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)

Changes in the prognostic values of modern cardiovascular biomarkers in relation to duration of diabetes mellitus

BACKGROUND

Based on the complex pathophysiology of type 2 diabetes and atherosclerosis we hypothesized a dynamic change in prognostic value of cardiovascular biomarkers over time.

METHODS

In this prospective study 746 patients with type 2 diabetes mellitus, being followed up for 60 months were analysed. The primary endpoint was defined as unplanned hospitalization for cardiovascular disease or death. Beside others, especially the prognostic performance of the biomarkers of interest (GDF-15, NT-proBNP, hs-TnT) was evaluated in relation to quartiles of diabetes duration.

RESULTS

In patients having a diabetes duration below 7 years lnGDF-15 (HR 2.84; p < 0.01) and lnhs-TnT (HR 2.96; p < 0.01) were significant predictors of the primary endpoint. LnAge (HR 40.01; p < 0.01) and lnNT-proBNP (HR 1.56; p = 0.03) were significant predictors in patients with a diabetes duration between 7 and 12 years. In the third quartile (diabetes duration 12-22 years) lnurinary albumin to creatinine ratio (HR 1.25; p = 0.005) and lnNT-proBNP (HR 2.13, p < 0.001) predicted the endpoint. In patients with a diabetes duration above 22 years, lnAge (HR 75.35; p = 0.001) and lnNT-proBNP (HR 2.0; p < 0.01) were the only significant predictors of the endpoint.

CONCLUSION

Prognostic power of cardiovascular biomarkers changes dynamically in relation to duration of type 2 diabetes mellitus. In patients with shorter duration of the disease markers of subclinical cardiovascular dysfunction and inflammation perform better than markers of systemic advanced organ dysfunction and cardiovascular disease.

Prognostic and comparative performance of cardiovascular risk markers in patients with type 2 diabetes

BACKGROUND

Diagnostic tests including echocardiography, albuminuria, electrocardiogram (ECG), high-sensitivity troponin I (hs-TnI), and N-terminal prohormone brain natriuretic peptide (NT-proBNP) have been suggested as cardiovascular (CV) risk predictors in type 2 diabetes. We studied the separate and combined prognostic yield of these risk markers.

METHODS

In all, 1030 patients with type 2 diabetes were recruited from specialized clinics in this prospective cohort study. Full echocardiographic evaluation was feasible in 886 patients in sinus rhythm with adequate image quality. ECG was performed in 998 patients. Albuminuria was measured in 1009 and NT-proBNP/hs-TnI in 933 patients. The end point was a composite of CV events.

RESULTS

The median follow-up was 4.7 years (interquartile range: 4.0-5.3), and 174 patients experienced a CV disease event. All considered markers, except hs-TnI, were significantly (P < .001) associated with the outcome: abnormal echocardiogram (hazard ratio 2.40 [1.70-3.39]), albuminuria 2.01 (1.47-2.76), abnormal ECG (2.27 [1.66-3.08]), high NT-proBNP (>150 pg/mL) 3.05 (2.11-4.40), and hs-TnI 1.12 (0.79-1.59). After adjusting for clinical variables, all remained significantly associated with the end point. However, after adjusting for each other, only NT-proBNP >150 pg/mL remained significantly associated with the end point (2.07 [1.28-3.34], P < .001). Measured by C-statistics, model performance was highest with log₂ (NT-proBNP) (0.70 [0.65-0.75]) and similar to clinical variables alone (0.71 [0.67-0.76]). Combining all risk markers only resulted in a very limited increase in C-statistics (0.69 [0.64-0.74]).

CONCLUSIONS

This study identified NT-proBNP over echocardiography, ECG, and albuminuria in risk prediction in patients with type 2 diabetes. The diagnostic yield in considering more than one risk marker was limited in this population.

Association between nutritional guidance or ophthalmological examination and discontinuation of physician visits in patients with newly diagnosed diabetes: A retrospective cohort study using a nationwide database

AIMS/INTRODUCTION

Discontinuation of diabetes care has been studied mostly in patients with prevalent diabetes and not in patients with newly diagnosed diabetes, whose dropout risk is highest. Because enrolling patients in a prospective study will influence adherence, we retrospectively examined whether guideline-recommended practices, defined as nutritional guidance or ophthalmological examination, can prevent patient discontinuation of diabetes care after its initiation.

MATERIALS AND METHODS

We retrospectively identified adults with newly screened diabetes during checkups using a large Japanese administrative claims database (JMDC, Tokyo, Japan) that contains laboratory data and lifestyle questionnaires. We defined discontinuation of physician visits as a follow-up interval exceeding 6 months. We divided the patients into those who received guideline-recommended practices (nutritional guidance or ophthalmology consultation) within the same month as the first visit and those who did not. We calculated propensity scores and carried out inverse probability of treatment weighting analyses to compare discontinuation between the two groups.

RESULTS

We identified 6,508 patients with at least one physician consultation for diabetes care within 3 months after their checkup, including 4,574 patients without and 1,934 with guideline-recommended practices. After inverse probability of treatment weighting, patients with guideline-recommended practices had a significantly lower proportion of discontinuation than those without (17.2% vs 21.8%; relative risk 0.79, 95% confidence interval 0.69-0.91).

CONCLUSIONS

This study is the first to show that after adjustment for both patient and healthcare provider factors, guideline-recommended practices within the first month of physician consultation for diabetes care can decrease subsequent discontinuation of physician visits in patients with newly diagnosed diabetes.

Do Weight trajectories influence diabetes control? A prospective study in Switzerland (CoLaus study)

OBJECTIVE

Identify anthropometric trajectories among subjects with type 2 diabetes mellitus (T2DM), and associate them with glycaemic control.

METHODS

Prospective study including 268 community-dwelling participants with T2DM (34% women, mean age 68.7 ± 8.9 years) followed for 10.7 years (range: 8.8-13.6 years). T2DM control was considered for 1) fasting plasma glucose (FPG) < 7.0 mmol/L, or 2) HbA1c < 7.0% (53 nmol/mol). Changes in weight or waist and weight variability were considered.

RESULTS

One half (FPG) and one third (HbA1c) of participants presented with uncontrolled T2DM. Half of the participants presented with obesity and 75% with abdominal obesity. During follow-up, half of the participants maintained their weight, 25% gained > 5 kg, and 25% lost < 5 kg; almost half increased their waist by > 5 cm. Using FPG as criterion, participants who lost > 5 cm waist were more likely to be controlled: multivariable-adjusted odds ratio (OR) and 95% confidence interval (CI): 3.10 (1.23-7.78). Participants with controlled T2DM also presented with a higher weight variability: multivariable adjusted mean ± standard error 4.8 ± 0.3 vs. 3.9 ± 0.3 kg, p = 0.028. Using HbA1c as criterion, participants who lost > 5 kg were less likely to be controlled: OR and (95% CI): 0.35 (0.18-0.66). Similar findings were obtained when restricting the analysis to participants who were diabetic throughout the whole study period.

CONCLUSION

In a Swiss community-based sample of participants with T2DM, T2DM control rates could be implemented. Neither weight nor waist variability was significantly and consistently associated with T2DM control.

Chronic kidney disease

Chronic kidney disease is a progressive disease with no cure and high morbidity and mortality that occurs commonly in the general adult population, especially in people with diabetes and hypertension. Preservation of kidney function can improve outcomes and can be achieved through non-pharmacological strategies (eg, dietary and lifestyle adjustments) and chronic kidney disease-targeted and kidney disease-specific pharmacological interventions. A plant-dominant, low-protein, and low-salt diet might help to mitigate glomerular hyperfiltration and preserve renal function for longer, possibly while also leading to favourable alterations in acid-base homoeostasis and in the gut microbiome. Pharmacotherapies that alter intrarenal haemodynamics (eg, renin-angiotensin-aldosterone pathway modulators and SGLT2 [SLC5A2] inhibitors) can preserve kidney function by reducing intraglomerular pressure independently of blood pressure and glucose control, whereas other novel agents (eg, non-steroidal mineralocorticoid receptor antagonists) might protect the kidney through anti-inflammatory or antifibrotic mechanisms. Some glomerular and cystic kidney diseases might benefit from disease-specific therapies. Managing chronic kidney disease-associated cardiovascular risk, minimising the risk of infection, and preventing acute kidney injury are crucial interventions for these patients, given the high burden of complications, associated morbidity and mortality, and the role of non-conventional risk factors in chronic kidney disease. When renal replacement therapy becomes inevitable, an incremental transition to dialysis can be considered and has been proposed to possibly preserve residual kidney function longer. There are similarities and distinctions between kidney-preserving care and supportive care. Additional studies of dietary and pharmacological interventions and development of innovative strategies are necessary to ensure optimal kidney-preserving care and to achieve greater longevity and better health-related quality of life for these patients.

Body surface area may explain sex differences in findings from the oral glucose tolerance test among subjects with normal glucose tolerance

BACKGROUND AND AIMS

Current guidelines on prediabetes and diabetes (T2D) recommend to regularly perform an oral glucose tolerance test (OGTT) on subjects at risk of T2D. However, it is not known why women tend to have relatively higher 2-h post-load plasma (2hPG) glucose concentrations during OGTT than men. The aim of the present study is to investigate if there are sex differences in fasting plasma glucose (FPG) and 2hPG concentrations in relation to body size in apparently healthy non-diabetic subjects with normal glucose tolerance. We hypothesized that sex differences in glucose tolerance are physiological and related to different body surface area (BSA) in men and women.

METHODS AND RESULTS

A 2-h 75 g OGTT was performed on 2010 subjects aged 45-70 years. Their BSA was calculated using the Mosteller formula. Men and women were separately divided into five BSA levels. Within the normal 2hPG range, women had higher mean 2hPG concentrations during the OGTT than men in all BSA levels estimated by sex-standardized BSA (p for linearity < 0.001). BSA adjusted for age, waist circumference, leisure-time physical activity, and smoking, showed an inverse association with 2hPG concentration in both sexes. Mean FPG concentrations were higher in men than in women.

CONCLUSIONS

Body size has a negative inverse association with 2hPG concentration in an OGTT even within a physiological plasma glucose range. This may cause underestimation of glucose disorders in individuals with larger BSA and overestimation in individuals with smaller BSA when using an OGTT.

Diabetes Mellitus and Heart Failure

Diabetes mellitus (DM) is a major risk factor for new-onset heart failure (HF) and vice versa. The pathogenesis of new-onset HF in DM is complex and has been largely attributed to the toxic cardiovascular effects of hyperglycemia and relevant metabolic abnormalities (diabetic cardiomyopathy) as well as the frequently coexisting morbidities such as hypertension (HTN), coronary artery disease (CAD), and diabetic nephropathy. In patients with type 1 DM (T1DM), HF develops in the setting of a dysregulated immune response, whereas in most patients with type 2 DM (T2DM), against a background of overweight/obesity. HF prevention in DM is feasible with rigorous treatment of cardiovascular risk factors and selective antidiabetic agents. Conversely, development of new-onset T2DM in HF (cardiogenic DM) is common and has been attributed to an increase in the resistance to insulin, especially in the skeletal muscle, liver, and adipose tissue as well as in diminished insulin secretory response to hyperglycemia by pancreatic β-cells. Cardiogenic DM further deteriorates cardiac dysfunction and adversely affects outcome in HF. Novel lifesaving medications employed in HF management such as sacubitril/valsartan and sodium glucose cotransporter 2 inhibitors (SGLT-2i) have a favorable metabolic profile and lower the incidence of cardiogenic diabetes. Whether mitigation of cardiogenic DM should be a treatment target in HF deserves further investigation.

Bleeding Events in Patients 75 Years of Age and Older Under Long-term Anticoagulant Therapy: A Real-life Study

OBJECTIVE

To investigate the risk of bleeding events in older patients under oral anticoagulant with a 4-year survey of a catchment area with 197,722 inhabitants of whom 15,267 were on warfarin and 10,397 on direct oral anticoagulants (DOACs).

METHODS

Patients presented to the Emergency Department with major bleeding were enrolled and stratified according to age ≥75 years and ongoing warfarin or DOACs. Primary endpoint was 1-month death.

RESULTS

Out of 1919 major bleeding, those of patients ≥75 years of age were 1127 (59%) versus 792 (41%) <75 years of age, P < 0.0001. In patients ≥75 years of age, brain hemorrhage accounted for 612 (54%) patients, gastrointestinal hemorrhage for 301 (27%), hematuria for 104 (9%), and other hemorrhage for 108 (10%). In patients ≥75 years of age, those on warfarin accounted for 175 versus 53 on DOACs, without difference of Charlson Comorbidity Index (5.25 ± 1.92 versus 5.09 ± 1.61; P = 0.5824). One-month death in patients ≥75 of age versus <75 years of age accounted for 77 (4.0%) versus 20 (1.0%); P < 0.0001. One-month death in patients ≥75 of age on DOACs was very low, without difference versus <75 years and within DOACs. Among DOACs, absolute bleeding events showed differences as follows: 3 bleeding events for edoxaban versus 21 for dabigatran; P < 0.001; versus 16 for rivaroxaban, P = 0.006; and versus 13 for apixaban, P = 0.02.

CONCLUSIONS

Major bleeding and 1-month death accounted for higher percentage in patients ≥75 years of age and in patients receiving warfarin. Among DOACs, edoxaban presented the lowest absolute rate of hemorrhage among the 4 available DOACs, without difference in mortality.

Effect of Rivaroxaban and Aspirin in Patients with Peripheral Artery Disease Undergoing Surgical Revascularization: Insights from the VOYAGER PAD Trial

Background: Patients with peripheral artery disease (PAD) requiring lower extremity revascularization (LER) are at high risk of adverse limb and cardiovascular events. VOYAGER PAD demonstrated that rivaroxaban significantly reduced this risk. The efficacy and safety of rivaroxaban has not been described in patients who underwent surgical LER. Methods: The VOYAGER PAD trial randomized patients with PAD after surgical and endovascular LER to rivaroxaban 2.5mg twice daily plus aspirin or matching placebo plus aspirin and followed for a median of 28 months. The primary endpoint was a composite of acute limb ischemia, major vascular amputation, myocardial infarction, ischemic stroke, or cardiovascular death. The principal safety outcome was Thrombolysis in Myocardial Infarction (TIMI) major bleeding. International Society on Thrombosis and Haemostasis (ISTH) bleeding was a secondary safety outcome. All efficacy and safety outcomes were adjudicated by a blinded independent committee. Results: Of the 6564 randomized, 2185 (33%) underwent surgical LER and 4379 (67%) endovascular. Compared to placebo, rivaroxaban reduced the primary endpoint consistently regardless of LER method (p-interaction 0.43). Following surgical LER, the primary efficacy outcome occurred in 199 (18.4%) patients in the rivaroxaban group and 242 (22.0%) patients in the placebo group with a cumulative incidence at 3 years of 19.7% and 23.9%, respectively (HR 0.81, 95% CI 0.67 - 0.98; p=0.026). In the overall trial, TIMI major bleeding and ISTH major bleeding were increased with rivaroxaban. There was no heterogeneity for TIMI major bleeding (p-interaction 0.17) or ISTH major bleeding (p-interaction 0.73) based on LER approach. Following surgical LER, the principal safety outcome occurred in 11 (1.0%) patients in the rivaroxaban group and 13 (1.2%) patients in the placebo group; 3-year cumulative incidence 1.3% and 1.4% respectively (HR 0.88, 95% CI 0.39-1.95; p=0.75) Among surgical patients, the composite of fatal bleeding or intracranial hemorrhage (p=0.95) and postprocedural bleeding requiring intervention (p=0.93) were not significantly increased. Conclusions: The efficacy of rivaroxaban is associated with a benefit in surgical LER patients. While bleeding was increased with rivaroxaban plus aspirin, the incidence was low, with no significant increase in fatal bleeding, intracranial hemorrhage or postprocedural bleeds requiring intervention. Clinical Trial Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT02504216.

Gaussian process-based kernel as a diagnostic model for prediction of type 2 diabetes mellitus risk using non-linear heart rate variability features

The main objective of the study was to develop a low-cost, non-invasive diagnostic model for the early prediction of T2DM risk and validation of this model on patients. The model was designed based on the machine learning classification technique using non-linear Heart rate variability (HRV) features. The electrocardiogram of the healthy subjects (n = 35) and T2DM subjects (n = 100) were recorded in the supine position for 15 min, and HRV features were extracted. The significant non-linear HRV features were identified through statistical analysis. It was found that Poincare plot features (SD1 and SD2) can differentiate the T2DM subject data from healthy subject data. Several machine learning classifiers, such as Linear Discriminant Analysis (LDA), Quadratic Discriminant Analysis, Naïve Bayes, and Gaussian Process Classifier (GPC), have classified the data based on the cross-validation approach. A GP classifier was implemented using three kernels, namely radial basis, linear, and polynomial kernel, considering the ability to handle the non-linear data. The classifier performance was evaluated and compared using performance metrics such as accuracy(AC), sensitivity(SN), specificity(SP), precision(PR), F1 score, and area under the receiver operating characteristic curve(AUC). Initially, all non-linear HRV features were selected for classification, but the specificity of the model was the limitation. Thus, only two Poincare plot features were used to design the diagnostic model. Our diagnostic model shows the performance using GPC based linear kernel as AC of 92.59%, SN of 96.07%, SP of 81.81%, PR of 94.23%, F1 score of 0.95, and AUC of 0.89, which are more extensive compared to other classification models. Further, the diagnostic model was deployed on the hardware module. Its performance on unknown/test data was validated on 65 subjects (healthy n = 15 and T2DM n = 50). Considering the desirable performance of the diagnostic model, it can be used as an initial screening test tool for a healthcare practitioner to predict T2DM risk.

Sudden cardiac death among Iranian population: a two decades follow-up of Tehran lipid and glucose study

Sudden cardiac death (SCD) is described as death within one hour, if observed, from the onset of symptoms, and within 24 h of being alive and well if not observe. Study population includes 3705 men and 4446 women, aged ≥ 30 years. Multivariable Cox proportional hazard models were used to determine the risk factors associated with SCD. After a median follow-up of 17.9 years, 244 SCD (165 in males) occurred. The age-standardized incidence rate (95% confidence intervals (CI)) of SCD was 2.3 (2.1-2.7) per 1000 person-year. Current smoking [Hazard ratio (HR): 2.43, 95% CI: 1.73-3.42], high waist circumference [1.49: 1.04-2.12], hypertension [1.39: 1.05-1.84], type 2 diabetes mellitus [2.78: 2.09-3.69], pulse rate ≥ 90 beats per/minute [1.72: 1.22-2.42] and prevalent cardiovascular disease [1.75: 1.26-2.45] were significant risk factors. The corresponding population attributed fractions (PAF) were 14.30, 16.58, 14.03, 19.60, 7.62, and 8.30, respectively. Being overweight [0.58: 0.40-0.83] and obese [0.61: 0.38-0.98] decreased the risk of SCD. After excluding known diabetes cases from our data analysis, the newly diagnosed diabetes still showed an HR of 2.0 (1.32-3.00) with a PAF of 7.15% in the full adjustment model. To deal with sudden death as a catastrophic outcome, multi-component strategies by policy health makers are suggested.

Mineralocorticoid Receptor Antagonist Improves Cardiac Structure in Type 2 Diabetes: Data From the MIRAD Trial

OBJECTIVES

This study investigated the impact of the MR antagonist (MRA) eplerenone on LVM in type 2 diabetes patients at high risk for cardiovascular disease (CVD).

BACKGROUND

MRA activation is associated with cardiac fibrosis and increased left ventricular mass (LVM), which is an independent predictor of adverse CVD, including heart failure in patients with type 2 diabetes.

METHODS

A prespecified analysis of secondary endpoints in a randomized, double-blinded clinical trial of 140 patients with type 2 diabetes at high risk of or established CVD. Patients were randomized to receive high-dose eplerenone therapy (100 mg-200 mg) or placebo as an add-on to standard care for 26 weeks. Indexed LVM (LVMi) and T1 time were measured using cardiac magnetic resonance (CMR) imaging. Biomarkers included N-terminal pro-B-type natriuretic peptide (NT-proBNP), pro-collagen type I N-terminal propeptide (P1NP), and type III N-terminal propeptide (P3NP).

RESULTS

Of 140 patients in the MIRAD trial, 104 patients were subject to CMR imaging (eplerenone: 54 patients; placebo: 50 patients). Mean LVMi at baseline was 74.2 ± 16 g/m². The treatment effect (ie, between-group differences) was a decrease of 3.7 g/m² following the eplerenone treatment (95% CI: -6.7 to -0.7; P = 0.017), with a corresponding decrease in absolute LVM. Plasma NT-proBNP concentrations decreased by 22% (P = 0.017) using eplerenone compared with placebo, and P1NP decreased 3.3 ng/mL (P = 0.019). No differences in T1 times or P3NP concentrations were observed between groups.

CONCLUSIONS

The addition of high-dose eplerenone in high-risk type 2 diabetes was associated with a clear reduction in LVMi and in NT-proBNP and P1NP levels, which may suggest a clinical benefit in heart failure prevention. (EU Clinical trials: Mineralocorticoid Receptor Antagonists in Type 2 Diabetes [MIRAD]; 2015-002519-14).

Novel molecular markers of cardiovascular disease risk in type 2 diabetes mellitus

Diabetes represents the leading risk factor for the development of cardiovascular disease (CVD). Chronic hyperglycemia and/or acute post-prandial changes in blood glucose determine an increase in reactive oxygen species (ROS), which play a fundamental role in endothelial dysfunction and in the nuclear transport of pro-atherogenic transcription factors that activate the "inflammasome". In addition, the glycemic alteration favors the formation and stabilization of atherosclerotic plaque through the mechanism of non-enzymatic glycation of different molecules, with the establishment of the so-called "advanced glycosylation end products" (AGE). Laboratory information provided by the level of biomarkers could make a quantitative and qualitative contribution to the clinical process of screening, prediction, prevention, diagnosis, prognosis and monitoring of cardiovascular (CV) risk linked to diabetes. This review describes the importance of specific biomarkers, with particular focus on novel ones, for stratifying and management of diabetes CV risk.

Relation between myocardial blood flow and cardiac events in diabetic patients with suspected coronary artery disease and normal myocardial perfusion imaging

BACKGROUND

We assessed the prognostic value of structural abnormalities and coronary vasodilator function in diabetic patients referred to a PET/CT for suspected coronary artery disease (CAD).

METHODS

We studied 451 diabetics and 451 nondiabetics without overt CAD and normal myocardial perfusion. Myocardial blood flow (MBF) was computed from the dynamic rest and stress imaging. Myocardial flow reserve (MFR) was defined as ratio of hyperemic to baseline MBF and was considered reduced when < 2.

RESULTS

During a mean follow-up of 44 months 33 events occurred. Annualized event rate (AER) was higher in diabetic than nondiabetic patients (1.4% vs 0.3%, P < .001). Diabetic patients with reduced MFR had higher AER compared to those with preserved MFR (3.3% vs 0.4%, P  < .001). At Cox analysis, age, BMI and reduced MFR were independent predictors of events in diabetic patients. Patients with diabetes and reduced MFR had lower event-free survival compared to nondiabetic patients and MFR < 2 (P < .001). Event-free survival was similar in patients with diabetes and normal MFR and those without diabetes and reduced MFR.

CONCLUSIONS

Diabetic patients with reduced MFR had higher AER and lower event-free survival compared to those with preserved MFR and to nondiabetic patients.

The Impact of Different Insulin-Related Measures on the Risk of Prediabetes Among the Chinese Han Population

INTRODUCTION

Diabetes mellitus (DM) has a serious impact on people's lives in the world. Interventions that affect risk factors for prediabetes can prevent and reduce diabetes occurrence. Proinsulin (PI), true insulin (TI), and proinsulin to insulin ratio (PI/TI) are risk factors for diabetes. The roles of these indicators in prediabetes are unclear. This study aimed to evaluate the impact of PI, TI, PI/TI, 2-h proinsulin (2hPI), 2-h true insulin (2hTI), and 2hPI/2hTI on the risk of prediabetes among the Chinese Han population.

METHODS

This cross-sectional study recruited 1688 subjects including 718 prediabetes cases and 970 non-prediabetes controls from Hainan Affiliated Hospital of Hainan Medical University. The cases involved 292 men and 426 women. The controls involved 324 men and 646 women. The mean age was 53.62 ± 12.43 years in the prediabetes group and 44.24 ± 12.87 years in the non-prediabetes group.

RESULTS

Our results showed that PI, TI, PI/TI, 2hPI, 2hTI, and 2hPI/2hTI were significantly correlated with prediabetes (all p < 0.05). Logistic regression analysis revealed that PI (OR 1.022, 95% CI 1.014-1.031, p = 0.00011), TI (OR 1.005, 95% CI 1.003-1.007, p = 0.00012), PI/TI (OR 1.517, 95% CI 1.080-2.131, p = 0.016), and 2hTI (OR 1.000, 95% CI 1.000-1.001, p = 0.002) were significantly associated with an increased risk of prediabetes. Receiver operating characteristic curve (ROC) analysis indicated that the area under the ROC curve (AUC) of the combination (PI + TI + PI/TI + 2hPI + 2hTI + 2hPI/2hTI) in diagnosing prediabetes was 0.627, which was larger than the diagnostic value of HOMA-IR (AUC 0.614) and HOMA-β (AUC 0.387).

CONCLUSIONS

Our study showed that PI, TI, PI/TI, and 2hTI could significantly enhance the risk of prediabetes in the Chinese Han population, which suggested that PI, TI, PI/TI, and 2hTI might be available risk factors for prediabetes.

Prevalence of type 2 diabetes mellitus in a representative sample of Greek adults and its association with modifiable risk factors: results from the Hellenic National Nutrition and Health Survey

OBJECTIVE

Diabetes mellitus is a disease associated with many complications leading to premature death. The aim of this study was to estimate prevalence of type 2 diabetes (T2D), and the proportion of the population unaware of the condition, in association with modifiable risk factors.

STUDY DESIGN

Data from the Hellenic National Nutrition and Health Survey were used (n = 3773 adults, 40.8% men) and were obtained by trained personnel.

METHODS

Diabetes mellitus disease status was categorized as per the International Classification of Diseases codes (10th version). A subsample from the two main metropolitan areas was used to assess T2D and impaired fasting glucose (IFG) (n = 990; 38.2% men) from plasma analysis.

RESULTS

The prevalence of T2D in the population was 5.2% in total, reaching 13.7% in adults aged >60 years (no sex differences). IFG was observed in 27.3% of adults in the two metropolitan areas, and 40% were unaware of having T2D in this subsample. The likelihood of having T2D significantly increased with age and body weight, whereas it decreased with higher educational level and physical activity (P for all <0.001).

CONCLUSION

The high T2D prevalence in adults, especially among the older age-groups, suggests a major public health problem in Greece.

Evidence for human diabetic cardiomyopathy

Growing interest has been accumulated in the definition of worsening effects of diabetes in the cardiovascular system. This is associated with epidemiological data regarding the high incidence of heart failure (HF) in diabetic patients. To investigate the detrimental effects both of hyperglycemia and insulin resistance, a lot of preclinical models were developed. However, the evidence of pathogenic and histological alterations of the so-called diabetic cardiomyopathy (DCM) is still poorly understood in humans. Here, we provide a stringent literature analysis to investigate unique data regarding human DCM. This approach established that lipotoxic-related events might play a central role in the initiation and progression of human DCM. The major limitation in the acquisition of human data is due to the fact of heart specimen availability. Postmortem analysis revealed the end stage of the disease; thus, we need to gain knowledge on the pathogenic events from the early stages until cardiac fibrosis underlying the end-stage HF.

Influence of Diabetes Duration and Glycemic Control on Dementia: A Cohort Study

BACKGROUND

To investigate the influence of diabetes duration and glycemic control, assessed by glycated hemoglobin (HbA1c) levels, on risk of incident dementia.

METHODS

The present study is a prospective study of 461,563 participants from the UK Biobank. The age at diabetes diagnosis was determined by self-report. Diabetes duration was calculated as baseline age minus age at diagnosis. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) with 95% confidential intervals (CIs).

RESULTS

During a median follow-up of 8.1 y, 2,233 dementia cases were recorded. As compared with normoglycemic individuals, individuals with diabetes had higher risk of all-cause dementia, and the risk increased with increasing duration of diabetes; compared with participants with diabetes duration of <5 y, the multivariable-adjusted HRs (95% CIs) were 1.49 (1.12-1.97), 1.71 (1.21-2.41), and 2.15 (1.60-2.90) for those with diabetes durations ≥5 to < 10, ≥10 to <15, and ≥ 15 y, respectively (P for trend < 0.001). Among participants with diabetes, those with both longer diabetes duration (diabetes duration ≥10 y) and poor glycemic control (HbA1c ≥8%) had the highest risk of All-cause dementia (multivariable-adjusted HR =2.07, 95% CI 1.45, 2.94), compared with patients with shorter duration of diabetes and better glycemic control (diabetes duration <10 y and HbA1c <8%).

CONCLUSIONS

Diabetes duration appeared to be associated with the risk of incident dementia due to factors beyond glycemic control. Clinicians should consider not only glycemic control but also diabetes duration in dementia risk assessments for patients with diabetes.

Efficacy and safety of liraglutide in type 2 diabetes mellitus patients complicated with coronary artery disease: A systematic review and meta-analysis of randomized controlled trials

To evaluate the efficacy and safety of liraglutide in patients with Type 2 Diabetes Mellitus (T2DM) complicated with Coronary Artery Disease (CAD), we searched PubMed, Cochrane Library, Embase, China National Knowledge Infrastructure (CNKI), Chinese VIP Information (VIP), Wanfang Database and Chinese Biomedical Literature database (CBM) for relevant randomized controlled trials (RCTs) from inception to 7 October 2020. A total of 18 RCTs including 1557 patients with T2DM complicated with CAD were included. Meta-analysis revealed liraglutide reduced hemoglobin A1c (HbA1c) (WMD = -0.67; 95% CI[-0.94 to -0.39]; P < 0.00001), fasting plasma glucose (FPG) (WMD = -0.80; 95% CI[-1.06 to -0.54]; P < 0.00001) and 2 h plasma glucose (2hPG) (WMD = -1.64; 95% CI[-2.12 to -1.16]; P＜0.00001); improved left ventricular ejection fraction(LVEF) (WMD = 4.79; 95% CI[4.08-5.51]; P < 0.00001), left ventricular end-diastolic diameter (LVEDD) (WMD = -5.70; 95% CI[-6.67 to -4.72]; P＜0.00001), E/A (WMD = 0.13; 95% CI[0.11-0.14]; P < 0.00001) and left ventricular posterior wall thickness (LVPWT) (WMD = -1.86; 95% CI[-2.16 to -1.55]; P < 0.00001); reduced total cholesterol (TC) (WMD = -0.48; 95% CI[-0.56 to -0.39]; P < 0.00001), triglycerides (TG) (WMD = -0.42; 95% CI[-0.59 to -0.26]; P < 0.00001), low-density lipoprotein cholesterol (LDL-C) (WMD = -0.41; 95% CI[-0.55 to -0.26]; P < 0.00001), and increased high-density lipoprotein cholesterol (HDL-C) (WMD = -0.19; 95% CI[0.13-0.24]; P = 0.0005). As for safety assessment, liraglutide did not increase the incidence of hypoglycemia (OR = 0.75, 95% CI[0.32-1.77], P = 0.51) and gastrointestinal (OR = 1.15, 95% CI[0.72-1.85], P = 0.55) events. Consequently, liraglutide had favorable effects on blood glucose, cardiac function, lipid profile and an acceptable safety profile.

Dapagliflozin alleviates cardiac fibrosis through suppressing EndMT and fibroblast activation via AMPKα/TGF-β/Smad signalling in type 2 diabetic rats

Diabetic cardiomyopathy (DCM) is one of the leading causes of heart failure in patients with diabetes mellitus, with limited effective treatments. The cardioprotective effects of sodium‐glucose cotransporter 2(SGLT2) inhibitors have been supported by amounts of clinical trials, which largely fills the gap. However, the underlying mechanism still needs to be further explored, especially in terms of its protection against cardiac fibrosis, a crucial pathophysiological process during the development of DCM. Besides, endothelial‐to‐mesenchymal transition (EndMT) has been reported to play a pivotal role in fibroblast multiplication and cardiac fibrosis. This study aimed to evaluate the effect of SGLT2 inhibitor dapagliflozin (DAPA) on DCM especially for cardiac fibrosis and explore the underlying mechanism. In vivo, the model of type 2 diabetic rats was built with high‐fat feeding and streptozotocin injection. Untreated diabetic rats showed cardiac dysfunction, increased myocardial fibrosis and EndMT, which was attenuated after treatment with DAPA and metformin. In vitro, HUVECs and primary cardiac fibroblasts were treated with DAPA and exposed to high glucose (HG). HG‐induced EndMT in HUVECs and collagen secretion of fibroblasts were markedly inhibited by DAPA. Up‐regulation of TGF‐β/Smad signalling and activity inhibition of AMPKα were also reversed by DAPA treatment. Then, AMPKα siRNA and compound C abrogated the anti‐EndMT effects of DAPA in HUVECs. From above all, our study implied that DAPA can protect against DCM and myocardial fibrosis through suppressing fibroblast activation and EndMT via AMPKα‐mediated inhibition of TGF‐β/Smad signalling.

Process evaluation of the Sophia Step Study- a primary care based three-armed randomized controlled trial using self-monitoring of steps with and without counseling in prediabetes and type 2 diabetes

Background

Describing implementation features of an intervention is required to compare interventions and to inform policy and best practice. The aim of this study was to conduct a process evaluation of the first 12 months of the Sophia Step Study: a primary care based RCT evaluating a multicomponent (self-monitoring of daily steps plus counseling) and a single component (self-monitoring of steps only) physical activity intervention to standard care on cardiometabolic health.

Methods

The evaluation was guided by the Medical Research Council Guidance for complex interventions. To describe the implementation communication with the health professionals implementing the interventions, attendance records and tracking of days with self-monitored pedometer-determined steps were used. Change in physical activity behaviour was measured at baseline, 6 and 12 months as daily steps by accelerometry.

Results

During April 2013 to January 2018 188 participants were randomized and intervened directly after inclusion. Response rate was 49% and drop out was 10%. A majority, 78%, had type 2 diabetes and 22% were diagnosed with prediabetes. Mean [Standard deviation (SD)] body mass index was 30.4 (4.4) kg/m² and steps per day was 6566 (3086). The interventions were delivered as intended with minor deviation from the protocol and dose received was satisfying for both the multicomponent and single component group. The mean [95% Confidence Interval (CI)] change in daily steps from baseline to 6 months was 941(227, 1655) steps/day for the multicomponent intervention group, 990 (145, 1836) step/day for the single component group and − 506 (− 1118, 107) for the control group. The mean (95% CI) change in daily steps from baseline to 12 months was 31(− 507, 570) steps/day for the multicomponent intervention group, 144 (− 566, 853) step/day for the single component group and − 890 (− 1485, − 294) for the control group. There was a large individual variation in daily steps at baseline as well as in step change in all three groups.

Conclusions

Applying self-monitoring of steps is a feasible method to implement as support for physical activity in the primary care setting both with and without counseling support.

Trial registration

ClinicalTrials.gov, NCT02374788. Registered 2 March 2015.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11222-9.

Prognostic value of stress cardiovascular magnetic resonance in asymptomatic patients without known coronary artery disease

OBJECTIVES

A few studies suggest a significant prognostic value of silent myocardial ischaemia detected in asymptomatic patients. However, the current guidelines do not recommend stress testing in asymptomatic individuals. To assess the long-term prognostic value of vasodilator stress perfusion cardiovascular magnetic resonance (CMR) in asymptomatic individuals without known coronary artery disease (CAD).

METHODS

Between 2009 and 2011, a retrospective cohort study with a median follow-up of 9.2 years (interquartile range: 7.8-9.6) included 1,027 consecutive asymptomatic individuals with ≥ 2 cardiovascular risk factors but without known known CAD referred for stress CMR. Major adverse cardiovascular events (MACE) included cardiovascular mortality and nonfatal myocardial infarction (MI).

RESULTS

Among 1,027 asymptomatic subjects, 903 (87.9%) (mean age 70.6 ± 12.4 years and 46.2% males) completed the follow-up, and 91 had MACE (10.1%). Using Kaplan-Meier analysis, silent ischaemia and unrecognised MI were associated with MACE (hazard ratio [HR]: 8.70; 95% CI: 5.79-13.10 and HR: 3.40; 95% CI: 2.15-5.38, respectively; both p < 0.001). In multivariable stepwise Cox regression, silent ischaemia and unrecognised MI were independent predictors of MACE (HR: 6.66; 95% CI 4.41-9.23; and HR: 2.42; 95% CI 1.23-3.21, respectively; both p < 0.001). The addition of silent ischaemia and unrecognised MI led to improved model discrimination for MACE (change in C statistic from 0.66 to 0.82; NRI = 0.497; IDI = 0.070).

CONCLUSIONS

Silent ischaemia and unrecognised MI are good long-term predictors for the incidence of MACE in selected asymptomatic individuals with multiple risk factors and without known CAD. These stress CMR parameters have incremental long-term prognostic value to predict MACE over traditional risk factors.

KEY POINTS

• Silent ischaemia and unrecognised myocardial infarction defined by stress CMR are good long-term predictors of cardiovascular events in asymptomatic individuals without known coronary artery disease. • The addition of stress cardiac MR imaging led to improved model discrimination for cardiovascular events over traditional risk factors in this specific population.

The Atrial Fibrillation Better Care pathway for managing atrial fibrillation: a review

The 2020 European Society of Cardiology guidelines endorse the Atrial Fibrillation Better Care (ABC) pathway as a structured approach for the management of atrial fibrillation (AF), addressing three principal elements: ‘A’ – avoid stroke (with oral anticoagulation), ‘B’ – patient-focused better symptom management, and ‘C’ – cardiovascular and comorbidity risk factor reduction and management. This review summarizes the definitions used for the ABC criteria in different studies and the impact of adherence/non-adherence on clinical outcomes, from 12 studies on seven different cohorts. All studies consistently showed statistically significant reductions in the risk of stroke, myocardial infarction, and mortality among those with ABC pathway adherent treatment. The ABC pathway provides a simple decision-making framework to enable consistent equitable care from clinicians in primary and secondary/tertiary care. Further research examining the impact of ABC pathway implementation in prospective cohorts utilizing consistent inclusion criteria and definitions of ‘A’, ‘B’, and ‘C’ adherent care is warranted.

Risk of Death and Heart Failure among Patients with Type 2 Diabetes Treated by Metformin and Nonmetformin Monotherapy: A Real-World Study

BACKGROUND

To assess the association of metformin monotherapy with the risk of all-cause deaths and cardiovascular deaths and events in type 2 diabetes patients in real clinical practice.

METHODS

This retrospective, observational study comprised patients with type 2 diabetes initially treated with metformin or nonmetformin monotherapy over 2011-2016. Data were extracted from the National Healthcare Big Data database in Fuzhou, China. Propensity score matching (PSM) was performed, matching each patient on metformin to one on nonmetformin in terms of a set of covariates. The primary endpoint was all-cause death, and secondary endpoints were cardiovascular death, heart failure, and heart failure hospitalization. Covariate-adjusted associations of metformin use with all the endpoints were assessed by Cox proportional hazards models.

RESULTS

Among 24,099 patients, 5491 were initially treated with metformin and 18,608 with nonmetformin. PSM yielded 5482 patients in each cohort. During a median follow-up of 2.02 years, we observed 110 and 211 deaths in the metformin and nonmetformin groups, respectively. Metformin was significantly associated with reduced risk of all-cause death (adjusted hazard ratio (aHR) 0.52, 95% confidence interval (CI) 0.39-0.69), cardiovascular death (aHR 0.63, 95% CI 0.43-0.91), and heart failure (aHR 0.61, 95% CI 0.52-0.73), whereas the reduced risk in heart failure hospitalization was not statistically significant (aHR 0.70, 95% CI 0.47-1.02).

CONCLUSIONS

In this analysis of electronic health record data from a large database in China, metformin as first-line monotherapy greatly reduced the risk of all-cause death, cardiovascular death, and heart failure in diabetes patients as compared with nonmetformin medications.

The Role of Essential Oils and Their Main Compounds in the Management of Cardiovascular Disease Risk Factors

Cardiovascular diseases (CVDs) are a global health burden that greatly impact patient quality of life and account for a huge number of deaths worldwide. Despite current therapies, several side effects have been reported that compromise patient adherence; thus, affecting therapeutic benefits. In this context, plant metabolites, namely volatile extracts and compounds, have emerged as promising therapeutic agents. Indeed, these compounds, in addition to having beneficial bioactivities, are generally more amenable and present less side effects, allowing better patient tolerance. The present review is an updated compilation of the studies carried out in the last 20 years on the beneficial potential of essential oils, and their compounds, against major risk factors of CVDs. Overall, these metabolites show beneficial potential through a direct effect on these risk factors, namely hypertension, dyslipidemia and diabetes, or by acting on related targets, or exerting general cellular protection. In general, monoterpenic compounds are the most studied regarding hypotensive and anti-dyslipidemic/antidiabetic properties, whereas phenylpropanoids are very effective at avoiding platelet aggregation. Despite the number of studies performed, clinical trials are sparse and several aspects related to essential oil’s features, namely volatility and chemical variability, need to be considered in order to guarantee their efficacy in a clinical setting.

Cardiovascular risk management in type 2 diabetes mellitus: A joint position paper of the Italian Cardiology (SIC) and Italian Diabetes (SID) Societies

AIM

This review represents a joint effort of the Italian Societies of Cardiology (SIC) and Diabetes (SID) to define the state of the art in a field of great clinical and scientific interest which is experiencing a moment of major cultural advancements, the cardiovascular risk management in type 2 diabetes mellitus.

DATA SYNTHESIS

Consists of six chapters that examine various aspects of pathophysiology, diagnosis and therapy which in recent months have seen numerous scientific innovations and several clinical studies that require extensive sharing.

CONCLUSIONS

The continuous evolution of our knowledge in this field confirms the great cultural vitality of these two cultural spheres, which requires, under the leadership of the scientific Societies, an ever greater and effective collaboration.

Efficacy of testosterone replacement therapy for treating metabolic disturbances in late-onset hypogonadism: a systematic review and meta-analysis

PURPOSE

Late onset hypogonadism (LOH) is an age-dependent reduction of testosterone associated with alterations of metabolic profile, including glucose control, insulin sensitivity, and lipid profile. The purpose of this study was to investigate the efficacy of testosterone replacement therapy (TRT) for treating metabolic disturbances through a meta-analysis of randomized clinical trials (RCTs).

METHODS

A systematic review of literature published from 1964 to November, 2019 was performed using the PubMed/Medline, Embase, and Cochrane databases. Among the 1562 articles screened, 17 articles were selected for qualitative analysis and 16 articles (n = 1373) were included for data synthesis following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). Criteria for final inclusion were RCTs.

RESULTS

Sixteen studies were finally included (TRT group, n = 709; placebo group, n = 664). Among the metabolic markers, HbA1C [Mean difference (MD) = - 0.172, 95% CI - 0.329, - 0.015], HOMA IR (MD = - 0.514, 95% CI - 0.863, - 0.165), serum insulin (MD = - 12.622, 95% CI - 19.660, - 5.585), and leptin (MD = - 2.381, 95% CI - 2.952, - 1.810) showed significant improvement after TRT versus placebo. Among the lipid profiles, total cholesterol showed significant improvement (MD = - 0.433, 95% CI - 0.761, - 0.105) after TRT. However, HDL showed a decrease (MD = - 0.069, 95% CI - 0.121, - 0.018) after TRT. Among anthropometric markers, waist circumference showed significant improvement (MD = - 0.1640, 95% CI - 2.857, - 0.423).

CONCLUSION

This study demonstrated greater improvement in metabolic profiles for patients given TRT versus placebo. Further well-designed trials are needed to verify our findings and further elucidate effects of TRT on lipid profiles. This systematic review demonstrates that TRT can exert a net beneficial effect on metabolic profiles.

Diabetes duration and glycaemic control as predictors of cardiovascular disease and mortality

AIMS

To assess the associations of diabetes duration and glycaemic control (defined by plasma glycated haemoglobin [HbA1c] level) with the risks of cardiovascular disease (CVD) and all-cause mortality and to determine whether the addition of either or both to the established CVD risk factors can improve predictions.

MATERIALS AND METHODS

A total of 435 679 participants from the UK Biobank without CVD at baseline were included. Cox models adjusting for classic risk factors (sociodemographic and anthropometric characteristics, lipid profiles and medication use) were used, and predictive utility was determined by the C-index and net reclassification improvement (NRI).

RESULTS

Compared with participants without diabetes, participants with longer diabetes durations and poorer glycaemic control had a higher risk of fatal/nonfatal CVD. Among participants with diabetes, the fully-adjusted hazard ratios (HRs) for diabetes durations of 5 to <10 years, 10 to <15 years and ≥15 years were 1.15 (95% confidence interval [CI] 0.99, 1.34), 1.50 (95% CI 1.26, 1.79) and 2.22 (95% CI 1.90, 2.58; P-trend <0.01), respectively, compared with participants with diabetes durations <5 years. In addition, those with the longest disease duration (≥15 years) and poorer glycaemic control (HbA1c ≥64 mmol/mol [8%]) had the highest risk of fatal/nonfatal CVD (HR 3.12, 95% CI 2.52, 3.86). Among participants with diabetes, the addition of both diabetes duration and glycaemic control levels significantly improved both the C-index (change in C-index +0.0254; 95% CI 0.0111, 0.0398) and the overall NRI for fatal/nonfatal CVD (0.0992; 95% CI 0.0085, 0.1755) beyond the use of the classic risk factors.

CONCLUSIONS

Both longer diabetes duration and poorer glycaemic control were associated with elevated risks of CVD and mortality. Clinicians should consider not only glycaemic control but also diabetes duration in CVD risk assessments for participants with diabetes.

Health service organisation impact on lower extremity amputations in people with type 2 diabetes with foot ulcers: systematic review and meta-analysis

AIMS

Despite the evidence available on the epidemiology of diabetic foot ulcers and associated complications, it is not clear how specific organizational aspects of health care systems can positively affect their clinical trajectory. We aim to evaluate the impact of organizational aspects of care on lower extremity amputation rates among people with type 2 diabetes affected by foot ulcers.

METHODS

We conducted a systematic review of the scientific literature published between 1999 and 2019, using the following key terms as search criteria: people with type 2 diabetes, diagnosed with diabetic foot ulcer, treated with specific processes and care pathways, and LEA as primary outcome. Overall results were reported as pooled odds ratios and 95% confidence intervals obtained using fixed and random effects models.

RESULTS

A total of 57 studies were found eligible, highlighting the following arrangements: dedicated teams, care pathways and protocols, multidisciplinary teams, and combined interventions. Among them, seven studies qualified for a meta-analysis. According to the random effects model, interventions including any of the four arrangements were associated with a 29% reduced risk of any type of lower extremity amputation (OR = 0.71; 95% CI 0.52-0.96). The effect was larger when focusing on major LEAs alone, leading to a 48% risk reduction (OR = 0.52; 95% CI 0.30-0.91).

CONCLUSIONS

Specific organizational arrangements including multidisciplinary teams and care pathways can prevent half of the amputations in people with diabetes and foot ulcers. Further studies using standardized criteria are needed to investigate the cost-effectiveness to facilitate wider implementation of improved organizational arrangements. Similarly, research should identify specific roadblocks to translating evidence into action. These may be structures and processes at the health system level, e.g. availability of professionals with the right skillset, reimbursement mechanisms, and clear organizational intervention implementation guidelines.

Sodium-glucose co-transporter-2 inhibitors in patients with type 2 diabetes mellitus without established cardiovascular disease: Do they have a role in primary prevention?

Most guidelines and cardiovascular outcome trials (CVOTs) focus on secondary prevention of cardiovascular disease (CVD) in type 2 diabetes mellitus (T2DM). Patients with T2DM without established CVD (eCVD) also form a critical cohort, for whom primary prevention with timely pharmacological and non-pharmacological interventions can effectively prevent or delay the onset of CVD. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) have demonstrated a promising role for primary prevention of CVD in CVOTs and real-world studies. The 2019 American College of Cardiology/American Heart Association guidelines on primary prevention of CVD recommend SGLT2i as one of the add-on treatment options to metformin for adults with T2DM and glycated hemoglobin >7% who have cardiovascular (CV) risk factors. The outcomes with maximal response to SGLT2i use in primary prevention are hospitalization for heart failure and chronic kidney disease. The cardiorenal benefits with SGLT2i are attributed to pleiotropic effects on CV risk factors, and interference with glucose and sodium handling in kidneys, independent of their glycemic benefits. Results therefore support a role for SGLT2i not only in patients with T2DM and eCVD but also in patients with T2DM without eCVD. This review examines the evidence for potential role of SGLT2i for primary prevention of CVD in T2DM.

Interdisciplinary assessment and diagnostic algorithm: The role of the cardiologist

Patients with diabetes have an increased risk of developing heart failure and those with heart failure are at higher risk of developing diabetes. In patients with diabetes antidiabetic medications and the metabolic alterations of diabetes increase the risk of developing heart failure. In diabetic patients with heart failure and in those with an increased likelihood of developing the disease a stepwise approach based on the use of natriuretic peptides and echocardiography to rule out the presence of heart failure should be used. Once the diagnosis of heart failure is established it will be important to define the phenotype according to the left ventricular function and, where appropriate, use additional tests to identify possible additional underlying causes of heart failure like coronary artery disease. A multidisciplinary heart failure management programs is recommended in all patients with diabetes mellitus and heart failure to enable appropriate investigations, accurate diagnosis, and appropriate agreed evidence-based therapy and care plan. The implementation of a multidisciplinary heart failure management program requires a multidisciplinary team that will have to follow the patients throughout the whole heart failure trajectory and that should consider a holistic approach to the diabetic patient with heart failure rather than focussing merely on either heart failure or diabetes.

Biochemical Urine Testing of Medication Adherence and Its Association With Clinical Markers in an Outpatient Population of Type 2 Diabetes Patients: Analysis in the DIAbetes and LifEstyle Cohort Twente (DIALECT)

OBJECTIVE

To assess adherence to the three main drug classes in real-world patients with type 2 diabetes using biochemical urine testing, and to determine the association of nonadherence with baseline demographics, treatment targets, and complications.

RESEARCH DESIGN AND METHODS

Analyses were performed of baseline data on 457 patients in the DIAbetes and LifEstyle Cohort Twente (DIALECT) study. Adherence to oral antidiabetics (OADs), antihypertensives, and statins was determined by analyzing baseline urine samples using liquid chromatography-tandem mass spectrometry. Primary outcomes were microvascular and macrovascular complications and treatment targets of LDL cholesterol, HbA1c, and blood pressure. These were assessed cross-sectionally at baseline.

RESULTS

Overall, 89.3% of patients were identified as adherent. Adherence rates to OADs, antihypertensives, and statins were 95.7%, 92.0%, and 95.5%, respectively. The prevalence of microvascular (81.6% vs. 66.2%; P = 0.029) and macrovascular complications (55.1% vs. 37.0%; P = 0.014) was significantly higher in nonadherent patients. The percentage of patients who reached an LDL cholesterol target of ≤2.5 mmol/L was lower (67.4% vs. 81.1%; P = 0.029) in nonadherent patients. Binary logistic regression indicated that higher BMI, current smoking, elevated serum LDL cholesterol, high HbA1c, presence of diabetic kidney disease, and presence of macrovascular disease were associated with nonadherence.

CONCLUSIONS

Although medication adherence of real-world type 2 diabetes patients managed in specialist care was relatively high, the prevalence of microvascular and macrovascular complications was significantly higher in nonadherent patients, and treatment targets were reached less frequently. This emphasizes the importance of objective detection and tailored interventions to improve adherence.

Outcomes after delayed primary percutaneous coronary intervention versus pharmaco-invasive strategy in ST-segment elevation myocardial infarction in Norway

Aims

Primary percutaneous coronary intervention (pPCI) is the preferred reperfusion strategy in patients with ST-segment elevation myocardial infarction (STEMI) provided it can be performed within 120 min from diagnosis. However, it is unclear whether pPCI or a pharmaco-invasive (P-I) strategy is the best choice in patients who cannot receive timely pPCI. The aim of the present study was to compare outcomes after delayed and late pPCI vs. a P-I strategy in STEMI patients who did not receive timely pPCI.

Methods and results

All patients with STEMI registered in the Norwegian Myocardial Infarction Registry (NORMI) between 2013 and 2019, with ≤12 h from symptom onset to first medical contact and available timelines were included in the study. The primary outcome was all-cause mortality, and follow-up was through 2019. A total of 21 121 (27% of 78 368) STEMI patients were registered in the NORMI. Among patients who met the inclusion criteria, 7238 (54%) patients underwent timely pPCI, 1537 (11%) delayed pPCI (121–180 min), 1012 (7%) late pPCI (>180 min), and 2338 (17%) patients were treated with a P-I strategy. After a median follow-up time of 2.5 years, mortality was higher in the delayed pPCI [adjusted hazard ratio (HR) 1.3, 95% confidence interval (CI) 1.0–1.5] and in the late pPCI group (adjusted HR 1.4, 95% CI 1.1–1.7) compared to the P-I strategy group, but bleeding complications were more frequent after P-I strategy.

Conclusions

In STEMI patients who did not receive timely percutaneous coronary intervention, a P-I strategy seemed to be associated with better long-term survival compared to delayed/late pPCI.

Safe care for people with diabetes in hospital

Diabetes is the most prevalent long-term condition, occurring in approximately 6.5% of the UK population. However, an average of 18% of all acute hospital beds are occupied by someone with diabetes. Having diabetes in hospital is associated with increased harm - however that may be defined. Over the last few years the groups such as the Joint British Diabetes Societies for Inpatient Care have produced guidelines to help medical and nursing staff manage inpatients with diabetes. These guidelines have been rapidly adopted across the UK. The National Diabetes Inpatient Audit has shown that over the last few years the care for people with diabetes has slowly improved, but there remain challenges in terms of providing appropriate staffing and education. Patient safety is paramount, and thus there remains a lot to do to ensure this vulnerable group of people are not at increased risk of harm.

Incidence and Predictors of Cardiovascular Disease among Type 1 and Type 2 Diabetes Mellitus in a Tertiary Health Care Setting of Ethiopia: 8-Year Retrospective Follow-Up Study

Background

Cardiovascular disease (CVD) is a major cause of death and disability among people with diabetes in the world and it is proving to be a major barrier to sustainable human development. Despite CVD continuing to devastate human survival, few studies in Ethiopia have focused on its prevalence which alone are insufficient to assess the risk of incident cardiovascular events. Therefore, we determined the incidence and predictors of cardiovascular disease among diabetic patients in a selected tertiary healthcare setting of Ethiopia.

Methods

A retrospective cohort study using secondary data was conducted on 399 randomly selected diabetes patients. Data were entered using Epi-Data and analyzed using Stata version 14. Multivariable Weibull proportional hazards regression analysis was used to identify the predictors of CVDs (namely, coronary heart disease (CHD), stroke, and peripheral arterial disease (PAD)) at 5% level of significance.

Results

After a median follow-up of 5.9 years, the overall incidence rate of CVD per 100 person–years (PY) was 2.71 (95% CI=16.9–17.6). The multivariable Weibull proportional hazard regression analysis showed a significant association of chronic kidney disease (CKD); (adjusted hazard ratio (AHR) [95% CI]=2.53 [1.36–4.72]), systolic blood pressure (SBP)≥140; (AHR [95% CI]=4.30 [2.12–8.73]) and triglyceride (TG)≥200 mg/dL; (AHR [95% CI[=5.10 [2.02–12.89]) with risk of incident CVD.

Conclusion

CVD is a public health problem among diabetic patients in Ethiopia. SBP≥140, chronic kidney disease, and high triglyceride were independent predictors of new CVD among diabetic patients. These findings emphasize the need of attention for CVD patients with CKD and hypertension (HTN) comorbidities and a longer follow-up period using a prospective study design to determine the long-term effects of predictors of CVD among diabetic patients.

Patients with Diabetes Complicated by Peripheral Artery Disease: the Current State of Knowledge on Physiotherapy Interventions

Diabetes mellitus (DM) is one of the major public health problems that account for morbidity, mortality, and disability worldwide. The presence of DM increases the risk of peripheral artery disease (PAD), as well as accelerates its course, making these patients more susceptible to ischemic events and impaired functional status. Unfortunately, alternative treatments for vascular complications in diabetes are poorly researched. Physiotherapy (kinesitherapy combined with different physical therapy agents) in individuals with DM and coexisting PAD may offer an important complementary therapy alternative. Early therapeutic measures can significantly improve patient outcomes, reduce cardiovascular risk, and improve daily life quality. The article provides an update on the current state of knowledge on physiotherapy interventions in the course of DM in patients with coexisting PAD.

Effects of melatonin supplementation on eating habits and appetite-regulating hormones: a systematic review of randomized controlled clinical and preclinical trials

Melatonin is a hormone involved in appetite regulation and food intake. Circadian chronorrupture caused by its absence has been associated with excessive food consumption, and there is evidence that exogenous melatonin supplementation can restore homeostasis. Therefore, the aim of this systematic review was to synthesize evidence from randomized controlled clinical and preclinical trials that evaluated the effects of exogenous melatonin supplementation on eating habits and appetite-regulating hormones. The protocol was registered in PROSPERO (number 42020175809). Medline, Scopus, Web of Science and Cochrane Library were systematically searched from January 2020 to February 2021. Of 3.695 articles identified, 2 clinical and 13 preclinical trials (n = 15) met the inclusion criteria. The outcomes were total food intake, calories, macronutrients, cholesterol intake, leptin and ghrelin levels. Interventions ranged from 28 to 336 days and dose of melatonin varied between 0.2 µg/mL of drinking water and 10 mg/day. Clinical trials were conducted with healthy adults, and preclinical trials with rodents and dogs. Of the 15 articles, five assessed food intake and leptin, four assessed food intake only, five assessed leptin only, and one assessed leptin and ghrelin serum levels. The majority of the articles were judged as having low risk of bias. Although findings are heterogeneous and do not allow a robust conclusion, this review adds to the growing body of evidence suggesting that exogenous melatonin may be a potential therapeutic agent against endocrine-metabolic disorders. This reversal is not necessarily associated with changes in food consumption, signaling that melatonin's metabolic effects may occur independently of energy intake. Further studies, especially with humans, are needed provide more evidences for melatonin supplementation in clinical practice, as well as to understand its role on eating habits and appetite-regulating hormones.

Effects of stent generation on clinical outcomes after acute myocardial infarction compared between prediabetes and diabetes patients

We investigated the effects of stent generation on 2-year clinical outcomes between prediabetes and diabetes patients after acute myocardial infarction (AMI). A total of 13,895 AMI patients were classified into normoglycemia (group A: 3673), prediabetes (group B: 5205), and diabetes (group C: 5017). Thereafter, all three groups were further divided into first-generation (1G)-drug-eluting stent (DES) and second-generation (2G)-DES groups. Patient-oriented composite outcomes (POCOs) defined as all-cause death, recurrent myocardial infarction (Re-MI), and any repeat revascularization were the primary outcome. Stent thrombosis (ST) was the secondary outcome. In both prediabetes and diabetes groups, the cumulative incidences of POCOs, any repeat revascularization, and ST were higher in the 1G-DES than that in the 2G-DES. In the diabetes group, all-cause death and cardiac death rates were higher in the 1G-DES than that in the 2G-DES. In both stent generations, the cumulative incidence of POCOs was similar between the prediabetes and diabetes groups. However, in the 2G-DES group, the cumulative incidences of Re-MI and all-cause death or MI were significantly higher in the diabetes group than that in the prediabetes group. To conclude, 2G-DES was more effective than 1G-DES in reducing the primary and secondary outcomes for both prediabetes and diabetes groups.

A Multifactorial Approach in Type 2 Diabetes Over 3 Years Decelerates Progression of Subclinical Arterial Disease in Routine Clinical Practice

The beneficial effect of multifactorial treatment of cardiovascular (CV) risk factors (RFs) in type 2 diabetes (T2D) is well established from randomized clinical trials. We prospectively evaluated the impact of such treatment in a real-world setting, on the development of subclinical arterial damage (SAD), as determined by structural/functional noninvasive biomarkers of vascular pathology (atheromatosis, carotid hypertrophy, arteriosclerosis). We prospectively studied 116 persons with T2D, treated with a multifactorial approach for CV RFs at a tertiary medical center, and 324 individuals without diabetes, for 3.2 years. The primary outcome was changes in vascular biomarkers related to SAD. At baseline, participants in the diabetes group had higher prevalence of SAD. At study end, the changes in clinical, biochemical, and lifestyle characteristics, as well as antihypertensive and lipid-lowering treatments, were comparable between the 2 groups. During follow-up, classical CV RFs (smoking, blood pressure, low-density lipoprotein-cholesterol, triglycerides) and behavioral features were significantly improved in both groups. Multivariate analysis, after adjusting for all classic CV RFs and use of antihypertensive/lipid-lowering therapies, demonstrated that all evaluated SAD biomarkers were similarly changed in the 2 groups. In conclusion, implementation of a multimodality approach of T2D treatment is feasible and efficacious in decelerating progression of SAD in routine clinical practice.

Eligibility for dapagliflozin in unselected patients hospitalised with decompensated heart failure

Patients with heart failure with reduced ejection fraction (HFrEF) who received the sodium-glucose co-transport 2 inhibitor, dapagliflozin, in the DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure) study have a significant reduction in worsening heart failure (HF) and cardiovascular death. It is uncertain what proportion of patients admitted to a large regional cardiac centre with decompensated heart failure would be eligible for dapagliflozin post-discharge based on their characteristics at discharge. The DAPA-HF study criteria were retrospectively applied to a cohort of 521 consecutive patients referred to the inpatient HF service in a tertiary cardiac centre in South West Wales between April 2017 and April 2018. Inclusion criteria: left ventricular ejection fraction (LVEF) < 40%, New York Heart Association (NYHA) class II-IV symptoms and an elevated N-terminal pro-B-type naturietic peptide (NT-proBNP). Exclusion criteria: systolic blood pressure (SBP) < 95 mmHg, estimated glomerular filtration rate (eGFR) < 30 ml/min/1.73 m2 or type 1 diabetes mellitus. We did not have complete NTproBNP data for the cohort, as it was not routinely measured at the time in our institute. There were 478 patients, mean age 78 ± 13 years, 57% male and 91% NYHA class II-IV symptoms, were included in the analysis. Of these, 247 patients had HFrEF, 219 (46%) patients met the inclusion criteria, 231 (48%) were excluded as LVEF was > 40%, and 48 (10%) were excluded with NYHA class I symptoms. Of the 219 patients who met the inclusion criteria, 13 (5.9%) had a SBP < 95 mmHg, 48 (22%) had eGFR < 30 ml/min/1.73 m2, leaving 136 (28.5% of total and 55% of those with HFrEF) who met DAPA-HF study criteria. In our study, 28.5% of all heart failure admissions and 55% of patients with HFrEF would be eligible for dapagliflozin post-discharge according to the DAPA-HF study entry criteria.

Balloon Angioplasty Versus Stenting in Patients With ST-Elevated Myocardial Infarction Before Subsequent Coronary Artery By-Pass Grafting

Decision of ad hoc revascularization strategy in patients who require coronary artery bypass grafting (CABG) following primary percutaneous coronary interventions (PCI) is challenging due to the pros and cons of only-ballooning and stenting. In this study, we aimed to compare the outcomes of only-balloon-angioplasty to stenting in primary PCI in patients with ST elevated myocardial infarction (STEMI) who required a subsequent CABG. We retrospectively analyzed 350 consecutive STEMI patients who needed CABG in addition to primary balloon angioplasty (n = 160) and stenting strategy (n = 190). In-hospital and 5-year outcomes of the patients were compared between the 2 groups. In-hospital mortality rates in the ballooning and stenting groups were not nonsignificantly different (11.2% vs 9.5%, respectively, P = .59); 5-year mortality rates were also similar between the 2 groups (9.2% vs 8.7%, P = .89). Additionally, major bleeding rates (3.8% vs 6.3%, P = .28) did not differ between the 2 groups. In conclusion, our study showed no significant difference in-hospital and long-term mortality rates in patients who require CABG after primary PCI irrespective of the ad hoc revascularization strategy.

Women With Diabetes Are at Increased Relative Risk of Heart Failure Compared to Men: Insights From UK Biobank

Aims: To investigate the effect of diabetes on mortality and incident heart failure (HF) according to sex, in the low risk population of UK Biobank. To evaluate potential contributing factors for any differences seen in HF end-point. Methods: The entire UK Biobank study population were included. Participants that withdrew consent or were diagnosed with diabetes after enrolment were excluded from the study. Univariate and multivariate cox regression models were used to assess endpoints of mortality and incident HF, with median follow-up periods of 9 years and 8 years respectively. Results: A total of 493,167 participants were included, hereof 22,685 with diabetes (4.6%). Two thousand four hundred fifty four died and 1,223 were diagnosed or admitted with HF during the follow up periods of 9 and 8 years respectively. Overall, the mortality and HF risk were almost doubled in those with diabetes compared to those without diabetes (hazard ratio (HR) of 1.9 for both mortality and heart failure) in the UK Biobank population. Women with diabetes (both types) experience a 22% increased risk of HF compared to men (HR of 2.2 (95% CI: 1.9-2.5) vs. 1.8 (1.7-2.0) respectively). Women with type 1 diabetes (T1DM) were associated with 88% increased risk of HF compared to men (HR 4.7 (3.6-6.2) vs. 2.5 (2.0-3.0) respectively), while the risk of HF for type 2 diabetes (T2DM) was 17% higher in women compared to men (2.0 (1.7-2.3) vs. 1.7 (1.6-1.9) respectively). The increased risk of HF in women was independent of confounding factors. The findings were similar in a model with all-cause mortality as a competing risk. This interaction between sex, diabetes and outcome of HF is much more prominent for T1DM (p = 0.0001) than T2DM (p = 0.1). Conclusion: Women with diabetes, particularly those with T1DM, experience a greater increase in risk of heart failure compared to men with diabetes, which cannot be explained by the increased prevalence of cardiac risk factors in this cohort.

ORAI1 Ca2+ Channel as a Therapeutic Target in Pathological Vascular Remodelling

In the adult, vascular smooth muscle cells (VSMC) are normally physiologically quiescent, arranged circumferentially in one or more layers within blood vessel walls. Remodelling of native VSMC to a proliferative state for vascular development, adaptation or repair is driven by platelet-derived growth factor (PDGF). A key effector downstream of PDGF receptors is store-operated calcium entry (SOCE) mediated through the plasma membrane calcium ion channel, ORAI1, which is activated by the endoplasmic reticulum (ER) calcium store sensor, stromal interaction molecule-1 (STIM1). This SOCE was shown to play fundamental roles in the pathological remodelling of VSMC. Exciting transgenic lineage-tracing studies have revealed that the contribution of the phenotypically-modulated VSMC in atherosclerotic plaque formation is more significant than previously appreciated, and growing evidence supports the relevance of ORAI1 signalling in this pathologic remodelling. ORAI1 has also emerged as an attractive potential therapeutic target as it is accessible to extracellular compound inhibition. This is further supported by the progression of several ORAI1 inhibitors into clinical trials. Here we discuss the current knowledge of ORAI1-mediated signalling in pathologic vascular remodelling, particularly in the settings of atherosclerotic cardiovascular diseases (CVDs) and neointimal hyperplasia, and the recent developments in our understanding of the mechanisms by which ORAI1 coordinates VSMC phenotypic remodelling, through the activation of key transcription factor, nuclear factor of activated T-cell (NFAT). In addition, we discuss advances in therapeutic strategies aimed at the ORAI1 target.

The co-existence of diabetes and subclinical atherosclerosis in rural central Appalachia: Do residential characteristics matter?

Aim Disparities exist in cardiovascular diseases (CVD) and diabetes in the United States (U.S.) with Central Appalachia having disproportionate burden. This study examined prevalence and correlates of CVD risk-factors among patients with diabetes/subclinical atherosclerosis in Central Appalachia.

METHODS

During 2012-2016, 3000 patients from Central Appalachia were screened for subclinical atherosclerosis, using coronary artery calcium (CAC) scores; 419 participants had diabetes. Patients were categorized into four groups, with emphasis on those having subclinical atherosclerosis, CAC score ≥ 1. Descriptive statistics and multilevel multinomial logistic regression were conducted to identify CVD risk and spatial factors associated with co-existence of diabetes and subclinical atherosclerosis.

RESULTS

Among participants, prevalence of CVD risk-factors ranged from 11.7% for current smokers to 69.2% for those with CVD family history. Average BMI was 29.8. Compared to patients with diabetes only, age [RR = 1.07; p ≤ 0.0001], being male [RR = 5.33; p ≤ 0.0001], having hypertension [RR = 2.37; p ≤ 0.05] and being a former smoker were associated with increased likelihood of having diabetes/subclinical atherosclerosis. At the zip-code level, unemployment rate [RR = 1.37; p ≤ 0.05] was significantly associated with having diabetes/subclinical atherosclerosis.

CONCLUSION

Consistent with clinical guidelines, study results suggest the need to integrate CAC screening into primary care diabetes programs while addressing spatial issues that predispose patients to have diabetes/subclinical atherosclerosis.

Macrovascular Risk Equations Based on the CANVAS Program

BACKGROUND

Widely used risk equations for cardiovascular outcomes for individuals with type 2 diabetes mellitus (T2DM) have been incapable of predicting cardioprotective effects observed in recent cardiovascular outcomes trials (CVOTs) involving individuals with T2DM at high risk for or with established cardiovascular disease (CVD).

OBJECTIVE

We developed cardiovascular and mortality risk equations using patient-level data from the CANVAS (CANagliflozin cardioVascular Assessment Study) Program to address this shortcoming.

METHODS

Data from 10,142 patients with T2DM at high risk for or with established CVD, randomized to canagliflozin + standard of care (SoC) or SoC alone and followed for a mean duration of 3.6 years in the CANVAS Program were used to derive parametric risk equations for myocardial infarction (MI), stroke, hospitalization for heart failure (HHF), and death. Accumulated knowledge from the widely used UKPDS-OM2 (United Kingdom Prospective Diabetes Study Outcomes Model 2) was leveraged, and any departures in parameterization were limited to those necessary to provide adequate goodness of fit. Candidate explanatory covariates were selected using only the placebo arm to minimize confounding effects. Internal validation was performed separately by study treatment arm.

RESULTS

UKPDS-OM2 predicted CANVAS Program outcomes poorly. Recalibrating UKPDS-OM2 intercepts improved calibration in some cases. Refitting the coefficients but otherwise preserving the UKPDS-OM2 structure improved the fit substantially, which was sufficient for stroke and death. For MI, reselecting UKPDS-OM2 covariates and functional form proved sufficient. For HHF, selection from a broad set of candidate covariates and inclusion of a canagliflozin indicator was required.

CONCLUSION

These risk equations address some of the limitations of widely used risk equations, such as the UKPDS-OM2, for modeling cardioprotective treatments for individuals with T2DM and high cardiovascular risk, including derivation from overly healthy patients treated with agents that lack cardioprotection and have been described as reflecting a different therapeutic era. Future work is needed to examine external validity.

Metabolic-associated fatty liver disease (MAFLD) in coeliac disease

BACKGROUND AND AIMS

Coeliac disease (CD) is considered a high-risk condition for developing non-alcoholic fatty liver disease (NAFLD) and other related metabolic disorders, particularly after commencing gluten-free diet (GFD). Recently, a new concept of metabolic-associated fatty liver disease (MAFLD) has been proposed to overcome the limitations of NAFLD definition. This study aimed at exploring the prevalence of NAFLD and MAFLD in CD patients at the time of CD diagnosis and after 2 years of GFD. Furthermore, we evaluated the role of PNPLA3 rs738409 in the development of NAFLD and MAFLD in the same population.

METHODS

We retrospectively enrolled all newly diagnosed CD patients who underwent clinical, laboratory and ultrasonography investigations both at diagnosis and after 2 years of follow-up. Moreover, a PNPLA3 rs738409 genotyping assay was performed.

RESULTS

Of 221 newly diagnosed CD patients, 65 (29.4%) presented NAFLD at CD diagnosis, while 32 (14.5%) met the criteria for MAFLD (k = 0.57). There were no significant differences between NAFLD and MAFLD, except for the higher rate of insulin resistance (IR) of MAFLD patients (75% vs 33.8%, P < .001). At 2 years of follow-up, 46.6% of patients developed NAFLD while 32.6% had MAFLD (k = 0.71). MAFLD subjects had higher transaminases (P = .03), LDL-cholesterol (P = .04), BMI and waist circumference and higher IR than NAFLD patients. MAFLD patients showed higher non-invasive liver fibrosis scores than NAFLD subjects (APRI = 1.43 ± 0.56 vs 0.91 ± 0.62, P < .001; NFS=-1.72 ± 1.31 vs -2.18 ± 1.41, P = .03; FIB-4 = 1.27 ± 0.77 vs 1.04 ± 0.74, P = .04). About PNPLA3 polymorphisms, at 2 years follow-up, NAFLD subjects presented a higher rate of heterozygosis (40.8%) and homozygosis (18.4%) polymorphisms than non-NAFLD (26.3% and 7.6%, respectively, P = .03 and 0.02), while no correlation between PNPLA3 polymorphisms and MAFLD was seen.

CONCLUSIONS

The new MAFLD definition better reflects the metabolic alterations following GFD in CD population. This new classification could be able to identify patients at higher risk of worse metabolic outcome, who need a close multidisciplinary approach for their multisystemic disease.