ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD: the Task Force on diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology (ESC) and developed in collaboration with the European Association for the Study of Diabetes (EASD)

Global research trends in prediabetes over the past decade: Bibliometric and visualized analysis

OBJECT

This study aimed to investigate global research advances and hot trends in prediabetes in the last decade based on a bibliometric analysis of publications. Publications from 2013 to 2022 were retrieved from the Web of Science Core Collection database through a topic search. With the use of CiteSpace, VOS viewer, and Bibliometrix R software packages, the number of publications, production categories, countries/regions, institutions, authors, journals, references, and keywords were comprehensively analyzed to sort out the hot spots and directions of prediabetes and predict the future research directions. A total of 13,223 papers were recruited for this study by the end of March 3, 2023. A generally increasing trend was observed in the number of annual publications. PLOS ONE (journal), USA (national), and the University of Copenhagen (institutional) published the most papers in this research area. The top 3 contributor authors were Tuomilehto Jaakko, Rathmann Wolfgang, and Peters Annette. "Intestinal microbiota" (2020-2022) was the most populated keyword in terms of intensity, and "biomarkers," "gut microbiota," and "metabolomics" were the most populated keywords in the last 3 years. "Prediabetes: a high-risk state for diabetes development-2012" was the strongest burst reference. This study summarized the research hotspots and trends in prediabetes research in the last decade. Frontier research can be found in the journal Diabetes Care and Journal of Clinical Endocrinology Metabolism. Prediabetes research focuses on preventing risk factors to reduce the prevalence of prediabetes, and current research hotspots focus on gut microbes and metabolism-related biomarkers.

Serum ACSL4 levels in patients with ST-segment elevation myocardial infarction (STEMI) and its association with one-year major adverse cardiovascular events (MACE): A prospective cohort study

In the present prospective cohort research, we aimed to explore the serum levels of Acyl-CoA synthetase long-chain family member 4 (ACSL4) in patients with ST-segment elevation myocardial infarction (STEMI) and its association with 1-year major adverse cardiovascular events (MACE). This prospective cohort study recruited 507 patients who underwent percutaneous coronary intervention for the treatment of STEMI at our hospital during August 2019 to July 2022. The serum ACSL4, tumor necrosis factor-α, interleukin (IL)-6, IL-1β, and C-reactive protein levels were measured by enzyme-linked immunosorbent assay. Demographic and clinical statistics were also collected. In addition, all patients were followed up for 1 year, and patients with MACE were defined as poor prognosis group. All data used SPSS 26.0 to statistical analyses. The poor prognosis group had significantly higher age and low-density leptin cholesterol (LDLC) levels compared to the favorable prognosis group (P < .05). STEMI patients exhibited significantly elevated serum levels of ACSL4, tumor necrosis factor-α, IL-6, IL-1β, and C-reactive protein (P < .05). Serum ACSL4 and IL-1β levels in the poor prognosis group were remarkably enhanced compared to the favorable prognosis group. Curvilinear regression analysis demonstrated that ACSL4 was associated with LDLC and IL-1β. Moreover, ACSL4 (B = 0.138, 95% CI 1.108-1.189, P < .001), LDLC (B = 2.317, 95% CI 5.253-19.603, P < .001), and IL-1β (B = 0.061, 95%CI 1.008-1.122, P = .025) levels were the risk factors for STEMI patients with 1-year MACE. This study showed that the serum ACSL4 levels was remarkably elevated in STEMI patients. This study might provide new targets and a comprehensive approach to cardiovascular protection in STEMI patients.

Cardiovascular and renal diseases in type 2 diabetes patients: 5-year cumulative incidence of the first occurred manifestation and hospitalization cost: a cohort within the French SNDS nationwide claims database

BACKGROUND

Myocardial infarction (MI), stroke, peripheral arterial disease (PAD), heart failure (HF) and chronic kidney disease (CKD) are common cardiovascular renal diseases (CVRD) manifestations for type 2 diabetes. The objective was to estimate the incidence of the first occurring CVRD manifestation and cumulative hospitalization costs of each CVRD manifestation for type 2 diabetes without CVRD history.

METHODS

A cohort study of all type 2 diabetes free of CVRD as of January 1st 2014, was identified and followed-up for 5 years within the French SNDS nationwide claims database. The cumulative incidence of the first occurring CVRD manifestation was estimated using the cumulative incidence function, with death as a competing risk. Cumulative hospitalization costs of each CVRD manifestations were estimated from the perspective of all payers.

RESULTS

From 2,079,089 type 2 diabetes without cancer or transplantation, 76.5% were free of CVRD at baseline with a mean age of 65 years, 52% of women and 7% with microvascular complications history. The cumulative incidence of a first CVRD manifestation was 15.3% after 5 years of follow-up with a constant linear increase over time for all CVRD manifestations: The most frequent was CKD representing 40.6% of first occurred CVRD manifestation, followed by HF (23.0%), then PAD (13.5%), stroke (13.2%) and MI (9.7%). HF and CKD together reached about one patient out of ten after 5 years and represented 63.6% of first CVRD manifestations. The 5-year global cost of all CVRD hospitalizations was 3.9 billion euros (B€), i.e. 2,450€ per patient of the whole cohort, with an exponential increase over time for each specific CVRD manifestation. The costliest was CKD (2.0 B€), followed by HF (1.2 B€), then PAD (0.7 B€), stroke (0.6 B€) and MI (0.3 B€).

CONCLUSIONS/INTERPRETATION

While MI, stroke and PAD remain classic major risks of complications for CVRD-free type 2 diabetes, HF and CKD nowadays represent individually a higher risk and cost than each of these classic manifestations, and jointly represents a risk and a cost twice as high as these three classic manifestations all together. This should encourage the development of specific HF and CKD preventive strategies.

What is the impact of ferroptosis on diabetic cardiomyopathy: a systematic review

Iron overload increases the production of harmful reactive oxygen species in the Fenton reaction, which causes oxidative stress in the body and lipid peroxidation in the cell membrane, and eventually leads to ferroptosis. Diabetes is associated with increased intracellular oxidative stress, inflammation, autophagy, microRNA alterations, and advanced glycation end products (AGEs), which cause cardiac remodeling and cardiac diastolic contractile dysfunction, leading to the development of diabetic cardiomyopathy (DCM). While these factors are also closely associated with ferroptosis, more and more studies have shown that iron-mediated ferroptosis is an important causative factor in DCM. In order to gain fresh insights into the functions of ferroptosis in DCM, this review methodically summarizes the traits and mechanisms connected with ferroptosis and DCM.

Silent myocardial infarction fatty scars detected by coronary calcium score CT scan in diabetic patients without history of coronary heart disease

OBJECTIVES

To evaluate the prevalence of intra-myocardial fatty scars (IMFS) most likely indicating previous silent myocardial infarction (SMI), as detected on coronary artery calcium (CAC) computed tomography (CT) scans in diabetic patients without history of coronary heart disease (CHD).

METHODS

Diabetic patients screened for silent coronary insufficiency in a tertiary-care, university hospital between Jan-2015 and Dec-2016 were categorized according to their CAC score in two groups comprising 242 patients with CACS = 0 and 145 patients with CACS ≥ 300. CAC-CT scans were retrospectively evaluated for subendorcardial and transmural IMFS of the left ventricle. Adipose remodeling, patients' characteristics, cardiovascular risk factors and metabolic profile were compared between groups.

RESULTS

Eighty-three (21%) patients with IMFS were identified, 55 (37.9%) in the group CACS ≥ 300 and 28 (11.6%) in the CACS = 0 (OR = 4.67; 95% CI = 2.78-7.84; p < 0.001). Total and average surface of IMFS and their number per patient were similar in both groups (p = 0.55; p = 0.29; p = 0.61, respectively). In the group CACS ≥ 300, patients with IMFS were older (p = 0.03) and had longer-lasting diabetes (p = 0.04). Patients with IMFS were older and had longer history of diabetes, reduced glomerular filtration rate, more coronary calcifications (all p < 0.05), and higher prevalence of carotid plaques (OR = 3.03; 95% CI = 1.43-6.39, p = 0.004). After correction for other variables, only a CACS ≥ 300 (OR = 5.12; 95% CI = 2.66-9.85; p < 0.001) was associated with an increased risk of having IMFS.

CONCLUSIONS

In diabetic patients without known CHD, IMFSs were found in patients without coronary calcifications, although not as frequently as in patients with heavily calcified coronary arteries. It remains to be established if this marker translates in an upwards cardiovascular risk restratification especially in diabetic patients with CACS = 0.

CLINICAL RELEVANCE STATEMENT

In diabetic patients without history of coronary heart disease, intramyocardial fatty scars, presumably of post-infarction origin, can be detected on coronary artery calcium CT scans more frequently, but not exclusively, if the coronary arteries are heavily calcified as compared to those without calcifications.

KEY POINTS

• Intramyocardial fatty scars (IMFS), presumably of post-infarction origin, can be detected on coronary artery calcium (CAC) CT scans more frequently, but not exclusively, in diabetic patients with CACS ≥ 300 as compared to patients CACS = 0. • Patients with IMFS were older and had longer history of diabetes, reduced glomerular filtration rate, and more coronary calcifications. • Carotid plaques and CACS ≥ 300 were associated with an increased risk of having IMFS, about three and five folds respectively.

Prediabetes-Associated Changes in Skeletal Muscle Function and Their Possible Links with Diabetes: A Literature Review

The skeletal muscle plays a critical role in regulating systemic blood glucose homeostasis. Impaired skeletal muscle glucose homeostasis associated with type 2 diabetes mellitus (T2DM) has been observed to significantly affect the whole-body glucose homeostasis, thereby resulting in other diabetic complications. T2DM does not only affect skeletal muscle glucose homeostasis, but it also affects skeletal muscle structure and functional capacity. Given that T2DM is a global health burden, there is an urgent need to develop therapeutic medical therapies that will aid in the management of T2DM. Prediabetes (PreDM) is a prominent risk factor of T2DM that usually goes unnoticed in many individuals as it is an asymptomatic condition. Hence, research on PreDM is essential because establishing diabetic biomarkers during the prediabetic state would aid in preventing the development of T2DM, as PreDM is a reversible condition if it is detected in the early stages. The literature predominantly documents the changes in skeletal muscle during T2DM, but the changes in skeletal muscle during prediabetes are not well elucidated. In this review, we seek to review the existing literature on PreDM- and T2DM-associated changes in skeletal muscle function.

Association of body mass index and long-term mortality in patients from nationwide LIPIDOGRAM 2004-2015 cohort studies: no obesity paradox?

BACKGROUND

An obesity paradox has been described in relation to adverse clinical outcomes (e.g., mortality) with lower body mass index (BMI).

AIMS

We sought to evaluate the association between BMI and weight loss with long-term all-cause mortality in adult populations under the care of family physicians.

METHODS

LIPIDOGRAM studies were conducted in primary care in Poland in 2004, 2006, and 2015 and enrolled a total of 45,615 patients. The LIPIDOGRAM Plus study included 1627 patients recruited in the LIPIDOGRAM 2004 and repeated measurements in 2006 edition. Patients were classified by BMI categories as underweight, normal weight, overweight and class I, II, or III (obesity). Follow-up data up to December 2021 were obtained from the Central Statistical Office. Differences in all-cause mortality were analyzed using Kaplan‒Meier and Cox regression analyses.

RESULTS

Of 45,615 patients, 10,987 (24.1%) were normal weight, 320 (0.7%) were underweight, 19,134 (41.9%) were overweight, and 15,174 (33.2%) lived with obesity. Follow-up was available for 44,620 patients (97.8%, median duration 15.3 years, 61.7% females). In the crude analysis, long-term all-cause mortality was lowest for the normal-weight group (14%) compared with other categories. After adjusting for comorbidities, the highest risk of death was observed for the class III obesity and underweight categories (hazard ratio, HR 1.79, 95% CI [1.55-2.05] and HR 1.57, 95% CI [1.22-2.04]), respectively. The LIPIDOGRAM Plus analysis revealed that a decrease in body weight (by 5 and 10%) over 2 years was associated with a significantly increased risk of death during long-term follow-up-HR 1.45 (95% CI 1.05-2.02, p = 0.03) and HR 1.67 (95% CI 1.02-2.74, p < 0.001). Patients who experienced weight loss were older and more burdened with comorbidities.

CONCLUSIONS

Being underweight, overweight or obese is associated with a higher mortality risk in a population of patients in primary care. Patients who lost weight were older and more burdened with cardiometabolic diseases, which may suggest unintentional weight loss, and were at higher risk of death in the long-term follow-up. In nonsmoking patients without comorbidities, the lowest mortality was observed in those with a BMI < 25 kg/m2, and no U-curve relationship was observed.

External validation of a cardiovascular risk model for Omani patients with type 2 diabetes mellitus: a retrospective cohort study

OBJECTIVES

To externally validate a recently developed cardiovascular disease (CVD) risk model for Omanis with type 2 diabetes mellitus (T2DM).

DESIGN

Retrospective cohort study.

SETTING

Nine primary care centres in Muscat Governorate, Oman.

PARTICIPANTS

A total of 809 male and female adult Omani patients with T2DM free of CVD at baseline were selected using a systematic random sampling strategy.

OUTCOME MEASURES

Data regarding CVD risk factors and outcomes were collected from the patients' electronic medical records between 29 August 2020 and 2 May 2021. The ability of the model to discriminate CVD risk was assessed by calculating the area under the curve (AUC) of the receiver-operating characteristic curve. Calibration of the model was evaluated using a Hosmer-Lemeshow χ2 test and the Brier score.

RESULTS

The incidence of CVD events over the 5-year follow-up period was 4.6%, with myocardial infarction being most frequent (48.6%), followed by peripheral arterial disease (27%) and non-fatal stroke (21.6%). A cut-off risk value of 11.8% demonstrated good sensitivity (67.6%) and specificity (66.5%). The area under the curve (AUC) was 0.7 (95% CI 0.60 to 0.78) and the Brier score was 0.01. However, the overall mean predicted risk was greater than the overall observed risk (11.8% vs 4.6%) and the calibration graph showed a relatively significant difference between predicted and observed risk levels in different subgroups.

CONCLUSIONS

Although the model slightly overestimated the CVD risk, it demonstrated good discrimination. Recalibration of the model is required, after which it has the potential to be applied to patients presenting to diabetic care centres elsewhere in Oman.

The impact of exercise modalities on blood glucose, blood pressure and body composition in patients with type 2 diabetes mellitus

BACKGROUND

Physical activity has been recommended as an important non-pharmacological therapeutic strategy for the management of type 2 diabetes mellitus (T2DM). The aim of this study was to investigate the effects of 12 weeks of strength, aerobic, and a combination of aerobic and resistance training on blood glucose level, blood pressure, and body composition in patients with T2DM.

METHODS

From Debremarkos referral hospital, 40 subjects with T2DM (mean age 42.45 years, 29 men, 11 women) were randomly assigned to one of three intervention groups or the control group. The following variables were measured: body mass index (BMI), fasting blood glucose (FBG), systolic blood pressure (SBP), diastolic blood pressure (DBP), and body fat percentage (BFP). Paired sample T-test and one-way ANCOVA were applied whilst controlling for diet, gender, and age.

RESULTS

All intervention groups showed improvement in a mean difference of FBG - 13.03 (t =-5.55, df = 39, p < 0.001), SBP - 21.63 mmHg - 17.6 mmHg (t =-6.51, df = 39, p < 0.001), DBP - 11.86 mmHg (t = -5.47, df = 39, p < 0.001) and BFP - 9.14 (t = -7.49, df = 39, p < 0.001). There was a significant difference in mean BMI reduction when diet, gender, and age were controlled in a one-way ANCOVA (F (3, 33) = 11.79, p < 0.001), SBP (F (3, 33) = 13.383, p < 0.001), DBP (F (3, 33) = 7.830, p < 0.001), FBG (F (3, 33) = 6.337, p < 0.001), BFP (F (3, 33) = 24.29, p < 0.001) between the exercise intervention groups and control group. Additionally, the estimated marginal means indicate that the combined strength and aerobic exercise intervention group experienced the greatest improvements.

CONCLUSION

Body composition, blood pressure, and fasting blood glucose were significantly lower in the combined (aerobic plus strength) treatment than in the individual treatment, indicating that the combined exercise intervention was more successful in altering these parameters.

mTORC1 and SGLT2 Inhibitors-A Therapeutic Perspective for Diabetic Cardiomyopathy

Diabetic cardiomyopathy is a critical diabetes-mediated co-morbidity characterized by cardiac dysfunction and heart failure, without predisposing hypertensive or atherosclerotic conditions. Metabolic insulin resistance, promoting hyperglycemia and hyperlipidemia, is the primary cause of diabetes-related disorders, but ambiguous tissue-specific insulin sensitivity has shed light on the importance of identifying a unified target paradigm for both the glycemic and non-glycemic context of type 2 diabetes (T2D). Several studies have indicated hyperactivation of the mammalian target of rapamycin (mTOR), specifically complex 1 (mTORC1), as a critical mediator of T2D pathophysiology by promoting insulin resistance, hyperlipidemia, inflammation, vasoconstriction, and stress. Moreover, mTORC1 inhibitors like rapamycin and their analogs have shown significant benefits in diabetes and related cardiac dysfunction. Recently, FDA-approved anti-hyperglycemic sodium-glucose co-transporter 2 inhibitors (SGLT2is) have gained therapeutic popularity for T2D and diabetic cardiomyopathy, even acknowledging the absence of SGLT2 channels in the heart. Recent studies have proposed SGLT2-independent drug mechanisms to ascertain their cardioprotective benefits by regulating sodium homeostasis and mimicking energy deprivation. In this review, we systematically discuss the role of mTORC1 as a unified, eminent target to treat T2D-mediated cardiac dysfunction and scrutinize whether SGLT2is can target mTORC1 signaling to benefit patients with diabetic cardiomyopathy. Further studies are warranted to establish the underlying cardioprotective mechanisms of SGLT2is under diabetic conditions, with selective inhibition of cardiac mTORC1 but the concomitant activation of mTORC2 (mTOR complex 2) signaling.

miR-200a-3p overexpression alleviates diabetic cardiomyopathy injury in mice by regulating autophagy through the FOXO3/Mst1/Sirt3/AMPK axis

OBJECTIVE

Hyperglycemia and insulin resistance or deficiency are characteristic features of diabetes. Diabetes is accompanied by cardiomyocyte hypertrophy, fibrosis and ventricular remodeling, and eventually heart failure. In this study, we established a diabetic cardiomyopathy (DCM) mouse model to explore the role and mechanism of miR-200a-3p in DCM.

METHODS

We used db/db mice to simulate the animal model of DCM and the expression of miR-200a-3p was then examined by RT-qPCR. Tail vein injection of mice was done with rAAV-miR-200a-3p for 8 weeks, and cardiac function was assessed by cardiac ultrasound. The levels of myocardial tissue injury, fibrosis, inflammation, apoptosis and autophagy in mice were detected by histological staining, TUNEL and other molecular biological experiments.

RESULTS

miR-200a-3p expression levels were significantly decreased in the myocardium of DCM mice. Diabetic mice developed cardiac dysfunction and presented pathological changes such as myocardial injury, myocardial interstitial fibrosis, cardiomyocyte apoptosis, autophagy, and inflammation. Overexpression of miR-200a-3p expression significantly ameliorated diabetes induced-cardiac dysfunction and myocardial injury, myocardial interstitial fibrosis, cardiomyocyte apoptosis, and inflammation, and enhanced autophagy. Mechanistically, miR-200a-3p interacted with FOXO3 to promote Mst1 expression and reduce Sirt3 and p-AMPK expression.

CONCLUSION

In type 2 diabetes, increased miR-200a-3p expression enhanced autophagy and participated in the pathogenic process of cardiomyopathy throug7 Mst1/Sirt3/AMPK axis regulation by its target gene FOXO3. This conclusion provides clues for the search of new gene targeted therapeutic approaches for diabetic cardiomyopathy.

Glycaemic control using mobile-based intervention in patients with diabetes undergoing coronary artery bypass-study protocol for a randomized controlled trial

BACKGROUND

Applying technology through the use of the Internet and mobile phones can help provide education and trained peer support for patients with diabetes after coronary artery bypass (CABG). We are conducting a randomized controlled trial to evaluate the efficacy and feasibility of mobile-based coaching intervention in improving risk-factor control and secondary prevention in patients with diabetes after CABG.

METHODS

The glycaemic control using miniprogram-based intervention in patients with diabetes undergoing coronary artery bypass to promote self-management (GUIDE ME) study is a multi-centre, randomized controlled trial of mobile intervention versus standard treatment with 6 months follow-up conducted in 2 hospitals in China. The interventions are education and a reminder system based on the WeChat mini-program. Participants in the intervention groups receive 180 videos (including lines) about secondary prevention education for 6 months as well as the standard treatment. Behavioural change techniques, such as prompting barrier identification, motivational skills, and goal setting, are employed. A total sample size of 820 patients would be adequate for the GUIDE ME study. The primary outcome is the change of glycaemic haemoglobin (HbA1c) at 6 months. Secondary outcomes include a change in the proportions of patients achieving HbA1c, fasting blood glucose, systolic blood pressure, low-density lipoprotein cholesterol (LDL-C) and medication adherence.

DISCUSSION

This trial is the first to investigate the efficacy of mobile phone WeChat-based video coaching and medication reminder mini-program system to improve self-management in patients with diabetes and coronary heart disease (CHD) after CABG and has the potential to be applied in resource-limited settings across diverse populations. If successful, such mobile intervention could be used and scaled up to improve care for this high-risk group of patients.

TRIAL REGISTRATION

ClinicalTrials, NCT04192409 . Registered on December 10, 2019.

An Easy-to-Use Nomogram Based on SII and SIRI to Predict in-Hospital Mortality Risk in Elderly Patients with Acute Myocardial Infarction

Aim

Inflammatory response is closely associated with poor prognosis in elderly patients with acute myocardial infarction (AMI). The aim of this study was to develop an easy-to-use predictive model based on medical history data at admission, systemic immune inflammatory index (SII), and systemic inflammatory response index (SIRI) to predict the risk of in-hospital mortality in elderly patients with AMI.

Methods

We enrolled 1550 elderly AMI patients (aged ≥60 years) with complete medical history data and randomized them 5:5 to the training and validation cohorts. Univariate and multivariate logistic regression analyses were used to screen risk factors associated with outcome events (in-hospital death) and to establish a nomogram. The discrimination, calibration, and clinical application value of nomogram were evaluated based on receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA), respectively.

Results

The results of multivariate logistic regression showed that age, body mass index (BMI), previous stroke, diabetes, SII, and SIRI were associated with in-hospital death, and these indicators will be included in the final prediction model, which can be obtained by asking the patient's medical history and blood routine examination in the early stage of admission and can improve the utilization rate of the prediction model. The areas under the ROC curve for the training and validation cohorts nomogram were 0.824 (95% CI 0.796 to 0.851) and 0.809 (95% CI 0.780 to 0.836), respectively. Calibration curves and DCA showed that nomogram could better predict the risk of in-hospital mortality in elderly patients with AMI.

Conclusion

The nomogram constructed by combining SII, SIRI, and partial medical history data (age, BMI, previous stroke, and diabetes) at admission has a good predictive effect on the risk of in-hospital death in elderly patients with AMI.

Risk of atrial fibrillation in individuals with dysglycemia and diabetes

OBJECTIVE

Diabetes is a risk factor for atrial fibrillation (AF), and increases the risk of thromboembolic events in persons with AF. However, the link between the two conditions is not fully elucidated. Few studies have investigated the association of dysglycemia and incident AF. We investigated the risk of incident AF and prognosis according to diabetes status.

RESEARCH DESIGN AND METHODS

The Copenhagen Primary Care Laboratory Database was merged with data on medical prescriptions, in- and outpatient contacts and vital status. The risk of AF according to diabetes status was investigated by use of Cox regression models.

RESULTS

Of 354.807 individuals with a hemoglobin A1c (HbA1c) measurement, 28.541 (8 %) had known diabetes, 13.038 (4 %) had new onset diabetes and 27.754 (8 %) had prediabetes (HbA1c 42-47 mmol/mol). Persons with dysglycemia (HbA1c > 42 mmol/mol) and diabetes were older, more were men, they had lower level of education and were more likely to be living alone. We observed a gradual increase in risk of developing AF from HbA1c levels of 40 to 60 mmol/mol. In adjusted analyses we found a stepwise increase in hazard of AF from normoglycemia over prediabetes to persons with diabetes (no diabetes: 1.00 [ref.]; prediabetes: 1.12 [1.08-1.16]; new-onset diabetes: 1.16 [1.10-1.22]; known diabetes: 1.15 [1.11-1.20]). Persons with known diabetes had a significant higher hazard of stroke, cardiovascular and all-cause mortality.

CONCLUSION

Increasing levels of HbA1c were associated with an increased hazard of developing AF. Persons with new onset of diabetes and those with known diabetes had similar hazard of developing AF, however persons with known diabetes had a significant higher hazard of stroke, cardiovascular- and all-cause mortality.

Gluconeogenesis Flux in Metabolic Disease

Gluconeogenesis is a critical biosynthetic process that helps maintain whole-body glucose homeostasis and becomes altered in certain medical diseases. We review gluconeogenic flux in various medical diseases, including common metabolic disorders, hormonal imbalances, specific inborn genetic errors, and cancer. We discuss how the altered gluconeogenic activity contributes to disease pathogenesis using data from experiments using isotopic tracer and spectroscopy methodologies. These in vitro, animal, and human studies provide insights into the changes in circulating levels of available gluconeogenesis substrates and the efficiency of converting those substrates to glucose by gluconeogenic organs. We highlight ongoing knowledge gaps, discuss emerging research areas, and suggest future investigations. A better understanding of altered gluconeogenesis flux may ultimately identify novel and targeted treatment strategies for such diseases.

Tanshinone IIA ameliorates experimental diabetic cardiomyopathy by inhibiting endoplasmic reticulum stress in cardiomyocytes via SIRT1

Diabetic cardiomyopathy (DCM) is a common complication in patients with diabetes, and ultimately leads to heart failure. Endoplasmic reticulum stress (ERS) induced by abnormal glycolipid metabolism is a critical factor that affects the occurrence and development of DCM. Additionally, the upregulation/activation of silent information regulation 2 homolog-1 (SIRT1) has been shown to protect against DCM. Tanshinone II A (Tan IIA), the main active component of Salviae miltiorrhizae radix et rhizome (a valuable Chinese medicine), has protective effects against cardiovascular disease and diabetes. However, its role and mechanisms in diabetes-induced cardiac dysfunction remain unclear. Therefore, we explored whether Tan IIA alleviates ERS-mediated DCM via SIRT1 and elucidated the underlying mechanism. The results suggested that Tan IIA alleviated the pathological changes in the hearts of diabetic mice, ameliorated the cytopathological morphology of cardiomyocytes, reduced the cell death rate, and inhibited the expression of ERS-related proteins and mRNA. The SIRT1 agonist inhibited the activities of glucose-regulated protein 78 (GRP78). Furthermore, the opposite results under the SIRT1 inhibitor. SIRT1 knockdown was induced by siRNA-SIRT1 transfection, and the degree of GRP78 acetylation was increased. Cumulatively, Tan IIA ameliorated DCM by inhibiting ERS and upregulating SIRT1 expression.

Comparative analysis of level of evidence and class of recommendation for 50 clinical practice guidelines released by the European Society of Cardiology from 2011 to 2022

BACKGROUND

The European Society of Cardiology (ESC) clinical practice guidelines are essential tools for decision-making.

AIM

To analyze the level of evidence (LOE) and the class of recommendations in the ESC guidelines released in the last 12 years.

METHODS

We evaluated 50 ESC guidelines released from 2011 to 2022, related to 27 topics and categorized them into seven macro-groups. We analyzed every recommendation in terms of LOE and class of recommendation, calculating their relative proportions and changes over time in consecutive editions of the same guideline.

RESULTS

A total of 6972 recommendations were found, with an increase in number per year over time. Among the 50 ESC guidelines, the proportional distribution of classes of recommendations was 49% for Class I, 29% for Class IIa, 15% for Class IIb, and 8% for Class III. Overall, 16% of the recommendations were classified as LOE A, 31% LOE B and 53% LOE C. The field of preventive cardiology had the largest proportion of LOE A, while the lowest was in the field of valvular, myocardial, pericardial and pulmonary diseases. The overall proportion of LOE A recommendations in the most recent guidelines compared to their prior versions increased from 17% to 20%.

CONCLUSIONS

The recommendations included in the ESC guidelines widely differ in terms of quality of evidence, with only 16% supported by the highest quality of evidence. Although a slight global increase in LOE A recommendations was observed in recent years, further scientific research efforts are needed to increase the quality of evidence.

Diabetes mellitus and adverse outcomes after carotid endarterectomy: A systematic review and meta-analysis

BACKGROUND

There is still uncertainty regarding whether diabetes mellitus (DM) can adversely affect patients undergoing carotid endarterectomy (CEA) for carotid stenosis. The aim of the study was to assess the adverse impact of DM on patients with carotid stenosis treated by CEA.

METHODS

Eligible studies published between 1 January 2000 and 30 March 2023 were selected from the PubMed, EMBASE, Web of Science, CENTRAL, and ClinicalTrials databases. The short-term and long-term outcomes of major adverse events (MAEs), death, stroke, the composite outcomes of death/stroke, and myocardial infarction (MI) were collected to calculate the pooled effect sizes (ESs), 95% confidence intervals (CIs), and prevalence of adverse outcomes. Subgroup analysis by asymptomatic/symptomatic carotid stenosis and insulin/noninsulin-dependent DM was performed.

RESULTS

A total of 19 studies (n = 122,003) were included. Regarding the short-term outcomes, DM was associated with increased risks of MAEs (ES = 1.52, 95% CI: [1.15-2.01], prevalence = 5.1%), death/stroke (ES = 1.61, 95% CI: [1.13-2.28], prevalence = 2.3%), stroke (ES = 1.55, 95% CI: [1.16-1.55], prevalence = 3.5%), death (ES = 1.70, 95% CI: [1.25-2.31], prevalence =1.2%), and MI (ES = 1.52, 95% CI: [1.15-2.01], prevalence = 1.4%). DM was associated with increased risks of long-term MAEs (ES = 1.24, 95% CI: [1.04-1.49], prevalence = 12.2%). In the subgroup analysis, DM was associated with an increased risk of short-term MAEs, death/stroke, stroke, and MI in asymptomatic patients undergoing CEA and with only short-term MAEs in the symptomatic patients. Both insulin- and noninsulin-dependent DM patients had an increased risk of short-term and long-term MAEs, and insulin-dependent DM was also associated with the short-term risk of death/stroke, death, and MI.

CONCLUSIONS

In patients with carotid stenosis treated by CEA, DM is associated with short-term and long-term MAEs. DM may have a greater impact on adverse outcomes in asymptomatic patients after CEA. Insulin-dependent DM may have a more significant impact on post-CEA adverse outcomes than noninsulin-dependent DM. Whether DM management could reduce the risk of adverse outcomes after CEA requires further investigation.

Women with type 2 diabetes have LDL cholesterol levels higher than those of men, regardless of their treatment and their cardiovascular risk level

BACKGROUND AND AIMS

Several works have shown that control of the principal cardiovascular risk factors, especially LDL-C, is poorer among women with type 2 diabetes than men with this disease. Our objectives were to compare the statin treatments and LDL-C levels between men and women with type 2 diabetes, according to the potency of the statin they take, while taking their cardiovascular risk level into account.

METHOD AND RESULTS

This is a descriptive cross-sectional study within the French CONSTANCES cohort. At inclusion, each individual completed several self-administered questionnaires. Data were then matched to their health insurance fund reimbursement data. The study population comprises cohort members with pharmacologically treated type 2 diabetes. We identified 2541 individuals with type 2 diabetes; 2214 had an available LDL-C value. In the total sample, treatment by statins did not differ between men and women, while the women had a higher mean LCL-C level than men. The analyses stratified by cardiovascular risk showed that women at very high cardiovascular risk received significantly less frequent statin delivery than men (OR = 0.72 [0.56-0.92]; p = 0.01). At the same time, women received the same rate of high-potency statins as men. Women taking equivalently potent statins had significantly higher LDL-C levels than men did.

CONCLUSION

For the same cardiovascular risk level and the same statin treatment, women had an LDL-C level higher than that of men. They thus present a residual cardiovascular risk that justifies intensification of their statin treatment if tolerance allows.

Prevalence of glucose metabolism disorders and its association with left atrial remodelling before and after catheter ablation in patients with atrial fibrillation

AIMS

To investigate the exact prevalence of glucose metabolism disorders, and their impact on left atrial (LA) remodelling and reversibility in patients with atrial fibrillation (AF).

METHODS AND RESULTS

We examined 204 consecutive patients with AF who underwent their first catheter ablation (CA). Oral glucose tolerance test was used to evaluate glucose metabolism disorders in 157 patients without known diabetes mellitus (DM). Echocardiography was performed before and 6 months after CA. Oral glucose tolerance test identified abnormal glucose metabolism in 86 patients [11 with newly diagnosed DM, 74 with impaired glucose tolerance (IGT) and 1 with impaired fasting glucose (IFG)]. Ultimately, 65.2% of patients had abnormal glucose metabolism. Diabetes mellitus group had the worst LA reservoir strain and LA stiffness (both P < 0.05), while there was no significant difference in baseline LA parameters between normal glucose tolerance (NGT) group and IGT/IFG group. The prevalence of LA reverse remodelling (≥15% decrease in the LA volume index at 6 months after CA) was significantly higher in NGT group compared with IGT/IFG and DM group (64.1 vs. 38.6 vs. 41.5%, P = 0.006). Both DM and IFG/IGT carry a significant risk of lack of LA reverse remodelling independent of baseline LA size and AF recurrence.

CONCLUSION

Approximately 65% of patients with AF who underwent their first CA had abnormal glucose metabolism. Patients with DM had significantly impaired LA function compared with non-DM patients. Impaired glucose tolerance/IFG as well as DM carries significant risk of unfavourable LA reverse remodelling. Our observations may provide valuable information regarding the mechanisms and therapeutic strategies of glucose metabolism-related AF.

Association between the Finnish Diabetes Risk Score and cancer in middle-aged and older adults: Involvement of inflammation

BACKGROUND

Diabetes is associated with increased risk of common cancers. However, evidence of cancer risk in individuals with different diabetes risk is still scarce, and the underlying mechanism remains unknown. Therefore, we aimed to evaluate the relationship between the Finnish Diabetes Risk Score (FINDRISC) and risks of cancer incidence and mortality in a prospective study, and to explore whether low-grade inflammation partially mediated the association.

METHODS

A total of 330,384 participants aged 37 to 73 at baseline from the UK Biobank database was included in this study. The Cox proportional hazards model was used to examine the relationship of the FINDRISC and low-grade inflammation with risks of cancer incidence and mortality. Then, we estimated the contribution of higher FINDRISC to risks of overall and site-specific cancers. In addition, the role of low-grade inflammation in the association between FINDRISC and cancer risks was investigated through mediation analysis.

RESULTS

The increased FINDRISC was dose-dependently associated with higher incidence and mortality risks of overall cancer and an overwhelming majority of site-specific cancers. The higher FINDRISC was a strong contributor to incidence of eighteen site-specific cancers and mortality of fourteen site-specific cancers, with a population-attributable risk of 8.1 %-39.1 %, 14.2 %-39.7 %, respectively. Additionally, low-grade inflammation mainly mediated the association between the FINDRISC and risks of incidence and mortality of overall cancer, colorectal cancer, etc. CONCLUSIONS: Our findings highlighted the higher FINDRISC as critical risk factors of cancer incidence and mortality, partially mediated by low-grade inflammation. Individuals with increased risk of diabetes are also needed to be concerned about cancer prevention.

Treatment of type 2 diabetes patients with heart conditions

INTRODUCTION

While type 2 diabetes mellitus (T2DM) increases the risk of cardiac complications, diabetes treatment choices may increase or decrease the rates of cardiac events. In the present review, we comprehensively discussed the treatment options of diabetic subjects with cardiac conditions.

AREAS COVERED

Current evidence related to diabetes treatment in cardiac situations has been reviewed. Clinical trials and meta-analyses on cardiac safety of anti-diabetic medicines are discussed. Treatment choices with proven benefits and those at least without associated increased cardiac risk were drawn from clinical trials; meta-analyses and cardiac safety studies in the recent medical literature were the basis of the suggestions in the present review.

EXPERT OPINION

We can suggest that hypoglycemia and extreme hyperglycemia should be avoided in acute ischemic heart conditions. Certain diabetic treatment options, especially sodium-glucose cotransporter-2 (SGLT2) inhibitors, can reduce overall cardiovascular mortality and hospitalization due to heart failure. Therefore, we suggest that physicians should choose SGLT2 inhibitors as the first-line treatment option in diabetic patients with heart failure or those who have a high risk of heart failure development. T2DM increases the risk of atrial fibrillation (AF), and metformin and pioglitazone seem to reduce the risk of AF in diabetic population.

Prognostic Utility of Coronary Computed Tomography Angiography-derived Plaque Information on Long-term Outcome in Patients With and Without Diabetes Mellitus

PURPOSE

To investigate the long-term prognostic value of coronary computed tomography angiography (cCTA)-derived plaque information on major adverse cardiac events (MACE) in patients with and without diabetes mellitus.

MATERIALS AND METHODS

In all, 64 patients with diabetes (63.3±10.1 y, 66% male) and suspected coronary artery disease who underwent cCTA were matched with 297 patients without diabetes according to age, sex, cardiovascular risk factors, and statin and antithrombotic therapy. MACE were recorded. cCTA-derived risk scores and plaque measures were assessed. The discriminatory power to identify MACE was evaluated using multivariable regression analysis and concordance indices.

RESULTS

After a median follow-up of 5.4 years, MACE occurred in 31 patients (8.6%). In patients with diabetes, cCTA risk scores and plaque measures were significantly higher compared with nondiabetic patients (all P <0.05). The following plaque measures were predictors of MACE using multivariable Cox regression analysis (hazard ratio [HR]) in patients with diabetes: segment stenosis score (HR=1.20, P <0.001), low-attenuation plaque (HR=3.47, P =0.05), and in nondiabetic patients: segment stenosis score (HR=1.92, P <0.001), Agatston score (HR=1.0009, P =0.04), and low-attenuation plaque (HR=4.15, P =0.04). A multivariable model showed a significantly improved C-index of 0.96 (95% confidence interval: 0.94-0.0.97) for MACE prediction, when compared with single measures alone.

CONCLUSION

Diabetes is associated with a significantly higher extent of coronary artery disease and plaque features, which have independent predictive values for MACE. cCTA-derived plaque information portends improved risk stratification of patients with diabetes beyond the assessment of obstructive stenosis on cCTA alone with subsequent impact on individualized treatment decision-making.

Epigenetic modifier alpha-ketoglutarate modulates aberrant gene body methylation and hydroxymethylation marks in diabetic heart

BACKGROUND

Diabetic cardiomyopathy (DCM) is a leading cause of death in diabetic patients. Hyperglycemic myocardial microenvironment significantly alters chromatin architecture and the transcriptome, resulting in aberrant activation of signaling pathways in a diabetic heart. Epigenetic marks play vital roles in transcriptional reprogramming during the development of DCM. The current study is aimed to profile genome-wide DNA (hydroxy)methylation patterns in the hearts of control and streptozotocin (STZ)-induced diabetic rats and decipher the effect of modulation of DNA methylation by alpha-ketoglutarate (AKG), a TET enzyme cofactor, on the progression of DCM.

METHODS

Diabetes was induced in male adult Wistar rats with an intraperitoneal injection of STZ. Diabetic and vehicle control animals were randomly divided into groups with/without AKG treatment. Cardiac function was monitored by performing cardiac catheterization. Global methylation (5mC) and hydroxymethylation (5hmC) patterns were mapped in the Left ventricular tissue of control and diabetic rats with the help of an enrichment-based (h)MEDIP-sequencing technique by using antibodies specific for 5mC and 5hmC. Sequencing data were validated by performing (h)MEDIP-qPCR analysis at the gene-specific level, and gene expression was analyzed by qPCR. The mRNA and protein expression of enzymes involved in the DNA methylation and demethylation cycle were analyzed by qPCR and western blotting. Global 5mC and 5hmC levels were also assessed in high glucose-treated DNMT3B knockdown H9c2 cells.

RESULTS

We found the increased expression of DNMT3B, MBD2, and MeCP2 with a concomitant accumulation of 5mC and 5hmC, specifically in gene body regions of diabetic rat hearts compared to the control. Calcium signaling was the most significantly affected pathway by cytosine modifications in the diabetic heart. Additionally, hypermethylated gene body regions were associated with Rap1, apelin, and phosphatidyl inositol signaling, while metabolic pathways were most affected by hyperhydroxymethylation. AKG supplementation in diabetic rats reversed aberrant methylation patterns and restored cardiac function. Hyperglycemia also increased 5mC and 5hmC levels in H9c2 cells, which was normalized by DNMT3B knockdown or AKG supplementation.

CONCLUSION

This study demonstrates that reverting hyperglycemic damage to cardiac tissue might be possible by erasing adverse epigenetic signatures by supplementing epigenetic modulators such as AKG along with an existing antidiabetic treatment regimen.

Achievement of the ESC recommendations for secondary prevention of cardiovascular risk factors in high-risk patients with type 2 diabetes: A real-world national cohort analysis

AIM

To assess compliance with European Society of Cardiology (ESC) secondary prevention recommendations in a nationwide contemporary population with diabetes mellitus (DM) and coronary artery disease.

METHOD

We conducted a retrospective observational study using linked health data in patients across Wales with DM undergoing percutaneous coronary intervention (2012-2017). The follow-up was for one year. We analysed the clinical characteristics, medications, target levels for HbA1c, low-density lipoprotein cholesterol (LDL-C), non-high-density lipoprotein cholesterol (non-HDL-C) and blood pressure against the ESC prevention guidelines.

RESULTS

Overall, 3478 patients with diabetes had available data at 1-year post-PCI. Only 43% had HbA1c levels <53 mmol/L, but 81% had blood pressure < 140/80 (current ESC targets). Prescribing frequency of the newer hypoglycaemic agents (glucagon-like peptide-1 receptor agonists and sodium-glucose co-transporter 2 inhibitors) was suboptimal, with a higher rate in patients with HbA1c ≥53 mmol/mol. Only 51% & 27% of the patients had LDL-C levels <1.8 &1.4 mmol/L (2016 & 2019 guidelines recommendations respectively), and 55% & 34% had non-HDL-C levels <2.6 & 2.2 mmol/L (2016 & 2019 guidelines respectively). Of the uncontrolled LDL-C patients, 42% (2016 target) and 35% (2019 target) were prescribed high-intensity statins. Females were more likely to have LDL-C targets above the recommended level.

CONCLUSION

Achievement of ESC treatment goals in this very-high risk cohort for DM and hyperlipidaemia was far from optimal, with a low prescription rate of the guidelines-recommended therapy. Target goals for hypertension were met more frequently. An up-to-date analysis reflecting the current practice against the most recent guidelines is warranted.

Pleiotropic Effects of Sodium-Glucose Cotransporter-2 Inhibitors in Cardiovascular Disease and Chronic Kidney Disease

Sodium-glucose cotransporter-2 inhibitors (SGLT2is) have been shown to improve cardiovascular and renal outcomes in patients with established cardiovascular disease, chronic kidney disease (CKD), and heart failure (HF) with reduced or preserved ejection fraction. Clinical benefit has been substantiated in patients with and without type 2 diabetes (T2D). Consequently, SGLT2is have an increasingly important role in HF and CKD management that extends beyond T2D treatment. Their pleiotropic pharmacological effects underlying their cardiovascular and renal benefits are not completely understood but include significant effects beyond blood glucose reduction. SGLT2is inhibit the reabsorption of glucose and sodium in the proximal tubule which, in addition to lowering blood glucose, activates tubuloglomerular feedback, leading to reduced glomerular hydrostatic pressure and the mitigation of glomerular filtration rate loss. SGLT2is have diuretic and natriuretic effects, leading to decreased blood pressure, preload, and left ventricular (LV) filling pressure, and improvements in other surrogates of afterload. In HF, SGLT2is mitigate the risks of hyperkalemia and ventricular arrhythmia and improve LV dysfunction. SGLT2is also reduce sympathetic tone and uric acid levels, increase hemoglobin levels, and are postulated to have anti-inflammatory properties. This narrative review discusses the multifactorial and interrelated pharmacological mechanisms underlying the cardiovascular and renal benefits of SGLT2is.

Replacement substance P reduces cardiac fibrosis in monkeys with type 2 diabetes

BACKGROUND

Type 2 diabetes mellitus (T2DM)-associated cardiac fibrosis contributes to heart failure. We previously showed that diabetic mice with cardiomyopathy, including cardiac fibrosis, exhibit low levels of the neuropeptide substance P; exogenous replacement of substance P reversed cardiac fibrosis, independent of body weight, blood glucose and blood pressure. We sought to elucidate the effectiveness and safety of replacement substance P to ameliorate or reverse cardiac fibrosis in type 2 diabetic monkeys.

METHODS

Four female T2DM African Green monkeys receive substance P (0.5 mg/Kg/day S.Q. injection) for 8 weeks. We obtained cardiac magnetic resonance imaging and blood samples to assess left ventricular function and fibrosis by T1 map-derived extracellular volume as well as circulating procollagen type I C-terminal propeptide. Hematological parameters for toxicities were also assessed in these monkeys and compared with three female T2DM monkeys receiving saline S.Q. as a safety comparison group.

RESULTS

Diabetic monkeys receiving replacement substance P exhibited a ∼20% decrease in extracellular volume (p = 0.01), concomitant with ∼25% decrease procollagen type I C-terminal propeptide levels (p = 0.008). Left ventricular ejection fraction was unchanged with substance P (p = 0.42); however, circumferential strain was improved (p < 0.01). Complete blood counts, glycosylated hemoglobin A1c, lipids, liver and pancreatic enzymes, and inflammation markers were unchanged (p > 0.05).

CONCLUSIONS

Replacement substance P reversed cardiac fibrosis in a large preclinical model of type 2 diabetes, independent of glycemic control. No hematological or organ-related toxicity was associated with replacement substance P. These results strongly support a potential application for replacement substance P as safe therapy for diabetic cardiac fibrosis.

Long-term aerobic and combined exercises enhance the satiety response and modulate the energy intake in patients with type 2 diabetes mellitus (T2DM): A randomized controlled trial

BACKGROUND

Energy homeostasis plays a vital role in achieving glycemic control in people with type 2 diabetes mellitus (T2DM). Exercise is known to increase energy expenditure. However, its role in energy intake has not been explored in people with T2DM. Thus, this study aimed at determining the impact of long-term aerobic and combined exercises in modulating hunger, satiety and energy intake in T2DM.

METHODS

A randomized controlled trial, with 108 people with T2DM, aged 35-60 years were assigned into an aerobic, combined (aerobic and resistance) and a control group. Primary outcomes were subjective levels of hunger and satiety measured by a 100 mm visual analogue scale in relation to a standard breakfast meal (453 kcal) and energy and macronutrient intake determined by a 3-day diet diary at 0, 3 and 6 months.

RESULTS

Aerobic and combined groups exhibited reduced hunger and increased satiety at 3 and 6 months (p < 0.05). The combined group demonstrated a profound increase in satiety at 3 and 6 months compared to aerobics (3 months; p = 0.008, 6 months; p = 0.002) and controls (3 months; p = 0.006, 6 months, p = 0.014). Mean daily energy intake was reduced only at 6 months in the aerobic group (p = 0.012), whereas it was reduced in the combined group at 3 and at 6 months compared to controls (3 months: p = 0.026, 6 months: p = 0.022).

CONCLUSIONS

Long-term aerobic and combined exercises produced a reduction in hunger, energy intake and increase satiety in people with T2DM. Despite energy expenditure, exercise seems to play a significant role in reducing energy intake as well. Combined exercises show more advantages over aerobic exercise since combined exercises have a greater impact on satiety and energy intake in people with T2DM.

TRIAL REGISTRATION NUMBER

SLCTR/2015/029, https://slctr.lk/trials/slctr-2015-029 .

HbA1c-based rather than fasting plasma glucose-based definitions of prediabetes identifies high-risk patients with angiographic coronary intermediate lesions: a prospective cohort study

BACKGROUND

Prediabetes is common and associated with poor prognosis in patients with acute coronary syndrome and those undergoing revascularization. However, the impact of prediabetes on prognosis in patients with coronary intermediate lesions remains unclear. The objective of the current study is to explore the impact of prediabetes and compare the prognostic value of the different definitions of prediabetes in patients with coronary intermediate lesions.

METHODS

A total of 1532 patients attending Fuwai hospital (Beijing, China), with intermediate angiographic coronary lesions, not undergoing revascularization, were followed-up from 2013 to 2021. Patients were classified as normal glucose tolerance (NGT), prediabetes and diabetes according to various definitions based on HbA1c or admission fasting plasma glucose (FPG). The primary endpoint was defined as major adverse cardiovascular events (MACE), the composite endpoint of all-cause death, non-fatal myocardial infarction and repeated revascularization therapy. Multivariate cox regression model was used to explore the association between categories of abnormal glucose category and MACE risk.

RESULTS

The proportion of patients defined as prediabetes ranged from 3.92% to 47.06% depending on the definition used. A total of 197 MACE occurred during a median follow-up time of 6.1 years. Multivariate cox analysis showed that prediabetes according to the International Expert Committee (IEC) guideline (6.0 ≤ HbA1c < 6.5%) was associated with increased risk of MACE compared with NGT (hazard ratio [HR]: 1.705, 95% confidence interval [CI] 1.143-2.543) and after confounding adjustment (HR: 1.513, 95%CI 1.005-2.277). Consistently, the best cut-off point of glycated haemoglobin (HbA1c) identified based on the Youden's index was also 6%. Restricted cubic spline analysis delineated a linear positive relationship between baseline HbA1c and MACE risk. Globally, FPG or FPG-based definition of prediabetes was not associated with patients' outcome.

CONCLUSIONS

In this cohort of patients with intermediate coronary lesions not undergoing revascularization therapy, prediabetes based on the IEC-HbA1c definition was associated with increased MACE risk compared with NGT, and may assist in identifying high-risk patients who can benefit from early lifestyle intervention.

Effects of delayed hospitalization on the 3-year clinical outcomes of patients with or without diabetes who had non-ST-segment-elevation myocardial infarction and underwent new-generation drug-eluting stent implantation

Clinical outcomes after non-ST-segment-elevation myocardial infarction (NSTEMI) in patients with (symptom-to-door time [SDT] ≥ 24 h) or without (SDT < 24 h) delayed hospitalization among patients with or without diabetes were compared. From the Korea Acute Myocardial Infarction Registry-National Institute of Health, a total of 4517 patients with NSTEMI who underwent new-generation drug-eluting stents implantation were recruited and they were classified into the diabetes mellitus (DM) and non-DM groups. These two groups were subdivided into groups with and without delayed hospitalization. The primary clinical outcome was the occurrence of major adverse cardiac and cerebrovascular events (MACCE), defined as all-cause death, recurrent myocardial infarction, repeat coronary revascularization, and stroke. The secondary clinical outcome was the occurrence of individual components of MACCE and stent thrombosis. Although after multivariable and propensity score-adjusted analyses in the DM group, the primary and secondary clinical outcomes between the SDT < 24 h and SDT ≥ 24 h groups were similar; in the non-DM group, all-cause (p = 0.003 and p = 0.007, respectively) and cardiac (p = 0.001 and p = 0.008, respectively) death rates were significantly higher in the SDT ≥ 24 h group than in the SDT < 24 h group. Our results suggested that there was no significant difference in prognosis between diabetic patients with and without delayed SDT, but delayed SDT was associated with poor prognosis in nondiabetic patients.

Muscle Lipid Oxidation Is Not Affected by Obstructive Sleep Apnea in Diabetes and Healthy Subjects

The molecular mechanisms linking obstructive sleep apnea (OSA) with type 2 diabetes mellitus (T2DM) remain unclear. This study investigated the effect of OSA on skeletal muscle lipid oxidation in nondiabetic controls and in type 2 diabetes (T2DM) patients. Forty-four participants matched for age and adiposity were enrolled: nondiabetic controls (control, n = 14), nondiabetic patients with severe OSA (OSA, n = 9), T2DM patients with no OSA (T2DM, n = 10), and T2DM patients with severe OSA (T2DM + OSA, n = 11). A skeletal muscle biopsy was performed; gene and protein expressions were determined and lipid oxidation was analyzed. An intravenous glucose tolerance test was performed to investigate glucose homeostasis. No differences in lipid oxidation (178.2 ± 57.1, 161.7 ± 22.4, 169.3 ± 50.9, and 140.0 ± 24.1 pmol/min/mg for control, OSA, T2DM, and T2DM+OSA, respectively; p > 0.05) or gene and protein expressions were observed between the groups. The disposition index, acute insulin response to glucose, insulin resistance, plasma insulin, glucose, and HBA1C progressively worsened in the following order: control, OSA, T2DM, and T2DM + OSA (p for trend <0.05). No association was observed between the muscle lipid oxidation and the glucose metabolism variables. We conclude that severe OSA is not associated with reduced muscle lipid oxidation and that metabolic derangements in OSA are not mediated through impaired muscle lipid oxidation.

The effect of type 2 diabetes mellitus on multiple obstructive coronary artery disease

BACKGROUND

Although type 2 diabetes mellitus (T2DM) individuals easily develop three-vessel disease (3VD) coronary artery disease (CAD), there is very little information available about their left ventricle (LV) functions. The purpose of this study is to evaluate the LV function using two-dimensional speckle tracking echocardiography (2-D STE) in T2DM patients with 3VD.

METHODS

One hundred and three consecutive patients with confirmed 3VD CAD were enrolled and divided into two groups, while 53 patients with DM and 50 patients without. The control group was composed of 30 age- and sex-matched healthy individuals. All patients underwent 2-D STE and standard echocardiograms. The durations of DM and the level of HbA1c were also recorded.

RESULT

Between the 3VD-DM and 3VD-non-DM groups, normal echocardiography did not reveal any appreciable differences. However, patients with 3VD-DM had significantly lower global longitudinal strain (GLS) than those with 3VD-non-DM (15.87 ± 2.51 vs.17.56 ± 2.72, p < .05) by 2-D STE strain measurement. Besides, patients whose duration of DM excess 5 years showed significant lower GLS than those with less than 5 years duration (14.25 ± 2.31 vs. 16.65 ± 1.96, p = .007). However, there was no difference in GLS between the 3VD-DM patients with HbA1c ≥ 7% and HbA1c < 7%.

CONCLUSIONS

Compared to patients with 3VD alone, those with 3VD-DM have a lower cardiac function. In 3VD-DM patients, the duration of DM is a significant factor that contributes to cardiac function deterioration, whereas, the glucose control state has limited influence.

The association of glycated hemoglobin A1c with coronary artery disease, myocardial infarction, and severity of coronary lesions

Glycated hemoglobin A1c (HbA1c) has been recognized as a predictor of cardiovascular events. However, the relationship between HbA1c and coronary artery disease (CAD) in the Chinese population has yet to be systematically explored. In addition, factors associated with HbA1c were generally analyzed linearly, thereby failing to appreciate more complex nonlinear associations. The study aimed to evaluate the relationship between the HbA1c value and the presence and severity of coronary artery stenosis. A total of 7192 consecutive patients who underwent coronary angiography were enrolled. Their biological parameters, including HbA1c, were measured. The severity of coronary stenosis was evaluated using Gensini score. After correcting for baseline confounding factors, a multivariate logistic regression analysis was used to evaluate the relationship between HbA1c and CAD severity. Restricted cubic splines were applied to explore the relation of HbA1c with the presence of CAD, myocardial infarction (MI), and the severity of coronary lesions. HbA1c was significantly associated with the presence and severity of CAD in patients without diagnosed diabetes (odds ratio: 1.306, 95% confidence interval: 1.053-1.619, p = 0.015). Spline analysis showed a U-shaped association of HbA1c with the presence of MI. Both HbA1c > 7.2% and HbA1c < 5.7% were associated with the presence of MI. In conclusion, HbA1c value was highly associated with the severity of coronary artery stenosis in the whole study population, and in CAD patients without diagnosed diabetes. Compared with patients with HbA1c levels between 6.0% and 7.0%, HbA1c < 5.7% and HbA1c > 7.2% were associated with higher presence of MI.

Empagliflozin attenuates arrhythmogenesis in diabetic cardiomyopathy by normalizing intracellular Ca2+ handling in ventricular cardiomyocytes

Diabetic cardiomyopathy has been reported to increase the risk of fatal ventricular arrhythmia. The beneficial effects of the selective sodium-glucose cotransporter-2 inhibitor have not been fully examined in the context of antiarrhythmic therapy, especially its direct cardioprotective effects despite the negligible SGLT2 expression in cardiomyocytes. We aimed to examine the antiarrhythmic effects of empagliflozin (EMPA) treatment on diabetic cardiomyocytes, with a special focus on Ca²⁺ handling. We conducted echocardiography and hemodynamic studies and studied electrophysiology, Ca²⁺ handling, and protein expression in C57BLKS/J-lepr^db/db mice (db/db mice) and their nondiabetic lean heterozygous Lepr^db/+ littermates (db/⁺ mice). Preserved systolic function with diastolic dysfunction was observed in 16-wk-old db/db mice. During arrhythmia induction, db/db mice had significantly increased premature ventricular complexes (PVCs) than controls, which was attenuated by EMPA. In protein expression analyses, calmodulin-dependent protein kinase II (CaMKII) Thr287 autophosphorylation and CaMKII-dependent RyR2 phosphorylation (S2814) were significantly increased in diabetic hearts, which were inhibited by EMPA. In addition, global O-GlcNAcylation significantly decreased with EMPA treatment. Furthermore, EMPA significantly inhibited ventricular cardiomyocyte glucose uptake. Diabetic cardiomyocytes exhibited increased spontaneous Ca²⁺ events and decreased sarcoplasmic reticulum (SR) Ca²⁺ content, along with impaired Ca²⁺ transient, all of which normalized with EMPA treatment. Notably, most EMPA-induced improvements in Ca²⁺ handling were abolished by the addition of an O-GlcNAcase (OGA) inhibitor. In conclusion, EMPA attenuated ventricular arrhythmia inducibility by normalizing the intracellular Ca²⁺ handling, and we speculated that this effect was, at least partly, due to the inhibition of O-GlcNAcylation via the suppression of glucose uptake into cardiomyocytes.NEW & NOTEWORTHY SGLT2is are known to improve cardiovascular outcomes regardless of the presence of diabetes and decrease traditional cardiovascular risk factors. We demonstrated, for the first time, that EMPA inhibited PVCs by normalizing Ca²⁺ handling in diabetic mice. Our data suggest that the effects of SGLT2is on calcium handling may occur because of suppression of O-GlcNAcylation through inhibition of glucose uptake and not because of NHE inhibition, as previously suggested.

Emerging Therapy for Diabetic Cardiomyopathy: From Molecular Mechanism to Clinical Practice

Diabetic cardiomyopathy is characterized by abnormal myocardial structure or performance in the absence of coronary artery disease or significant valvular heart disease in patients with diabetes mellitus. The spectrum of diabetic cardiomyopathy ranges from subtle myocardial changes to myocardial fibrosis and diastolic function and finally to symptomatic heart failure. Except for sodium–glucose transport protein 2 inhibitors and possibly bariatric and metabolic surgery, there is currently no specific treatment for this distinct disease entity in patients with diabetes. The molecular mechanism of diabetic cardiomyopathy includes impaired nutrient-sensing signaling, dysregulated autophagy, impaired mitochondrial energetics, altered fuel utilization, oxidative stress and lipid peroxidation, advanced glycation end-products, inflammation, impaired calcium homeostasis, abnormal endothelial function and nitric oxide production, aberrant epidermal growth factor receptor signaling, the activation of the renin–angiotensin–aldosterone system and sympathetic hyperactivity, and extracellular matrix accumulation and fibrosis. Here, we summarize several important emerging treatments for diabetic cardiomyopathy targeting specific molecular mechanisms, with evidence from preclinical studies and clinical trials.

Multicenter Randomized Trial of Intermittently Scanned Continuous Glucose Monitoring Versus Self-Monitoring of Blood Glucose in Individuals With Type 2 Diabetes and Recent-Onset Acute Myocardial Infarction: Results of the LIBERATES Trial

OBJECTIVE

To analyze the impact of modern glucose-monitoring strategies on glycemic and patient-related outcomes in individuals with type 2 diabetes (T2D) and recent myocardial infarction (MI) and assess cost effectiveness.

RESEARCH DESIGN AND METHODS

LIBERATES was a multicenter two-arm randomized trial comparing self-monitoring of blood glucose (SMBG) with intermittently scanned continuous glucose monitoring (isCGM), also known as flash CGM, in individuals with T2D and recent MI, treated with insulin and/or a sulphonylurea before hospital admission. The primary outcome measure was time in range (TIR) (glucose 3.9-10 mmol/L/day) on days 76-90 post-randomization. Secondary and exploratory outcomes included time in hypoglycemia, hemoglobin A1c (HbA1c), clinical outcome, quality of life (QOL), and cost effectiveness.

RESULTS

Of 141 participants randomly assigned (median age 63 years; interquartile range 53, 70), 73% of whom were men, isCGM was associated with increased TIR by 17 min/day (95% credible interval -105 to +153 min/day), with 59% probability of benefit. Users of isCGM showed lower hypoglycemic exposure (<3.9 mmol/L) at days 76-90 (-80 min/day; 95% CI -118, -43), also evident at days 16-30 (-28 min/day; 95% CI -92, 2). Compared with baseline, HbA1c showed similar reductions of 7 mmol/mol at 3 months in both study arms. Combined glycemic emergencies and mortality occurred in four isCGM and seven SMBG study participants. QOL measures marginally favored isCGM, and the intervention proved to be cost effective.

CONCLUSIONS

Compared with SMBG, isCGM in T2D individuals with MI marginally increases TIR and significantly reduces hypoglycemic exposure while equally improving HbA1c, explaining its cost effectiveness. Studies are required to understand whether these glycemic differences translate into longer-term clinical benefit.

Association of type 2 diabetes according to the number of risk factors within the recommended range with incidence of major depression and clinically relevant depressive symptoms: a prospective analysis

BACKGROUND

Type 2 diabetes is associated with an increased risk of depression, but the extent to which risk factor modification can mitigate this risk is unclear. We aimed to examine the association between the incidence of major depression and clinically relevant depressive symptoms among individuals with type 2 diabetes, according to the number of risk factors within the recommended target range, compared with individuals without diabetes.

METHODS

We did a prospective analysis of population-based data from the UK Biobank and the Maastricht Study. Individuals with type 2 diabetes were categorised according to the number of risk factors within the recommended target range (non-smoking, guideline-recommended levels of glycated haemoglobin (HbA_1c), blood pressure, BMI, albuminuria, physical activity, and diet). The primary outcome, based on data from the UK Biobank, was the incidence of major depression ascertained from hospital records; the secondary outcome, based on data from the UK Biobank and the Maastricht Study, was clinically relevant depressive symptoms based on a score of 10 or higher on the Patient Health Questionnaire (PHQ-9).

FINDINGS

The study population of the UK Biobank comprised 77 786 individuals (9047 with type 2 diabetes and 68 739 without diabetes; median age 59 years [IQR 51-64]; 34 136 [43·9%] women and 43 650 [56·1%] men). A median of 12·7 years (IQR 11·8-13·4) after recruitment (between March 13, 2006, and Oct 1, 2010), 493 (5·5%) of 9047 individuals with type 2 diabetes and 2574 (3·7%) of 68 739 individuals without diabetes developed major depression. Compared with individuals without diabetes, those with type 2 diabetes had a higher risk of major depression (hazard ratio [HR] 1·61 [95% CI 1·49-1·77]). Among individuals with type 2 diabetes, the excess risk of depression decreased stepwise with an increasing number of risk factors within the recommended target range (HR 2·04 [95% CI 1·65-2·52] for up to two risk factors within the recommended target range; 1·95 [1·65-2·30] for three risk factors within the recommended target range; 1·38 [1·16-1·65] for four risk factors within the recommended target range; and 1·34 [1·12-1·62] for five to seven risk factors within the recommended target range). In the UK Biobank dataset, a median of 7·5 years (IQR 6·8-8·2) after the baseline examination, 147 (7·5%) of 1953 individuals with type 2 diabetes and 954 (4·5%) of 21 413 individuals without diabetes had developed clinically relevant depressive symptoms. The study population of the Maastricht Study comprised 4530 individuals (1158 with type 2 diabetes and 3372 without diabetes; median age 60 years [IQR 53-66]; 2244 [49·5%] women and 2286 [50·1%] men). A median of 5·1 years (IQR 4·1-6·1) after recruitment (between Sept 1, 2010, and Dec 7, 2017), 170 (14·7%) of 1158 individuals with type 2 diabetes and 227 (6·7%) of 3372 individuals without diabetes developed clinically relevant depressive symptoms. Similarly, in both the UK Biobank dataset and the Maastricht Study cohort, among individuals with type 2 diabetes, the excess risk of clinically relevant depressive symptoms decreased stepwise with an increasing number of risk factors within the recommended target range.

INTERPRETATION

Among individuals with type 2 diabetes, the excess risk of major depression and clinically relevant depressive symptoms decreased stepwise with an increasing number of risk factors within the recommended target range. This study provides further evidence to promote risk factor modification strategies in individuals with type 2 diabetes and to encourage the adoption of a healthy lifestyle.

FUNDING

ZonMW, Hartstichting, and Diabetes Fonds.

Rationale and design of the Aldose Reductase Inhibition for Stabilization of Exercise Capacity in Heart Failure Trial (ARISE-HF) in patients with high-risk diabetic cardiomyopathy

BACKGROUND

Diabetic cardiomyopathy (DbCM) is a specific form of heart muscle disease that may result in substantial morbidity and mortality in individuals with type 2 diabetes mellitus (T2DM). Hyperactivation of the polyol pathway is one of the primary mechanisms in the pathogenesis of diabetic complications, including development of DbCM. There is an unmet need for therapies targeting the underlying metabolic abnormalities that drive this form of Stage B heart failure (HF).

METHODS

Aldose reductase (AR) catalyzes the first and rate-limiting step in the polyol pathway, and AR inhibition has been shown to reduce diabetic complications, including DbCM in animal models and in patients with DbCM. Previous AR inhibitors (ARIs) were limited by poor specificity resulting in unacceptable tolerability and safety profile. AT-001 is a novel investigational highly specific ARI with higher binding affinity and greater selectivity than previously studied ARIs. ARISE-HF (NCT04083339) is an ongoing Phase 3 randomized, placebo-controlled, double blind, global clinical study to investigate the efficacy of AT-001 (1000 mg twice daily [BID] and 1500 mg BID) in 675 T2DM patients with DbCM at high risk of progression to overt HF. ARISE-HF assesses the ability of AT-001 to improve or prevent decline in exercise capacity as measured by functional capacity (changes in peak oxygen uptake [peak VO₂]) over 15 (and possibly 27) months of treatment. Additional endpoints include percentage of patients progressing to overt HF, health status metrics, echocardiographic measurements, and changes in cardiacbiomarkers.

RESULTS

The ARISE-HF Trial is fully enrolled.

CONCLUSIONS

This report describes the rationale and study design of ARISE-HF.

Effects of β-blockers on all-cause mortality in patients with diabetes and coronary heart disease: A systematic review and meta-analysis

Beta-blockers have been considered as an effective treatment in secondary prevention of coronary heart disease (CHD). However, there is still disputed whether β-blockers can increase all-cause mortality in patients with coronary heart disease and diabetes mellitus (DM). Here, our systematic review and meta-analysis is aiming to assess the effects of β-blockers on all-cause mortality in patients with coronary heart disease and diabetes mellitus. Four databases (PubMed, Embase, Cochrane Library and Web of Science) and other sources were searched to collect randomized controlled trials (RCTs) and cohort studies related to the treatment of β-blockers for coronary heart disease and diabetes mellitus patients. We further evaluated quality of evidence using the grading of recommendations assessment, development, and evaluation (GRADE) approach. Finally, a total of 16,188 records were identified, and four randomized controlled trials and six cohort studies (206,490 patients) were included. Random effects analysis revealed that β-blockers combined with routine treatment (RT) significantly decreased all-cause mortality in patients with coronary heart disease and diabetes mellitus compared with RT in control group (RR 0.59, 95% CI 0.47 to 0.75; p < 0.000 01; I² = 72%). Subgroup analysis of all-cause mortality by the subtype of diabetes mellitus and definite MI patients (RR 0.54, 95% CI 0.45 to 0.65, p < 0.000 01, I² = 29%) and the subtype of randomized controlled trials (RR 0.49, 95% CI 0.32 to 0.76, p = 0.001, I² = 0%) indicated a relatively small heterogeneity and stable results. β-blockers application significantly reduced cardiovascular death as well (RR 0.56, 95% CI 0.42 to 0.74; p < 0.000 1; I² = 0%). Our meta-analysis provided critical evidence of β-blockers treatment for patients with coronary heart disease (especially MI type) and diabetes mellitus, and discussed the advantages and potential metabolic risks for the clinical use of β-blockers. This study suggested that β-blockers application may improve all-cause mortality and cardiovascular death in coronary heart disease (especially MI type) and diabetes mellitus patients. However, given a small number of included studies, the aforementioned conclusion should be confirmed in a multi-center, large-scale, and strictly designed trial.

Oral 24-week probiotics supplementation did not decrease cardiovascular risk markers in patients with biopsy proven NASH: A double-blind placebo-controlled randomized study

INTRODUCTION AND OBJECTIVES

Cardiovascular disease (CVD) is the major cause of death in non-alcoholic fatty liver disease (NAFLD), a clinical condition without any approved pharmacological therapy. Probiotics are often indicated for the disease, but their results are controversial in part due to the poor quality of studies. Thus, we investigated the impact of 24-week probiotics supplementation on cardiovascular risk (CVR) in biopsy-proven non-alcoholic steatohepatitis (NASH) patients.

PATIENTS AND METHODS

Double-blind, placebo-controlled, single-center study (NCT03467282), adult NASH, randomized for 24 weeks daily sachets of probiotic mix (10⁹CFU of Lactobacillus acidophilus, Lactobacillus rhamnosus, Lactobacillus paracasei and Bifidobacterium lactis) or placebo. Clinical scores (atherogenic indexes, atherosclerotic cardiovascular disease-ASCVD and systematic coronary risk evaluation-SCORE), biochemistry, miR-122, miR-33a, plasminogen activator inhibitor-1 (PAI-1), intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), were determined before and after the intervention.

RESULTS

Forty-six patients were enrolled (23 received probiotics and 23 placebo), with a mean age of 51.7 years, most of them females and whites. Clinical and demographic features were similar between the groups at the baseline. The Median NAFLD activity score was 4.13 in both groups. Fibrosis was mild in most patients (15.2% and 65.2% F0 and F1, respectively). Treatment did not promote any clinically significant changes in body mass index or laboratory, including lipid and glucose profile. High CVR patients through atherogenic indexes decreased from baseline in both groups, as well as PAI-1 and miR-122 levels, although there was no difference between probiotics and placebo.

CONCLUSIONS

A 24-week probiotic mix administration was not superior to placebo in reducing CVR markers in patients with NASH.

Metabolic syndrome in antiphospholipid syndrome versus rheumatoid arthritis and diabetes mellitus: Association with arterial thrombosis, cardiovascular risk biomarkers, physical activity, and coronary atherosclerotic plaques

Background

Cardiovascular disease (CVD) is the foremost cause of morbidity and deaths in antiphospholipid syndrome (APS), driven by thrombo-inflammation and atherothrombosis mechanisms. Metabolic syndrome (MetS) is a proinflammatory and prothrombotic state characterized by increased CVD risk. We aimed to evaluate the prevalence of MetS in APS patients compared to rheumatoid arthritis (RA) and diabetes mellitus (DM) and its associations with clinical and laboratory patient characteristics and vascular ultrasound (US) markers of subclinical atherosclerosis.

Methods

We included 414 patients in our study: 138 patients with APS (median age: 44.9 years, females 70%) and matched 1:1 for age and sex RA and DM subjects. Three sets of criteria were used for MetS diagnosis: Joint Interim Statement (JIS), International Diabetes Federation (IDF) and modified National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATPIII). The demographic, clinical and laboratory characteristics of all participants were recorded and carotid and femoral US was performed in patients with APS. Multivariate regression models were applied.

Results

Prevalence of MetS was 23.9%, 23.2%, 20.3% (based on JIS, IDF, modified NCEP-ATPIII criteria, respectively) in APS versus 17.4%, 17.4%, 13% in RA (p=0.181, p=0.231, p=0.106, respectively), and 44.2%, 44.2%, 40.6% in DM patients. In multivariate analysis, patients with systemic lupus erythematosus- related APS had an approximately 2.5-fold higher risk of MetS versus RA patients. MetS in APS was independently associated with arterial thrombosis (Odds ratio 3.5, p=0.030). Odds ratio for MetS was 1.16 for each one unit increase in C-reactive protein levels according to JIS and IDF criteria, and 1.49 and 1.47 for each one unit increase in uric acid levels using the IDF and modified NCEP-ATPIII models, respectively. APS patients with atherosclerotic carotid plaques had 4 to 6.5-fold increased risk of MetS. Odds for MetS were decreased by 26% with an increase in physical activity by one hour per week.

Conclusions

MetS is present in approximately one-fourth of APS patients at a comparable prevalence to that observed in patients with RA. MetS in APS is associated with arterial thrombosis, cardiovascular risk biomarkers, physical activity, and subclinical atherosclerosis, supporting its role in cardiovascular risk stratification and management in APS.

Dietary cholesterol consumption and incidence of type 2 diabetes mellitus: A dose-response meta-analysis of prospective cohort studies

BACKGROUND AND AIM

The purpose of this meta-analysis was to evaluate the dose-response relationship between dietary cholesterol (DC) consumption and the incidence of type 2 diabetes mellitus (T2DM).

METHODS AND RESULTS

Prospective studies with the endpoint of T2DM were included. The Random-effect model weighted by inverse variance was used. Meta-regression and subgroup analyses were conducted to explore the potential sources of heterogeneity by specified study characteristics. Restricted cubic splines regression models were used to estimate the dose-response relationship. 11 prospective studies comprising of 355 230 subjects were included. Compared to lowest DC consumption, highest DC consumption was associated with an increased risk of T2DM (RR 1.15, 95% CI 1.03 to 1.28, P = 0.012; chi-squared = 31.41, I-squared 58.6%, P _{heterogeneity} = 0.003). Subgroup analyses have shown that this positive association was more evident in western countries than in eastern countries (RR 1.19, 95% CI 1.06 to 1.36 VS 1.34, 95% CI 0.84 to 1.29; P _{subgroup difference} = 0.02). For 100 mg/d increment in DC intake, the pooled RR was 1.05, (95% CI 1.04 to 1.07, P_linearity = 0.000, P_nonlinearity = 0.02), 1.06 (95% CI 1.04 to 1.07, P_linearity=0.000), and 1.01 (95% CI 0.98 to 1.05, P_linearity = 0.525) for the incidence of T2DM, in western and eastern countries, respectively.

CONCLUSIONS

Our study suggests that there is a positive dose-response association between DC consumption and the incidence of T2DM, especially in western countries.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020216318.

Evaluation and Management of Patients With Diabetes and Heart Failure: A Korean Diabetes Association and Korean Society of Heart Failure Consensus Statement

Diabetes mellitus is a major risk factor for the development of heart failure. Furthermore, the prognosis of heart failure is worse in patients with diabetes mellitus than in those without it. Therefore, early diagnosis and proper management of heart failure in patients with diabetes mellitus are important. This review discusses the current criteria for diagnosis and screening tools for heart failure and the currently recommended pharmacological therapies for heart failure. We also highlight the effects of anti-diabetic medications on heart failure.

Evaluation and Management of Patients with Diabetes and Heart Failure: A Korean Diabetes Association and Korean Society of Heart Failure Consensus Statement

Diabetes mellitus is a major risk factor for the development of heart failure. Furthermore, the prognosis of heart failure is worse in patients with diabetes mellitus than in those without it. Therefore, early diagnosis and proper management of heart failure in patients with diabetes mellitus are important. This review discusses the current criteria for diagnosis and screening tools for heart failure and the currently recommended pharmacological therapies for heart failure. We also highlight the effects of anti-diabetic medications on heart failure.

Real-world evaluation of glucose-lowering therapies and the use of weight-adjusted variable rate intravenous insulin infusion in the management of hyperglycaemia in patients with acute coronary syndrome (REGULATE-ACS)

INTRODUCTION

Admission hyperglycaemia in acute coronary syndromes (ACS) is a strong independent predictor of adverse clinical outcomes post-ACS. We examined the safety, efficacy, and feasibility of a modified, weight-adjusted variable rate intravenous insulin infusion (VRIII) and evaluated current practice of prescribing novel cardio-protective glucose-lowering therapies in patients presenting with acute hyperglycaemia across the ACS spectrum.

METHODS

REGULATE-ACS was an observational single-centre study of consecutive patients admitted with acute hyperglycaemia post-ACS between 2020 and 2021. Following updated local guidance on a modified VRIII, we evaluated its safety and efficacy in glycaemic control, cardio-metabolic complications including hypoglycaemia (blood glucose <3 mmol/L) and 30-day mortality. We also determined the prescription of glucose-lowering therapies pre-discharge.

RESULTS

Out of 107 patients, mean age was 64.9 ± 12.2 years, 82% had known diabetes, and 15% newly diagnosed diabetes. 86.9% (n = 93) had an admission glucose ≥11 mmol/L. In patients treated with VRIII (n = 63/93, 67.7%), glucose improved from 17.5 to 9.0 mmol/L (IQR 7.1-12.1), which was 3 mmol/L lower (p = 0.03) than in patients not treated with VRIII (n = 30/93, 32.3%) where median glucose reduced from 12.6 to 12 mmol/L (IQR 8.6-13.9). No significant hypoglycaemia, arrhythmia or worsening pulmonary oedema associated with VRIII was found. Novel glucose-lowering therapies were initiated in 20/71 (28.2%) and 3/15 (20.0%) of patients with prior and newly diagnosed diabetes, respectively.

CONCLUSION

This real-world analysis provides further support of efficacy, safety, and feasibility of a modified, weight-adjusted VRIII in managing acute hyperglycaemia in ACS. Despite established cardio-protective benefits of novel glucose-lowering therapies, <1/3 of eligible patients received such agents pre-discharge, demanding further research and awareness.

Diagnostic Performance of Cerebrospinal Fluid Neurofilament Light Chain and Soluble Amyloid-β Protein Precursor β in the Subcortical Small Vessel Type of Dementia

BACKGROUND

The subcortical small vessel type of dementia (SSVD) is a common subtype of vascular dementia, but there is a lack of disease-specific cerebrospinal fluid (CSF) biomarkers.

OBJECTIVE

We investigated whether CSF concentrations of neurofilament light chain (NFL), soluble amyloid-β protein precursor α (sAβPPα), sAβPPβ, and CSF/serum albumin ratio could separate SSVD from healthy controls, Alzheimer's disease (AD), and mixed dementia (combined AD and SSVD).

METHODS

This was a mono-center study of patients with SSVD (n = 38), AD (n = 121), mixed dementia (n = 62), and controls (n = 96). The CSF biomarkers were measured using immunoassays, and their independent contribution to the separation between groups were evaluated using the Wald test. Then, the area under the receiver operating characteristics curve (AUROC) and 95% confidence intervals (CIs) were calculated.

RESULTS

Elevated neurofilament light chain (NFL) and decreased sAβPPβ independently separated SSVD from controls, and sAβPPβ also distinguished SSVD from AD and mixed dementia. The combination of NFL and sAβPPβ discriminated SSVD from controls with high accuracy (AUROC 0.903, 95% CI: 0.834-0.972). Additionally, sAβPPβ combined with the core AD biomarkers (amyloid-β42, total tau, and phosphorylated tau181) had a high ability to separate SSVD from AD (AUROC 0.886, 95% CI: 0.830-0.942) and mixed dementia (AUROC 0.903, 95% CI: 0.838-0.968).

CONCLUSIONS

The high accuracy of NFL and sAβPPβ to separate SSVD from controls supports that SSVD is a specific diagnostic entity. Moreover, SSVD was distinguished from AD and mixed dementia using sAβPPβ in combination with the core AD biomarkers.

Exercise modalities for type 2 diabetes: A systematic review and network meta-analysis of randomized trials

AIMS

We aimed to determine the effects of different exercise modalities in patients with type 2 diabetes mellitus (T2DM).

METHODS

We searched PubMed, Embase, and the Cochrane Library from their inception until July 2020 to identify randomised controlled trials (RCTs) on exercise in adults with T2DM. Paired reviewers independently performed study selection, data extraction, and risk of bias assessment. The certainty of the evidence was assessed using the Confidence in Network Meta-Analysis (CINeMA) framework.

RESULTS

A total of 106 RCTs that enroled eight exercise modalities with 7438 patients were included. Six exercise modalities, except unsupervised aerobic/resistance exercise, significantly reduced glycosylated haemoglobin (HbA1c), with mean differences (MDs) ranging from 0.71 (95% confidence interval [CI]: 0.34-1.08) to 0.34 (95% CI: 0.17-0.52), low to high certainty, in comparison with no exercise. The evidence of low to moderate certainty showed that supervised aerobic/resistance exercise improved glycaemic control, body weight, blood pressure, and blood lipid profiles compared with no exercise. Flexibility exercise may be associated with glycaemic control (HbA1c: MD = 0.71, 95% CI: 0.34-1.08); fasting plasma glucose (MD = 1.48, 95% CI: 0.78-2.17), and weight loss (MD = 1.80, 95% CI: 0.85-2.75) compared with controls, but not blood pressure and lipid profiles. Balance exercise showed the largest benefit in improving total cholesterol (MD = 52.81, 95% CI: 28.47-77.16) and low certainty. We found no significant differences between exercises and the triacylglycerol (TG) level.

CONCLUSIONS

Overall, our network meta-analyses support the recommendation for exercise in patients with T2DM, especially supervised exercises. Limited evidence supports the benefits of flexibility and balance exercises. The effectiveness of exercise modalities for TG reduction remains unclear.

Budget Impact Analysis of Empagliflozin in the Treatment of Patients With Type 2 Diabetes With Established Cardiovascular Disease in South Africa

OBJECTIVES

This study aimed to estimate the budget impact and affordability of empagliflozin added to usual care compared with usual care alone, in a diabetic population with established cardiovascular disease, from a private healthcare payer perspective in South Africa.

METHODS

A budget impact model was adapted and localized. Epidemiological data were obtained from the South African Council for Medical Schemes. Clinical event rates were sourced from the EMPA-REG OUTCOME trial and drug costs from list prices. Clinical event costs were derived from a claims data analysis of the South African private healthcare sector and microcosting. Scenario analyses were performed on select inputs. The modeled outcomes included annual budget impact of empagliflozin, the incremental cost per life per month, cardiovascular deaths averted, and incremental cost per life saved, over 3 years.

RESULTS

A total of 9 503 patients were eligible for empagliflozin (year 1), 12 670 (year 2), and 16 947 (year 3). The incremental cost was $1 272 297, $1 764 705, and $2 455 235, for years 1 to 3, respectively. The incremental cost per beneficiary per month was calculated as $0.012 (year 1), $0.016 (year 2), and $0.023 (year 3). The model estimated a 38.6% reduction in cardiovascular deaths, 305 lives saved, and an incremental cost per life saved of $17 999.

CONCLUSIONS

Adding empagliflozin to usual care has a marginal budget implication and is highly affordable for private healthcare payers, with an acceptable incremental cost based on clinical outcomes.

Prognostic value of 1,5-anhydro-D-glucitol incorporating syntax score in acute coronary syndrome

The utility of adding information on 1,5-anhydro-D-glucitol (1,5-AG), a marker for postprandial hyperglycemia, to a pre-existing scoring system in acute coronary syndrome (ACS) patients is unknown. This retrospective cohort study included 266 ACS patients. The end point was major adverse cardiac and cerebral events (MACCE) through 5 years of follow-up. To evaluate incremental benefits of combining 1,5-AG with the syntax score, we applied time-dependent receiver operating curve (ROC) analysis, net reclassification improvement (NRI), integrated discrimination improvement (IDI) and decision curve analysis (DCA). Temporal changes to the area under time-dependent ROC curves showed that addition of 1,5-AG parameters to syntax score did not provide any incremental value (area under the curve for syntax alone, 0.673 (95% confidence interval (CI), 0.599-0.747) vs. with 1,5-AG combined, 0.671 (95%CI 0.596-0.746; Delong p = 0.65). Incorporating 1,5-AG into syntax score yielded a significant NRI of 0.291 (95%CI 0.015-0.567) and IDI of 0.055 (95%CI 0.018-0.093), while DCA analysis showed the limited net benefit in combination with 1,5-AG and syntax score. 1,5-AG values exhibited significant discriminatory utility for detecting MACCE within the ACS population. However, 1,5-AG levels contributed limited utility beyond syntax score based on time-dependent ROC and DCA analyses.Trial registration: UMIN000023837.