the past decades was glycemic variability (GV), which typically refers to peaks and nadirs of blood glucose measured over a given time interval. GV can be dichotomized into two main categories: short-term and long-term. Short-term GV reflects within-day and between-day glycemic oscillations, and its contribution to diabetic complications remains an enigma. In this review, we summarize the available data about short-term GV and its possible association with both microvascular and macrovascular complications, evaluating different pathogenic mechanisms and demonstrating nonpharmaceutical, as well as pharmaceutical, therapeutic interventions.

Effect of repeated bolus and continuous glucose infusion on a panel of circulating biomarkers in healthy volunteers

HYPOTHESIS

Glycaemic variability (GV) refers to fluctuations in the blood glucose level and may contribute to complications in patients suffering from Diabetes. Several studies show negative effects of GV on the cardiovascular system, however there is still a lack of conclusive evidence. Using an explorative cardiovascular panel, it is possible to simultaneously measure the effects on proteins relevant for cardiovascular processes. The aim of this study was to investigate the effects of rapid glucose excursions on cardiovascular and metabolic parameters in healthy individuals.

METHODS

An explorative single-blinded cross-over study was performed in ten healthy men. Subjects received 3 times 20 grams of glucose i.v. over 5 minutes or 60 grams of glucose continuously over 3 hours. Blood was taken for repeated measurements of the cardiovascular panel over the following 6 hours and again after 24 and 48 hours.

RESULTS

We observed a significant elevation of 7 cardiovascular biomarkers (BMP6, SLAMF7, LOX-1, ADAMTS13, IL-1RA, IL-4RA, PTX3) at t = 360min after rapid glucose infusion compared to a continuous glucose infusion.

CONCLUSIONS

Intraday GV seems to have acute effects on cardiovascular proteins in healthy test persons. Rapid glucose administration compared to continuous administration showed significant changes in BMP6, SLAMF7, ADAMTS13, IL1RA, PTX3, IL-4RA and LOX-1.

CLINICAL TRIAL REGISTRATION

NCT04488848.

Anagliptin twice-daily regimen improves glycaemic variability in subjects with type 2 diabetes: A double-blind, randomized controlled trial

AIM

To determine whether the twice-daily (BID) regimen is superior to the once-daily (QD) regimen for managing glycaemic variability by comparing the effects of anagliptin 100 mg BID versus sitagliptin 100 mg QD.

MATERIALS AND METHODS

A double-blinded, randomized, multicentre study was performed in 89 patients with type 2 diabetes treated with metformin alone (6.5% < HbA1c < 8.5%). Subjects were randomly assigned to anagliptin 100 mg BID or sitagliptin 100 mg QD in a 1:1 ratio for 12 weeks. Continuous glucose monitoring was used to measure the mean amplitude of glycaemic excursion (MAGE) and postprandial time in range (TIR) before and after dipeptidyl peptidase-4 (DPP-4) inhibitor treatment to compare glycaemic variability.

RESULTS

The decrease from baseline in MAGE at 12 weeks after DPP-4 inhibitor treatment was significantly greater in the anagliptin BID group than in the sitagliptin QD group (P < .05); -30.4 ± 25.6 mg/dl (P < .001) in the anagliptin group versus -9.5 ± 38.0 mg/dl (P = .215) in the sitagliptin group. The TIR after dinner increased by 33.0% ± 22.0% (P < .001) in the anagliptin group and by 14.6% ± 28.2% (P = .014) in the sitagliptin group, with a statistically significant difference (P = .009). No statistically significant differences were observed between the groups in the changes in HbA1c and fasting plasma glucose (FPG).

CONCLUSIONS

The anagliptin BID regimen for the treatment of type 2 diabetes was superior in blood glucose control after dinner to improve glycaemic variability, as indicated by MAGE and TIR, but was equivalent to the QD regimen in terms of HbA1c and FPG.

Low FT3/FT4 Ratio Is Linked to Poor Prognosis of Acute Myocardial Infarction in Euthyroid Patients with Type 2 Diabetes Mellitus

This is an observational, retrospective, single-center study aimed to determine whether the free triiodothyronine (FT3) to free thyroxine (FT4) ratio was related to acute myocardial infarction (AMI) prognosis in individuals with type 2 diabetes mellitus (T2DM). A total of 294 euthyroid T2DM patients with new-onset AMI were enrolled. FT3/FT4 ratio tertiles were used to categorize patients into Group 1 (FT3/FT4 ≥ 4.3), Group 2 (3.5 ≤ FT3/FT4 < 4.3), and Group 3 (FT3/FT4 < 3.5). Major adverse cardiac events (MACE), including nonfatal myocardial infarction, target vessel revascularization (TVR), and cardiac mortality, served as the primary endpoint. Group 3 demonstrated a considerably higher incidence of MACE than the other two groups over the average follow-up duration of 21 ± 6.5 months (all p < 0.001). Multivariable Cox regression analysis showed that a low FT3/FT4 ratio was an independent risk factor for MACE after AMI (Group 1 as a reference; Group 2: hazard ratio [HR] 1.275, 95% confidence interval [CI]: 0.563−2.889, p = 0.561; Group 3: HR 2.456, 95% CI: 1.105−5.459, p = 0.027). Moreover, the area under the receiver-operating characteristic curve (AUC) indicates a good predictive value of FT3/FT4 ratio for MACE (AUC = 0.70). Therefore, in T2DM patients with AMI, a low FT3/FT4 ratio was strongly linked to poor prognosis.

Cost-Effectiveness of Intensive Versus Standard Blood Pressure Treatment in Older Patients With Hypertension in China

Background:

In the STEP trial (Strategy of Blood Pressure Intervention in older Hypertensive Patients), the risk of cardiovascular events is significantly lower in patients who received intensive systolic blood psressure (BP) treatment than in those who received standard treatment. This study compared the lifetime health benefits and medical costs of intensive BP treatment with those of standard BP treatment.

Methods:

A microsimulation model included 10 000 hypothetical samples of Chinese adults aged 60 to 80 years old with baseline systolic BP higher than 140 mm Hg. Primary outcome was the incremental cost-effectiveness ratio from a payer’s perspective. Secondary outcome was cardiovascular events, including acute coronary syndrome, stroke, acute decompensated heart failure, atrial fibrillation, and death from cardiovascular causes.

Results:

The model simulated that cardiovascular events occurred in 36.88% of the patients in the intensive treatment group, as compared to 41.28% of the patients in the standard treatment group over the lifetime horizon. The mean number of quality-adjusted life-years would be 0.16 higher in patients who received intensive treatment than in those who received standard treatment and would cost Chinese yuan 12 614 (International dollars 3018) more per quality-adjusted life-year gained. Most simulation results indicated that intensive treatment would be cost-effective (82%–95% below the willingness-to-pay threshold of Chinese yuan 72 000 [1× the gross domestic product per capita in China in 2020]). Sensitivity analyses showed that these conclusions were robust.

Conclusions:

In this study, intensive BP treatment prevented cardiovascular events among older patients with hypertension in China and was cost-effective in most scenarios.

Registration:

URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03015311

Association Between Time in Range and Postprandial Glucose Contribution Rate in Non-Insulin-Treated Type 2 Diabetes Patients: Inverse Correlation of Time in Range with Postprandial Glucose Contribution Rate

Background: Whether time in range (TIR), a parameter derived from continuous glucose monitoring (CGM), is a marker of postprandial hyperglycemia remains to be determined. In this study, we examined the association between TIR and postprandial glucose in non-insulin-treated type 2 diabetic patients. Methods: Our cross-sectional study included 729 non-insulin-treated patients with type 2 diabetes who underwent CGM without any changes in drug therapy on admission. The 24-h CGM record was analyzed for average glucose, standard deviation, percentage coefficient of variation, time above range, TIR, time below range, area under the curve (AUC) of basal glucose, AUC of postprandial glucose, and postprandial glucose contribution rate (%). The primary endpoint was the association between TIR and the postprandial glucose contribution rate. Results: We made TIR groups divided into 10% increments for a 7-group and compared with <40% to >90%. The basal and postprandial glucose AUCs correlated negatively with TIR. The postprandial glucose contribution rate correlated with TIR. The cutoff value for TIR, where postprandial glucose contribution rate was lower than the basal glucose contribution rate, was 66.3%. Conclusions: In non-insulin-treated type 2 diabetic patients, postprandial glucose AUC was higher in the high TIR group, whereas the basal glucose AUC was higher in the low TIR group. Good glycemic control can be achieved with therapeutic interventions that target postprandial glucose and basal glucose in patients with TIR ≥66.3% and <66.3%, respectively. University Medical Information Network [UMIN] ID: UMIN0000254333.

Evaluating Atherosclerosis of the Abdominal Aorta in Rabbits Using 2-D Strain Imaging

After establishment of an animal model of atherosclerosis, speckle tracking imaging was performed to analyze the correlation between ultrasound characteristics and pathological manifestations. Rabbits were divided into the normal control (NC) and atherosclerosis (AS) groups. Rabbits in the AS group were subjected to ultrasound-guided balloon injury of the abdominal aorta and fed a high-fat diet for 16 wk. Rabbits in the NC group were fed a normal diet for the same period. After 16 wk, all animals underwent serological tests, ultrasound and speckle tracking circumferential strain analysis. In the AS group, 28 hypo-echoic plaques had formed. The circumferential strain of six segments at the short axis of plaques in the AS group was lower than that in the NC group (p < 0.001), and global circumferential strain (GCS) in the AS group was significantly reduced compared with the NC group (p < 0.001). In the AS group, the area ratio of type I to type III collagen fibers was smaller than that in the NC group. The GCS of atherosclerotic plaques was positively correlated with the area ratio of type I to type III collagen fibers in plaques (r = 0.7181, p < 0.001). In conclusion, there is a significant positive correlation between the decreased circumferential strain and the decreased area ratio of type I to type III collagen fibers in hypo-echoic plaques.

Glycaemic variability and risk of adverse cardiovascular events in acute coronary syndrome

OBJECTIVE

The relationship between different glycaemic variability (GV) indexes and adverse cardiovascular outcomes is not well understood. This study aims to determine whether GV is related to the occurrence of adverse cardiovascular events in patients with acute coronary syndrome (ACS).

METHODS

PubMed, EMBASE, and Web of Science were comprehensively searched from the establishment of databases to 29 June 2022. The relationship between two important GV indexes, including the mean amplitude of glycemic excursion (MAGE) and standard deviation (SD), and the adverse cardiovascular events in ACS patients were evaluated, respectively.

RESULTS

A total of 11 studies with 3709 ACS patients were included. Pooled results showed that patients with higher GV had significantly increased risk of adverse cardiovascular events, including MAGE (relative risk [RR] = 1.76, 95% CI: 1.40 to 2.22, p < 0.001, I² = 25%) and SD (RR = 2.14, 95% CI: 1.73 to 2.66, p < 0.001, I² = 0%).

CONCLUSIONS

Increased GV is related to the poor prognosis in patients with ACS. Additionally, more well-designed studies comparing different indicators of GV with adverse cardiovascular events in ACS patients are still warranted.

Continuous glucose monitoring for detection of glycemic variability, hypoglycemia, and hyperglycemia in women with eating disorders

Background

The aim of this study was to investigate the relationships between hypoglycemia, hyperglycemia, glycemic variability (GV), and eating behavior by measuring daily glucose levels through an intermittently scanned continuous glucose monitoring (isCGM) system in outpatients classified according to eating disorder subtypes.

Methods

We analyzed data for 18 patients (four ANR, nine ANBP, and five BN cases). A FreeStyle Libre Pro® device was attached to the posterior aspect of the upper arm for glucose monitoring. This device conducted measurements every 15 min for five consecutive days. We estimated the mean amplitude of glycemic excursions (MAGE), hypoglycemia, and hyperglycemia.

Results

The mean glucose levels were 91.1 ± 2.2 mg/dL in the ANR group, 94.8 ± 7.5 mg/dL in the ANBP group, and 87.1 ± 8.0 mg/dL in the BN group (P = 0.174). The overall mean MAGE index was 52.8 ± 20.5 mg/dL. The mean MAGE values according to the subtypes were 42.2 ± 5.6 mg/dL in the ANR group, 57.4 ± 23.7 mg/dL in the ANBP group, and 53.0 ± 21.8 mg/dL in the BN group (P = 0.496). Over the course of five days, the frequency of hypoglycemia was as follows: three occurrences in the ANBP group, five occurrences in the BN group, and no occurrences in the ANR group (P = 0.016). Moreover, the occurrence of hypoglycemia was statistically significantly higher in the BN group than in the ANR group (P = 0.013). In the BN group, the frequency of hypoglycemia was highest between 2 and 6 AM, while hypoglycemia was observed throughout the day in the ANBP group. The frequency of hyperglycemia was one occurrence in the ANR group, one occurrence in the BN group, and zero occurrences in the ANBP group (P = 0.641).

Conclusions

Varying GV, hypoglycemia, and hyperglycemia were observed in all subtypes of eating disorders. Our findings suggest that eating behaviors such as binge eating and purging are associated with GV and hypoglycemia. We showed the importance of developing different nutritional approaches tailored to the subtype of eating disorder to prevent hypoglycemia. Additional studies are needed to explore the relationship between glucose levels and eating behaviors in patients with eating disorders.

Neuromuscular Electrical Stimulation during Hemodialysis Suppresses Postprandial Hyperglycemia in Patients with End-Stage Diabetic Kidney Disease: A Crossover Controlled Trial

Hemodialysis patients with diabetic kidney disease (DKD) experience blood glucose fluctuations owing to insulin removal. We evaluated the effects of single and long-term application of neuromuscular electrical stimulation (NMES) during hemodialysis on glycemic control. This trial was conducted in two stages: Stage 1, following a crossover design and 4 week washout period, eleven outpatients with DKD either underwent a single bout of NMES for 30 min (NMES period) or rested (control period) after receiving nutritional support during hemodialysis; Stage 2, following a crossover design and 4 week washout period, each participant received the intervention for 12 weeks. NMES was administered for 30 min at the maximum tolerable intensity. The mean subcutaneous glucose concentration and mean amplitude of glycemic excursion (MAGE) were determined by flash glucose monitoring for 24 h. Changes in glycoalbumin and MAGE before and after NMES initiation were evaluated. The mean blood glucose level and MAGE after a single bout of NMES were significantly lower than those after rest. Glycoalbumin levels and echo intensity of the rectus femoris tended to decrease, but not significantly by ANOVA due to a lack in statistical power after the dropout of three patients. NMES in end-stage DKD decreased blood glucose levels during and after hemodialysis.

Prognostic impact of stress hyperglycemia ratio in acute myocardial infarction patients with and without diabetes mellitus

BACKGROUND AND AIMS

Stress hyperglycemia ratio (SHR) is associated with increased in-hospital morbidity and mortality in patients with acute myocardial infarction (AMI). We aimed to investigate the impact of stress "hyperglycemia" on long-term mortality after AMI in patients with and without diabetes mellitus (DM).

METHODS AND RESULTS

We included 2089 patients with AMI between February 2014 and March 2018. SHR was measured with the fasting glucose divided by the estimated average glucose derived from glycosylated hemoglobin (HbA1c). The primary endpoint was all-cause death. Of 2 089 patients (mean age: 65.7 ± 12.4, 76.7% were men) analyzed, 796 (38.1%) had DM. Over a median follow-up of 2.7 years, 141 (6.7%) and 150 (7.2%) all-cause deaths occurred in the diabetic and nondiabetic cohorts, respectively. Compared with participants with low SHR (<1.24 in DM; <1.14 in non-DM), the hazard ratios and 95% confidence intervals for those with high SHR (≥1.24 in DM; ≥1.14 in non-DM) for all-cause mortality were 2.23 (1.54-3.23) and 1.79 (1.15-2.78); for cardiovascular mortality were 2.42 (1.63-3.59) and 2.10 (1.32-3.35) in DM and non-DM subjects, respectively. The mortality prediction was improved in the diabetic individuals with the incorporation of SHR into the Global Registry of Acute Coronary Events (GRACE) score, showing an increase in a continuous net reclassification index of 0.184 (95%CI: 0.003-0.365) and an absolute integrated discrimination improvement of 0.014 (95%CI: 0.002-0.025).

CONCLUSION

The improvement in the prediction of long-term mortality beyond the GRACE score indicates the potential of SHR as a biomarker for post-MI risk stratification among patients with DM.

REGISTRATION NUMBER FOR CLINICAL TRIALS

NCT03533543.

Evaluation of the relationship between hemodialysis-related glycemic variability and hormonal profiles in patients with type 2 diabetes on hemodialysis: a pilot study

Background

The number of dialysis patients with diabetes is currently increasing in Japan and a similar proportion worldwide. It was suggested that approximately 20% of these patients had hypoglycemia after dialysis session and most of these hypoglycemia were unconscious. Furthermore, it was suggested that glucose variabilities induced by hemodialysis may be related to insulin and insulin-counter hormones, such as glucagon, adrenocorticotropic hormone (ACTH), and cortisol and growth hormone, but conclusive evidence has not still been obtained.

Methods

We investigated in detail the glucose and hormonal profiles in 7 patients with type 2 diabetes on hemodialysis (all male, HbA1c 6.8 ± 2.1%, glycated albumin 24.7 ± 10.2%). All participants were attached continuous glucose monitoring (iPro2®). Blood glucose level, C-peptide immunoreactivity, plasma glucagon, ACTH, cortisol and growth hormone were measured by 7 points blood tests at before breakfast, after breakfast (predialysis), 2 h and 4 h after starting dialysis, after lunch and before/after dinner on the dialysis day and 6 points at before/after each meal on the non-dialysis day, and these relationship with blood glucose dynamics were examined. The meal contents were set to the indicated energy amount, and the same menu was served daily for breakfast, lunch, and dinner on dialysis and non-dialysis days of this study period. In addition, the start time of lunch on non-dialysis day was the same as the start time of lunch on the dialysis day.

Results

Serum C-peptide level was significantly increased by taking breakfast and lunch on the hemodialysis day, significantly decreased during hemodialysis, and was significantly lower before and after lunch on the hemodialysis day than on the non-hemodialysis day. Plasma glucagon level significantly decreased during hemodialysis and that before lunch on hemodialysis day was significantly lower than on non-hemodialysis day. ACTH, cortisol, and growth hormone did not show any changes related to hemodialysis.

Conclusions

It was suggested that C-peptide and glucagon play an important role in hemodialysis-related glycemic variabilities in patients with type 2 diabetic hemodialysis.

Trial registration UMIN Clinical Trial Registry (Registration Number UMIN000018707). Registered 18 August 2015, https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=brows&type=summary&language=J&recptno=R000021647.

The clinical impact of serum 1,5-anhydro-D-glucitol levels on coronary artery calcification and adverse outcomes assessed by coronary optical coherence tomography in diabetic patients

Background

Serum 1,5-anhydro-D-glucitol (1,5-AG) is a novel biomarker for short-term glycemic status and postprandial hyperglycemia. The association between serum 1,5-AG levels and coronary artery calcification (CAC) through a quantitative assessment using optical coherence tomography (OCT) is unclear. We aimed to evaluate this association using OCT in patients with diabetes mellitus (DM).

Methods

From June 2016 to December 2019, we prospectively enrolled 256 patients who underwent OCT-guided percutaneous coronary intervention (PCI). Half of the patients had diabetes. Patients were followed up for a mean period of 1.8 ± 0.8 years (median: 2.2 years). The relative calcium index and relative lipid core index measured by quantitative OCT analysis were used to evaluate the intra-plaque calcium and lipid levels of culprit plaques. We also analyzed the correlation between serum 1,5-AG levels and long-term major adverse cardiovascular events.

Results

Serum 1,5-AG levels were significantly lower in diabetic patients than in non-diabetic patients (DM vs. non-DM: 55.6 ± 27.9 μg/mL vs. 63.7 ± 26.1 μg/mL, p = 0.016), and lower in fibrocalcified lesions than in fibrotic or fibrolipidic lesions (fibrocalcified vs. fibrotic or fibrolipidic: 42.8 ± 19.1 vs. 72.9 ± 25.2 or 66.4 ± 27.5 μg/mL, p &lt; 0.001, respectively). In addition, we found a significant inverse correlation between serum 1,5-AG levels and relative calcium index (r = −0.729, p &lt; 0.001). In multivariate Cox regression analysis, low serum 1,5-AG level was identified as an independent predictor for major adverse cardiovascular events in diabetic patients (p = 0.043), but not in non-diabetic patients (p = 0.748) after adjusting for age and sex.

Conclusion

This study revealed that low serum 1,5-AG levels were associated with an increased risk of CAC as assessed by OCT, especially in diabetic patients. Low serum 1,5-AG levels may predict future major adverse cardiovascular events in diabetic patients undergoing OCT-guided PCI.

Effects of Carvedilol on Blood Pressure, Blood Sugar, and Blood Lipids in Elderly Patients with Refractory Hypertension

Refractory hypertension seriously affects the life safety of patients. To investigate the effect of carvedilol combined with conventional antihypertensive therapy on blood pressure, blood sugar, blood lipids, and cardiovascular and cerebrovascular complications in elderly patients with refractory hypertension, a total of 80 elderly patients with refractory hypertension who were admitted from June 2019 to September 2021 were selected as the retrospective research objects and divided into the observation group and the control group according to the random number table method, 40 cases in each group, and the control group received conventional antihypertensive therapy. On this basis, the observation group was treated with carvedilol, and the effects of blood pressure, blood sugar, blood lipids, and cardiovascular and cerebrovascular complications were analyzed in the two groups. After treatment, the systolic blood pressure, diastolic blood pressure, adrenal medulla (AM), and endothelin (ET) of the observation group were significantly lower than those of the control group, but the heart rate and NO of the observation group were significantly higher than those of the control group. After treatment, the fasting blood glucose, insulin, triacylglycerol (TG), cholesterol (CHO), and low-density lipoprotein (LDL-C) of the observation group were significantly higher than those of the control group, but the ISI and HDL-C of the observation group were significantly lower than those of the control group. After treatment, the levels of IL-1β, IL-6, TNF-α, UAER, BUN, and SCr in the observation group were significantly lower than those in the control group. The TC of the observation group was lower than that of the control group. Combination therapy has a remarkably stable, sustained, and safe antihypertensive effect on patients with refractory hypertension.

Divergent effect of blood glucose dysregulation on long-term clinical outcome in acute decompensated heart failure: A reappraisal in contemporary practice

BACKGROUND

The prognostic implication of elevated or decreased blood glucose (BG) level in acute decompensated heart failure (ADHF) has been still controversial. Indices of stress hyperglycemia, expressed by the ratio of BG and chronic BG control, has been reported to be associated with poor outcome in different disease population. We sought to assess BG at admission and %ΔBG, an index of BG deviation from estimated average BG calculated from glycated hemoglobin (HbA1c), on the long-term outcome in ADHF patients.

METHODS AND RESULTS

The West Tokyo Heart Failure (WET-HF) Registry is a prospective multicenter registry enrolling consecutive hospitalized ADHF patients. Among the patients (N = 3078, 77 [67-84] years, male 59%), BG at admission discriminated the long-term (1000 days) incidence of ADHF rehospitalization, but not cardiac death. BG at admission showed a U-shape relationship with the long-term incidence of ADHF rehospitalization after adjustment for covariates. Especially, in patients with HbA1c ≥ 6.5%, the lowest quartile showed the highest risk of ADHF rehospitalization. On the contrary, %ΔBG showed U-shape relationship with the long-term incidence of cardiac death after discharge, rather than ADHF rehospitalization after adjustment for covariates. In addition, elevated %ΔBG was associated with the long-term risk of sudden cardiac death (SCD) even after adjustment for covariates.

CONCLUSIONS

For ADHF patients, BG at admission and %ΔBG might be a simple, useful tool for predicting and stratifying long-term risk of cardiac events. Especially, elevated %ΔBG might be an important in predicting hard events such as cardiac death or SCD.

Newly diagnosed diabetes based on an oral glucose tolerance test predicts cardiovascular outcomes in patients with coronary artery disease: An observational study

Diabetes is prevalent in patients with coronary artery disease (CAD). Using the oral glucose tolerance test (OGTT), abnormal glucose regulation can be detected early in CAD patients without known diabetes. In the present study, we assessed the impact of abnormal glucose regulation on the long-term cardiovascular outcomes of patients with established CAD. Patients hospitalized for a scheduled angiography due to angina were enrolled in Taichung Veterans General Hospital. Fasting plasma glucose (FPG) and 2-hour postload glucose (2hPG) were assessed using the OGTT. Hemoglobin A1c (HbA1c) and other biochemical analyses were assessed using fasting blood samples. During a median follow-up period of 4.6 years, a composite of all-cause mortality, nonfatal myocardial infarction, and nonfatal stroke was recorded as the primary endpoint. In 682 enrolled patients who completed the follow-up, there were 16 myocardial infarction events, 12 stroke events, and 58 deaths as composite endpoints. According to FPG and 2hPG, patients with newly diagnosed diabetes had a 2-fold higher risk for the composite endpoint than those in the normal glucose group (hazard ratio [HR], 2.011; 95% confidence interval (CI), 1.101-3.673; P = .023); however, prediabetes was not significantly associated with the composite endpoint (HR, 1.452; 95% CI, 0.788-2.675; P = .232). On the other hand, patients with diabetes diagnosed by FPG and HbA1c did not have a significantly higher risk for the composite endpoint than those in the normal glucose group (HR, 1.321; 95% CI, 0.686-2.545; P = .405). A 2hPG ≥7.8 mmol/L was a significant predictor for the composite endpoint (odds ratio, 1.743; 95% CI, 1.060-2.863; P = .028) after adjusting for age, sex, and estimated glomerular filtration rate. Diabetes, but not prediabetes, detected via OGTT is associated with a significantly increased risk for the composite endpoint in patients with established CAD. The 2hPG provided a greater predictive power for the composite endpoint than fasting glucose and HbA1c.

Impact of Dietitian-Led Nutrition Therapy of Food Order on 5-Year Glycemic Control in Outpatients with Type 2 Diabetes at Primary Care Clinic: Retrospective Cohort Study

The aim of this retrospective cohort study was to evaluate the effect of 5-year follow-up of dietitian-led medical nutrition therapy (eating vegetables before carbohydrates) on glycemic control in outpatients with type 2 diabetes (T2DM) at a primary care clinic. A total of 138 patients with dietitian-led medical nutrition therapy (intervention group) and 104 patients without dietitian-led nutrition therapy (control group) were compared for glycemic control, serum lipid, blood pressure, and diabetic complications for 5 years. Each patient in the intervention group received dietary education focused on food order (eating vegetables before carbohydrates) by dietitians. A significant improvement in HbA1c after 5 years in the intervention group [8.5 ± 1.7% (69 mmol/mol) to 7.6 ± 1.1% (59 mmol/mol), p < 0.001] was observed, whereas no change was observed in the control group [7.9 ± 1.2% (62 mmol/mol) to 8.0 ± 1.2% (63 mmol/mol)]. Dietary intake of protein, fat, carbohydrates, cholesterol, and salt in the intervention group demonstrated significant reduction, while the intake of dietary fiber significantly increased after the dietary education. Simple dietary education of ‘eating vegetables before carbohydrates’ presented by dietitians achieved good glycemic control after a 5-year period in outpatients with T2DM at primary care clinic.

Nanozyme-mediated cascade reaction system for electrochemical detection of 1,5-anhydroglucitol

Diabetes is one of metabolic diseases affecting major human health. The early diagnosis and treatment of diabetes have significant benefits. 1,5-anhydroglucitol (1,5-AG) accurately reflects a patient's average blood glucose level for the past 3-7 days and becomes a promising marker for real-time detection of diabetes. In this study, a novel biosensor for determination 1,5-AG is constructed using reduce graphene oxide-carboxymethylated chitosan-hemin@platinum nanocomposites (rGO-CMC-H@Pt NCs) nanozyme and pyranose oxidase (PROD) enzyme as the electrochemical biosensing platform. The rGO-CMC-H@Pt NCs nanozyme has good electro-conductibility, high specific surface area, and admirable peroxide-like catalysis effect to enhance the electrochemical response. 1,5-AG is catalyzed by PROD and produces hydrogen peroxide (H₂O₂), which in turn can be decomposed by rGO-CMC-H@Pt NCs and produce a current signal recorded by differential pulse voltammetry (DPV) technique. Under optimal conditions, the response currents have a linear relationship in the 1,5-AG concentration of 0.1-2.0 mg/mL with R² of 0.9869. The sensitivity is 2.1895 μA/μg·mL^-1 and the limit of detection (LOD) is 38.2 μg/mL (S/N = 3). In addition, the specificity, reproducibility, stability and recovery (94.5-107.6%) of 1,5-AG biosensors all exhibit good performance. Therefore, the designed 1,5-AG biosensor has a good effect and can be used for the diagnosis of diabetes.