Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes-2020

Association of Epicardial Fat with Diastolic and Vascular Functions in Children with Type 1 Diabetes

We aimed to examine the relationship between epicardial fat thickness (EFT) measured by echocardiography and cardiovascular functional parameters in children with type 1 diabetes mellitus (T1DM). The study included 50 type 1 diabetic children and 50 healthy subjects matched by sex, age, and body mass index. In addition to laboratory tests, all participants underwent transthoracic echocardiography for EFT, cardiac dimensions and left ventricular functions, and ultrasonographic examination for brachial artery flow-mediated dilation (FMD) response and carotid intima-media thickness (CIMT). Multivariate linear regression was used to analyze the relationship between EFT and CIMT, FMD, lateral mitral E' velocity, and mitral E/E' ratio. EFT was significantly increased in diabetic children compared with controls (P < 0.001). In comparison with controls diabetic children had significantly increased mitral A, decreased lateral mitral E', decreased mitral E/A ratio, decreased lateral mitral E'/A' ratio, and increased mitral E/E' ratio (P < 0.001). FMD response was significantly lower in diabetic group versus controls (P < 0.001) and CIMT was significantly increased in diabetics versus controls (P = 0.03). EFT was negatively correlated with lateral mitral E' velocity (r =  - 0.613, P < 0.001), positively correlated with mitral E/E' ratio (r = 0.60, P < 0.001), positively correlated with CIMT (r = 0.881, P < 0.001), and negatively correlated with FMD (r =  - 0.533, P < 0.001). By multivariate regression analysis, the EFT was independently and positively associated with CIMT mean and E/E' mean and negatively associated with FMD mean and E' mean. The cut-off point for EFT as predictor of endothelial dysfunction was 6.95 mm. Our findings suggest that children with T1DM have subclinical LV diastolic and vascular endothelial dysfunctions associated with increased EFT.

Improvement in Age at Mortality and Changes in Causes of Death in the Population with Diabetes: An Analysis of Data from the Korean National Health Insurance and Statistical Information Service, 2006 to 2018

BACKGRUOUND

Diabetes is a leading cause of death that is responsible for 1.6 million annual deaths worldwide. However, the life expectancy and age at death of people with diabetes have been a matter of debate.

METHODS

The National Health Insurance Service claims database, merged with death records from the National Statistical Information Service in Korea from 2006 to 2018, was analyzed.

RESULTS

In total, 1,432,567 deaths were collected. The overall age at death increased by 0.44 and 0.26 year/year in the diabetes and control populations, respectively. The disparity in the mean age at death between the diabetes and control populations narrowed from 5.2 years in 2006 to 3.0 years in 2018 (p<0.001). In a subgroup analysis according to the presence of comorbid diseases, the number and proportion of deaths remained steady in the group with diabetes only, but steadily increased in the groups with diabetes combined with dyslipidemia and/or hypertension. Compared to the control population, the increase in the mean death age was higher in the population with diabetes. This trend was more prominent in the groups with dyslipidemia and/or hypertension than in the diabetes only group. Deaths from vascular disease and diabetes decreased, whereas deaths from cancer and pneumonia increased. The decline in the proportion of deaths from vascular disease was greater in the diabetes groups with hypertension and/or dyslipidemia than in the control population.

CONCLUSION

The age at death in the population with diabetes increased more steeply and reached a comparable level to those without diabetes.

Statins effect on insulin resistance after a meal and exercise in hypercholesterolemic pre-diabetic individuals

Aim

To study if statins, a widely prescribed, inexpensive medication to prevent coronary artery diseases may cause insulin resistance (IR).

Methods

Fasted (HOMA‐IR) and post‐meal insulin resistance were assessed in 21 pre‐diabetic hypercholesterolemic individuals treated with statins (STA trial). Measurements were compared to another trial conducted 96 h after statin withdrawal using placebo pills (PLAC trial). Trials were duplicated 16–18 h after a bout of moderate‐intensity exercise (500 kcal of energy expenditure) to reduce IR and better appreciate statin effects (EXER+STA and EXER+PLAC trials).

Results

Statin withdrawal did not affect fasting (HOMA‐IR; 2.35 ± 1.05 vs. 2.18 ± 0.87 for STA vs. PLAC trials; p = 0.150) or post‐meal insulin resistance (i.e., Matsuda‐index, STA 6.23 ± 2.83 vs. PLAC 6.49 ± 3.74; p = 0.536). A bout of aerobic exercise lowered post‐meal IR (p = 0.043), but statin withdrawal did not add to the exercise actions (p = 0.564). Statin withdrawal increased post‐meal plasma free glycerol concentrations (0.136 ± 0.073 vs. 0.185 ± 0.090 mmol·L⁻¹ for STA vs. PLAC trials; p < 0.001) but not plasma free fatty acids or fat oxidation (p = 0.981, and p = 0.621, respectively). Post‐meal fat oxidation was higher in the exercise trials (p = 0.002).

Conclusions

Withdrawal of statin medication does not affect fasting or post‐meal insulin resistance in pre‐diabetic hypercholesterolemic individuals. Furthermore, statin use does not interfere with the beneficial effects of exercise on lowering IR.

The use of glucagon-like-peptide-1 receptor agonist in the cardiology practice

The presence of type 2 diabetes confronts the patient with an elevated risk to develop atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), or chronic kidney disease (CKD). Glucose control in itself does not prevent these complications in their entirety. More recently several agents within the class of Sodium-Glucose cotransporter 2 inhibitors (SGLT2-I) and Glucagon-like-peptide-1 receptor agonists (GLP-1RA) have emerged as preferred agents to tackle the residual risk of ASCVD, HF, and CKD in patients with type 2 diabetes. Despite compelling trial data and professional society endorsement, the uptake of these agents in clinical practice is low. Especially GLP-1RA is only used in 8% of eligible candidates with type 2 diabetes and <5% of these prescriptions are attributed to cardiologists. This low uptake amongst cardiologists is related to the unfamiliarity with this class, its initiation, and titration, hesitation regarding simultaneous adjustment of other glucose-lowering agents, the unaccustomedness to prescribing injectable agents, and differential medical priorities. This review aims to offer cardiologists a practical tool for the optimal use of a GLP-1RA in their suitable patients and is focussed on the Belgian field of practice.

National Trends in Use of Sodium-Glucose Cotransporter-2 Inhibitors and Glucagon-like Peptide-1 Receptor Agonists by Cardiologists and Other Specialties, 2015 to 2020

Background

Sodium‐glucose cotransporter‐2 inhibitors (SGLT2is) and glucagon‐like peptide‐1 receptor agonists (GLP‐1RAs) mitigate cardiovascular risk in individuals with type 2 diabetes, but most eligible patients do not receive them. We characterized temporal trends in SGLT2i and GLP‐1RA use by cardiologists compared with other groups of clinicians.

Methods and Results

We conducted a descriptive analysis of serial, cross‐sectional data derived from IQVIA’s National Prescription Audit, a comprehensive audit capturing ≈90% of US retail prescription dispensing and projected to population‐level data, to estimate monthly SGLT2is and GLP‐1RAs dispensed from January 2015 to December 2020, stratified by prescriber specialty and molecule. We also used the American Medical Association’s Physician Masterfile to calculate average annual SGLT2is and GLP‐1RAs dispensed per physician. Between January 2015 and December 2020, a total of 63.2 million SGLT2i and 63.4 million GLP‐1RA prescriptions were dispensed in the United States. Monthly prescriptions from cardiologists increased 12‐fold for SGLT2is (from 2228 to 25 815) and 4‐fold for GLP‐1RAs (from 1927 to 6981). Nonetheless, cardiologists represented only 1.5% of SGLT2i prescriptions and 0.4% of GLP‐1RA prescriptions in 2020, while total use was predominated by primary care physicians/internists (57% of 2020 SGLT2is and 52% of GLP‐1RAs). Endocrinologists led in terms of prescriptions dispensed per physician in 2020 (272 SGLT2is and 405 GLP‐1RAs). Cardiologists, but not noncardiologists, increasingly used SGLT2is over GLP‐1RAs, with accelerated uptake of empagliflozin and dapagliflozin coinciding with their landmark cardiovascular outcomes trials and subsequent US Food and Drug Administration label expansions.

Conclusions

While use of SGLT2is and GLP‐1RAs by cardiologists in the United States increased substantially over a 6‐year period, cardiologists still account for a very small proportion of all use, contributing to marked undertreatment of individuals with type 2 diabetes at high cardiovascular risk.

The Prevalence of Cardiovascular Disease in Adults with Type 2 Diabetes in China: Results from the Cross-Sectional CAPTURE Study

INTRODUCTION

Cardiovascular disease (CVD) is the leading cause of death in Chinese adults with type 2 diabetes (T2D), and treatment guidelines have increasingly focused on the comprehensive management of T2D and CVD. Here, we report data from the Chinese population within the CAPTURE study, including CVD prevalence in patients with T2D and insights into their management.

METHODS

CAPTURE (a multinational, non-interventional, cross-sectional study in adults with T2D) included data from eight centers in China from July to September 2019. Overall CVD prevalence estimates were calculated, and descriptive data regarding CVD subtypes and treatment were collected and reported here.

RESULTS

Of 805 adults with T2D enrolled in China (61.9% male, median age 59 years), 273 had established CVD, with an estimated prevalence (95% CI) of 33.9% (30.6%, 37.3%). Most CVD cases were atherosclerotic (94.9%). Coronary heart disease had the highest estimated prevalence (16.0%), followed by carotid artery disease (9.6%) and cerebrovascular disease (7.7%). Use of glucose-lowering agents (GLAs) with proven cardiovascular benefits (glucagon-like peptide-1 receptor agonists and/or sodium-glucose cotransporter-2 inhibitors) was low in the China sample (7.7%). Approximately half of the CVD subgroup in the China sample was receiving cardiovascular medication, but use of guideline-directed agents was low (e.g., statins: 35.9%; angiotensin II receptor blockers: 15%; angiotensin-converting enzyme inhibitors: 2.6%).

CONCLUSIONS

In the Chinese CAPTURE population, one-third of patients had established CVD, with atherosclerotic CVD largely accounting for the CVD burden; use of GLAs with proven cardiovascular benefits and cardiovascular medications was low, suggesting an unmet need for optimal management in this group.

Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Low-dose aspirin is used for primary cardiovascular disease prevention and may have benefits for colorectal cancer prevention.

OBJECTIVE

To review the benefits and harms of aspirin in primary cardiovascular disease prevention and colorectal cancer prevention to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMed, Embase, and the Cochrane Central Register of Controlled Trials through January 2021; literature surveillance through January 21, 2022.

STUDY SELECTION

English-language randomized clinical trials (RCTs) of low-dose aspirin (≤100 mg/d) compared with placebo or no intervention in primary prevention populations.

DATA EXTRACTION AND SYNTHESIS

Single extraction, verified by a second reviewer. Quantitative synthesis using Peto fixed-effects meta-analysis.

MAIN OUTCOMES AND MEASURES

Cardiovascular disease events and mortality, all-cause mortality, colorectal cancer incidence and mortality, major bleeding, and hemorrhagic stroke.

RESULTS

Eleven RCTs (N = 134 470) and 1 pilot trial (N = 400) of low-dose aspirin for primary cardiovascular disease prevention were included. Low-dose aspirin was associated with a significant decrease in major cardiovascular disease events (odds ratio [OR], 0.90 [95% CI, 0.85-0.95]; 11 RCTs [n = 134 470]; I2 = 0%; range in absolute effects, -2.5% to 0.1%). Results for individual cardiovascular disease outcomes were significant, with similar magnitude of benefit. Aspirin was not significantly associated with reductions in cardiovascular disease mortality or all-cause mortality. There was limited trial evidence on benefits for colorectal cancer, with the findings highly variable by length of follow-up and statistically significant only when considering long-term observational follow-up beyond randomized trial periods. Low-dose aspirin was associated with significant increases in total major bleeding (OR, 1.44 [95% CI, 1.32-1.57]; 10 RCTs [n = 133 194]; I2 = 4.7%; range in absolute effects, 0.1% to 1.0%) and in site-specific bleeding, with similar magnitude.

CONCLUSIONS AND RELEVANCE

Low-dose aspirin was associated with small absolute risk reductions in major cardiovascular disease events and small absolute increases in major bleeding. Colorectal cancer results were less robust and highly variable.

Fibroblast Growth Factor 21 Levels Exhibit the Association With Renal Outcomes in Subjects With Type 2 Diabetes Mellitus

Background

Whether microalbuminuria predicts renal outcomes in patients with type 2 diabetes mellitus (T2DM) is argued. Fibroblast growth factor 21 (FGF-21) levels were elevated by the pathogenic process of diabetic kidney disease. The purpose of the study was to evaluate the associations of FGF-21 and renal outcomes in subjects with T2DM.

Methods

Chinese patients with T2DM were enrolled and then observed prospectively, and FGF-21 levels at baseline were measured. The associations of FGF-21 levels and renal composite events, defined by a drop > 30% of eGFR or worsening category of albuminuria, were evaluated using Cox analysis. The appropriate cut-off value of FGF-21 was mapped by the receiver operating characteristic (ROC) curve.

Results

Among 312 subjects, higher FGF-21 levels were associated with higher risks of renal events in Cox analysis. The area under the curve of FGF-21 levels in the ROC curve was optimal (0.67, p < 0.001), and the cut-off value of 1.40 pg/dl exhibited the best sensitivity (76.2%) and specificity (53.5%). The frequency of renal composite events was higher in subjects with FGF-21 ≥ 1.40 pg/dl than in others (30% vs. 10%, p<0.001 by the log-rank test). The worse renal outcomes predicted by FGF-21 ≥ 1.40 pg/dl were confirmed using the adjustments of Cox sequential models (hazard ratio 2.28, 95% confidence interval 1.23-4.24, p=0.009) and consistent across subjects with different status of baseline characteristics and renal risks.

Conclusion

FGF-21 levels were proportional to the risks of renal events in broad- spectrum Chinese T2DM subjects, making it a potential biomarker to predict the renal outcomes of T2DM.

Rationale and design of the Brazilian diabetes study: a prospective cohort of type 2 diabetes

BACKGROUND

Optimal control of traditional risk factors only partially attenuates the exceeding cardiovascular mortality of individuals with diabetes. Employment of machine learning (ML) techniques aimed at the identification of novel features of risk prediction is a compelling target to tackle residual cardiovascular risk. The objective of this study is to identify clinical phenotypes of T2D which are more prone to developing cardiovascular disease.

METHODS

The Brazilian Diabetes Study is a single-center, ongoing, prospective registry of T2D individuals. Eligible patients are 30 years old or older, with a confirmed T2D diagnosis. After an initial visit for the signature of the informed consent form and medical history registration, all volunteers undergo biochemical analysis, echocardiography, carotid ultrasound, ophthalmologist visit, dual x-ray absorptiometry, coronary artery calcium score, polyneuropathy assessment, advanced glycation end-products reader, and ambulatory blood pressure monitoring. A 5-year follow-up will be conducted by yearly phone interviews for endpoints disclosure. The primary endpoint is the difference between ML-based clinical phenotypes in the incidence of a composite of death, myocardial infarction, revascularization, and stroke. Since June/2016, 1030 patients (mean age: 57 years, diabetes duration of 9.7 years, 58% male) were enrolled in our study. The mean follow-up time was 3.7 years in October/2021.

CONCLUSION

The BDS will be the first large population-based cohort dedicated to the identification of clinical phenotypes of T2D at higher risk of cardiovascular events. Data derived from this study will provide valuable information on risk estimation and prevention of cardiovascular and other diabetes-related events.

CLINICALTRIALS.GOV IDENTIFIER

NCT04949152.

The Theory of Hyperlipidemic Memory of Type 1 Diabetes

A literature search was conducted to identify publications addressing the early phases of lipid phenotypes in children and adults with either type 1 diabetes or type 2 diabetes. Medline, EMBASE, and Ovid were searched using the following search terms: clinical remission, partial remission, partial clinical remission, honeymoon phase, C-peptide, type 1 or 2 diabetes, children, pediatric type 1 or 2 diabetes, and paediatrics type 1 or 2 diabetes, adults, adult type 1 or type 2 diabetes. Partial clinical remission (PR) of type 1 diabetes (T1D) is characterized by continued endogenous production of insulin and C-peptide following the diagnosis and the introduction of exogenous insulin therapy. PR is associated with improved glycemic control and reduced prevalence of diabetes complications. The theory of hyperglycemic memory was proposed to explain this concept of improved glycemic outcomes in remitters (those who experienced PR) versus non-remitters (those who did not experience PR). However, this theory is incomplete as it does not explain the dichotomy in early lipid phenotypes in T1D based on PR status, which is an understudied area in diabetology and lipidology. To fill this knowledge gap, we propose the Theory of Hyperlipidemic Memory of T1D. This theory is premised on our 5-year research on early post-diagnostic dichotomy in lipid phenotypes between remitters and non-remitters across the lifespan. It provides a more rigorous explanation for the differences in lifelong atherosclerotic cardiovascular disease (ASCVD) risk between remitters and non-remitters. We conducted 4 clinical studies in pediatric and adult subjects with diabetes mellitus to characterize the particulars of the hyperlipidemic memory. In the first investigation, we explored the impact of the presence or absence of PR on lipid parameters in children and adolescents with T1D. In the second, we investigated whether pubertal maturation influenced our findings in T1D; and whether these findings could be replicated in healthy, non-diabetic children and adolescents. In the third, we leveraged our findings from T1D and controls to investigate the mechanisms of early lipid changes in T2D by comparing the earliest lipid phenotype of subjects with type 2 diabetes (T2D) to those of remitters, non-remitters, and controls. In the fourth, we investigated the impact of PR on the earliest lipid phenotypes in adults with T1D and compared these early lipid data to those of T2D subjects and controls. This body of work across the lifespan in children, adolescents, and adults supports the Theory of Hyperlipidemic Memory. This new theory clarifies why PR largely determines the risks for early-phase dyslipidemia, mid-term microvascular disease risk, and long-term ASCVD risk in subjects with T1D.

Compliance with Cardiovascular Prevention Guidelines in Type 2 Diabetes Individuals in a Middle-Income Region: A Cross-Sectional Analysis

Stricter control of risk factors has been pursued as a compelling strategy to mitigate cardiovascular events (CVE) in type 2 diabetes (T2D) individuals. However, the achievement rate of the recommended goals has remained low in clinical practice. This study investigated the 2019 ESC guideline recommendation attainment among T2D individuals enrolled in a national cohort held in Brazil. Data from 1030 individuals (mean age: 58 years old; 54% male; mean T2D duration: 9.7 years) were analyzed. The control rates were 30.6% for SBP, 18.8% for LDL-C, and 41% for A1c, and only 3.2% of the study participants met all three targets. Statins and high-intensity lipid-lowering therapy prescription rates were 45% and 8.2%, respectively. Longer T2D duration and those at higher CV risk were less likely to be controlled. Longer diabetes duration and higher CV risk were inversely related to the chance of achieving the recommended targets. Treatment escalation using conventional therapies would be sufficient to gain optimal control in most of the study sample. In conclusion, a minimal proportion of T2D individuals comply with guidelines-oriented CV prevention targets. Given the significant burden of the disease, and the substantial effect size predicted for these therapies, bridging this gap between guidelines and clinical practice should be considered an urgent call to public health managers.

Universal Clinician Device for improving risk prediction and management of patients with atrial fibrillation: an assumed benefit analysis

Aim

Atrial fibrillation (AF) management guidelines advise using risk tools to optimize AF treatment. This study aims to develop a dynamic and clinically applicable digital device to assess stroke and bleeding risk, and to facilitate outcome improvements in AF patients. The device will provide tailored treatment recommendations according to easily attainable individual patient data.

Methods and Results

This Universal Clinician Device (UCD) was created using the GARFIELD-AF registry using a split sample approach. The GARFIELD-AF risk tool was adapted with two modifications. First, predictors with ≥1000 missing data points were separated, allowing expected risks estimation. Second, recommendations for modifiable risk factors and associated 2-year outcome estimates were incorporated. Outcomes of interest were all-cause mortality, non-haemorrhagic stroke/systemic embolism (SE), and major bleeding. All patients were randomized to a derivation (n = 34853) and validation cohort (n = 17165). In the derivation cohort, predictors were identified using least absolute shrinkage and selection operator regression. Cox models were fitted with the selected parameters. The UCD demonstrated superior predictive power compared with CHA₂DS₂VASc for all-cause mortality [0.75(0.75-0.76) vs. 0.71(0.70-0.72)] and non-haemorrhagic stroke/SE [0.68(0.66-0.70) vs. 0.65(0.63-0.67)], and with HAS-BLED for major bleeding [0.69(0.67-0.71) vs. 0.64(0.62-0.65)]. Universal Clinician Device recommendations reduced all-cause mortality (8.45-5.42%) and non-haemorrhagic stroke/SE (2.58-1.50%). Patients with concomitant diabetes and chronic kidney disease benefitted further, reducing mortality risk from 13.15% to 8.67%. One-third of patients with a CHA₂DS₂VASc score of >1 had the lowest risk of stroke.

Conclusion

The UCD simultaneously predicts mortality, stroke, and bleeding risk in patients using easily attainable individual clinical data and guideline-based optimized treatment plans.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier for GARFIELD-AF: NCT01090362.

Association of Impaired Fasting Glucose With Cardiovascular Disease in the Absence of Risk Factor

BACKGROUND

The association between impaired fasting glucose and cardiovascular disease (CVD) in participants without atherosclerotic CVD (ASCVD) risk factors based on current definitions is unclear. The study aimed to examine the association of fasting glucose levels with CVD and its subtypes in persons without ASCVD risk factors.

METHODS

This study included 38 297 participants [men 62.1%; mean age 47.9 (12.9) years] who were free of a history of CVD and absent of ASCVD risk factors and had a fasting plasma glucose (FPG) level between 70 to 125 mg/dL at baseline from Kailuan Study during 2006 and 2007. Participants were followed until new-onset CVD event, death, or December 31, 2017. Cox proportional hazards models were performed to evaluate the associations.

RESULTS

During a median follow-up of 11.0 years (interquartile range 10.7-11.2 years), we observed 1217 incident CVD events. Compared with participants with FPG 70 to 99 mg/dL, the multivariable adjusted hazard ratios for CVD among participants with FPG 100 to 109 mg/dL and 110 to 125 mg/dL were 1.18 (95% CI 1.02-1.38) and 1.27 (95% CI 1.03-1.55), respectively. Multivariable-adjusted spline regression model showed a J-shaped association between FPG and the risk of CVD.

CONCLUSIONS

We found that among individuals without diabetes or other traditional ASCVD risk factors, there is an increased risk of incident CVD with increasing abnormal FPG levels. These results highlight the importance of primordial prevention for FPG level increases along with other traditional ASCVD risk factors.

Caring for Young Adults With Diabetes in the Adult Care Setting: Summary of a Multidisciplinary Roundtable

Aims

A multidisciplinary team of clinicians and researchers, patients and family members, and representative from national advocacy groups and research organization met to review the literature, highlight gaps, and identify best practices to improve adult care delivery for young adults (YA) with diabetes.

Methods

The participants prepared presentations in advance, rotated through sessions, and contributed to group discussions in three areas: physical health, mental health, and quality of life (QoL). Session moderators and scribes used thematic analysis to summarize discussions for each topic.

Results

Thematic analysis revealed four foci for addressing physical health, mental health and QoL: 1) best practices to facilitate the process of transfer; 2) age-specific curricula and guidelines for prevention and management of comorbidities and complications; 3) collaboration with behavioral health clinicians to address diabetes distress and mental health disorders; and 4) research on the impact of diabetes on QoL in YA.

Conclusion

There was substantial interest and need among adult clinicians to work in concert with pediatric and mental health professionals to identify best practices and future directions to improve healthcare process and diabetes-related outcome measures in YA with diabetes.

Triglycerides: How to Manage Patients with Elevated Triglycerides and When to Refer?

Hypertriglyceridemia (HTG) is among the most common dyslipidemias seen in clinical practice. Studies in recent years have demonstrated a causal relationship between triglyceride-rich lipoproteins (TRL) and cardiovascular disease (CVD). This is primarily due to enhanced atherogenicity of cholesterol-enriched remnants, the metabolic byproducts of TRLs. Other factors influencing atherogenicity of TRLs include apolipoprotein CIII-directed proinflammatory signaling pathways and triglyceride enrichment of low-density lipoprotein that results in overabundance of small dense atherogenic particles within a prooxidative milieu that serves as the gateway for unregulated incorporation by vascular wall macrophages. HTG is caused by familial and metabolic disorders as well as selected medications that impair TRL hydrolysis.

Relative contributions of statin intensity, achieved low-density lipoprotein cholesterol level, and statin therapy duration to cardiovascular risk reduction in patients with type 2 diabetes: population based cohort study

Background

Current guidelines recommend life-long use of statin for patients with type 2 diabetes (T2D), however, a number of patients discontinue statin therapy in clinical practice. We aimed to estimate the optimal statin therapy including statin therapy duration, statin intensity, and low-density lipoprotein cholesterol (LDL-C) level among patients with T2D in a real-world setting.

Methods

From Korean National Health Insurance Service Cohort (2007–2015), 8937 patients with T2D (≥ 40 years of age) who received statin therapy for at least 90 days were included. Risk of major adverse cardiovascular event (MACE) including ischemic heart disease, ischemic stroke, and cardiovascular death was estimated according to statin intensity, achieved serum LDL-C level, and statin therapy duration, respectively. The relative contributions of these factors to MACE risk were quantified by calculating the proportion of log-likelihood explained by each factor.

Results

The hazard ratio (HR) of MACE was lower in patients receiving moderate- or high-intensity statins than in those receiving low-intensity statins (HR, 0.72; p = 0.027). Among patients who received moderate- or high-intensity statins, lower achieved LDL-C level was associated with lower cardiovascular risk. Notably, the longer the patients received statins, the lower was the risk of MACE; the HR of MACE was significantly reduced after at least 18 months (adjusted HR, 0.70; p = 0.009) as a reference to 3–6 months of therapy. The proportion of explainable log-likelihood for MACE was greatest for statin duration (2.55), followed by achieved LDL-C level (2.18), and statin intensity (0.95).

Conclusions

Statin therapy duration is as important as or more crucial than statin intensity or achieved LDL-C level for the reduction of cardiovascular risk in T2D patients. The concept of “longer is better” regarding statin therapy should be considered in clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01466-z.

Real-world evaluation of insulin requirements after GLP1 agonist or SGLT2 inhibitor initiation and titration

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

To describe insulin adjustments made following initiation of glucagon-like peptide 1 agonist (GLP1a) or sodium-glucose cotransporter-2 inhibitor (SGLT2i) therapy in patients within a primary care setting.

METHODS

This was a multicenter, retrospective cohort study conducted at an academic health system. Adults with type 2 diabetes mellitus initiated on a GLP1a or SGLT2i while on insulin and managed by an ambulatory care pharmacist were included. The primary endpoint was the percent change in total daily insulin dose at specified time points (2 weeks, 4 weeks, 6 weeks, 3 months, and 6 months) after agent initiation. The secondary endpoints included a glycosylated hemoglobin (HbA1c) value of less than 8%, change from baseline HbA1c, and safety profiles of GLP1a therapy and SGLT2i therapy.

RESULTS

Of the 150 patients included, 123 were initiated on a GLP1a and 27 on an SGLT2i. After 6 months, GLP1a initiation had resulted in a mean 23.5% decrease (P < 0.001) in insulin dosage and SGLT2i resulted in a mean 0.2% increase (P = 0.20). Insulin dosage reduction with GLP1a use was significantly different between baseline and each time point (P < 0.001). About 72% of patients initiated on a GLP1a and 59% of those initiated on an SGLT2i achieved an HbA1c value of less than 8%. The mean absolute change from baseline in HbA1c concentration was -1.7% with GLP1a use and -1.5% with SGLT2i use (P < 0.001 for both comparisons with baseline values). Hypoglycemia occurred in 21% of patients on a GLP1a and 11% of those on an SGLT2i.

CONCLUSION

After GLP1a initiation, the mean total daily insulin dose decreased by 23.5%; after SGLT2i initiation, insulin requirements increased by a mean of 0.2%. These results will help guide insulin adjustments after initiation of these medications.

Contraception use and knowledge related to pregnancy in diabetic women

BACKGROUND

Diabetes mellitus prevalence is increasing among women of child-bearing age. Diabetic pregnancy is associated with major maternal and fetal risks, and these can be reduced by Preconception Care. Pregnancy can be planned using appropriate effective contraception. The objective of this study was to assess diabetic patients' knowledge about pregnancy and to describe their contraceptive use.

STUDY DESIGN

An observational study was conducted from February to July 2020 at Reims University Hospital, France. Inclusion criteria were: women aged 18 to 40 years, with type 1 (T1D) or type 2 diabetes (T2D). Patients filled out a survey about contraceptive use and knowledge regarding diabetic pregnancy and data were completed from medical records.

RESULTS

Eighty-nine T1D and 33 T2D patients were included, with mean ages of 27.9±6.3 and 32.6±4.6 years, respectively. Seventy-five percent reported that they had been informed about pregnancy-related risks and 67% about the need to plan pregnancy. The preconception HbA1c target was known by 33% of patients. Appropriate knowledge about pregnancy was greater in T1D patients (65.9%, versus 36.4% in T2D patients; p=0.003). The rate of patients using an effective contraceptive method was 66.4%. Fifteen percent patients for whom contraception was recommended reported having no contraceptive method; 12.5% of contraception users were using a contraindicated method.

CONCLUSION

A large majority of diabetic women were aware of pregnancy-related risks and the importance of pregnancy planning, but there are still gaps, especially in T2D patients. We need to improve our practices by providing more information and better access to appropriate effective contraception.

Efficacy and Mechanism of the Jiangtang Tiaozhi Recipe in the Management of Type 2 Diabetes and Dyslipidaemia: A Clinical Trial Protocol

Background: Type 2 diabetes mellitus (T2DM) complicated with dyslipidaemia is associated with a high risk of cardiovascular diseases. The Jiangtang Tiaozhi (JTTZ) recipe is a Chinese herbal formula that has been used to regulate the blood glucose and lipid levels for many years. Interestingly, a previous study has demonstrated its efficacy; however, the associated mechanism remains unclear. We hypothesised that the therapeutic effect of the JTTZ on patients with T2DM may be mediated by the modulation of metabolites secreted by the gut microbiota. This study aims to examine this mechanism.

Methods and analysis: This study is a randomised, positive drug parallel-controlled, open-label clinical trial in patients with T2DM and dyslipidaemia. A total of 96 patients will be recruited and randomly assigned to treatment with JTTZ or metformin for 12 weeks. The primary outcome will be the rates of effectively regulated blood glucose and lipid levels (measured with the levels of glycated haemoglobin, fasting plasma glucose, 2-h plasma glucose, triglyceride, and low-density lipoprotein cholesterol). The secondary outcomes will be the changes in body weight, body mass index, and waist circumference and Traditional Chinese Medicine symptom scores. In addition, 16S rRNA gene sequencing will be performed on the gut microbiota obtained from faeces, and metabolomics analysis will be performed based on blood and gut microbiota samples. Intention-to-treat, per-protocol analysis and safety analysis will be performed.

Clinical trial registration number: https://clinicaltrials.gov/ct2/show/NCT04623567

High atherogenic risk concomitant with elevated HbA1c among persons with type 2 diabetes mellitus in North Ethiopia

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a chronic disease associated with worse clinical presentation. However, the current investigation practices in Ethiopia have limitations to demonstrate the scope of the clinical burden. Hence, this study was aimed at assessing the glycemic status and coronary heart disease (CHD) risk of persons with T2DM using HbA1c and atherogenic index of plasma (AIP).

METHOD

This institution-based cross-sectional study was conducted among 421 adults with T2DM from September to November 2019. Demographic, socioeconomic, and lifestyle data were collected through a face-to-face interview. Clinical information was retrieved from medical records whereas anthropometric and biochemical measurements were performed using the WHO protocols. Glycemic status was determined using HbA1c and CHD risk assessed using an atherogenic index of plasma (AIP). Gaussian variables were expressed using mean and standard deviation (SD), Log-normal variables using geometric mean and 95% CI and non- Gaussian variables using median and interquartile ranges. Categorical variables were summarized using absolute frequencies and percentages. Multivariable logistic regression was used to identify factors associated with glycemic control with a statistical significance set at 5%.

RESULT

A total of 195 male and 226 female subjects were involved in this study. The results demonstrated that 77% (324) had HbA1c value ≥7% and 87.2% (367) had high atherogenic risk for CHD. Besides, 57% and 67.9% of persons with T2DM had metabolic syndrome according to International Diabetes Federation (IDF) and the National Cholesterol Education Program-Adult treatment panel III (NCEP-ATP III) criteria, respectively. About 36.8% had one or more comorbidities. Having healthy eating behavior [AOR 1.95; CI 1.11-3.43] and taking metformin [AOR 4.88; CI 1.91-12.44] were associated with better glycemic outcomes.

CONCLUSION

High AIP level concomitant with poor glycemic control indicates increased risk for coronary heart disease among persons with T2DM in Northern Ethiopia.

Long-Term Glycemic Variability and Risk of Cardiovascular Events in Type 2 Diabetes: A Meta-Analysis

Long-term glycemic fluctuation has been associated with cardiovascular risk in patients with type 2 diabetes mellitus (T2DM). However, the findings are inconsistent. We performed a meta-analysis to summarize the association between parameters of long-term glycemic variability and risk of cardiovascular events in T2DM patients. Medline, Embase, and Web of Science databases were searched for longitudinal follow-up studies comparing the incidence of cardiovascular events in T2DM patients with higher or lower long-term glycemic variability. A random-effect model incorporating the potential heterogeneity among the included studies was used to pool the results. Twelve follow-up studies with 146 653 T2DM patients were included. The mean follow-up duration was 4.9 years. Pooled results showed that compared to those with the lowest glycemic variability, patients with the highest glycemic variability had significantly increased risk of cardiovascular events, as evidenced by the standard deviation of glycated hemoglobin [HbA1c-SD: relative risk (RR)=1.44, 95% confidence interval (CI): 1.23 to 1.69, p<0.001; I²=70%], HbA1c coefficient of variation (HbA1c-CV: RR=1.46, 95% CI: 1.19 to 1.79. p<0.001; I²=83%), standard deviation of fasting plasma glucose (FPG-SD: RR=1.33, 95% CI: 1.07 to 1.65, p=0.009; I²=0%), and FPG coefficient of variation (FPG-CV: RR=1.29, 95% CI: 1.01 to 1.64, p=0.04; I²=47%). In conclusion, increased long-term glycemic variability may be an independent risk factor for cardiovascular events in T2DM patients.

Continuous glucose monitoring in the hospital: an update in the era of COVID-19

PURPOSE OF REVIEW

Continuous glucose monitoring (CGM) systems are Food and Drug Administration approved devices for the ambulatory setting; however, they remain investigational systems for inpatient use. This review summarizes the most recent and relevant literature on the use of continuous glucose monitoring in the hospital setting.

RECENT FINDINGS

CGM provides real-time glucose data that enable healthcare professionals to make proactive and timelier clinical decisions with regards to diabetes management. CGM devices appear to be safe and accurate systems for glucose monitoring in the hospital setting. Real-time CGM systems and glucose telemetry can decrease hypoglycemia and reduce hyperglycemia in hospitalized patients with diabetes. Remote glucose monitoring decreases the need of frequent Point-of-care checks and personal protective equipment use while also mitigating staff exposure risk which is timely in the advent of the COVID-19 pandemic. Although most nursing staff have limited exposure and training on CGM technology, early studies show that CGM use in the hospital is well received by nurses.

SUMMARY

Given the evidence in the current literature regarding CGM use in the hospital, CGM devices may be incorporated in the inpatient setting.

Cardiovascular risk profiles: A cross-sectional study evaluating the generalizability of the glucagon-like peptide-1 receptor agonist cardiovascular outcome trials REWIND, LEADER and SUSTAIN-6 to the real-world type 2 diabetes population in the United Kingdom

AIMS

To determine the proportion of UK patients with type 2 diabetes (T2D) who meet the cardiovascular (CV) or combined CV/core eligibility criteria used for the CV outcome trials (CVOTs) of UK-marketed glucagon-like peptide-1 receptor agonists (GLP-1RAs) showing CV benefit (dulaglutide in REWIND, liraglutide in LEADER and injectable semaglutide in SUSTAIN-6).

MATERIALS AND METHODS

Adults with T2D on/before June 2018 were identified from the UK Clinical Practice Research Datalink GOLD primary care database and linked to Hospital Episode Statistics data (Protocol 19_262). Patient CV and clinical data were evaluated against the CVOT eligibility criteria. Data were analysed descriptively.

RESULTS

The study cohort (N = 33 118 patients with T2D) had a mean (standard deviation) age of 66.0 (13.3) years and 56.6% were male. Almost two-thirds (64.5%) of the study cohort met the CV criteria for REWIND, versus 43.0% for both LEADER and SUSTAIN-6. The proportions of the study cohort who met the CVOT criteria of "established CV disease" and "CV risk factors only" for REWIND were 22.4% and 42.1%, respectively, versus 38.7% and 4.3%, respectively, for both LEADER and SUSTAIN-6. The proportions of patients satisfying both CV and core criteria were 44.4% for REWIND, 13.3% for LEADER and 13.5% for SUSTAIN-6. Study findings remained consistent when restricted to GLP-1RA users.

CONCLUSIONS

REWIND captured a trial population more representative of the real-world T2D population in the United Kingdom than LEADER or SUSTAIN-6 with regard to both CV and combined CV/core eligibility criteria.

Does diabetes affect paraneoplastic thrombocytosis in colorectal cancer?

Background

A large variety of factors can affect colorectal cancer (CRC) survival, including type 2 diabetes mellitus (T2DM) and paraneoplastic thrombocytosis. Although several common factors play a role in their development and platelets are damaged in both diseases, the combined relationship of the three conditions was never investigated previously.

Methods

A prospective, real-life observational cohort study was conducted with the inclusion of 108 CRC patients and 166 voluntary non-CRC subjects. Plasma interleukin-6 and thrombopoietin levels were measured.

Results

Study participants were divided into cohorts based on the presence of T2DM. Platelet count (p < 0.0500) and interleukin-6 (p < 0.0100) level were significantly higher in the CRC groups. Thrombopoietin level was higher in the T2DM, CRC, and CRC + T2DM groups (p < 0.0500). Analysis of parameter changes over time and survival models revealed that neither platelet count, interleukin-6, nor thrombopoietin levels were affected by T2DM. Death of patients was associated with higher baseline platelet count (p = 0.0042) and interleukin-6 level (p < 0.0001).

Conclusion

Although the independent, disease-worsening effect of paraneoplastic thrombocytosis and T2DM is known, the coexistence of the two did not further impair the survival of CRC patients, suggesting that T2DM has no significant effect over paraneoplastic thrombocytosis.

Long-term glycemic variability and risk of stroke in patients with diabetes: a meta-analysis

OBJECTIVES

Long-term glycemic variability has been related to increased risk of vascular complication in patients with diabetes. However, the association between parameters of long-term glycemic variability and risk of stroke remains not fully determined. We performed a meta-analysis to systematically evaluate the above association.

METHODS

Medline, Embase, and Web of Science databases were searched for longitudinal follow-up studies comparing the incidence of stroke in diabetic patients with higher or lower long-term glycemic variability. A random-effect model incorporating the potential heterogeneity among the included studies were used to pool the results.

RESULTS

Seven follow-up studies with 725,784 diabetic patients were included, and 98% of them were with type 2 diabetes mellitus (T2DM). The mean follow-up duration was 7.7 years. Pooled results showed that compared to those with lowest category of glycemic variability, diabetic patients with the highest patients had significantly increased risk of stroke, as evidenced by glycemic variability analyzed by fasting plasma glucose coefficient of variation (FPG-CV: risk ratio [RR] = 1.24, 95% confidence interval [CI] 1.11 to 1.39, P < 0.001; I² = 53%), standard deviation of FPG (FPG-SD: RR = 1.16, 95% CI 1.02 to 1.31, P = 0.02; I² = 74%), HbA1c coefficient of variation (HbA1c-CV: RR = 1.88, 95% CI 1.61 to 2.19 P < 0.001; I² = 0%), and standard deviation of HbA1c (HbA1c-SD: RR = 1.73, 95% CI 1.49 to 2.00, P < 0.001; I² = 0%).

CONCLUSIONS

Long-term glycemic variability is associated with higher risk of stroke in T2DM patients.

Contemporary (2019) prevalence of cardiovascular disease in adults with type 2 diabetes in Brazil: the cross-sectional CAPTURE study

BACKGROUND

Type 2 diabetes (T2D) is a known risk factor for cardiovascular disease (CVD), and CVD is a major cause of mortality in patients with T2D. The CAPTURE study investigated the contemporary (2019) prevalence of established CVD in adults with T2D around the world. We report the findings from Brazil.

METHODS

The multinational, non-interventional, cross-sectional CAPTURE study was conducted across 13 countries from five continents. The current manuscript explores data for the CAPTURE study sample in Brazil. Standardized demographic and clinical data were collected from adults with T2D aged ≥ 18 years attending a single routine healthcare visit in primary or specialized care between December 2018 and September 2019. Data were analyzed descriptively.

RESULTS

Data from 912 adults with T2D were collected in the CAPTURE study in Brazil, with 822 patients from primary care and 90 patients from specialized care. Median (interquartile range [IQR]) patient characteristics were as follows: age 64 years (57; 71), diabetes duration 11 years (6; 19), glycated hemoglobin 7.7% (6.7; 9.1), and body mass index 29.5 kg/m² (26.4; 33.5); 59% were female. The CVD prevalence and atherosclerotic CVD prevalence in the Brazil sample were 43.9% (95% confidence interval [CI] 40.9; 46.8) and 37.6% (95% CI 34.7; 40.5), respectively. The majority of patients with CVD had atherosclerotic CVD (85.8%). For the specific CVD subtypes, coronary heart disease prevalence was 27.9% (95% CI 25.2; 30.5), heart failure was 12.4% (95% CI 10.4; 14.4), cerebrovascular disease was 8.7% (95% CI 6.8; 10.5), and carotid artery disease was 3.4% (95% CI 2.3; 4.5). Glucagon-like peptide-1 receptor agonists and/or sodium-glucose co-transporter-2 inhibitors with proven cardiovascular benefit were prescribed to 15.5% of patients with CVD, compared with 18.4% of patients without CVD.

CONCLUSIONS

CAPTURE was the first multinational, standardized study to provide contemporary data on CVD prevalence in adults with T2D in Brazil, and it demonstrated that almost one in two adults with T2D had established CVD. Except for carotid artery disease, the prevalence of all CVD subtypes in adults with T2D in Brazil appeared higher than the global CAPTURE prevalence. Trial registration NCT03786406, NCT03811288.

Screening for Primary Aldosteronism in the Diabetic Population: a cohort study

CONTEXT

Primary aldosteronism (PA) is the most common endocrine cause of hypertension. It is associated with higher cardio-metabolic risk than essential hypertension. Hypertension is common in patients with type 2 diabetes who carry increased cardiovascular risk, however, it is unknown how frequently they are tested for PA.

OBJECTIVE

The study aims to assess the extent to which the Endocrine Society's 2016 PA screening guidelines have been applied in a tertiary diabetes care setting and evaluate the demographic, clinical and biochemical characteristics of patients who met screening criteria compared to those who did not.

RESEARCH DESIGN & METHODS

This is a retrospective cohort study. Data were collected from 272 patients who attended tertiary Diabetes Clinics and had two or more blood pressure measurements from January to December 2018.

RESULTS

Of 272 patients, 63 (23.2%) had indication(s) for PA screening but only 15 (23.8% of 63) were screened using the aldosterone-to-renin ratio (ARR). Four patients who did not meet screening criteria were screened. Only one of 19 patients screened had an abnormal ARR, however 16 were taking medications known to affect aldosterone and/or renin production.

CONCLUSIONS

In a tertiary diabetes outpatient setting, only a minority of patients who fulfilled the Endocrine Society criteria for PA screening were actually screened. Appropriate screening for PA in the diabetic hypertensive population is necessary for the diagnosis and targeted treatment of a highly modifiable cardiovascular risk factor. Further studies are needed to develop feasible strategies to identify patients with PA in this population. This article is protected by copyright. All rights reserved.

Research Progress on the Cardiovascular Protective Effect of Glucagon-Like Peptide-1 Receptor Agonists

The risk of cardiovascular diseases is closely related to diabetes. Macrovascular disease is the main cause of death and disability in patients with type 2 diabetes. In recent years, the glucagon-like peptide-1 receptor agonist (GLP-1RA), a new type of hypoglycemic drug, has been shown to regulate blood sugar levels, improve myocardial ischemia, regulate lipid metabolism, improve endothelial function, and exert a protective role in the cardiovascular system. This study reviewed the protective effects of GLP-1RA on the cardiovascular system.

Human cell-based anti-inflammatory effects of rosiglitazone

PURPOSE

The C-X-C motif chemokine ligand 10 (CXCL10) participates in diabetes and diabetic cardiomyopathy development from the early stages. Rosiglitazone (RGZ) exhibits anti-inflammatory properties and can target cardiomyocytes secreting CXCL10, under interferon (IFN)γ and tumor necrosis factor (TNF)α challenge. Cardiomyocyte remodeling, CD4 + T cells and dendritic cells (DCs) significantly contribute to the inflammatory milieu underlying and promoting disease development. We aimed to study the effect of RGZ onto inflammation-induced secretion of CXCL10, IFNγ, TNFα, interleukin (IL)-6 and IL-8 by human CD4 + T and DCs, and onto IFNγ/TNFα-dependent signaling in human cardiomyocytes associated with chemokine release.

METHODS

Cells maintained within an inflammatory-like microenvironment were exposed to RGZ at near therapy dose (5 µM). ELISA quantified cytokine secretion; qPCR measured mRNA expression; Western blot analyzed protein expression and activation; immunofluorescent analysis detected intracellular IFNγ/TNFα-dependent trafficking.

RESULTS

In human CD4 + T cells and DCs, RGZ inhibited CXCL10 release likely with a transcriptional mechanism, and reduced TNFα only in CD4 + T cells. In human cardiomyocytes, RGZ impaired IFNγ/TNFα signal transduction, blocking the phosphorylation/nuclear translocation of signal transducer and activator of transcription 1 (Stat1) and nuclear factor-kB (NF-kB), in association with a significant decrease in CXCL10 expression, IL-6 and IL-8 release.

CONCLUSION

As the combination of Th1 biomarkers like CXCL10, IL-8, IL-6 with classical cardiovascular risk factors seems to improve the accuracy in predicting T2D and coronary events, future studies might be desirable to further investigate the anti-Th1 effect of RGZ.

A Contemporary Insight of Metabolomics Approach for Type 1 Diabetes: Potential for Novel Diagnostic Targets

High-throughput omics has been widely applied in metabolic disease, type 1 diabetes (T1D) was one of the most typical diseases. Effective prevention and early diagnosis are very important because of infancy and persistent characteristics of T1D. The occurrence and development of T1D is a chronic and continuous process, in which the production of autoantibodies (ie serum transformation) occupies the central position. Metabolomics can evaluate the metabolic characteristics of serum before seroconversion, the changes with age and T1D complications. And the addition of natural drug metabolomics is more conducive to the systematic and comprehensive diagnosis and treatment of T1D. This paper reviewed the metabolic changes and main pathogenesis from pre-diagnosis to treatment in T1D. The metabolic spectrum of significant abnormal energy and glucose-related metabolic pathway, down-regulation of lipid metabolism and up-regulation of some antioxidant pathways has appeared before seroconversion, indicating that the body has been in the dual state of disease progression and disease resistance before T1D onset. Some metabolites (such as methionine) are closely related to age, and the types of autoantibodies produced are age-specific. Some metabolites may jointly predict DN with eGFR, and metabolomics can further contribute to the pathogenesis based on the correlation between DN and DR. Many natural drug components have been proved to act on abnormal metabolic pathways of T1D and have a positive impact on some metabolic levels, which is very important for further finding therapeutic targets and developing new drugs with small side effects. Metabolomics can provide auxiliary value for the diagnosis of T1D and provide a new direction to reveal the pathogenesis of T1D and find new therapeutic targets. The development of T1D metabolomics shows that high-throughput research methods are expected to be introduced into clinical practice.

Characteristics of patients with diabetes and a history of myocardial infarction initiating PCSK9 and SGLT2 inhibitors

Study objective

Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) reduce the risk for atherosclerotic cardiovascular disease (ASCVD) events in patients with diabetes and ASCVD. We assessed factors associated with initiating either medication among patients with diabetes and a prior myocardial infarction (MI).

Setting/participants

US adults ≥19 years old with private health insurance (MarketScan) or government health insurance (Medicare) who had diabetes and a prior MI and initiated a PCSK9i or an SGLT2i in 2017 or 2018.

Main outcome measures

PCSK9i or SGLT2i initiation was identified using pharmacy claims.

Results

Overall, 8102 patients initiated a PCSK9i (n = 1501; 18.5%) or an SGLT2i (n = 6601; 81.5%). Patients with 2 and ≥3 versus 1 prior MI (risk ratio [RR]: 1.32 [95%CI: 1.17-1.48] and 1.68 [1.41-2.01], respectively), prior coronary revascularization (1.47 [1.31-1.64]), prior stroke (1.28 [1.06-1.56]), history of peripheral artery disease (1.27 [1.14-1.41]), receiving cardiologist care (1.51 [1.36-1.67]) or taking ezetimibe (2.57 [2.35-2.82]) were more likely to initiate a PCSK9i versus an SGLT2i. Patients with a history of short-term (RR 1.07 [95%CI 1.05-1.09]) or long-term (1.07 [1.04-1.09]) diabetes complications, and taking a low/moderate- and high-intensity statin dosage (1.61 [1.51-1.70] and 1.68 [1.58-1.77], respectively) were more likely to initiate an SGLT2i versus a PCSK9i. Among patients who initiated a PCSK9i, 2.9% subsequently initiated an SGLT2i; 0.8% who initiated an SGLT2i subsequently initiated a PCSK9i.

Conclusion

The decision to initiate PCSK9i or SGLT2i is explained by having very high cardiovascular disease risk for those initiating PCSK9i and diabetes complications for those initiating SGLT2i.

Racial, Ethnic, and Socioeconomic Inequities in Glucagon-Like Peptide-1 Receptor Agonist Use Among Patients With Diabetes in the US

Importance

Randomized clinical trials have shown that glucagon-like peptide-1 receptor agonists (GLP-1 RAs) cause significant weight loss and reduce cardiovascular events in patients with type 2 diabetes (T2D). Black patients have a disproportionate burden of obesity and cardiovascular disease and have a higher rate of cardiovascular-related mortality. Racial and ethnic disparities in health outcomes are largely attributable to the pervasiveness of structural racism, and patients who are marginalized by racism have less access to novel therapeutics.

Objectives

To evaluate GLP-1 RA uptake among a commercially insured population of patients with T2D; identify associations of race, ethnicity, sex, and socioeconomic status with GLP-1 RA use; and specifically examine its use among the subgroup of patients with atherosclerotic cardiovascular disease (ASCVD) because of the known benefit of GLP-1 RA use for this population.

Design Setting and Participants

This was a retrospective cohort analysis using data from OptumInsight Clinformatics Data Mart of commercially insured adult patients with T2D (with or without ASCVD) in the US. Data from October 1, 2015, to June 31, 2019, were included, and the analyses were performed in July 2020. We estimated multivariable logistic regression models to identify the association of race, ethnicity, sex, and socioeconomic status with GLP-1 RA use.

Main Outcome and Measure

A prescription for a GLP-1 RA.

Results

Of the 1 180 260 patients with T2D (median [IQR] age, 69 [59-76] years; 50.3% female; 57.7% White), 90 934 (7.7%) were treated with GLP-1 RA during the study period. From 2015 to 2019, the percentage of T2D patients treated with an GLP-1 RA increased from 3.2% to 10.7%. Among patients with T2D and ASCVD, use also increased but remained low (2.8%-9.4%). In multivariable analyses, lower rates of GLP-1 RA use were found among Asian (aOR, 0.59; 95% CI, 0.56-0.62), Black (adjusted odds ratio [aOR] 0.81; 95% CI, 0.79-0.83), and Hispanic (aOR, 0.91; 95% CI, 0.88-0.93) patients with T2D. Female sex (aOR, 1.22; 95% CI, 1.20-1.24) and higher zip code-linked median household incomes (>$100 000 [OR, 1.13; 95% CI, 1.11-1.16] and $50 000-$99 999 [OR, 1.07; 95% CI, 1.05-1.09] vs <$50 000) were associated with higher GLP-1 RA use. These results were similar to those found among patients with ASCVD.

Conclusions and Relevance

In this cohort study of US patients with T2D, GLP-1 RA use increased, but remained low overall for treatment of T2D, particularly among patients with ASCVD who are likely to derive the most benefit. Asian, Black, and Hispanic patients and those with low income were less likely to receive treatment with a GLP-1 RA. Strategies to lower barriers to GLP-1 RA use, such as lower cost, are needed to prevent the widening of well-documented inequities in cardiovascular disease outcomes in the US.

Cardiovascular risk in patients with and without diabetes presenting with chronic coronary syndrome in 2004-2016

Background

It was recently shown that new-onset diabetes patients without previous cardiovascular disease have experienced a markedly reduced risk of adverse cardiovascular events from 1996 to 2011. However, it remains unknown if similar improvements are present following the diagnosis of chronic coronary syndrome. The purpose of this study was to examine the change in cardiovascular risk among diabetes patients with chronic coronary syndrome from 2004 to 2016.

Methods

We included patients with documentation of coronary artery disease by coronary angiography between 2004 and 2016 in Western Denmark. Patients were stratified by year of index coronary angiography (2004–2006, 2007–2009, 2010–2012, and 2013–2016) and followed for two years. The main outcome was major adverse cardiovascular events (MACE) defined as myocardial infarction, ischemic stroke, or death. Analyses were performed separately in patients with and without diabetes. We estimated two-year risk of each outcome and adjusted incidence rate ratios (aIRR) using patients examined in 2004-2006 as reference.

Results

Among 5931 patients with diabetes, two-year MACE risks were 8.4% in 2004–2006, 8.5% in 2007–2009, and then decreased to 6.2% in 2010–2012 and 6.7% in 2013–2016 (2013–2016 vs 2004–2006: aIRR 0.70, 95% CI 0.53–0.93). In comparison, 23,540 patients without diabetes had event rates of 6.3%, 5.2%, 4.2%, and 3.9% for the study intervals (2013–2016 vs 2004–2006: aIRR 0.57, 95% CI 0.48–0.68).

Conclusions

Between 2004 and 2016, the two-year relative risk of MACE decreased by 30% in patients with diabetes and chronic coronary syndrome, but slightly larger absolute and relative reductions were observed in patients without diabetes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02312-y.

Beneficial effects of glucagon-like peptide 1 receptor agonists on glucose control, cardiovascular risk profile, and non-alcoholic fatty liver disease. An expert opinion of the Italian diabetes society

Patients with type 2 diabetes mellitus (T2DM) show an increased risk of cardiovascular diseases (CVD) and mortality. Many factors are implicated in the pathogenesis of CVD in patients with T2DM. Among the factors involved, chronic hyperglycemia and the cluster of CVD risk factors, such as dyslipidemia, hypertension, and obesity, play a major role. For many years, the control of hyperglycemia has been complicated by the fact that the use of many available drugs was associated with an increased risk of hypoglycemia. Paradoxically, hypoglycemia per se represents a risk factor for CVD. Recently, new drugs for the control of hyperglycemia have become available: many of them can determine a good control of hyperglycemia with minor risks of hypoglycemia. Among these new classes of drugs, glucagon-like peptide-1 receptor agonists (GLP-1RAs) offer many advantages. In addition to a strong anti-hyperglycemic action, they possess the ability to act on body weight and other relevant risk factors for CVD. Consistently, some of the GLP-1RAs have demonstrated, in RCT designed to assess their safety, to reduce the risk of major adverse cardiovascular events. Furthermore, GLP-1RAs possess properties useful to treat additional conditions, as the capability of improving liver damage in patients with NAFLD or NASH, highly prevalent conditions in people with T2DM. In this document, written by experts of the Italian diabetes society (SID), we will focus our attention on the therapy with GLP-1RAs in patients with T2DM, particularly on the effects on hyperglycemia, cardiovascular disease risk factors, NAFLD/NASH and CVD prevention.

Blood Pressure and Cardiovascular Disease in Older Patients With Diabetes: Retrospective Cohort Study

Background

Blood pressure (BP) targets in elderly patients with diabetes remain unclear. We evaluated the association between BP and cardiovascular disease in elderly patients with diabetes without cardiovascular disease or heart failure.

Methods and Results

We performed a retrospective cohort study of 225 563 elderly (aged ≥65 years) patients with diabetes without cardiovascular disease or heart failure from 2009 to 2017 using the National Health Information Database. We divided the participants by systolic BP (SBP) and diastolic BP. Primary composite outcomes were stroke, myocardial infarction, heart failure, and all‐cause death analyzed by Cox proportional hazards regression analysis adjusted for baseline covariates. During a median follow‐up of 7.76 years, the incidence rate of primary composite outcomes was 26.62 per 1000 person‐years. In multivariable Cox proportional hazard modeling, the risk of the primary outcome had a U‐curved association with SBP/diastolic blood pressure with a nadir between 120 and 129 mm Hg/65 and 69 mm Hg, respectively. Hypertension medication was associated with lower risk of primary composite outcomes in SBP ≥140 mm Hg (P for interaction for SBP <0.001) and diastolic blood pressure ≥90 mm Hg (P for interaction for diastolic blood pressure=0.018). In participants aged ≥80 years, SBP ≥160 mm Hg was only a marginally higher risk for primary composite outcomes (hazard ratio=1.11; 95% CI, 0.98–1.24).

Conclusions

In this large sample of older Korean patients with diabetes, cardiovascular events were more common in people with resting SBP or diastolic BP ≥140 or 95 mm Hg, respectively, and also more common in people with resting SBP or diastolic BP <120 or 65 mm Hg, respectively.

A dietary pattern high in full-fat dairy and sweetened beverages is associated with glycated hemoglobin and weight in Mexican patients with type-2 diabetes

OBJECTIVE

the aim of this study was to identify dietary patterns in a sample of patients with type-2 diabetes, and to evaluate their association with markers of metabolic control.

METHODS

a cross-sectional study in 395 patients with type-2 diabetes in primary care was conducted. Fasting blood levels of glycated hemoglobin (A1c), glucose, total cholesterol, low- (LDL-c) and high-density lipoprotein cholesterol (HDL-c), and triglycerides were measured. Waist circumference, body mass index (BMI), and blood pressure were evaluated. Dietary intake was assessed by a food frequency questionnaire, and dietary patterns were derived by cluster analysis. Three dietary patterns were identified: 'fruits and vegetables', 'dairy and sweetened beverages', and 'diverse with alcohol'.

RESULTS

an association between the 'dairy and sweetened beverages' dietary pattern and A1c levels was identified (ß = 0.61; 95 % CI: 0.09, 1.12, p = 0.021), considering the 'fruits and vegetables' dietary pattern as the reference group. We also observed a trend towards an adjusted increased risk of A1c ≥ 7 % (odds ratio [OR]: 1.56; 95 % CI: 0.92, 2.64; p = 0.099) and an increased risk of BMI ≥ 25 kg/m2 (OR: 2.62, 95 % CI: 1.20, 5.71, p = 0.015) among patients in the 'dairy and sweetened beverages' dietary pattern as compared to the reference group.

CONCLUSIONS

a dietary pattern characterized by a high intake of full-fat dairy and sweetened beverages was associated with higher A1c levels and increased risk of high glucose and BMI when compared to a dietary pattern with a higher consumption of fruits and vegetables.

Long-term effects of the mean hemoglobin A1c levels after percutaneous coronary intervention in patients with diabetes

BACKGROUND/AIMS

The clinical benefit of strict blood glucose-lowering therapy for patients with coronary artery disease (CAD) is still debated. We aimed to evaluate the long-term outcomes of patients with diabetes who underwent percutaneous coronary intervention (PCI), according to the mean hemoglobin A1c (HbA1c) level after PCI.

METHODS

We evaluated 675 diabetes patients with CAD treated with PCI. We categorized the study population into three groups based on the mean observed HbA1c levels during the follow-up duration, as follows: aggressive control (AC) group (HbA1c level < 6.5%, n = 148), moderate control (MC) group (HbA1c level ≥ 6.5% and < 7.0%, n = 138), and uncontrolled (UC) group (HbA1c level ≥ 7.0%, n = 389). The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCEs), defined as cardiac death, myocardial infarction, repeat target vessel revascularization, and stroke.

RESULTS

The mean HbA1c level of the AC group was significantly lower than that of the MC and UC groups (6.04% ± 0.36% vs. 6.74% ± 0.14% vs. 8.39% ± 1.20%, p < 0.001). The incidence of MACCEs was significantly lower in the AC group than in the MC and UC groups (16.0% vs. 24.3% vs. 26.3%, p = 0.010), mostly driven by the incidence of stroke (4.4% vs. 14.0% vs. 11.4%, p = 0.013). Multivariate Cox regression analysis showed that only the AC group was associated with a reduced rate of MACCEs (hazard ratio, 0.499; 95% confidence interval, 0.316 to 0.786; p = 0.004) compared with the UC group.

CONCLUSION

Our study showed that intensive glycemic control (HbA1c level < 6.5%) is associated with improved clinical outcomes after PCI in patients with diabetes.

Evolving Concepts of Type 2 Diabetes Management

With the concept of patient-centered care in mind, this article outlines the current diabetes medications available for glucose lowering and the characteristics of each of these medications that need to be considered in shared decision-making for durable and effective therapy. Important patient characteristics such as weight, risk for hypoglycemia, cost, social determinants of health, and medical literacy need to be considered. The evidence-base informing the use of antihyperglycemic agents has changed dramatically due to 2008 FDA guidance for cardiovascular safety and cardiorenal protection with antihyperglycemic agents. New evidence supports an approach to diabetes management that addresses pre-existing cardiorenal disease.

Glycemic control is associated with dyslipidemia over time in youth with type 2 diabetes: The SEARCH for diabetes in youth study

BACKGROUND

Dyslipidemia has been documented in youth with type 2 diabetes. There is a paucity of studies examining dyslipidemia over time in youth with type 2 diabetes and associated risk factors.

OBJECTIVE

To evaluate lipids at baseline and follow-up and associated risk factors in youth with type 2 diabetes.

METHODS

We studied 212 youth with type 2 diabetes at baseline and after an average of 7 years of follow-up in the SEARCH for Diabetes in Youth Study. Abnormal lipids were defined as high-density lipoprotein cholesterol (HDL-C) < 35, low-density lipoprotein cholesterol (LDL-C) > 100, or triglycerides >150 (all mg/dl). We evaluated participants for progression to abnormal lipids (normal lipids at baseline and abnormal at follow-up), regression (abnormal lipids at baseline and normal at follow-up), stable normal, and stable abnormal lipids over time for HDL-C, LDL-C, and triglycerides. Associations between hemoglobin A1c (HbA1c) and adiposity over time (area under the curve [AUC]) with progression and stable abnormal lipids were evaluated.

RESULTS

HDL-C progressed, regressed, was stable normal, and stable abnormal in 12.3%, 11.3%, 62.3%, and 14.2% of participants, respectively. Corresponding LDL-C percentages were 15.6%, 12.7%, 42.9%, and 28.8% and triglycerides were 17.5%, 10.8%, 55.7%, and 16.0%. Each 1% increase in HbA1c AUC was associated with a 13% higher risk of progression and stable abnormal triglycerides and a 20% higher risk of progression and stable abnormal LDL-C. Higher adiposity AUC was marginally (p = 0.049) associated with abnormal HDL-C.

CONCLUSIONS

Progression and stable abnormal LDL-C and triglycerides occur in youth with type 2 diabetes and are associated with higher HbA1c.

Changing the Concept: From the Traditional Glucose-centric to the New Cardiorenal-metabolic Approach for the Treatment of Type 2 Diabetes

Type 2 diabetes mellitus (T2DM) is a chronic disease with a constantly increasing prevalence worldwide. It is well established that T2DM affects both the macro- and microvasculature, and its presence is associated with a high risk of acute and chronic cardiovascular events. Traditionally, the management of T2DM has been mainly focused on the optimization of blood glucose levels with the use of antidiabetic medications. During recent years, however, an impressive accumulation of evidence has arisen from studies designed to explore the plausible effects of new antidiabetic drugs on cardiovascular outcomes in patients with diabetes. This review article aims to emphasize the findings of these studies and to highlight the substantial role of the newer classes of antidiabetic drugs in treating T2DM in a holistic, cardiorenal-metabolic approach, thus shifting the paradigm from the traditional, simplistic, glucose-lowering approach.

Cardiovascular risk profile and clinical characteristics of diabetic patients: a cross-sectional study in China

Background:

Cardiovascular (CV) disease is the leading cause of morbidity and mortality in adults with type 2 diabetes (T2D). The aim of this study was to determine the CV risk in Chinese patients with T2D based on the 2019 European Society of Cardiology (ESC) and the European Association for the Study of Diabetes (EASD) guidelines on diabetes, pre-diabetes, and CV diseases.

Methods:

A total of 25,411 patients with T2D, who participated in the study of China Cardiometabolic Registries 3B study, were included in our analysis. We assessed the proportions of patients in each CV risk category according to 2019 ESC/EASD guidelines.

Results:

Based on the 2019 ESC/EASD guidelines, 16,663 (65.6%), 1895 (7.5%), and 152 (0.6%) of patients were included in “very high risk,” “high risk,” and “moderate risk” categories, respectively. The proportions of patients in each category varied based on age, sex, body mass index, and duration. While 58.7% (9786/16,663) of elderly patients were classified to “very high risk” group, 89.6% (3732/4165) of patients with obesity were divided into “very high risk” group. Almost all patients with a duration of diabetes >10 years had “very high risk” or “high risk.” However, 6701 (26.4%) of Chinese T2D patients, who had shorter duration, and one or two risk factors, could not be included in any category (the “unclear risk” category).

Conclusions:

In China, most patients with T2D have “very high” or “high” CV risk based on 2019 ESC/EASD guidelines. However, the risk of patients in “unclear risk” group needs to be further classified.

Expert opinion on the preoperative medical optimization of adults with diabetes undergoing metabolic surgery

Diabetes mellitus (DM) and obesity are interrelated in a complex manner, and their coexistence predisposes patients to a plethora of medical problems. Metabolic surgery has evolved as a promising therapeutic option for both conditions. It is recommended that patients, particularly those of Asian origin, maintain a lower body mass index threshold in the presence of uncontrolled DM. However, several comorbidities often accompany these chronic diseases and need to be addressed for successful surgical outcome. Laparoscopic Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) are the most commonly used bariatric procedures worldwide. The bariatric benefits of RYGB and LSG are similar, but emerging evidence indicates that RYGB is more effective than LSG in improving glycemic control and induces higher rates of long-term DM remission. Several scoring systems have been formulated that are utilized to predict the chances of remission. A glycemic target of glycated hemoglobin < 7% is a reasonable goal before surgery. Cardiovascular, pulmonary, gastrointestinal, hepatic, renal, endocrine, nutritional, and psychological optimization of surgical candidates improves perioperative and long-term outcomes. Various guidelines for preoperative care of individuals with obesity have been formulated, but very few specifically focus on the concerns arising from the presence of concomitant DM. It is hoped that this statement will lead to the standardization of presurgical management of individuals with DM undergoing metabolic surgery.

Older Age, Polypharmacy, and Low Systolic Blood Pressure Are Associated With More Hypotension-Related Adverse Events in Patients With Type 2 Diabetes Treated With Antihypertensives

Background and Aims: Low systolic blood pressure (SBP) levels while being treated with antihypertensives may cause hypotension-related adverse events (hrAEs), especially in the elderly, women, and frail patients. We aimed to assess the association between the occurrence of hrAEs and low SBP levels, age, sex, and polypharmacy among patients with type 2 diabetes (T2D) treated with antihypertensives.

Methods: In this cohort study, we used the Groningen Initiative to ANalyse Type 2 diabetes Treatment (GIANTT) database which includes patients managed for T2D in primary care from the north of the Netherlands. Patients treated with ≥1 antihypertensive drug and ≥1 SBP measurement between 2012 and 2014 were included. The outcome was the presence of an hrAE, i.e. postural hypotension, dizziness, weakness/tiredness, and syncope in 90 days before or after the lowest recorded SBP level. Age (≥70 vs. <70 years), sex (women vs. men), polypharmacy (5–9 drugs or ≥10 drugs vs. <5 drugs), and SBP level (<130 or ≥130 mmHg) were included as determinants. Logistic regression analyses were conducted for age, sex and polypharmacy, including the SBP level and their interaction, adjusted for confounders. Odds ratios (OR) with 95% confidence intervals (CI) are presented.

Results: We included 21,119 patients, 49% of which were ≥70 years old, 52% were women, 57% had polypharmacy, 61% had an SBP level <130 mmHg and 5.4% experienced an hrAE. Patients with an SBP level <130 mmHg had a significantly higher occurrence of hrAEs than patients with a higher SBP level (6.2 vs. 4.0%; ORs 1.41, 95%CI 1.14–1.75, 1.43, 95%CI 1.17–1.76 and 1.33, 95%CI 1.06–1.67 by age, sex, and polypharmacy, respectively). Older patients (OR 1.29, 95%CI 1.02–1.64) and patients with polypharmacy (OR 5–9 drugs 1.27, 95%CI 1.00–1.62; OR ≥10 drugs 2.37, 95% CI 1.67–3.37) were more likely to experience an hrAE. The association with sex and the interactions between the determinants and SBP level were not significant.

Conclusion: Low SBP levels in patients with T2D treated with antihypertensives is associated with an increase in hrAEs. Older patients and those with polypharmacy are particularly at risk of hrAEs. Age, sex, and polypharmacy did not modify the risk of hrAEs associated with a low SBP level.

Baseline and Cumulative Blood Pressure in Predicting the Occurrence of Cardiovascular Events

Background: Both baseline blood pressure (BP) and cumulative BP have been used to estimate cardiovascular event (CVE) risk of higher BP, but which one is more reliable for recommendation to routine clinical practice is unclear.

Methods: In this prospective study, conducted in the Kailuan community of Tanshan City, China, a total of 95,702 participants free of CVEs at baseline (2006–2007) were included and followed up until 2017. Time-weighted cumulative BP that expresses the extent of cumulative BP exposure is defined as the sum of the mean of two consecutive systolic or diastolic BP times the interval between the two determinations, then normalized by the total follow-up duration. Incident CVEs during 2006–2017 were confirmed by review of medical records. We performed a competing risk regression analysis to assess CVE risk of the different durations of higher BP exposure. ROC analysis was performed to assess the predictive value of higher BP on CVE occurrence.

Results: We found that when the risk of higher BP on CVE occurrence was estimated based on time-weighted cumulative BP, the hazard ratios (HRs) increased with the increase in duration of higher BP exposure in each of the four BP groups: <120/<80, 120–129/<80, 130–139/80–89, and ≥140/≥90 mmHg; this time trend also occurred across the four different BP groups, with the higher BP group exhibiting CVE risk earlier during the follow-up. These results were confirmed by the same analysis performed on participants without baseline hypertension. However, such reasonable time trends did not occur when a single baseline BP was used as the primary estimation. We also demonstrated that the predictive values of baseline systolic and diastolic BP that predict CVE occurrence were only 0.6–3.2 and 0.2–3.1% lower, respectively, than those of cumulative BP combined with baseline BP during follow-up.

Conclusions: Baseline BP remains a useful indicator for predicting future occurrence of CVEs. Nevertheless, time-weighted cumulative BP could more reliably estimate the CVE risk of higher BP exposure than baseline BP.

Effectiveness of combined exercise in people with type 2 diabetes and concurrent overweight/obesity: a systematic review and meta-analysis

OBJECTIVE

To synthesise the available scientific evidence on the effects of combined exercise on glycaemic control, weight loss, insulin sensitivity, blood pressure and serum lipids among patients with type 2 diabetes (T2D) and concurrent overweight/obesity.

DESIGN AND SAMPLE

PubMed, EMBASE, Web of Science, the Cochrane library, WANFANG, CNKI, SinoMed, OpenGrey and ClinicalTrials.gov were searched from inception through April 2020 to identify randomised controlled trials (RCTs) that reported the effects of combined exercise in individuals with T2D and concurrent overweight/obesity.

METHODS

Quality assessment was performed using the Cochrane Collaboration's risk of bias tool. The mean difference (MD) with its corresponding 95% CI was used to estimate the effect size. Meta-analysis was performed using Review Manager V.5.3.

RESULTS

A total of 10 RCTs with 978 participants were included in the meta-analysis. Pooled results demonstrated that combined exercise significantly reduced haemoglobin A1c (MD=-0.16%, 95% CI: -0.28 to -0.05, p=0.006); body mass index (MD=-0.98 kg/m², 95% CI: -1.41 to -0.56, p<0.001); homeostasis model assessment of insulin resistance (MD=-1.19, 95% CI: -1.93 to -0.46, p=0.001); serum insulin (MD=-2.18 μIU/mL, 95% CI: -2.99 to -1.37, p<0.001) and diastolic blood pressure (MD=-3.24 mm Hg, 95% CI: -5.32 to -1.16, p=0.002).

CONCLUSIONS

Combined exercise exerted significant effects in improving glycaemic control, influencing weight loss and enhancing insulin sensitivity among patients with T2D and concurrent overweight/obesity.

Hypertension in Diabetes: An Update of Basic Mechanisms and Clinical Disease

Epidemiological studies have documented that insulin resistance and diabetes not only constitute metabolic abnormalities but also predispose to hypertension, vascular stiffness, and associated cardiovascular disease. Meanwhile, excessive arterial stiffness and impaired vasorelaxation, in turn, contribute to worsening insulin resistance and the development of diabetes. Molecular mechanisms promoting hypertension in diabetes include inappropriate activation of the renin-angiotensin-aldosterone system and sympathetic nervous system, mitochondria dysfunction, excessive oxidative stress, and systemic inflammation. This review highlights recent studies which have uncovered new underlying mechanisms for the increased propensity for the development of hypertension in association with diabetes. These include enhanced activation of epithelial sodium channels, alterations in extracellular vesicles and their microRNAs, abnormal gut microbiota, and increased renal sodium-glucose cotransporter activity, which collectively predispose to hypertension in association with diabetes. This review also covers socioeconomic factors and currently recommended blood pressure targets and related treatment strategies in diabetic patients with hypertension.

Glucose-lowering therapy in patients undergoing percutaneous coronary intervention

The number of individuals with diabetes and pre-diabetes is constantly increasing. These conditions are overrepresented in patients undergoing percutaneous coronary intervention and are associated with adverse prognosis. Optimal glycaemic control during an acute coronary syndrome is a relevant factor for the improvement of longer-term outcomes. In addition, the implementation of newer glucose-lowering drugs with proven cardiovascular benefits has a remarkable impact on recurrence of events, hospitalisations for heart failure and mortality. In this narrative review, we outline the current state-of-the art recommendations for glucose-lowering therapy in patients with diabetes undergoing coronary intervention. In addition, we discuss the most recent evidence-based indications for revascularisation in patients with diabetes as well as the targets for glycaemic control post revascularisation. Current treatment goals for concomitant risk factor control are also addressed. Lastly, we acknowledge the presence of knowledge gaps in need of future research.