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)

Optimising the Inflammatory Bowel Disease Unit to Improve Quality of Care: Expert Recommendations

INTRODUCTION

The best care setting for patients with inflammatory bowel disease [IBD] may be in a dedicated unit. Whereas not all gastroenterology units have the same resources to develop dedicated IBD facilities and services, there are steps that can be taken by any unit to optimise patients' access to interdisciplinary expert care. A series of pragmatic recommendations relating to IBD unit optimisation have been developed through discussion among a large panel of international experts.

METHODS

Suggested recommendations were extracted through systematic search of published evidence and structured requests for expert opinion. Physicians [n = 238] identified as IBD specialists by publications or clinical focus on IBD were invited for discussion and recommendation modification [Barcelona, Spain; 2014]. Final recommendations were voted on by the group. Participants also completed an online survey to evaluate their own experience related to IBD units.

RESULTS

A total of 60% of attendees completed the survey, with 15% self-classifying their centre as a dedicated IBD unit. Only half of respondents indicated that they had a defined IBD treatment algorithm in place. Key recommendations included the need to develop a multidisciplinary team covering specifically-defined specialist expertise in IBD, to instil processes that facilitate cross-functional communication and to invest in shared care models of IBD management.

CONCLUSIONS

Optimising the setup of IBD units will require progressive leadership and willingness to challenge the status quo in order to provide better quality of care for our patients. IBD units are an important step towards harmonising care for IBD across Europe and for establishing standards for disease management programmes.

Acarbose Monotherapy and Type 2 Diabetes Prevention in Eastern and Western Prediabetes: An Ethnicity-specific Meta-analysis

PURPOSE

Acarbose is effective in delaying or preventing the progression of prediabetes to type 2 diabetes mellitus (T2DM). The aim of this study was to assess differences in the preventive effects of acarbose in Eastern and Western populations with prediabetes.

METHODS

We performed a systematic search of databases and reference lists of clinical trials conducted through August 2013. Randomized controlled trials of acarbose alone, with a minimum intervention duration of 3 years and which provided data on T2DM incidence, were included for analysis. Analyses were conducted by using Review Manager version 5.1 software.

FINDINGS

Eight randomized controlled trials with 2628 participants were included. Acarbose decreased the occurrence of T2DM (number needed to treat [NNT], 6.7). Compared with the control (placebo and/or lifestyle intervention), the incidence of T2DM was significantly lower in the Eastern group (NNT, 5.9) than in the Western group (NNT, 11.1) (P < 0.0001, I(2) = 94.7%). At the end of follow-up, reversal of prediabetes to normal glucose tolerance was more likely in the Eastern group (NNT, 4.3) than in the Western group (NNT, 25) (P = 0.004, I(2) = 92%). Among those remaining prediabetic, there was no significant difference between the subtotal estimates for the subgroups (P = 0.17, I(2) = 46.5%). There was no positive correlation between preventive effect and dose, and no difference in studies with varying follow-up durations within and across either ethnic group.

IMPLICATIONS

The preventive effect of acarbose on the development of diabetes seems superior in Eastern populations with prediabetes compared with Western populations.

Oral hypoglycemic agents and the heart failure conundrum: Lessons from and for outcome trials

AIM

Type 2 diabetes is not only an independent risk factor for cardiovascular (CV) disease but is also associated with a greater incidence of heart failure (HF). The aim of this review is to examine the effects of oral antidiabetic drugs on CV disease and HF.

DATA SYNTHESIS

Trials of anti-diabetic agents are now designed to assess CV safety, but frequently HF is not included as a primary endpoint. However, HF in patients with diabetes is more frequent than other CV events and seems to be underestimated. A burning question is therefore if the most used trial design to monitor CV safety, i.e. non-inferiority, allows clinical translation of trial findings. Available data further suggest that the CV effects of anti-diabetic drugs may be rather class-specific and are only partly due to their glucose-lowering actions. Metformin, recommended as first line in most guidelines, shows positive CV effects while other classes like thiazolidinediones may precipitate HF. Experimental results on the relatively novel dipeptidyl peptidase IV (DPP IV) inhibitors imply CV protective effects, but the non-inferiority trials published to date show an overall neutral CV outcome and a potential increase in HF by saxagliptin. However, results on sitagliptin of the recently released TECOS indicate that HF is not a class-dependent effect of DPP IV inhibitors.

CONCLUSION

Further basic research and long-term outcome studies to clarify the effects of antidiabetic agents on CV and HF are required so that we can select the optimal antidiabetic therapy for our patients.

Systematic review and meta-analysis of randomized clinical trials comparing efficacy and safety outcomes of insulin glargine with NPH insulin, premixed insulin preparations or with insulin detemir in type 2 diabetes mellitus

AIMS

A variety of basal insulin preparations are used to treat patients with type 2 diabetes mellitus (T2DM). We aimed to summarize scientific evidence on relative efficacy and safety of insulin glargine (IGlar) and other insulins in T2DM.

METHODS

A systematic review was carried out in major medical databases up to December 2012. Relevant studies compared efficacy and safety of IGlar, added to oral drugs (OAD) or/and in combination with bolus insulin, with protamine insulin (NPH) or premixed insulin (MIX) in the same regimen, as well as with insulin detemir (IDet), in T2DM. Target HbA1c level without hypoglycemic events was considered the primary endpoint.

RESULTS

Twenty eight RCTs involving 12,669 T2DM patients followed for 12-52 weeks were included in quantitative analysis. IGlar + OAD use was associated with higher probability of reaching target HbA1c level without hypoglycemia as compared to NPH + OAD (RR = 1.32 [1.09, 1.59]) or MIX without OAD (RR = 1.61 [1.22, 2.13]) and similar effect as IDet + OAD (RR = 1.07 [0.87, 1.33]) and MIX + OAD (RR = 1.09 [0.86, 1.38]). IGlar + OAD demonstrated significantly lower risk of symptomatic hypoglycemia as compared to NPH + OAD (RR = 0.89 [0.83, 0.96]), MIX + OAD (RR = 0.75 [0.68, 0.83]) and MIX without OAD(RR = 0.75 [0.68, 0.83]), but not with IDet + OAD (RR = 0.99 [0.90, 1.08]). In basal-bolus regimens, IGlar demonstrated similar proportion of T2DM patients achieving target HbA1c as compared to NPH (RR = 1.14 [0.91, 1.44]) but higher than MIX (RR = 1.26 [1.12, 1.42) or IDet (RR = 1.38 [1.11, 1.72]). The risk of severe hypoglycemia was lower in IGlar than in NPH (RR = 0.77 [0.63, 0.94]), with no differences in comparison with MIX (RR = 0.74 [0.46, 1.20]) and IDet (RR = 1.10 [0.54, 2.25]). IGlar + OAD has comparable safety profile to NPH, with less frequent adverse events leading to treatment discontinuation than MIX + OAD (RR = 0.41 [0.22, 0.76]) and IDet + OAD (RR = 0.40 [0.24, 0.69]). Also severe adverse reactions were less common for IGlar + OAD when compared to MIX + OAD (RR = 0.71 [0.52; 0.98]).

CONCLUSION

For the majority of examined efficacy and safety outcomes, IGlar use in T2DM patients was superior or non-inferior to the alternative insulin treatment options.

Anthropometric profile and diabetic foot risk: a cross-sectional study using thermography

Diabetes is one of the greatest todays public health problems with enormous social and economic implications for society. Diabetic foot disorders represent a substantial economic burden with detrimental effects on quality of life with special impairment in physical domain. Early detection strategies of these complications should be implemented in order to avoid possible wounds, ulcerations and amputations. This work can be characterized as a cross-sectional study with an analytical approach. It involved 44 volunteers of both genders (22 women and 22 men; 66.70 ± 6.26 years of age) with type 2 diabetes (diagnosed at 11.84 ± 8.22 years), selected among the candidates to Diabetes em Movimento® (a community-based exercise program for patients with type 2 diabetes developed in the city of Vila Real, Portugal). Foot plantar thermal images were acquired through a high-resolution infrared camera (FLIR Systems Inc. Model SC2000; 320 × 240 pixels). Three regions of interest (ROI) were defined for evaluation: first finger, fifth finger and the heel. From the three pairs of ROIs evaluated, the higher temperature asymmetry was selected for diabetic foot risk analysis. The results showed the existence of a positive and significant association between BMI and fat mass with asymmetries in feet temperature. Three subjects with diabetes-related foot complications (ROIs higher temperature asymmetry ≥ 2.20 °C) were identified in the sample. All participants with detected diabetes-related foot complications were obese (BMI ≥ 30 kg/m²) with high levels of body fat (≥ 45%). It can be concluded that exist a positive association either of BMI (r=0.399, p=0.007) either of body fat percentage (r=0.432, p=0.003), with diabetic foot risk in patients with type 2 diabetes.

Risk factor differences between type 2 diabetes patients with ischemic cerebrovascular versus coronary heart diseases at admission

AIMS

Type 2 diabetes mellitus (T2DM) is a major risk factor, and shares many common risk factors with ischemic cerebrovascular diseases (ICVD) and coronary heart diseases (CHD). Few studies have directly compared the differences in common risk factors between T2DM patients with ICVD and CHD at admission.

METHODS

In this cross-sectional study, T2DM patients with or without first-ever ICVD or CHD admitted to our hospital over 3 years were enrolled. Patients' data were retrospectively collected and compared using multivariate logistic regression analyses.

RESULTS

In total, 1208 T2DM patients were enrolled (57.5% men). The median age was 59 years (interquartile range [IQR] 51-69), and duration of diabetes was 7 years (IQR 3-10). Two hundred and two patients (16.7%) were diagnosed with ICVD, 345 (28.6%) with CHD, and 661 (54.7%) had neither ICVD nor CHD. Compared with T2DM patients without ICVD or CHD, ICVD and CHD patients had higher systolic blood pressure (SBP) and older age but lower high-density lipoprotein cholesterol levels (all p<0.01), whereas reduced estimated glomerular filtration rate was only associated with CHD (p<0.05). Furthermore, ICVD patients had higher SBP (every 10-mmHg increase, OR=1.38, 95% CI: 1.26-1.51) and HbA1c levels (OR=1.18, 95% CI: 1.06-1.31) than CHD patients.

CONCLUSIONS

T2DM patients with ICVD and CHD have differences in common risk factors at admission. Higher systolic blood pressure and HbA1c levels may indicate ICVD.

Increased plasma dipeptidyl peptidase-4 activities are associated with high prevalence of subclinical atherosclerosis in Chinese patients with newly diagnosed type 2 diabetes: a cross-sectional study

OBJECTIVE

Hyperglycemia, insulin resistance, dislipidemia, oxidative stress and inflammation are well-documented risk factors for subclinical atherosclerosis. Dipeptidyl peptidase-4(DPP4) is a newly identified adipokine related to these risk factors. Hence, we aimed to investigate the association between plasma DPP4 activities and subclinical atherosclerosis in type 2 diabetes.

METHODS

A total of 985 newly diagnosed type 2 diabetic subjects were studied. Plasma DPP4 activity, mannose 6-phosphate receptor (M6P-R), oxidative stress parameters, inflammatory markers and common carotid artery Intima-Media Thickness (c-IMT) were measured in all participants.

RESULTS

Participants in the highest quartile of DPP4 activity had higher HbA1c, homeostatic model assessment of insulin resistance(HOMA-IR), triglyceride, low-density lipoprotein cholesterol(LDL-C), oxidized LDL, nitrotyrosine, 8-iso-PGF2a, interleukin-6 (IL-6), high-sensitivity C-reactive protein (hs-CRP), M6P-R, c-IMT compared with participants in the lowest quartile (all P < 0.001). DPP4 activities were associated positively with HbA1c, HOMA-IR, triglyceride, LDL-C, oxidized LDL, nitrotyrosine, 8-iso-PGF2a, IL-6, hs-CRP, M6P-R and c-IMT (all P < 0.05). The ORs for insulin resistance, dislipidemia, oxidative stress and inflammation were higher with increasing DPP4 quartiles (P < 0.001 for trend). In the highest DPP4 quartile, subclinical atherosclerosis risk was significantly higher (OR 4.97; 95% CI 3.03-8.17) than in the lowest quartile. This association remained strong (2.17; 1.21-3.89) after further controlling for HbA1c, HOMA-IR, triglyceride, oxidized LDL, nitrotyrosine, and IL-6.

CONCLUSIONS

This study shows that increased DPP4 activities are positively and independently associated with subclinical atherosclerosis in type 2 diabetes. Our findings suggest of potential role of DPP4 in the pathogenesis of subclinical atherosclerosis and in the prevention and management of this disease.

Assessment of dipyridamole stress echocardiography for risk stratification of diabetic patients

BACKGROUND

Despite advances in medical therapy, cardiovascular disease, mainly coronary artery disease (CAD), remains the leading cause of mortality among patients with diabetes mellitus (DM). The objective of the present study was to assess the effectiveness of dipyridamole stress echocardiography in identify diabetic patients at high risk for cardiovascular events.

METHODS

Dipyridamole stress echocardiography was administered to 483 diabetic patients (294 women; mean age 63.41 ± 11.28 years) between July 2006 and December 2012.

RESULTS

Follow-up data were available for 264 patients (163 women; mean age 64.3 ± 10.5 years): 250 with a negative stress echocardiography and 14 with a positive stress echo. During a mean follow-up time of 18 ± 14 months, a cardiovascular event occurred in 18 (6.8%) patients, 12 (4.8%) in patients with a negative stress echo (n = 250) during a mean follow-up period of 20 ± 16 months and 6 (42%) in patients with positive stress echo (n = 14) during a mean follow-up of 13 ± 13 months. The positive and negative predictive values of stress echocardiography were 42% and 96% respectively. The accuracy value was 92%. A Cox regression model showed that CAD (hazard ratio [HR] 5.4, 95% confidence interval [CI] 1.9-15.4; p = 0.002) and positive stress echocardiography (HR 7.1, 95% CI 2.5-20.5; p < 0.001) were significant predictors of cardiovascular events.

CONCLUSIONS

For patients with diabetes, a negative dipyridamole stress echocardiogram predicts favorable outcome during the first year of follow-up. A new stress imaging test should be done after 12 months in diabetic patients.

Association of diet and lifestyle with glycated haemoglobin in type 1 diabetes participants in the EURODIAB prospective complications study

BACKGROUND/OBJECTIVES

Diet and lifestyle advice for type 1 diabetes (T1DM) patients is based on little evidence and putative effects on glycaemic control. Therefore, we investigated the longitudinal relation between dietary and lifestyle variables and HbA1c levels in patients with type 1 diabetes.

SUBJECTS/METHODS

A 7-year prospective cohort analysis was performed in 1659 T1DM patients (52% males, mean age 32.5 years) participating in the EURODIAB Prospective Complications Study. Baseline dietary intake was assessed by 3- day records and physical activity, smoking status and alcohol intake by questionnaires. HbA1c during follow-up was centrally assessed by immunoassay. Analysis of variance (ANOVA) and restricted cubic spline regression analyses were performed to assess dose-response associations between diet and lifestyle variables and HbA1c levels, adjusted for age, sex, lifestyle and body composition measures, baseline HbA1c, medication use and severe hypoglycaemic attacks.

RESULTS

Mean follow-up of our study population was 6.8 (s.d. 0.6) years. Mean HbA1c level was 8.25% (s.d. 1.85) (or 66.6 mmol/mol) at baseline and 8.27% (s.d. 1.44) at follow-up. Physical activity, smoking status and alcohol intake were not associated with HbA1c at follow-up in multivariable ANOVA models. Baseline intake below the median of vegetable protein (<29 g/day) and dietary fibre (<18 g/day) was associated with higher HbA1c levels. Restricted cubic splines showed nonlinear associations with HbA1c levels for vegetable protein (P (nonlinear)=0.008) and total dietary fibre (P (nonlinear)=0.0009).

CONCLUSIONS

This study suggests that low intake of vegetable protein and dietary fibre are associated with worse glycaemic control in type 1 diabetes.

Physical activity promotion in the primary care setting in pre- and type 2 diabetes - the Sophia step study, an RCT

Background

Physical activity prevents or delays progression of impaired glucose tolerance in high-risk individuals. Physical activity promotion should serve as a basis in diabetes care. It is necessary to develop and evaluate health-promoting methods that are feasible as well as cost-effective within diabetes care. The aim of Sophia Step Study is to evaluate the impact of a multi-component and a single component physical activity intervention aiming at improving HbA_1c (primary outcome) and other metabolic and cardiovascular risk factors, physical activity levels and overall health in patients with pre- and type 2 diabetes.

Methods/design

Sophia Step Study is a randomized controlled trial and participants are randomly assigned to either a multi-component intervention group (A), a pedometer group (B) or a control group (C). In total, 310 patients will be included and followed for 24 months. Group A participants are offered pedometers and a website to register steps, physical activity on prescription with yearly follow-ups, motivational interviewing (10 occasions) and group consultations (including walks, 12 occasions). Group B participants are offered pedometers and a website to register steps. Group C are offered usual care. The theoretical framework underpinning the interventions is the Health Belief Model, the Stages of Change Model, and the Social Cognitive Theory. Both the multi-component intervention (group A) and the pedometer intervention (group B) are using several techniques for behavior change such as self-monitoring, goal setting, feedback and relapse prevention.

Measurements are made at week 0, 8, 12, 16, month 6, 9, 12, 18 and 24, including metabolic and cardiovascular biomarkers (HbA_1c as primary health outcome), accelerometry and daily steps. Furthermore, questionnaires were used to evaluate dietary intake, physical activity, perceived ability to perform physical activity, perceived support for being active, quality of life, anxiety, depression, well-being, perceived treatment, perceived stress and diabetes self- efficacy.

Discussion

This study will show if a multi-component intervention using pedometers with group- and individual consultations is more effective than a single- component intervention using pedometers alone, in increasing physical activity and improving HbA_1c, other metabolic and cardiovascular risk factors, physical activity levels and overall health in patients with pre- and type 2 diabetes.

Trial registration

ClinicalTrials.gov Identifier: NCT02374788. Registered 28 January 2015.

Left and right ventricular systolic function impairment in type 1 diabetic young adults assessed by 2D speckle tracking echocardiography

AIMS

Subclinical left ventricular (LV) and right ventricular (RV) systolic dysfunction has been proved in type 2 diabetes mellitus (DM). There is lack of uniform data on systolic myocardial function in type 1 DM. The aim of this study was to evaluate LV and RV function with 2D speckle tracking echocardiography (2D STE) in adult type 1 diabetic patients.

METHODS AND RESULTS

Totally, 50 patients with type 1 DM and 50 control subjects in the same range of age were prospectively evaluated. The 2D STE assessment of LV longitudinal, radial, circumferential strain and RV free-wall longitudinal strain was performed. In diabetic group, left ventricular global longitudinal strain (LVGLS), left ventricular global circumferential strain (LVGCS), left ventricular radial strain at basal level (LVRS-basal), and right ventricular free-wall global longitudinal strain (RVGLS) were significantly lower compared with the controls: LVGLS (-20.3 ± 2.0% vs. -22.2 ± 1.8%, P < 0.001), LVGCS (-21.1 ± 2.5% vs. -22.2 ± 2.4%, P < 0.05), LVRS-basal (50.5% ± 11.5 vs. 57.1% ±17.0, P < 0.05), and RVGLS (-30.1% ± 3.5 vs. -32.7% ± 3.9, P < 0.01). Multivariable logistic regression analysis showed that the only independent predictor of reduced LVGLS was low-density lipoprotein cholesterol [odds ratio 3.65 (95% confidence interval: 1.27-10.5), P = 0.014].

CONCLUSION

Type 1 DM is associated with subclinical LV systolic dysfunction and worse RV systolic function, which can be detected with 2D STE.

Hyperhomocysteinaemia is associated with low plasma apolipoprotein AI levels in patients with impaired glucose tolerance

Homocysteine suppresses hepatic apolipoprotein AI synthesis in mice. We assessed the relationship between homocysteine and apolipoprotein AI levels in patients with impaired glucose tolerance. A total of 217 participants, including 95 impaired glucose tolerance patients and 122 healthy subjects, were classified as normal control subjects without hyperhomocysteinaemia, control subjects with hyperhomocysteinaemia, impaired glucose tolerance patients without hyperhomocysteinaemia (n-IGT) and impaired glucose tolerance patients with hyperhomocysteinaemia (H-IGT). The impaired glucose tolerance patients had higher plasma levels of homocysteine and homeostasis model assessment index of insulin resistance values, and lower plasma apolipoprotein AI levels than the normal control and control subjects with hyperhomocysteinaemia (all p < 0.01). Decreased plasma apolipoprotein AI levels and increased homeostasis model assessment index of insulin resistance values were observed in the H-IGT group compared with the n-IGT group (p < 0.05). Plasma homocysteine levels were negatively correlated with apolipoprotein AI levels after adjusting for age, gender, body mass index and homeostasis model assessment index of insulin resistance. Plasma homocysteine level independently influenced the apolipoprotein AI levels (β = -0.02, p < 0.05). In conclusion, increased plasma homocysteine levels were associated with decreased apolipoprotein AI levels in impaired glucose tolerance subjects.

Reduced Lysosomal Acid Lipase Activity in Adult Patients With Non-alcoholic Fatty Liver Disease

Non-alcoholic fatty liver disease (NAFLD) is characterized by intra-hepatic fat accumulation and mechanisms involved in its pathogenesis are not fully explained. Lysosomal Acid Lipase (LAL) is a key enzyme in lipid metabolism. We investigated its activity in patients with fatty liver. LAL activity (nmol/spot/h) was measured in 100 adult healthy subjects (HS) and in 240 NAFLD patients. A sub-analysis on 35 patients with biopsy-proven non-alcoholic steatohepatitis (NASH) was performed. Median LAL activity was 1.15 (0.95-1.72) in HS. It was significantly reduced in NAFLD [0.78 (0.61-1.01), p < 0.001 vs. HS]. A further reduction was observed in the subgroup of NASH [0.67 (0.51-0.77), p < 0.001 vs. HS]. Patients with LAL activity below median had higher values of serum total cholesterol (p < 0.05) and LDL-c (p < 0.05), and increased serum liver enzymes (ALT, p < 0.001; AST, p < 0.01; GGT, p < 0.01). At multivariable logistic regression analysis, factors associated with LAL activity below median were ALT (OR: 1.018, 95% CI 1.004-1.032, p = 0.011) and metabolic syndrome (OR: 2.551, 95% CI 1.241-5.245, p = 0.011), whilst statin use predicted a better LAL function (OR: 0.464, 95% CI 0.248-0.866, p = 0.016). Our findings suggest a strong association between impaired LAL activity and NAFLD. A better knowledge of the role of LAL may provide new insights in NAFLD pathogenesis.

Sudden cardiac death in patients with diabetes mellitus and chronic heart failure

In patients with diabetes mellitus, around 50% of deaths due to cardiovascular causes are sudden cardiac deaths. The prevalence of diabetes in cohorts with chronic heart failure is increasing, and while sudden cardiac death is an increasingly rare mode of death in chronic heart failure patients as a whole, the risk of this outcome remains high in those with diabetes. This review summarises the current knowledge on the incidence of sudden cardiac death in patients with diabetes and chronic heart failure, before discussing the causes of the excess risk seen in those with these coexistent conditions. We then describe current strategies for risk stratification and prevention of sudden cardiac death in these patients before discussing the priorities for further study in this area.

Therapeutic Use of Metformin in Prediabetes and Diabetes Prevention

People with elevated, non-diabetic, levels of blood glucose are at risk of progressing to clinical type 2 diabetes and are commonly termed 'prediabetic'. The term prediabetes usually refers to high-normal fasting plasma glucose (impaired fasting glucose) and/or plasma glucose 2 h following a 75 g oral glucose tolerance test (impaired glucose tolerance). Current US guidelines consider high-normal HbA1c to also represent a prediabetic state. Individuals with prediabetic levels of dysglycaemia are already at elevated risk of damage to the microvasculature and macrovasculature, resembling the long-term complications of diabetes. Halting or reversing the progressive decline in insulin sensitivity and β-cell function holds the key to achieving prevention of type 2 diabetes in at-risk subjects. Lifestyle interventions aimed at inducing weight loss, pharmacologic treatments (metformin, thiazolidinediones, acarbose, basal insulin and drugs for weight loss) and bariatric surgery have all been shown to reduce the risk of progression to type 2 diabetes in prediabetic subjects. However, lifestyle interventions are difficult for patients to maintain and the weight loss achieved tends to be regained over time. Metformin enhances the action of insulin in liver and skeletal muscle, and its efficacy for delaying or preventing the onset of diabetes has been proven in large, well-designed, randomised trials, such as the Diabetes Prevention Program and other studies. Decades of clinical use have demonstrated that metformin is generally well-tolerated and safe. We have reviewed in detail the evidence base supporting the therapeutic use of metformin for diabetes prevention.

Lost in translation: dietary management of cardiovascular risk factors is seldom implemented

OBJECTIVE

To assess dietary management of cardiovascular risk factors (CVRFs) in the general population.

METHOD

Cross-sectional study conducted between 2009 and 2012 on 4811 participants (2567 women, 58±11years) living in Lausanne, Switzerland.

RESULTS

Sixteen percent of participants diagnosed with overweight/obesity reported a slimming diet. Slimming diet was associated with diagnosis of hypertension: Odds ratio and (95% confidence interval): 0.61 (0.40-0.93); older age [0.84 (0.58-1.21), 0.79 (0.53-1.18) and 0.47 (0.27-0.81) for [50-60[, [60-70[ and [70+ years, respectively]; female gender [1.84 (1.36-2.48)] and diagnosis of diabetes [2.16 (1.13-4.12)]. Only 8% of participants diagnosed with hypertension reported a low-salt diet. Low-salt diet was associated with antihypertensive drug treatment [2.17 (1.28-3.68)] and diagnosis of diabetes [2.72 (1.26-5.86)]. One-third of participants diagnosed with dyslipidemia reported a low-fat diet. Low-fat diet was associated with female gender [1.47 (1.17-1.86)]; older age [1.29 (0.89-1.87), 1.71 (1.18-2.48) and 2.01 (1.33-3.03) for [50-60[, [60-70[ and [70+ years, respectively]; hypolipidemic drug treatment [OR=1.68 (1.29-2.18)]; current smoking [0.70 (0.51-0.96)] and obesity [0.67 (0.45-1.00)]. Approximately half of participants diagnosed with diabetes reported an antidiabetic diet. Antidiabetic diet was associated with current smoking [0.44 (0.22-0.88)] and antidiabetic drug treatment [OR=3.26 (1.81-5.86)].

CONCLUSION

Dietary management of CVRFs is seldom implemented in Switzerland.

Dapagliflozin's Effects on Glycemia and Cardiovascular Risk Factors in High-Risk Patients With Type 2 Diabetes: A 24-Week, Multicenter, Randomized, Double-Blind, Placebo-Controlled Study With a 28-Week Extension

OBJECTIVE

To assess the efficacy and safety of dapagliflozin, a selective sodium-glucose cotransporter 2 inhibitor, compared with placebo in patients with type 2 diabetes (T2D), documented pre-existing cardiovascular disease (CVD), and a history of hypertension.

RESEARCH DESIGN AND METHODS

Patients (N = 922) were randomized to receive 10 mg dapagliflozin or placebo in a double-blind trial for 24 weeks, followed by a 28-week extension period. In patients receiving insulin, the insulin dose was reduced by 25% at randomization. Patients were stratified by age, insulin use, and time from the most recent qualifying cardiovascular (CV) event. Co-primary end points were a change from baseline in hemoglobin A1c (HbA1c) and the proportion of patients achieving a combined reduction in HbA1c of ≥0.5% (5.5 mmol/mol), body weight (BW) of ≥3%, and systolic blood pressure (SBP) of ≥3 mmHg.

RESULTS

At 24 weeks, dapagliflozin significantly reduced HbA1c (-0.38% [-4.2 mmol/mol]) from baseline (8.18%) compared with a slight increase with placebo from baseline (8.08%) (0.08% [0.9 mmol/mol]). Significantly more patients met the three-item end point with treatment with dapagliflozin than with placebo (11.7% vs. 0.9%, respectively). Changes were maintained over 52 weeks. Although ∼42% of patients were ≥65 years old, similar results were observed in both age-stratified groups. Serious adverse events, hypoglycemia, urinary tract infections, and cardiac disorders were similar between groups. Adverse events of hypotension, dehydration, hypovolemia, genital infection, and renal failure or impairment occurred more often with dapagliflozin treatment.

CONCLUSIONS

In this study that evaluated T2D patients who were at high risk for future CVD events, dapagliflozin administration had significantly greater effects in reducing HbA1c, BW, and SBP, without adversely impacting CV safety when compared with placebo treatment.

Prevention of cardiovascular disease in rheumatoid arthritis

The increased risk of cardiovascular disease (CVD) in rheumatoid arthritis (RA) has been recognized for many years. However, although the characteristics of CVD and its burden resemble those in diabetes, the focus on cardiovascular (CV) prevention in RA has lagged behind, both in the clinical and research settings. Similar to diabetes, the clinical picture of CVD in RA may be atypical, even asymptomatic. Therefore, a proactive screening for subclinical CVD in RA is warranted. Because of the lack of clinical trials, the ideal CVD prevention (CVP) in RA has not yet been defined. In this article, we focus on challenges and controversies in the CVP in RA (such as thresholds for statin therapy), and propose recommendations based on the current evidence. Due to the significant contribution of non-traditional, RA-related CV risk factors, the CV risk calculators developed for the general population underestimate the true risk in RA. Thus, there is an enormous need to develop adequate CV risk stratification tools and to identify the optimal CVP strategies in RA. While awaiting results from randomized controlled trials in RA, clinicians are largely dependent on the use of common sense, and extrapolation of data from studies on other patient populations. The CVP in RA should be based on an individualized evaluation of a broad spectrum of risk factors, and include: 1) reduction of inflammation, preferably with drugs decreasing CV risk, 2) management of factors associated with increased CV risk (e.g., smoking, hypertension, hyperglycemia, dyslipidemia, kidney disease, depression, periodontitis, hypothyroidism, vitamin D deficiency and sleep apnea), and promotion of healthy life style (smoking cessation, healthy diet, adjusted physical activity, stress management, weight control), 3) aspirin and influenza and pneumococcus vaccines according to current guidelines, and 4) limiting use of drugs that increase CV risk. Rheumatologists should take responsibility for the education of health care providers and RA patients regarding CVP in RA. It is immensely important to incorporate CV outcomes in testing of anti-rheumatic drugs.

Prediction of mortality by stress echocardiography in 2835 diabetic and 11 305 nondiabetic patients

BACKGROUND

To compare the capability by stress echocardiography results to predict overall mortality in a large unselected cohort of diabetic and nondiabetic patients.

METHODS AND RESULTS

The study group comprised 14 140 patients (2835 diabetics and 11 305 nondiabetics) who underwent stress echocardiography for evaluation of known (n=5671) or suspected (n=8469) coronary artery disease. Ischemia at stress echocardiography was observed in 768 (27%) diabetics and 2644 (23%) nondiabetics. During a median follow-up of 30 months (first quartile, 9; third quartile, 63), 1213 patients died. In diabetics, multivariable indicators of mortality were age (hazard ratio [HR], 1.07, 95% confidence interval [CI], 1.06-1.09), rest wall motion abnormality (HR, 2.43; 95% CI, 1.83-3.22), and ischemia at stress echocardiography (HR, 1.71; 95% CI, 1.34-2.18). In nondiabetics, multivariable indicators of mortality were age (HR, 1.07; 95% CI, 1.06-1.08), rest wall motion abnormality (HR, 2.19; 95% CI, 1.86-2.57), male sex (HR, 1.65; 95% CI, 1.41-1.93), ischemia at stress echocardiography (HR, 1.54; 95% CI, 1.32-1.80), and antischemic therapy at the time of test (HR, 1.15; 95% CI, 1.00-1.32). In stress echo negative subjects for ischemia, antischemic therapy showed increased annual mortality in nondiabetic patients with (3.8% versus 3.1%; P=0.04) or without rest wall motion abnormality (1.6% versus 0.9%; P<0.0001); it failed to do so in diabetic patients with (5.7% versus 5.8%; P=0.89) or without rest wall motion abnormality (2.6% versus 1.9%; P=0.10).

CONCLUSIONS

Ischemia at stress echocardiography is a strong and independent predictor of total mortality in diabetic as well as nondiabetic patients. Antischemic therapy markedly affects the negative predictive value of stress echocardiography in nondiabetic patients, whereas it is prognostically neutral in the diabetic population.

The role of lifestyle change for prevention of cardiovascular disease in diabetes

The burden of cardiovascular disease (CVD) is disproportionately greater in those with diabetes than in the general population, including higher rates of hospitalization, stroke, myocardial infarction, and mortality. Health-promoting lifestyle factors reduce both diabetes and CVD in healthy individuals; however, the efficacy of these strategies for CVD reduction in people with preexisting diabetes is unclear. In this review, we describe the most recent evidence (2013-2014) surrounding the effects of lifestyle changes on CVD outcomes in those with diabetes, and we contextualize the evidence against a backdrop of earlier key findings. Two major randomized controlled trials were identified, providing opposing conclusions about the role of lifestyle factors on CVD events in those with diabetes. Other recent prospective observational analyses support associations of physical activity and reduced CVD risk in diabetes. Limitations across studies include the use of self-report for measurement of lifestyle or lifestyle change, the length of follow-up needed to measure CVD outcomes, and the role of participants' medications on associations of lifestyle factors and CVD outcomes. Equivocal findings from the two randomized controlled trials support the need for additional research to identify the specific lifestyle factors that reduce CVD mortality and macrovascular complications in populations with diabetes.

Lower-extremity arterial revascularization: Is there any evidence for diabetic foot ulcer-healing?

The presence of peripheral arterial disease (PAD) is an important consideration in the management of diabetic foot ulcers. Indeed, arteriopathy is a major factor in delayed healing and the increased risk of amputation. Revascularization is commonly performed in patients with critical limb ischaemia (CLI) and diabetic foot ulcer (DFU), but also in patients with less severe arteriopathy. The ulcer-healing rate obtained after revascularization ranges from 46% to 91% at 1 year and appears to be improved compared to patients without revascularization. However, in those studies, healing was often a secondary criterion, and there was no description of the initial wound or its management. Furthermore, specific alterations associated with diabetes, such as microcirculation disorders, abnormal angiogenesis and glycation of proteins, can alter healing and the benefits of revascularization. In this review, critical assessment of data from the literature was performed on the relationship between PAD, revascularization and healing of DFUs. Also, the impact of diabetes on the effectiveness of revascularization was analyzed and potential new therapeutic targets described.

["Heart, arteries and women" an innovative care pathway for women at high risk: First evaluation at one year]

INTRODUCTION

Cardiovascular diseases remain the first cause of death in women. To improve women's health cardiologists and gynaecologists should work together on women's specific cardiovascular risk factor.

METHOD

Our study evaluated a care pathway named "heart, arteries and women". One hundred and ninety-one women were included for vascular (n=55) or hypertensive (n=136) explorations from January the first to December the 31st of 2013. We studied their clinical presentation and medical management.

RESULTS

All women were at high cardiovascular risk (38% of them at very high risk). The average age was 52 years old. A woman on three had experienced high blood pressure or diabetes during pregnancy. One on two was postmenopausal woman. We stopped twelve estrogen-progesterone contraceptions; 60% didn't have gynaecological follow-up; 146 had high blood pressures (73% at night, 50% had no dipping blood pressure profile and 15 were newly diagnosed for hypertension). Sleep apnoea syndrome was suspected in half women. Medical therapies were optimized especially for women with atheroma in which 30 to 46% were properly treated (P=0.0005). Only 18% of the gynecologists received conclusive reports.

CONCLUSION

At one year, our care pathway "heart, arteries and women" allowed to optimize medical therapy and clinical management. Everyone should be aware of this program.

Adherence to diabetes medication: a systematic review

AIMS

To investigate the extent of and factors associated with adherence to Type 2 diabetes medication.

METHODS

The CINAHL, Embase, International Pharmaceutical Abstracts, Medline, PubMed and PsychINFO databases were searched for the period January 2004 to July 2013. Papers were included in the present review if they reported the prevalence of adherence (the percentage of the study population that is classified as adherent) to Type 2 diabetes medication and used validated adherence measures with a defined cut-off point to indicate adherence. Reported factors were classified as potential predictors if the studies that examined that particular variable reported consistent findings.

RESULTS

Of the 27 studies included in the present review, the prevalence of adherence ranged from 38.5 to 93.1%. Only six out of 27 studies (22.2%) reported prevalence of adherence of ≥ 80% among their study population. Depression and medication cost were found to be consistent and potentially modifiable predictors for diabetes medication-taking behaviour. The associations between adherence and other factors were inconsistent among the reviewed studies.

CONCLUSIONS

Adherence to diabetes medication remains an ongoing problem. This review has highlighted the urgent need to develop consensus about what constitutes good adherence in diabetes. Further research is needed to clarify modifiable factors, in addition to depression and medication cost, that influence adherence and may provide a focus for targeted interventions to promote adherence, optimize diabetes control and limit the progression of diabetes.

Increased cardiovascular disease, resource use, and costs before the clinical diagnosis of diabetes in veterans in the southeastern U.S

IMPORTANCE

Screening for diabetes might be more widespread if adverse associations with cardiovascular disease (CVD), resource use, and costs were known to occur earlier than conventional clinical diagnosis.

OBJECTIVE

The purpose of this study was to determine whether adverse effects associated with diabetes begin prior to clinical diagnosis.

DESIGN

Veterans with diabetes were matched 1:2 with controls by follow-up, age, race/ethnicity, gender, and VA facility. CVD was obtained from ICD-9 codes, and resource use and costs from VA datasets.

SETTING

VA facilities in SC, GA, and AL.

PARTICIPANTS

Patients with and without diagnosed diabetes.

MAIN OUTCOME MEASURES

Diagnosed CVD, resource use, and costs.

RESULTS

In this study, the 2,062 diabetic patients and 4,124 controls were 63 years old on average, 99 % male, and 29 % black; BMI was 30.8 in diabetic patients vs. 27.8 in controls (p<0.001). CVD prevalence was higher and there were more outpatient visits in Year -4 before diagnosis through Year +4 after diagnosis among diabetic vs. control patients (all p<0.01); in Year -2, CVD prevalence was 31 % vs. 24 %, and outpatient visits were 22 vs. 19 per year, respectively. Total VA costs/year/veteran were higher in diabetic than control patients from Year -4 ($4,083 vs. $2,754) through Year +5 ($8,347 vs. $5,700) (p<0.003) for each, reflecting underlying increases in outpatient, inpatient, and pharmacy costs (p<0.05 for each). Regression analysis showed that diabetes contributed an average of $1,748/year to costs, independent of CVD (p<0.001).

CONCLUSIONS AND RELEVANCE

VA costs per veteran are higher--over $1,000/year before and $2,000/year after diagnosis of diabetes--due to underlying increases in outpatient, inpatient, and pharmacy costs, greater number of outpatient visits, and increased CVD. Moreover, adverse associations with veterans' health and the VA healthcare system occur early in the natural history of the disease, several years before diabetes is diagnosed. Since adverse associations begin before diabetes is recognized, greater consideration should be given to systematic screening in order to permit earlier detection and initiation of preventive management. Keeping frequency of CVD and marginal costs in line with those of patients before diabetes is currently diagnosed has the potential to save up to $2 billion a year.

Insulin and GH-IGF-I axis: endocrine pacer or endocrine disruptor?

Growth hormone/insulin-like growth factor (IGF) axis may play a role in maintaining glucose homeostasis in synergism with insulin. IGF-1 can directly stimulate glucose transport into the muscle through either IGF-1 or insulin/IGF-1 hybrid receptors. In severely decompensated diabetes including diabetic ketoacidosis, plasma levels of IGF-1 are low and insulin delivery into the portal system is required to normalize IGF-1 synthesis and bioavailability. Normalization of serum IGF-1 correlated with the improvement of glucose homeostasis during insulin therapy providing evidence for the use of IGF-1 as biomarker of metabolic control in diabetes. Taking apart the inherent mitogenic discussion, diabetes treatment using insulins with high affinity for the IGF-1 receptor may act as an endocrine pacer exerting a cardioprotective effect by restoring the right level of IGF-1 in bloodstream and target tissues, whereas insulins with low affinity for the IGF-1 receptor may lack this positive effect. An excessive and indirect stimulation of IGF-1 receptor due to sustained and chronic hyperinsulinemia over the therapeutic level required to overtake acute/chronic insulin resistance may act as endocrine disruptor as it may possibly increase the cardiovascular risk in the short and medium term and mitogenic/proliferative action in the long term. In conclusion, normal IGF-1 may be hypothesized to be a good marker of appropriate insulin treatment of the subject with diabetes and may integrate and make more robust the message coming from HbA1c in terms of prediction of cardiovascular risk.

Incidence of myocardial infarction and vascular death in elderly patients with atrial fibrillation taking anticoagulants: relation to atherosclerotic risk factors

BACKGROUND

Recent findings suggest that patients with atrial fibrillation (AF), in addition being at thromboembolic risk, are at risk of myocardial infarction (MI). Our aim was to investigate predictors of MI and cardiovascular death in a cohort of patients with AF who were taking anticoagulants.

METHODS

We prospectively followed up 1,019 patients with AF for a median of 33.7 months (3,223 person-years). All patients were treated with oral vitamin K antagonists. Primary outcome was a composite end point of cardiovascular events (CVEs) including fatal/nonfatal MI, cardiac revascularization, and cardiovascular death.

RESULTS

The mean age of the patients was 73.2 years, and 43.8% were women. At follow-up, 111 CVEs (3.43%/y) had occurred: 47 fatal-nonfatal MI/revascularization and 64 cardiovascular deaths. In addition, 31 stroke/transient ischemic attacks (0.96%/y) were recorded. Patients experiencing CVEs were older (P < .001) and had a higher prevalence of metabolic syndrome (MetS) (P = .005), heart failure (P = .001), and prior cardiac (P < .001) and cerebrovascular events (P < .001). On a Cox proportional hazard analysis, age (hazard ratio [HR], 1.083; 95% CI, 1.053-1.113; P < .001), smoking (HR, 2.158; 95% CI, 1.193-3.901; P = .011), history of cerebrovascular (HR, 1.704; 95% CI, 1.119-2.597; P = .013) and cardiac (HR, 1.658; 95% CI, 1.105-2.489; P = .015) events, MetS (HR, 1.663; 95% CI, 1.107-2.499; P = .014), heart failure (HR, 1.584; 95% CI, 1.021-2.456; P = .040), and male sex (HR, 1.499; 95% CI, 1.010-2.223; P = .044) predicted CVEs.

CONCLUSIONS

Patients with AF still experience a high rate of CVEs despite receiving anticoagulant treatment. MetS is a common clinical feature in patients with AF, which increases the risk of CVEs. A holistic approach is needed to reduce the cardiovascular risk in patients with AF.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT01882114; URL: www.clinicaltrials.gov.

Diagnosis and assessment of peripheral arterial disease in the diabetic foot

Approximately half of all patients with a diabetic foot ulcer have co-existing peripheral arterial disease. Identifying peripheral arterial disease among patients with foot ulceration is important, given its association with failure to heal, amputation, cardiovascular events and increased risk of premature mortality. Infection, oedema and neuropathy, often present with ulceration, may adversely affect the performance of diagnostic tests that are reliable in patients without diabetes. Early recognition and expert assessment of peripheral arterial disease allows measures to be taken to reduce the risk of amputation and cardiovascular events, while determining the need for revascularization to promote ulcer healing. When peripheral arterial disease is diagnosed, the extent of perfusion deficit should be measured. Patients with a severe perfusion deficit, likely to affect ulcer healing, will require further imaging to define the anatomy of disease and indicate whether a revascularization procedure is appropriate.

Inflammatory markers and cardiometabolic diseases

OBJECTIVES

A growing body of evidence emerges that obesity, metabolic syndrome, type 2 diabetes and cardiovascular disease are intimately related to chronic inflammation.

METHODS

A narrative review summarizing the most recent data of the literature describing the pathological implications of inflammation in obese patients with cardiometabolic disorders.

RESULTS

Besides high-sensitive C-reactive protein, various circulating or in situ inflammatory markers have been identified, presumably reflecting the presence of inflammation in various key-organs (visceral adipose tissue, skeletal muscle, pancreatic islets, liver, intestine, arterial wall). Available data support the concept that targeting inflammation, not only reduces systemic inflammatory markers, but also improves insulin sensitivity and ameliorates glucose control in insulin-resistant patients, thus potentially reducing the risk of cardiovascular complications.

CONCLUSION

These observations confirm the role of inflammation in cardiometabolic diseases and support the development of pharmacological strategies that aim at reducing inflammation, especially in patients with type 2 diabetes.

Diabetes mellitus and platelet reactivity in patients under prasugrel or ticagrelor treatment: an observational study

Background

The influence of diabetes mellitus (DM) on platelet reactivity (PR) in prasugrel or ticagrelor treated patients is not well studied.

Methods

In an observational study involving 777 patients with acute coronary syndrome undergoing percutaneous coronary intervention treated by either prasugrel 10 mg od (n = 315) or ticagrelor 90 mg bid (n = 462), platelet function was assessed using the VerifyNow P2Y₁₂ function assay (in PRU) at one month post intervention.

Results

In the overall population, ticagrelor and insulin-treated DM affected PR, with a decrease in log by 0.88 (corresponding to a 58 % decrease in PR) compared to prasugrel-treated patients (p < 0.001), and an increase in log by 0.26 (corresponding to a 30 % increase in PR) compared to non-diabetic patients (p = 0.01), respectively. PR in prasugrel-treated patients differed significantly by DM status: 70.0 (36.3-113.0) in non-diabetic vs 69.0 (44.5-115.3) in non insulin-treated diabetic vs 122.0 (69.0-161.0) in insulin-treated diabetic patients, p for trend = 0.01. No differences were observed in ticagrelor-treated patients. By multivariate analysis, in prasugrel-treated patients insulin-treated DM was the only factor predicting PR, with log of PR increased by 0.42 (corresponding to a 52 % increase in PR) compared to non-diabetic patients (p = 0.001). No factor was found to affect PR in ticagrelor-treated patients.

Conclusions

Patients with insulin-treated DM treated with prasugrel post PCI have higher PR, than patients without DM or non insulin-treated diabetic patients treated with this drug. Ticagrelor treated patients have overall lower PR than patients on prasugrel, independent of DM status or insulin treatment.

Trial registration

Clinical Trials Gov. NCT01774955

Subendocardial Systolic Dysfunction in Asymptomatic Normotensive Diabetic Patients

BACKGROUND

It remains uncertain whether diabetes itself causes specific echocardiographic features of myocardial morphology and function in the absence of hypertension or ischemic heart disease. The purpose of the present study was to determine the characteristics of pure diabetic cardiomyopathy-related echocardiographic morphology and function using layer-by-layer evaluation with myocardial strain echocardiography.

METHODS AND RESULTS

We enrolled 104 patients with poorly controlled type 2 diabetes mellitus (mean HbA1c level, 10%) with (n=74) or without (n=40) hypertension and 24 age- and sex-matched healthy volunteers. Patients with coronary artery stenosis or structural heart disease were excluded. Myocardial layer-specific strain was analyzed by speckle tracking echocardiography. Compared with the healthy control group, the normotensive diabetes group showed no significant difference in ejection fraction, left ventricular mass index, diastolic properties, left atrial volume index, or B-type natriuretic protein (BNP) level, but global longitudinal strain and subendocardial radial strain were significantly deteriorated. The deterioration of longitudinal strain correlated with body mass index (R=0.49, P<0.01) and blood pressure (R=0.36, P<0.01) in the normotensive diabetes group.

CONCLUSIONS

Deterioration of left ventricular longitudinal shortening accompanied by decreased subendocardial wall thickening are the characteristic functional abnormalities of diabetic cardiomyopathy in patients without hypertrophy, diastolic dysfunction, or elevated BNP. Obesity and blood pressure may also play important roles in this strain abnormality in asymptomatic patients with type 2 diabetes.

Sex Differences in the Excess Risk of Cardiovascular Diseases Associated with Type 2 Diabetes: Potential Explanations and Clinical Implications

Strong evidence suggests that type 2 diabetes confers a stronger excess risk of cardiovascular diseases in women than in men; with women having a 27 % higher relative risk of stroke and a 44 % higher relative risk of coronary heart disease compared with men. The mechanisms that underpin these sex differences in the associations between diabetes and cardiovascular disease risk are not fully understood. Some of the excess risk may be the result of a sex disparity in the management and treatment of diabetes, to the detriment of women. However, accruing evidence suggests that real biological differences between men and women underpin the excess risk of diabetes-related cardiovascular risk in women such that there is a greater decline in risk factor status in women than in men in the transition from normoglycemia to overt diabetes. This greater risk factor decline appears to be associated with women having to put on more weight than men, and thus attain a higher body mass index, to develop diabetes. Further studies addressing the mechanisms responsible for sex differences in the excess risk of cardiovascular diseases associated with diabetes are needed to improve the prevention and management of diabetes in clinical practise.

Monoamine Oxidases as Potential Contributors to Oxidative Stress in Diabetes: Time for a Study in Patients Undergoing Heart Surgery

Oxidative stress is a pathomechanism causally linked to the progression of chronic cardiovascular diseases and diabetes. Mitochondria have emerged as the most relevant source of reactive oxygen species, the major culprit being classically considered the respiratory chain at the inner mitochondrial membrane. In the past decade, several experimental studies unequivocally demonstrated the contribution of monoamine oxidases (MAOs) at the outer mitochondrial membrane to the maladaptative ventricular hypertrophy and endothelial dysfunction. This paper addresses the contribution of mitochondrial dysfunction to the pathogenesis of heart failure and diabetes together with the mounting evidence for an emerging role of MAO inhibition as putative cardioprotective strategy in both conditions.

The vulnerable vessel. Vascular disease in diabetes mellitus

Diabetes represents one of the most important risk factors for atherosclerosis, which is the leading cause of mortality worldwide. Recent imaging studies employing intravascular ultrasound or computed coronary angiography tomography clearly confirm that diabetes is associated with larger plaque burden and with more lesions displaying features of instability. Various molecular mechanisms promoting atherogenesis and plaque destabilization in diabetics have been described in the past. The current review specifically focuses on recent papers that have addressed the effects of diabetes and hyperglycemia (i) on myeloid cells, (ii) on oxidative stress, and (iii) on protein kinase C (PKC) activation. Thus, it has been demonstrated that hyperglycemia may promote myelopoiesis and differentiation of pro-inflammatory macrophages. Furthermore, novel studies emphasize the interplay between inflammation and oxidative stress at both the molecular and the genetic level. Finally, experimental studies shed light on the role of PKC-β in diabetes-associated atherosclerosis. Several of these recent studies suggest that atherogenesis and plaque destabilization in diabetic individuals may be mediated by diabetes-specific mechanisms. This may open the door for developing tailored anti-atherosclerotic therapies for diabetic patients.

Relation of nonalcoholic fatty liver disease and Framingham Risk Score to flow-mediated dilation in patients with cardiometabolic risk factors

Nonalcoholic fatty liver disease (NAFLD) has a high prevalence in the general population. Brachial artery flow-mediated dilation (FMD) is a surrogated marker of early atherosclerosis. Few data investigating the relation between FMD, NAFLD, and cardiovascular (CV) risk are available. We recruited 367 consecutive outpatients with cardiometabolic risk factors who underwent ultrasound scanning for liver steatosis and FMD. Mean age was 54.2 ± 12.2 years, and 37% were women. NAFLD was present in 281 patients (77%). Median FMD was 5.1%. FMD was significantly reduced in patients with NAFLD (p <0.001), diabetes (p = 0.001), history of coronary heart disease (p = 0.034), and metabolic syndrome (p = 0.050) and in those taking antihypertensive drugs (p = 0.022). Women disclosed greater FMD than males (p = 0.033). Moreover, FMD inversely correlated with age (Spearman rank correlation test [Rs], -0.171; p = 0.001), waist circumference (Rs, -0.127; p = 0.016), fasting blood glucose (Rs, -0.204; p <0.001), and gamma-glutamyl transpeptidase (Rs, -0.064; p = 0.234). At multivariate regression analysis, fasting blood glucose (β, -0.148; p = 0.008), age (β, -0.158; p = 0.005), and the presence of NAFLD (β, -0.132; p = 0.016) inversely correlated with FMD, whereas female gender predicted a better FMD (β, 0.125; p = 0.022). FMD and Framingham Risk Score (FRS) were inversely correlated (Rs, -0.183; p <0.001). After dividing patients into low (FRS <10; FMD, 5.5% [3.1% to 8.9%]), intermediate (FRS 10 to 20; FMD, 4.9% [2.7% to 7.5%]), and high (FRS >20; FMD, 3.3% [1.7% to 4.5%]) risk, FMD significantly decreased across risk classes of FRS (p = 0.003). At multivariate regression analysis, both FRS (β, -0.129; p = 0.016) and NAFLD (β, -0.218; p <0.001) were variables independently associated with FMD. In conclusion, the presence of NAFLD and FRS inversely correlated with FMD.

Chronic hyperglycemia is associated with acute kidney injury in patients undergoing CABG surgery--a cohort study

Background

Chronic hyperglycemia (CHG) with HbA1c as an indicator affects postoperative mortality and morbidity after coronary artery bypass grafting surgery (CABG). Acute kidney injury (AKI) is one of the frequent postoperative complications after CABG impacting short-and long-term outcomes. We investigated the association between CHG and postoperative incidence of AKI in CABG patients with and without history of diabetes mellitus (DM).

Methods

This cohort study consecutively enrolled patients undergoing CABG in 2009 at the department for cardiovascular surgery. CHG was defined as HbA1c ≥ 6.0 %. Patients with advanced chronic kidney disease (CKD) were excluded. The incidence of postoperative AKI and its association with CHG was analyzed by univariate and multivariate logistic regression modeling.

Results

Three-hundred-seven patients were analyzed. The incidence of AKI was 48.2 %. Patients with CHG (n = 165) were more likely to be female and had greater waist circumference as well as other comorbid conditions, such as smoking, history of DM, CKD, hypertension, pulmonary hypertension, and chronic obstructive pulmonary disease (all p ≤ 0.05). Preoperative eGFR, atrial fibrillation (AF), history of DM and CHG were associated with an increased risk of postoperative AKI in univariate analyses. In multivariate modelling, history of DM as well as preoperative eGFR and AF lost significance, while age, CHG and prolonged OP duration (p < 0.05) were independently associated with postoperative AKI.

Conclusions

Our results suggest that CHG defined on a single measurement of HbA1c ≥ 6.0 % was associated with the incidence of AKI after CABG. This finding might implicate that treatment decisions, including the selection of operative strategies, could be based on HbA1c measurement rather than on a recorded history of diabetes.

Association of peripheral nerve conduction in diabetic neuropathy with subclinical left ventricular systolic dysfunction

BACKGROUND

Subclinical left ventricular (LV) longitudinal myocardial systolic dysfunction occurs in patients with diabetes mellitus (DM) and preserved LV ejection fraction (LVEF), and is closely related to DM-related complications. However, the association of diabetic neuropathy (DN) with subclinical LV systolic longitudinal dysfunction in such patients has not been fully clarified.

METHODS

The subjects of this study were 112 consecutive DM patients with preserved LVEF (all ≥50%) without coronary artery disease and overt heart failure (aged 59 ± 14 years; 60 women, 52 men). Global longitudinal strain (GLS) was determined as the average peak strain of 18 segments from the three standard apical views, and was expressed as an absolute value. DN was diagnosed by experienced diabetologists. Median, ulnar, and sural nerves were subjected to motor and sensory nerve conduction studies. F-wave latency was defined as the minimum F-wave latency after a total of 16 stimulations of the tibial nerve.

RESULTS

Forty-one (37%) patients were clinically diagnosed with DN. LV functions of DM patients with and without DN were similar except for GLS being significantly smaller in patients with than in patients without DN (18 ± 2% vs. 20 ± 2%, p < 0.001). It was noteworthy that, of the parameters for the nerve conduction study, only F-wave latency correlated with GLS (r = -0.34, p < 0.001), and also was identified as an independent determinative value of GLS in a multivariate linear regression model (β = -0.25, p = 0.001) even after adjustment for other closely related GLS factors.

CONCLUSIONS

Monitoring of F-wave latency may aid early detection of not only DN but also subclinical LV dysfunction. Joint planning of assessment by diabetologists and cardiologists is therefore advisable for better management of DM patients.

Postprandial Dysmetabolism and Oxidative Stress in Type 2 Diabetes: Pathogenetic Mechanisms and Therapeutic Strategies

Postprandial dysmetabolism in type 2 diabetes (T2D) is known to impact the progression and evolution of this complex disease process. However, the underlying pathogenetic mechanisms still require full elucidation to provide guidance for disease prevention and treatment. This review focuses on the marked redox changes and inflammatory stimuli provoked by the spike in blood glucose and lipids in T2D individuals after meals. All the causes of exacerbated postprandial oxidative stress in T2D were analyzed, also considering the consequence of enhanced inflammation on vascular damage. Based on this in-depth analysis, current strategies of prevention and pharmacologic management of T2D were critically reexamined with particular emphasis on their potential redox-related rationale.