201
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Haloot J, Krokar L, Badin A. Effect of SLGT2 Inhibitors on Patients with Atrial Fibrillation. J Atr Fibrillation 2021; 14:20200502. [PMID: 34950375 PMCID: PMC8691277 DOI: 10.4022/jafib.20200502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 04/16/2021] [Accepted: 05/12/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Sodium glucose cotransporter 2 (SGLT2) inhibitors have been associated with various cardiovascular benefits. There is limited data examining the effect of these medications on atrial fibrillation (AF) associated clinical outcomes. We compared ischemic stroke, acute coronary syndrome (ACS), cardioversion, and all-cause mortality outcomes in AF patients on SGLT2 inhibitors to propensity matched controls. MATERIALS AND METHODS We conducted a retrospective study with a global medical research network database. AF patients were identified via ICD codes that must have been present for at least one month. Patients on SGLT2 inhibitors were identified as those on dapagliflozin, empagliflozin, or canagliflozin for at least one month. AF patients on SGLT2 inhibitors were propensity matched to those not on SGLT2 inhibitors based on age, race, ethnicity, cardiovascular comorbidities, valvular disease, pulmonary disease, urinary diseases, cardiovascular procedures, cardiovascular medications, and anticoagulants. We examined incidence of ischemic stroke, at least one ACS episode, cardioversion, and all-cause mortality. RESULTS In 26,269 AF patients, SGLT2 inhibitors were associated with lower risk of cardioversion (HR 0.921, 95% CI 0.841 - 0.999, p = 0.0245) and all-cause mortality (HR 0.676, 95% CI 0.635 - 0.721, p < 0.0001). However, there was an association with increased risk for ischemic stroke (HR 1.081, 95% CI 1.012 - 1.154, p 0.0201). There was no clear association with ACS events. CONCLUSIONS In patients with AF, use of SGLT2 inhibitors was associated with a lower risk of cardioversion and all-cause mortality and higher probability of survival based on Kaplan-Meier analysis.
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Affiliation(s)
- Justin Haloot
- University of Texas Health San Antonio, San Antonio, TX
| | | | - Auroa Badin
- University of Texas Health San Antonio, San Antonio, TX
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202
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Abstract
After 12 years of rigorous cardiovascular outcome trials (CVOTs), sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) emerged as new therapeutic options for patients with type 2 diabetes mellitus to reduce the risk of heart disease. SGLT2i additionally cause a reduction in heart failure and renal events in patients both with and without diabetes. This article reviews the major CVOTs that support the use of these agents, describes the mechanisms of action that lead to their broad cardiorenal benefits, explains current guidelines, and offers practical clinical advice to initiate and monitor treatment with these agents.
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Affiliation(s)
- Enrico G Ferro
- Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA. https://twitter.com/DLBhattMD
| | - Mohamed B Elshazly
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, 601 North Caroline Street, Suite 7200, Baltimore, MD 21287, USA; Division of Cardiology, Department of Medicine, Weill Cornell Medical College-Qatar, Education City, PO Box 24144, Doha, Qatar
| | - Deepak L Bhatt
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA; Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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203
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Optimizing prognosis in atrial fibrillation: A call to action in Portugal. Rev Port Cardiol 2021; 40:595-605. [PMID: 34392904 DOI: 10.1016/j.repce.2020.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/10/2020] [Indexed: 11/22/2022] Open
Abstract
Atrial fibrillation (AF), the most common arrhythmia in the adult population worldwide, represents a significant burden in terms of cardiovascular mortality and morbidity and has repercussions on health economics. Oral anticoagulation (OAC) is key to stroke prevention in AF and, in recent years, results from landmark clinical trials of non-vitamin K oral anticoagulants (NOAC) have triggered a paradigm shift in thrombocardiology. Despite these advances, there is still a significant residual vascular risk associated with silent AF, bleeding, premature sudden death and heart failure. The authors review AF epidemiologic data, the importance of new tools for early AF detection, the current role of catheter ablation for rhythm control in AF, the state-of-the-art in periprocedural OAC, the optimal management of major bleeding, the causes of residual premature death and future strategies for improvements in AF prognosis.
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204
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Optimizing prognosis in atrial fibrillation: A call to action in Portugal. Rev Port Cardiol 2021. [DOI: 10.1016/j.repc.2020.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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205
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Tsai WH, Chuang SM, Liu SC, Lee CC, Chien MN, Leung CH, Liu SJ, Shih HM. Effects of SGLT2 inhibitors on stroke and its subtypes in patients with type 2 diabetes: a systematic review and meta-analysis. Sci Rep 2021; 11:15364. [PMID: 34321571 PMCID: PMC8319393 DOI: 10.1038/s41598-021-94945-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/19/2021] [Indexed: 02/07/2023] Open
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors have shown impressive effects in reducing major vascular events in several randomized controlled trials (RCTs). The purpose of this study was to perform a meta-analysis to evaluate the effect of SGLT2 inhibitors on the risk of stroke and its subtypes. All data from prospective RCTs up to 20 October 2020 involving SGLT2 inhibitors that reported stroke events as the primary endpoint or safety in subjects with type 2 diabetes were subjected to meta-analysis. Five eligible RCTs (EMPA-REG, CANVAS, DECLARE-TIMI 58, CREDENCE and VERTIS CV) involving 46,969 participants were included. Pooled analysis of the RCTs showed no significant effect of SGLT2 inhibitors on total stroke [risk ratio (RR) = 0.95; 95% confidence interval (CI) 0.79-1.13, P = 0.585]. Subgroup analysis indicated that SGLT2 inhibitors had no significant effect against fatal stroke, non-fatal stroke, ischemic stroke or transient ischemic attack. When only hemorrhagic stroke was included, SGLT2 inhibitors were associated with a significant 50% reduction compared with placebo (RR = 0.49, 95% CI 0.30-0.82, P = 0.007). This meta-analysis shows that SGLT2 inhibitors have a neutral effect on the risk of stroke and its subtypes but a potential protective effect against hemorrhagic stroke.
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Affiliation(s)
- Wen-Hsuan Tsai
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Taipei, 10449, Taiwan
| | - Shih-Ming Chuang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Taipei, 10449, Taiwan. .,Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan. .,Department of Medicine, Mackay Medical Collage, New Taipei City, Taiwan.
| | - Sung-Chen Liu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Taipei, 10449, Taiwan.,Department of Medicine, Mackay Medical Collage, New Taipei City, Taiwan
| | - Chun-Chuan Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Taipei, 10449, Taiwan
| | - Ming-Nan Chien
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Taipei, 10449, Taiwan.,Department of Medicine, Mackay Medical Collage, New Taipei City, Taiwan
| | - Ching-Hsiang Leung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Taipei, 10449, Taiwan
| | - Shu-Jung Liu
- Medical Library, MacKay Memorial Hospital, Tamsui Branch, New Taipei City, Taiwan
| | - Hong-Mou Shih
- Division of Nephrology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan.,Graduate Institute of Physiology, College of Medicine, National Taiwan University, Taipei, Taiwan
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206
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Trum M, Riechel J, Wagner S. Cardioprotection by SGLT2 Inhibitors-Does It All Come Down to Na +? Int J Mol Sci 2021; 22:ijms22157976. [PMID: 34360742 PMCID: PMC8347698 DOI: 10.3390/ijms22157976] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 07/22/2021] [Accepted: 07/22/2021] [Indexed: 12/15/2022] Open
Abstract
Sodium-glucose co-transporter 2 inhibitors (SGLT2i) are emerging as a new treatment strategy for heart failure with reduced ejection fraction (HFrEF) and—depending on the wistfully awaited results of two clinical trials (DELIVER and EMPEROR-Preserved)—may be the first drug class to improve cardiovascular outcomes in patients suffering from heart failure with preserved ejection fraction (HFpEF). Proposed mechanisms of action of this class of drugs are diverse and include metabolic and hemodynamic effects as well as effects on inflammation, neurohumoral activation, and intracellular ion homeostasis. In this review we focus on the growing body of evidence for SGLT2i-mediated effects on cardiac intracellular Na+ as an upstream mechanism. Therefore, we will first give a short overview of physiological cardiomyocyte Na+ handling and its deterioration in heart failure. On this basis we discuss the salutary effects of SGLT2i on Na+ homeostasis by influencing NHE1 activity, late INa as well as CaMKII activity. Finally, we highlight the potential relevance of these effects for systolic and diastolic dysfunction as well as arrhythmogenesis.
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207
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Could Sodium/Glucose Co-Transporter-2 Inhibitors Have Antiarrhythmic Potential in Atrial Fibrillation? Literature Review and Future Considerations. Drugs 2021; 81:1381-1395. [PMID: 34297330 DOI: 10.1007/s40265-021-01565-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2021] [Indexed: 12/11/2022]
Abstract
The global burden of atrial fibrillation (AF) is constantly increasing, necessitating novel and effective therapeutic options. Sodium glucose co-transporter 2 (SGLT2) inhibitors have been introduced in clinical practice as glucose-lowering medications. However, they have recently gained prominence for their potential to exert substantial cardiorenal protection and are being evaluated in large clinical trials including patients with type 2 diabetes and normoglycemic adults. In this review we present up-to-date available evidence in a pathophysiology-directed manner from cell to bedside. Preclinical and clinical data regarding a conceivable antiarrhythmic effect of SGLT2 inhibitors are beginning to accumulate. Herein we comprehensively present data that explore the potential pathophysiological link between SGLT2 inhibitors and AF. With regard to clinical data, no randomized controlled trials evaluating SGLT2 inhibitors effects on AF as a pre-specified endpoint are available. However, data from randomized controlled trial post-hoc analysis as well as observational studies point to a possible beneficial effect of SGLT2 inhibitors on AF. Meta-analyses addressing this question report inconsistent results and the real magnitude of AF prevention by SGLT2 inhibition remains unclear. Still, while (i) pathophysiologic mechanisms involved in AF might be favorably affected by SGLT2 inhibitors and (ii) emerging, yet inconsistent, clinical data imply that SGLT2 inhibitor-mediated cardiorenal protection could also exert antiarrhythmic effects, the argument of whether these novel drugs will reduce AF burden is unsettled and mandates appropriately designed and adequately sized randomized controlled studies.
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208
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Brown E, Heerspink HJL, Cuthbertson DJ, Wilding JPH. SGLT2 inhibitors and GLP-1 receptor agonists: established and emerging indications. Lancet 2021; 398:262-276. [PMID: 34216571 DOI: 10.1016/s0140-6736(21)00536-5] [Citation(s) in RCA: 213] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 02/12/2021] [Accepted: 02/24/2021] [Indexed: 12/21/2022]
Abstract
SGLT2 inhibitors and GLP-1 receptor agonists are used in patients with type 2 diabetes as glucose lowering therapies, with additional benefits of weight loss and blood pressure reduction. Data from cardiovascular outcome trials have highlighted that these drugs confer protection against major cardiovascular disease in those with established atherosclerotic cardiovascular disease, reduce the risk of admission to hospital for heart failure, and reduce cardiovascular and all-cause mortality. Ongoing research using hard renal endpoints such as end stage kidney disease rather than surrogate markers might clarify the renoprotective benefits of both agents. When used for glucose lowering, SGLT2 inhibitors are most effective if the estimated glomerular filtration rate is more than 60 ml per min per 1·73m2 at initiation and should be avoided where there is a risk of diabetic ketoacidosis. GLP-1 receptor agonists are contraindicated in those with a history of medullary thyroid cancer and used with caution in patients with a history of pancreatitis of a known cause. These drugs are now second-line, or even arguably first-line, glucose lowering therapies in patients with cardiorenal disease, irrespective of glycaemic control. If an SGLT2 inhibitor or GLP-1 receptor agonist is considered suitable in patients with type 2 diabetes, treatment should be prioritised according to existing evidence: GLP-1 receptor agonists should be considered in patients at a high risk of, or with established, cardiovascular disease and SGLT2 inhibitors considered for patients with heart failure (with reduced ejection fraction) or chronic kidney disease (with or without established cardiovascular disease). There is now compelling data on the benefits of these drugs for a range of other clinical indications even without type 2 diabetes, including for GLP-1 receptor agonists in patients with obesity and overweight with weight-related comorbidities.
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Affiliation(s)
- Emily Brown
- Department of Metabolic and Cardiovascular Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Liverpool University Hospitals NHS Foundation Trust, Longmoor Lane, Liverpool, UK
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Daniel J Cuthbertson
- Department of Metabolic and Cardiovascular Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Liverpool University Hospitals NHS Foundation Trust, Longmoor Lane, Liverpool, UK.
| | - John P H Wilding
- Department of Metabolic and Cardiovascular Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Liverpool University Hospitals NHS Foundation Trust, Longmoor Lane, Liverpool, UK
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209
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Anastasiou G, Hatziagelaki E, Liberopoulos E. Could Dapagliflozin Attenuate COVID-19 Progression in High-Risk Patients With or Without Diabetes? Behind DARE-19 Concept. J Cardiovasc Pharmacol 2021; 78:e12-e19. [PMID: 34001719 PMCID: PMC8253377 DOI: 10.1097/fjc.0000000000001011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 02/20/2021] [Indexed: 02/06/2023]
Abstract
ABSTRACT Epidemiological studies indicate that diabetes is the second most common comorbidity in COVID-19 (coronavirus disease 2019). Dapagliflozin, a sodium-glucose co-transporter 2 inhibitor, exerts direct cardioprotective and nephroprotective effects. DARE-19 (Dapagliflozin in Respiratory Failure in Patients With COVID-19), an ongoing clinical trial, is designed to investigate the impact of dapagliflozin on COVID-19 progression. This article discusses the potential favorable impact of dapagliflozin on COVID-19 and its complications.
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Affiliation(s)
- Georgia Anastasiou
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece; and
| | - Erifili Hatziagelaki
- Second Department of Internal Medicine, Research Institute and Diabetes Center, “Attikon” University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Liberopoulos
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece; and
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210
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Ajjan RA, Kietsiriroje N, Badimon L, Vilahur G, Gorog DA, Angiolillo DJ, Russell DA, Rocca B, Storey RF. Antithrombotic therapy in diabetes: which, when, and for how long? Eur Heart J 2021; 42:2235-2259. [PMID: 33764414 PMCID: PMC8203081 DOI: 10.1093/eurheartj/ehab128] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/26/2021] [Accepted: 02/23/2021] [Indexed: 02/07/2023] Open
Abstract
Cardiovascular disease remains the main cause of mortality in individuals with diabetes mellitus (DM) and also results in significant morbidity. Premature and more aggressive atherosclerotic disease, coupled with an enhanced thrombotic environment, contributes to the high vascular risk in individuals with DM. This prothrombotic milieu is due to increased platelet activity together with impaired fibrinolysis secondary to quantitative and qualitative changes in coagulation factors. However, management strategies to reduce thrombosis risk remain largely similar in individuals with and without DM. The current review covers the latest in the field of antithrombotic management in DM. The role of primary vascular prevention is discussed together with options for secondary prevention following an ischaemic event in different clinical scenarios including coronary, cerebrovascular, and peripheral artery diseases. Antiplatelet therapy combinations as well as combination of antiplatelet and anticoagulant agents are examined in both the acute phase and long term, including management of individuals with sinus rhythm and those with atrial fibrillation. The difficulties in tailoring therapy according to the variable atherothrombotic risk in different individuals are emphasized, in addition to the varying risk within an individual secondary to DM duration, presence of complications and predisposition to bleeding events. This review provides the reader with an up-to-date guide for antithrombotic management of individuals with DM and highlights gaps in knowledge that represent areas for future research, aiming to improve clinical outcome in this high-risk population.
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Affiliation(s)
- Ramzi A Ajjan
- The LIGHT Laboratories, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 7JT, UK
| | - Noppadol Kietsiriroje
- The LIGHT Laboratories, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 7JT, UK.,Endocrinology and Metabolism Unit, Internal Medicine Department, Faculty of Medicine, Prince of Songkla University, Songkhla 90110, Thailand
| | - Lina Badimon
- Cardiovascular Program ICCC, Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Sant Antoni M. Claret 167, 08025 Barcelona, Spain.,Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Instituto de Salud Carlos III, Sant Antoni M. Claret 167, 08025 Barcelona, Spain.,Cardiovascular Research Chair, Universidad Autónoma Barcelona (UAB), Sant Antoni M. Claret 167, 08025 Barcelona, Spain
| | - Gemma Vilahur
- Cardiovascular Program ICCC, Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Sant Antoni M. Claret 167, 08025 Barcelona, Spain.,Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Instituto de Salud Carlos III, Sant Antoni M. Claret 167, 08025 Barcelona, Spain
| | - Diana A Gorog
- University of Hertfordshire, College Lane Campus Hatfield, Hertfordshire AL10 9AB, UK.,National Heart and Lung Institute, Guy Scadding Building, Dovehouse St, London SW3 6LY, UK
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, 655 West, 8th Street, Jacksonville, FL 32209, USA
| | - David A Russell
- The LIGHT Laboratories, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 7JT, UK.,Leeds Vascular Institute, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
| | - Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Beech Hill Road, Sheffield S10 2RX, UK
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211
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Abstract
Heart failure with preserved ejection fraction (HFpEF) accounts for more than one-half of patients with heart failure. Effective treatment of HFpEF has not been established, largely because of the complexities and heterogeneity in the phenotypes of HFpEF. Categorizing patients based on clinical and pathophysiologic phenotype may provide more targeted and efficacious therapies. Despite this clinical need, there is no consensus on how to categorize patients with HFpEF into phenogroups. Possible metrics include the presence or absence of specific comorbidities that influence pathophysiology, imaging, hemodynamics, or other biomarkers. This article describes currently recognized phenotypes of HFpEF and potential treatment strategies.
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212
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Chen YC, Voskoboinik A, Gerche AL, Marwick TH, McMullen JR. Prevention of Pathological Atrial Remodeling and Atrial Fibrillation: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 77:2846-2864. [PMID: 34082914 DOI: 10.1016/j.jacc.2021.04.012] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 04/07/2021] [Indexed: 12/29/2022]
Abstract
Atrial enlargement in response to pathological stimuli (e.g., hypertension, mitral valve disease) and physiological stimuli (exercise, pregnancy) can be comparable in magnitude, but the diseased enlarged atria is associated with complications such as atrial fibrillation (AF), whereas physiological atrial enlargement is not. Pathological atrial enlargement and AF is also observed in a small percentage of athletes undergoing extreme/intense endurance sport and pregnant women with preeclampsia. Differences between physiological and pathological atrial enlargement and underlying mechanisms are poorly understood. This review describes human and animal studies characterizing atrial enlargement under physiological and pathological conditions and highlights key knowledge gaps and clinical challenges, including: 1) the limited ability of atria to reverse remodel; and 2) distinguishing physiological and pathological enlargement via imaging/biomarkers. Finally, this review discusses how targeting distinct molecular mechanisms underlying physiological and pathological atrial enlargement could provide new therapeutic and diagnostic strategies for preventing or reversing atrial enlargement and AF.
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Affiliation(s)
- Yi Ching Chen
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Aleksandr Voskoboinik
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Heart Center, Alfred Hospital, Melbourne, Victoria, Australia; Department of Cardiology, Western Health, Melbourne, Victoria, Australia; Monash University, Melbourne, Victoria, Australia
| | - Andre La Gerche
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Department of Cardiometabolic Health, The University of Melbourne, Melbourne, Victoria, Australia; National Centre for Sports Cardiology, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Thomas H Marwick
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Heart Center, Alfred Hospital, Melbourne, Victoria, Australia; Department of Cardiology, Western Health, Melbourne, Victoria, Australia; Monash University, Melbourne, Victoria, Australia; Department of Cardiometabolic Health, The University of Melbourne, Melbourne, Victoria, Australia.
| | - Julie R McMullen
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Monash University, Melbourne, Victoria, Australia; Department of Cardiometabolic Health, The University of Melbourne, Melbourne, Victoria, Australia; Department of Physiology, Anatomy and Microbiology, La Trobe University, Bundoora, Victoria, Australia.
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213
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Implications of SGLT Inhibition on Redox Signalling in Atrial Fibrillation. Int J Mol Sci 2021; 22:ijms22115937. [PMID: 34073033 PMCID: PMC8198069 DOI: 10.3390/ijms22115937] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/25/2021] [Accepted: 05/26/2021] [Indexed: 12/20/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained (atrial) arrhythmia, a considerable global health burden and often associated with heart failure. Perturbations of redox signalling in cardiomyocytes provide a cellular substrate for the manifestation and maintenance of atrial arrhythmias. Several clinical trials have shown that treatment with sodium-glucose linked transporter inhibitors (SGLTi) improves mortality and hospitalisation in heart failure patients independent of the presence of diabetes. Post hoc analysis of the DECLARE-TIMI 58 trial showed a 19% reduction in AF in patients with diabetes mellitus (hazard ratio, 0.81 (95% confidence interval: 0.68-0.95), n = 17.160) upon treatment with SGLTi, regardless of pre-existing AF or heart failure and independent from blood pressure or renal function. Accordingly, ongoing experimental work suggests that SGLTi not only positively impact heart failure but also counteract cellular ROS production in cardiomyocytes, thereby potentially altering atrial remodelling and reducing AF burden. In this article, we review recent studies investigating the effect of SGLTi on cellular processes closely interlinked with redox balance and their potential effects on the onset and progression of AF. Despite promising insight into SGLTi effect on Ca2+ cycling, Na+ balance, inflammatory and fibrotic signalling, mitochondrial function and energy balance and their potential effect on AF, the data are not yet conclusive and the importance of individual pathways for human AF remains to be established. Lastly, an overview of clinical studies investigating SGLTi in the context of AF is provided.
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214
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Mitochondrial Dysfunction in Atrial Fibrillation-Mechanisms and Pharmacological Interventions. J Clin Med 2021; 10:jcm10112385. [PMID: 34071563 PMCID: PMC8199309 DOI: 10.3390/jcm10112385] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/20/2021] [Accepted: 05/25/2021] [Indexed: 12/22/2022] Open
Abstract
Despite the enormous progress in the treatment of atrial fibrillation, mainly with the use of invasive techniques, many questions remain unanswered regarding the pathomechanism of the arrhythmia and its prevention methods. The development of atrial fibrillation requires functional changes in the myocardium that result from disturbed ionic fluxes and altered electrophysiology of the cardiomyocyte. Electrical instability and electrical remodeling underlying the arrhythmia may result from a cellular energy deficit and oxidative stress, which are caused by mitochondrial dysfunction. The significance of mitochondrial dysfunction in the pathogenesis of atrial fibrillation remains not fully elucidated; however, it is emphasized by the reduction of atrial fibrillation burden after therapeutic interventions improving the mitochondrial welfare. This review summarizes the mechanisms of mitochondrial dysfunction related to atrial fibrillation and current pharmacological treatment options targeting mitochondria to prevent or improve the outcome of atrial fibrillation.
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215
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Naccarelli GV, Filippone EJ, Foy A. Do Mineralocorticoid Receptor Antagonists Suppress Atrial Fibrillation/Flutter? J Am Coll Cardiol 2021; 78:153-155. [PMID: 34015479 DOI: 10.1016/j.jacc.2021.04.080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 04/30/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Gerald V Naccarelli
- Penn State University Heart and Vascular Institute, Penn State University College of Medicine, Hershey, Pennsylvania, USA.
| | - Edward J Filippone
- Division of Nephrology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Andrew Foy
- Penn State University Heart and Vascular Institute, Penn State University College of Medicine, Hershey, Pennsylvania, USA. https://twitter.com/AndrewFoy82
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216
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Filippatos G, Bakris GL, Pitt B, Agarwal R, Rossing P, Ruilope LM, Butler J, Lam CSP, Kolkhof P, Roberts L, Tasto C, Joseph A, Anker SD. Finerenone Reduces New-Onset Atrial Fibrillation in Patients With Chronic Kidney Disease and Type 2 Diabetes. J Am Coll Cardiol 2021; 78:142-152. [PMID: 34015478 DOI: 10.1016/j.jacc.2021.04.079] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) and type 2 diabetes (T2D) are at risk of atrial fibrillation or flutter (AFF) due to cardiac remodeling and kidney complications. Finerenone, a novel, selective, nonsteroidal mineralocorticoid receptor antagonist, inhibited cardiac remodeling in preclinical models. OBJECTIVES This work aims to examine the effect of finerenone on new-onset AFF and cardiorenal effects by history of AFF in the Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease (FIDELIO-DKD) study. METHODS Patients with CKD and T2D were randomized (1:1) to finerenone or placebo. Eligible patients had a urine albumin-to-creatinine ratio ≥30 to ≤5,000 mg/g, an estimated glomerular filtration rate (eGFR) ≥25 to <75 ml/min/1.73 m2 and received optimized doses of renin-angiotensin system blockade. Effect on new-onset AFF was evaluated as a pre-specified outcome adjudicated by an independent cardiologist committee. The primary composite outcome (time to first onset of kidney failure, a sustained decrease of ≥40% in eGFR from baseline, or death from renal causes) and key secondary outcome (time to first onset of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure) were analyzed by history of AFF. RESULTS Of 5,674 patients, 461 (8.1%) had a history of AFF. New-onset AFF occurred in 82 (3.2%) patients on finerenone and 117 (4.5%) patients on placebo (hazard ratio: 0.71; 95% confidence interval: 0.53-0.94; p = 0.016). The effect of finerenone on primary and key secondary kidney and cardiovascular outcomes was not significantly impacted by baseline AFF (interaction p value: 0.16 and 0.85, respectively). CONCLUSIONS In patients with CKD and T2D, finerenone reduced the risk of new-onset AFF. The risk of kidney or cardiovascular events was reduced irrespective of history of AFF at baseline. (EudraCT 2015-000990-11 [A randomized, double-blind, placebo-controlled, parallel-group, multicenter, event-driven Phase III study to investigate the efficacy and safety of finerenone, in addition to standard of care, on the progression of kidney disease in subjects with type 2 diabetes mellitus and the clinical diagnosis of diabetic kidney disease]; Efficacy and Safety of Finerenone in Subjects With Type 2 Diabetes Mellitus and Diabetic Kidney Disease [FIDELIO-DKD]; NCT02540993).
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Affiliation(s)
- Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens, Greece.
| | - George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, Indiana, USA
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Luis M Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, Madrid, Spain; CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain; Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, Mississippi, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | - Peter Kolkhof
- Research and Development, Preclinical Research Cardiovascular, Bayer AG, Wuppertal, Germany
| | - Luke Roberts
- Study Medical Experts, Bayer PLC, Reading, United Kingdom
| | - Christoph Tasto
- Research and Development, Statistics and Data Insights, Bayer AG, Wuppertal, Germany
| | - Amer Joseph
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | - Stefan D Anker
- Department of Cardiology (CVK), and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
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Otake S, Sato A, Babazono T. Prevalence and predictors of atrial fibrillation in Japanese patients with type 2 diabetes. Diabetol Int 2021; 13:101-107. [DOI: 10.1007/s13340-021-00509-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/21/2021] [Indexed: 11/29/2022]
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218
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Li HL, Lip GYH, Feng Q, Fei Y, Tse YK, Wu MZ, Ren QW, Tse HF, Cheung BMY, Yiu KH. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) and cardiac arrhythmias: a systematic review and meta-analysis. Cardiovasc Diabetol 2021; 20:100. [PMID: 33962654 PMCID: PMC8106208 DOI: 10.1186/s12933-021-01293-8] [Citation(s) in RCA: 97] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 04/27/2021] [Indexed: 02/06/2023] Open
Abstract
Background Cardiac arrhythmias are associated with poorer outcomes in patients with heart failure (HF), diabetes mellitus (DM), and chronic kidney disease (CKD). Previous studies have shown inconsistent conclusions regarding the association between sodium-glucose cotransporter 2 inhibitors (SGLT2i) and the risk of developing arrhythmias. This study aims to investigate the association of SGLT2i treatment with arrhythmia outcomes in clinical trials of patients with HF, DM, or CKD. Methods MEDLINE, EMBASE, and ClinicalTrials.gov were searched from inception up to 27 August 2020. Randomized controlled trials that randomized patients with DM, CKD, or HF to SGLT2i or placebo were included. The outcomes of interest include atrial fibrillation (AF), embolic stroke, atrial flutter (AFL), AF/AFL, ventricular tachycardia (VT), and cardiac arrest. Relative risks (RRs) and 95% confidence intervals (CI) were pooled using a random-effects model. Results Out of 4,532 citations, 22 trials with altogether 52,115 patients were included (mean age 63.2 years; 33,747 [64.8%] of participants were men). SGLT2i were associated with a lower risk of AF (RR 0.82, 95% CI 0.70–0.96), embolic stroke (RR 0.32, 95% CI 0.12–0.85), AF/AFL (RR 0.82, 95% CI 0.71–0.95), and VT (RR 0.73, 95% CI 0.53–0.99), while the risk reductions in AFL (RR 0.83, 95% CI 0.58–1.17) and cardiac arrest (RR 0.83, 95% CI 0.61–1.14) did not reach statistical significance. The associations appeared to be consistent across different baseline conditions (DM vs CKD vs HF; atherosclerotic cardiovascular disease [ASCVD] vs no ASCVD) and the SGLT2i used. Conclusions SGLT2i reduced the risk of cardiac arrhythmias. Our study provides further evidence for recommending the use of SGLT2i in patients with DM, CKD, and HF. Further research is needed to fully elucidate the mechanism by which SGLT2i protect against arrhythmias. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-021-01293-8.
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Affiliation(s)
- Hang-Long Li
- Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Room 1929B/K1931, Block K, Hong Kong, China.,Division of Cardiology, Department of Medicine, The University of Hong Kong Shenzhen Hospital, Shenzhen, China
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Qi Feng
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Yue Fei
- Division of Clinical Pharmacology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Yi-Kei Tse
- Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Room 1929B/K1931, Block K, Hong Kong, China
| | - Mei-Zhen Wu
- Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Room 1929B/K1931, Block K, Hong Kong, China.,Division of Cardiology, Department of Medicine, The University of Hong Kong Shenzhen Hospital, Shenzhen, China
| | - Qing-Wen Ren
- Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Room 1929B/K1931, Block K, Hong Kong, China.,Division of Cardiology, Department of Medicine, The University of Hong Kong Shenzhen Hospital, Shenzhen, China
| | - Hung-Fat Tse
- Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Room 1929B/K1931, Block K, Hong Kong, China.,Division of Cardiology, Department of Medicine, The University of Hong Kong Shenzhen Hospital, Shenzhen, China
| | - Bernard-M Y Cheung
- Division of Clinical Pharmacology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Kai-Hang Yiu
- Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Room 1929B/K1931, Block K, Hong Kong, China. .,Division of Cardiology, Department of Medicine, The University of Hong Kong Shenzhen Hospital, Shenzhen, China.
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Sodium-Glucose Cotransporter-2 Inhibitors and Protection Against stroke in Patients with type 2 Diabetes and Impaired Renal Function: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2021; 30:105708. [DOI: 10.1016/j.jstrokecerebrovasdis.2021.105708] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/16/2021] [Accepted: 02/18/2021] [Indexed: 01/25/2023] Open
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Chan YH, Chen SW, Chao TF, Kao YW, Huang CY, Chu PH. The impact of weight loss related to risk of new-onset atrial fibrillation in patients with type 2 diabetes mellitus treated with sodium-glucose cotransporter 2 inhibitor. Cardiovasc Diabetol 2021; 20:93. [PMID: 33941171 PMCID: PMC8091721 DOI: 10.1186/s12933-021-01285-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 04/20/2021] [Indexed: 12/12/2022] Open
Abstract
Background Sodium–glucose cotransporter 2 inhibitor (SGLT2i) use reduces body weight (BW) in patients with type 2 diabetes mellitus (T2DM). Obesity and T2DM are strong risk factors of new-onset atrial fibrillation (AF). However, whether BW loss following SGLT2i treatment reduces AF risk in patients with T2DM remains unclear. Methods We used a medical database from a multicenter health care provider in Taiwan, which included 10,237 patients with T2DM, from June 1, 2016 to December 31, 2018, whose BW data at baseline and at 12 weeks of SGLT2i treatment were available. Patients were followed up from the drug index date until the occurrence of new-onset AF, discontinuation of the SGLT2i, or the end of the study period, whichever occurred first. Results The patients’ baseline body mass index (BMI) was 28.08 \documentclass[12pt]{minimal}
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\begin{document}$$\pm$$\end{document}± 3.28 kg (1.78%\documentclass[12pt]{minimal}
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\begin{document}$$\pm$$\end{document}± 4.47%). There were 37.4%, 47.0%, and 15.6% of patients experienced no-BW loss (n = 3832), BW loss 0.0–4.9% (n = 4814), and \documentclass[12pt]{minimal}
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\begin{document}$$\ge$$\end{document}≥ 5.0% (n = 1591) following SGLT2i treatment, respectively. Compared with patients with baseline BMI < 23 kg/m2, AF risk significantly increased in patients with baseline BMI \documentclass[12pt]{minimal}
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\begin{document}$$\ge$$\end{document}≥ 27.5 kg/m2 (P for trend = 0.015). Compared with those without BW loss after SGLT2i treatment, AF risk significantly decreased with a BW loss of \documentclass[12pt]{minimal}
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\begin{document}$$\ge$$\end{document}≥ 5.0% (adjusted hazard ratios [95% confidence intervals]: 0.39[0.22–0.68]). Use of diuretics, old age, high-dose SGLT2i, higher estimated glomerular filtration rate, and baseline BMI were independent factors associated with a BW loss of \documentclass[12pt]{minimal}
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\begin{document}$$\ge$$\end{document}≥ 5.0% following SGLT2i initiation. By contrast, neither baseline BMI nor BW loss after SGLT2i treatment predicted major cardiovascular adverse events or heart failure hospitalization risk (P for trend > 0.05). Conclusion BW loss of ≥ 5.0% following SGLT2i treatment was associated with a lower risk of new-onset AF in patients with T2DM in real-world practice.
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Affiliation(s)
- Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Shao-Wei Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Linkou Medical Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan.,Center for Big Data Analytics and Statistics, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Wei Kao
- Graduate Institute of Business Administration, College of Management, Fu Jen Catholic University, Taipei, Taiwan
| | - Chien-Ying Huang
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan
| | - Pao-Hsien Chu
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.
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Zhou Z, Jardine MJ, Li Q, Neuen BL, Cannon CP, de Zeeuw D, Edwards R, Levin A, Mahaffey KW, Perkovic V, Neal B, Lindley RI. Effect of SGLT2 Inhibitors on Stroke and Atrial Fibrillation in Diabetic Kidney Disease: Results From the CREDENCE Trial and Meta-Analysis. Stroke 2021; 52:1545-1556. [PMID: 33874750 PMCID: PMC8078131 DOI: 10.1161/strokeaha.120.031623] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Chronic kidney disease with reduced estimated glomerular filtration rate or elevated albuminuria increases risk for ischemic and hemorrhagic stroke. This study assessed the effects of sodium glucose cotransporter 2 inhibitors (SGLT2i) on stroke and atrial fibrillation/flutter (AF/AFL) from CREDENCE (Canagliflozin and Renal Events in Diabetes With Established Nephropathy Clinical Evaluation) and a meta-analysis of large cardiovascular outcome trials (CVOTs) of SGLT2i in type 2 diabetes mellitus. METHODS CREDENCE randomized 4401 participants with type 2 diabetes mellitus and chronic kidney disease to canagliflozin or placebo. Post hoc, we estimated effects on fatal or nonfatal stroke, stroke subtypes, and intermediate markers of stroke risk including AF/AFL. Stroke and AF/AFL data from 3 other completed large CVOTs and CREDENCE were pooled using random-effects meta-analysis. RESULTS In CREDENCE, 142 participants experienced a stroke during follow-up (10.9/1000 patient-years with canagliflozin, 14.2/1000 patient-years with placebo; hazard ratio [HR], 0.77 [95% CI, 0.55-1.08]). Effects by stroke subtypes were: ischemic (HR, 0.88 [95% CI, 0.61-1.28]; n=111), hemorrhagic (HR, 0.50 [95% CI, 0.19-1.32]; n=18), and undetermined (HR, 0.54 [95% CI, 0.20-1.46]; n=17). There was no clear effect on AF/AFL (HR, 0.76 [95% CI, 0.53-1.10]; n=115). The overall effects in the 4 CVOTs combined were: total stroke (HRpooled, 0.96 [95% CI, 0.82-1.12]), ischemic stroke (HRpooled, 1.01 [95% CI, 0.89-1.14]), hemorrhagic stroke (HRpooled, 0.50 [95% CI, 0.30-0.83]), undetermined stroke (HRpooled, 0.86 [95% CI, 0.49-1.51]), and AF/AFL (HRpooled, 0.81 [95% CI, 0.71-0.93]). There was evidence that SGLT2i effects on total stroke varied by baseline estimated glomerular filtration rate (P=0.01), with protection in the lowest estimated glomerular filtration rate (<45 mL/min/1.73 m2]) subgroup (HRpooled, 0.50 [95% CI, 0.31-0.79]). CONCLUSIONS Although we found no clear effect of SGLT2i on total stroke in CREDENCE or across trials combined, there was some evidence of benefit in preventing hemorrhagic stroke and AF/AFL, as well as total stroke for those with lowest estimated glomerular filtration rate. Future research should focus on confirming these data and exploring potential mechanisms. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02065791.
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Affiliation(s)
- Zien Zhou
- The George Institute for Global Health, UNSW Sydney, Australia (Z.Z., M.J.J., Q.L., B.L.N., V.P., B.N.).,Department of Radiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, China (Z.Z.)
| | - Meg J Jardine
- The George Institute for Global Health, UNSW Sydney, Australia (Z.Z., M.J.J., Q.L., B.L.N., V.P., B.N.).,Concord Repatriation General Hospital, Sydney, Australia (M.J.J.)
| | - Qiang Li
- The George Institute for Global Health, UNSW Sydney, Australia (Z.Z., M.J.J., Q.L., B.L.N., V.P., B.N.)
| | - Brendon L Neuen
- The George Institute for Global Health, UNSW Sydney, Australia (Z.Z., M.J.J., Q.L., B.L.N., V.P., B.N.)
| | - Christopher P Cannon
- Cardiovascular Division, Brigham and Women's Hospital and Baim Institute for Clinical Research, Boston, MA (C.P.C.)
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, the Netherlands (D.d.Z.)
| | | | - Adeera Levin
- Division of Nephrology, University of British Columbia, Vancouver, BC, Canada (A.L.)
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, CA (K.W.M.)
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW Sydney, Australia (Z.Z., M.J.J., Q.L., B.L.N., V.P., B.N.).,Royal North Shore Hospital, Sydney, Australia (V.P.)
| | - Bruce Neal
- The George Institute for Global Health, UNSW Sydney, Australia (Z.Z., M.J.J., Q.L., B.L.N., V.P., B.N.).,Charles Perkins Centre, University of Sydney, Australia (B.N.).,Imperial College London, London, United Kingdom (B.N.)
| | - Richard I Lindley
- Westmead Applied Research Centre, University of Sydney, Sydney, Australia (R.I.L.).,The George Institute for Global Health, Sydney, Australia (R.I.L.)
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Peigh G, Shah SJ, Patel RB. Left Atrial Myopathy in Atrial Fibrillation and Heart Failure: Clinical Implications, Mechanisms, and Therapeutic Targets. Curr Heart Fail Rep 2021; 18:85-98. [PMID: 33864224 DOI: 10.1007/s11897-021-00510-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW This review discusses the mechanisms, clinical implications, and treatments of left atrial (LA) myopathy in comorbid atrial fibrillation (AF) and heart failure (HF) across the spectrum of ejection fraction. RECENT FINDINGS AF and HF are highly comorbid conditions. Left atrial (LA) myopathy, characterized by impairments in LA structure, function, or electrical conduction, plays a fundamental role in the development of both AF and HF with preserved ejection fraction (AF-HFpEF) along with AF and HF with reduced ejection fraction (AF-HFrEF). While the nature of LA myopathy in AF-HFpEF is unique from that of AF-HFrEF, LA myopathy also leads to progression of both of these conditions. There may be a vulnerable cohort of AF-HF patients who have a disproportionate degree of LA myopathy compared with left ventricular (LV) dysfunction. Further investigations are required to identify therapies to improve LA function in this cohort.
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Affiliation(s)
- Graham Peigh
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Sanjiv J Shah
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ravi B Patel
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA. .,Division of Cardiology, Northwestern Memorial Hospital, 676 N St. Clair Suite 600, Chicago, IL, 60611, USA.
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Vrachatis DA, Papathanasiou KA, Kossyvakis C, Giotaki SG, Raisakis K, Iliodromitis KE, Reimers B, Stefanini GG, Cleman M, Sianos G, Lansky A, Deftereos SG, Giannopoulos G. Atrial fibrillation risk in patients suffering from type I diabetes mellitus. A review of clinical and experimental evidence. Diabetes Res Clin Pract 2021; 174:108724. [PMID: 33647332 DOI: 10.1016/j.diabres.2021.108724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/31/2021] [Accepted: 02/09/2021] [Indexed: 12/12/2022]
Abstract
Atrial fibrillation (AF) and diabetes mellitus (DM) are commonly encountered in clinical practice. Although, the long term macrovascular and microvascular sequela of DM are well validated, the association between the less prevalent type 1 DM (T1DM) and atrial arrhythmogenesis is poorly understood. In the present review we highlight the current experimental and clinical data addressing this complex interaction. Animal studies support that T1DM, characterized by insulin deficiency and glycemic variability, impairs phosphatidylinositol 3‑kinase (PI3K)/protein kinase B signaling pathway. This pathway holds a central role in atrial electrical and structural remodeling responsible for arrhythmia initiation and maintenance. The molecular ''footprint'' of T1DM in atrial myocytes seems to involve a state of increased oxidative stress, impaired glucose transportation, ionic channel dysregulation and eventually fibrosis. On the contrary only a few clinical studies have examined the role of T1DM as an independent risk factor for AF development, and are discussed here. Further research is needed to solidify the real magnitude of this association and to investigate the clinical implications of PI3K molecular signaling pathway in atrial fibrillation management.
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Affiliation(s)
- Dimitrios A Vrachatis
- Humanitas Clinical and Research Center IRCCS, Milan, Italy; National and Kapodistrian University of Athens, Athens, Greece
| | | | | | | | | | | | | | | | - Michael Cleman
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - George Sianos
- Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Lansky
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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Halimi JM. [SGLT2 inhibitors: A new era for our patients]. Nephrol Ther 2021; 17:143-148. [PMID: 33773943 DOI: 10.1016/j.nephro.2020.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 12/12/2020] [Accepted: 12/21/2020] [Indexed: 12/11/2022]
Abstract
Since 2015, 10 randomized clinical trials assessed the cardiovascular safety of SGLT2 inhibitors, and then assessed the potential renal and cardiovascular benefits of these drugs (EMPAREG Outcome, CANVAS, DECLARE, DAPA-HF, CREDENCE, EMPEROR-reduced, VERTIS, DAPA-CKD, SCORED, SOLOIST-WHF) in over 88,000 patients. The results of EMPAREG Outcome showed major renal and cardiovascular protection but they were unexpected. The other trials regarding the effects of dapagliflozin, canagliflozin, empagliflozin and more recently sotagliflozin have confirmed most of these results and extended them to other populations. There is no scientific doubt that these drugs confer a marked renal protection in patients already treated with renin angiotensin system blockers (reduction of the risk of end-stage renal disease: -35 to 40%) et reduce the risk of hospitalization for heart failure (-30 to 35%), especially in patients with heart failure with reduced ejection fraction. The benefit/risk profile is highly favorable but minor (genital candidosis, urinary tract infections, euglycemic acido-ketosis) and serious (Fournier gangrene) side effects must not be forgotten. Renal protection is twice the effect of renin angiotensin system blockers, and is maintained in patients already treated with them, in patients with GFR 25mL/min/1.73m2 and over, regardless of whether they have type 2 diabetes mellitus or not (of note, patients with type 1 diabetes mellitus, polycystic kidney disease, lupus and vasculitis were excluded in these studies). Reduction of the incidence of heart failure is similar to that observed with sacubitril/valsartan, and is maintained in patients already treated with sacubitril/valsartan. SGLT2 inhibitors have now defined a new standard of care, and it will be necessary to explore the proper use of the new mineralocorticoid receptor antagonist finerenone that demonstrated significant renal and cardiovascular protection in mostly SGLT2 inhibitors-untreated diabetic patients with chronic kidney disease (or even some GLP-1 agonists). A new era for our patients.
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Affiliation(s)
- Jean-Michel Halimi
- Service de néphrologie-HTA, dialyses et transplantation rénale, hôpital Bretonneau, CHU de Tours, 2, boulevard Tonnellé, 37044 Tours cedex, France.
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Fernandes GC, Fernandes A, Cardoso R, Penalver J, Knijnik L, Mitrani RD, Myerburg RJ, Goldberger JJ. Association of SGLT2 inhibitors with arrhythmias and sudden cardiac death in patients with type 2 diabetes or heart failure: A meta-analysis of 34 randomized controlled trials. Heart Rhythm 2021; 18:1098-1105. [PMID: 33757845 DOI: 10.1016/j.hrthm.2021.03.028] [Citation(s) in RCA: 116] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 03/11/2021] [Accepted: 03/15/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitors (SGLT2is) reduce hospitalizations and death from heart failure (HF), but their effect on arrhythmia expression has been poorly investigated. OBJECTIVE The purpose of this study was to evaluate the association of SGLT2is with arrhythmias in patients with type 2 diabetes mellitus (T2DM) or HF. METHODS We searched PubMed and ClinicalTrials.gov. Two independent investigators identified randomized double-blind trials that compared SGLT2is with placebo or active control for adults with T2DM or HF. Primary outcomes were incident atrial arrhythmias, ventricular arrhythmias (VAs), and sudden cardiac death (SCD). RESULTS We included 34 randomized (25 placebo-controlled and 9 active-controlled) trials with 63,166 patients (35,883 SGLT2is vs 27,273 control: mean age 53-67 years; 63% male). Medications included canagliflozin, dapagliflozin, empagliflozin, or ertugliflozin. Except for 1 study of HF, all patients had T2DM. Follow-up ranged from 24 weeks to 5.7 years. The cumulative incidence of events was low: 3.6, 1.4, and 2.5 per 1000 patient-years for atrial arrhythmias, VAs and SCD, respectively. SGLT2i therapy was associated with a significant reduction in the risk of incident atrial arrhythmias (odds ratio 0.81; 95% confidence interval 0.69-0.95; P = .008) and the "SCD" component of the SCD outcome (odds ratio 0.72; 95% confidence interval 0.54-0.97; P = .03) compared with control. There was no significant difference in incident VA or the "cardiac arrest" SCD component between groups. CONCLUSION SGLT2is are associated with significantly reduced risks of incident atrial arrhythmias and SCD in patients with T2DM. Prospective trials are warranted to confirm the antiarrhythmic effect of SGLT2is and whether this is a class or drug-specific effect.
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Affiliation(s)
- Gilson C Fernandes
- Division of Cardiology, University of Miami Miller School of Medicine, Miami, Florida
| | - Amanda Fernandes
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Rhanderson Cardoso
- Division of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jorge Penalver
- Division of Cardiology, University of Miami Miller School of Medicine, Miami, Florida
| | - Leonardo Knijnik
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Raul D Mitrani
- Division of Cardiology, University of Miami Miller School of Medicine, Miami, Florida
| | - Robert J Myerburg
- Division of Cardiology, University of Miami Miller School of Medicine, Miami, Florida
| | - Jeffrey J Goldberger
- Division of Cardiology, University of Miami Miller School of Medicine, Miami, Florida.
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Li D, Liu Y, Hidru TH, Yang X, Wang Y, Chen C, Li KHC, Tang Y, Wei Y, Tse G, Xia Y. Protective Effects of Sodium-Glucose Transporter 2 Inhibitors on Atrial Fibrillation and Atrial Flutter: A Systematic Review and Meta- Analysis of Randomized Placebo-Controlled Trials. Front Endocrinol (Lausanne) 2021; 12:619586. [PMID: 33815278 PMCID: PMC8018283 DOI: 10.3389/fendo.2021.619586] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/15/2021] [Indexed: 12/14/2022] Open
Abstract
Background Hyperglycemia is associated with an increased risk of developing atrial fibrillation (AF) and atrial flutter (AFL). Sodium-glucose transporter 2 inhibitors (SGLT2i) have been reported to prevent AF/AFL in some studies, but not others. Therefore, a meta-analysis was performed to investigate whether SGLT2i use is associated with lower risks of AF/AFL. Methods PubMed, Scopus, Web of Science, Cochrane library databases were searched for randomized placebo-controlled trials comparing SGLT2i and placebo. Results A total of 33 trials involving 66,685 patients were included. The serious adverse events (SAEs) of AF/AFL occurrence were significantly lower in the SGLT2i group than the placebo group (0.96% vs. 1.19%; RR 0.83; 95% CI 0.71-0.96; P = 0.01; I2 25.5%). Similarly, the SAEs of AF occurrence was significantly lower in the SGLT2i group (0.82% vs. 1.06%; RR 0.81; 95% CI 0.69-0.95; P = 0.01; I2 10.2%). The subgroup analysis showed that the reduction in AF/AFL was significant only for dapagliflozin (1.02% vs. 1.49%; RR 0.73; 95% CI 0.59-0.89; P = 0.002; I2 0%), but not for canagliflozin (1.00% vs 1.08%; RR 0.83; 95% CI 0.62-1.12; P = 0.23; I2 0%), empagliflozin (0.88% vs 0.70%; RR 1.20; 95% CI 0.76-1.90; P = 0.43; I2 0%), ertugliflozin (1.01% vs 0.96%; RR 1.08; 95% CI 0.66-1.75; P = 0.76; I2 0%), and sotagliflozin (0.16% vs 0.10%; RR 1.09; 95% CI 0.13-8.86; P = 0.93; I2 0%). Conclusions SGLT2i use is associated with a 19.33% lower SAEs of AF/AFL compared with the placebo. Dapagliflozin users had the lowest SAEs of AF/AFL incidence. Further studies are needed to determine whether canagliflozin, empagliflozin, ertugliflozin, and sotagliflozin similarly exert protective effects against AF/AFL development.
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Affiliation(s)
- Daobo Li
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yingying Liu
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | | | - Xiaolei Yang
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yunsong Wang
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Cheng Chen
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | | | - Yuqi Tang
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yushan Wei
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Gary Tse
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yunlong Xia
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
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227
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Aguilar M, Rose RA, Takawale A, Nattel S, Reilly S. New aspects of endocrine control of atrial fibrillation and possibilities for clinical translation. Cardiovasc Res 2021; 117:1645-1661. [PMID: 33723575 PMCID: PMC8208746 DOI: 10.1093/cvr/cvab080] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/25/2021] [Accepted: 03/11/2021] [Indexed: 12/20/2022] Open
Abstract
Hormones are potent endo-, para-, and autocrine endogenous regulators of the function of multiple organs, including the heart. Endocrine dysfunction promotes a number of cardiovascular diseases, including atrial fibrillation (AF). While the heart is a target for endocrine regulation, it is also an active endocrine organ itself, secreting a number of important bioactive hormones that convey significant endocrine effects, but also through para-/autocrine actions, actively participate in cardiac self-regulation. The hormones regulating heart-function work in concert to support myocardial performance. AF is a serious clinical problem associated with increased morbidity and mortality, mainly due to stroke and heart failure. Current therapies for AF remain inadequate. AF is characterized by altered atrial function and structure, including electrical and profibrotic remodelling in the atria and ventricles, which facilitates AF progression and hampers its treatment. Although features of this remodelling are well-established and its mechanisms are partly understood, important pathways pertinent to AF arrhythmogenesis are still unidentified. The discovery of these missing pathways has the potential to lead to therapeutic breakthroughs. Endocrine dysfunction is well-recognized to lead to AF. In this review, we discuss endocrine and cardiocrine signalling systems that directly, or as a consequence of an underlying cardiac pathology, contribute to AF pathogenesis. More specifically, we consider the roles of products from the hypothalamic-pituitary axis, the adrenal glands, adipose tissue, the renin–angiotensin system, atrial cardiomyocytes, and the thyroid gland in controlling atrial electrical and structural properties. The influence of endocrine/paracrine dysfunction on AF risk and mechanisms is evaluated and discussed. We focus on the most recent findings and reflect on the potential of translating them into clinical application.
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Affiliation(s)
- Martin Aguilar
- Department of Medicine and Research Center, Montreal Heart Institute and Université de Montréal, Montréal, QC, Canada.,Department of Pharmacology and Physiology/Institute of Biomedical Engineering, Université de Montréal, Montréal, QC, Canada
| | - Robert A Rose
- Department of Cardiac Sciences, Department of Physiology and Pharmacology, Libin Cardiovascular Institute, Cumming School of Medicine, Health Research Innovation Center, University of Calgary, AB, Canada
| | - Abhijit Takawale
- Department of Medicine and Research Center, Montreal Heart Institute and Université de Montréal, Montréal, QC, Canada.,Department of Pharmacology and Physiology/Institute of Biomedical Engineering, Université de Montréal, Montréal, QC, Canada.,Department of Pharmacology and Therapeutics, McGill University, Montreal, QC, Canada
| | - Stanley Nattel
- Department of Pharmacology and Therapeutics, McGill University, Montreal, QC, Canada.,Faculty of Medicine, Department of Pharmacology and Physiology, and Research Centre, Montreal Heart Institute and University of Montreal, Montreal, QC, Canada.,Institute of Pharmacology, West German Heart and Vascular Center, Faculty of Medicine, University Duisburg-Essen, Germany.,IHU LIRYC and Fondation Bordeaux Université, Bordeaux, France
| | - Svetlana Reilly
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, British Heart Foundation Centre of Research Excellence, University of Oxford, John Radcliffe Hospital, Oxford, UK
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228
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Koufakis T, Pavlidis AN, Metallidis S, Kotsa K. Sodium-glucose co-transporter 2 inhibitors in COVID-19: meeting at the crossroads between heart, diabetes and infectious diseases. Int J Clin Pharm 2021; 43:764-767. [PMID: 33751323 PMCID: PMC7942520 DOI: 10.1007/s11096-021-01256-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/22/2021] [Indexed: 12/15/2022]
Abstract
Sodium-glucose co-transporter 2 inhibitors (SGLT2i) are a new class of glucose-lowering agents which have changed the landscape of diabetes therapy, due to their remarkable cardiorenal protective properties. The attack of severe acute respiratory syndrome coronavirus 2 on the heart and kidneys shares similarities with diabetes; therefore, the notion that SGLT2i might have a role in the future management of Coronavirus Disease 2019 (COVID-19) is based on a solid pathophysiological hypothesis. SGLT2i have been proved to decrease the expression of proinflammatory cytokines, ameliorate oxidative stress and reduce sympathetic activity, thus resulting in downregulation of both systemic and adipose tissue inflammation. On the other hand, they have been linked to an increased risk of euglycemic diabetic ketoacidosis. Therefore, the efficacy and safety of SGLT2i in COVID-19 are still debatable and remain to be clarified by ongoing randomized trials, to assess whether the benefits of treatment with these drugs outweigh the potential risks.
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Affiliation(s)
- Theocharis Koufakis
- Division of Endocrinology and Metabolism and Diabetes Center, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 1 St. Kiriakidi Street, 54636, Thessaloníki, Greece
| | | | - Symeon Metallidis
- Infectious Diseases Division, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloníki, Greece
| | - Kalliopi Kotsa
- Division of Endocrinology and Metabolism and Diabetes Center, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 1 St. Kiriakidi Street, 54636, Thessaloníki, Greece.
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229
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Shi W, Zhang W, Zhang D, Ren G, Wang P, Gao L, Chen H, Ding C. Comparison of the effect of glucose-lowering agents on the risk of atrial fibrillation: A network meta-analysis. Heart Rhythm 2021; 18:1090-1096. [PMID: 33684547 DOI: 10.1016/j.hrthm.2021.03.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/28/2021] [Accepted: 03/01/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Diabetes is associated with the progression of atrial fibrillation (AF) and atrial flutter (AFL). However, whether glucose-lowering agents could reduce AF/AFL remains unclear. We hypothesized that different glucose-lowering agents exhibit different characteristic effects on the risk of AF/AFL. OBJECTIVES The goals of this study were to evaluate the effect of different glucose-lowering agents and identify the optimal treatment that can reduce AF/AFL events in patients with diabetes. METHODS We searched PubMed, Embase, and the Cochrane Library from their inception to September 30, 2020. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used in this network meta-analysis. The primary end point of our study was AF or AFL. Only studies that reported AF/AFL as clinical end points with a follow-up period of at least 12 months were included. The results from trials were presented as odds ratios (ORs) with 95% confidence intervals (CIs). The results were pooled using a Bayesian random-effects model. RESULTS Five eligible studies (9 glucose-lowering agents, including thiazolidinedione, metformin, sulfonylurea, insulin, dipeptidyl peptidase-4 inhibitor, glucagon-like peptide-1 receptor agonist [GLP-1RA], sodium-glucose cotransporter 2 inhibitor, alpha-glucosidase inhibitor, and non-sulfonylurea) consisting of 263,583 patients with type 2 diabetes mellitus were included. Based on the pooled results, GLP-1RA significantly reduced AF/AFL events compared with metformin (OR 0.17; 95% CI 0.04-0.61), sulfonylurea (OR 0.23; 95% CI 0.07-0.73), insulin (OR 0.20; 95% CI 0.07-0.86), and non-sulfonylurea (OR 0.18; 95% CI 0.04-0.66). CONCLUSION Compared with other glucose-lowering agents, GLP-1RA could reduce the risk of AF/AFL in patients with diabetes.
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Affiliation(s)
- Wence Shi
- Aerospace Center Hospital, Beijing, China; and Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Wenchang Zhang
- Aerospace Center Hospital, Beijing, China; and Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Da Zhang
- Aerospace Center Hospital, Beijing, China; and Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Ge Ren
- Aerospace Center Hospital, Beijing, China; and Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Pengfei Wang
- Aerospace Center Hospital, Beijing, China; and Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Lihua Gao
- Aerospace Center Hospital, Beijing, China; and Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Haonan Chen
- Aerospace Center Hospital, Beijing, China; and Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Chunhua Ding
- Aerospace Center Hospital, Beijing, China; and Peking University Aerospace School of Clinical Medicine, Beijing, China.
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Deshmukh A, Ghannam M, Liang J, Saeed M, Cunnane R, Ghanbari H, Latchamsetty R, Crawford T, Batul SA, Chung E, Bogun F, Jongnarangsin K, Pelosi F, Chugh A, Morady F, Oral E, Oral H. Effect of metformin on outcomes of catheter ablation for atrial fibrillation. J Cardiovasc Electrophysiol 2021; 32:1232-1239. [PMID: 33600005 DOI: 10.1111/jce.14954] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/31/2020] [Accepted: 01/27/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Diabetes mellitus (DM) is a risk factor for atrial fibrillation (AF). The effect of antidiabetic medications on AF or the outcomes of catheter ablation (CA) has not been well described. We sought to determine whether metformin treatment is associated with a lower risk of atrial arrhythmias after CA in patients with DM and AF. METHODS AND RESULTS A first CA was performed in 271 consecutive patients with DM and AF (age: 65 ± 9 years, women: 34%; and paroxysmal AF: 51%). At a median of 13 months after CA (interquartile range: 6-30), 100/182 patients (55%) treated with metformin remained in sinus rhythm without antiarrhythmic drug therapy, compared with 36/89 patients (40%) not receiving metformin (p = .03). There was a significant association between metformin therapy and freedom from recurrent atrial arrhythmias after CA in multivariable Cox hazards models (hazard ratio [HR]: 0.66; ±95% confidence interval [CI]: 0.44-0.98; p = .04) that adjusted for age, sex, body mass index, AF type (paroxysmal vs. nonparoxysmal), antiarrhythmic medication, obstructive sleep apnea, chronic kidney disease, coronary artery disease, left ventricular ejection fraction, and left atrial diameter. A Cox model that also incorporated other antidiabetic agents and fasting blood glucose demonstrated a similar reduction in the risk of recurrent atrial arrhythmias with metformin treatment (HR: 0.63; ±95% CI: 0.42-0.96; p = .03). CONCLUSIONS In patients with DM, treatment with metformin appears to be independently associated with a significant reduction in the risk of recurrent atrial arrhythmias after CA for AF. Whether this effect is due to glycemic control or pleiotropic effects on electroanatomical mechanisms of AF remains to be determined.
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Affiliation(s)
- Amrish Deshmukh
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael Ghannam
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jackson Liang
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Mohammed Saeed
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Ryan Cunnane
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Hamid Ghanbari
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Rakesh Latchamsetty
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Thomas Crawford
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Syeda A Batul
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Eugene Chung
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Frank Bogun
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Krit Jongnarangsin
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Frank Pelosi
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Aman Chugh
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Fred Morady
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Elif Oral
- Division of Metabolism, Endocrinology & Diabetes, University of Michigan, Ann Arbor, Michigan, USA
| | - Hakan Oral
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
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231
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Kumar N, Echouffo‐Tcheugui JB. Diabetes and atrial fibrillation in hospitalized patients in the United States. Clin Cardiol 2021; 44:340-348. [PMID: 33539595 PMCID: PMC7943913 DOI: 10.1002/clc.23533] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 12/06/2020] [Accepted: 12/07/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Data on the burden of atrial fibrillation (AF) associated with diabetes among hospitalized patients are scarce. We assessed the AF-related hospitalizations trends in patients with diabetes, and compared AF outcomes in patients with diabetes to those without diabetes. HYPOTHESIS AF-related health outcomes differ between patient with diabetes and without diabetes. METHODS Using the National Inpatient Sample (NIS) 2004-2014, we studied trends in AF hospitalization rate among diabetic patients, and compared in-hospital case fatality rate, length of stay (LOS), cost and utilization of rhythm control therapies, and 30-day readmission rate between patients with and without diabetes. Logistic or Cox regression models were used to assess the differences in AF outcomes by diabetes status. RESULTS Over the study period, there were 4 325 522 AF-related hospitalizations, of which 1 075 770 (24.9%) had a diagnosis of diabetes. There was a temporal increase in AF hospitalization rate among diabetic patients (10.4 to 14.4 per 1000 hospitalizations among patients with diabetes; +4.4% yearly change, p-trend < .0001). Among AF patients, those with diabetes had a lower in-hospital mortality (adjusted odds ratio [aOR]: 0.68; 95% CI: 0.65-0.72) and LOS (aOR: 0.95; 95% CI: 0.94-0.96), but no difference in costs (aOR: 0.95; 95% CI: 0.94-0.96) and a higher 30-day rate of readmissions compared with no diabetes (aHR 1.05; 95% CI: 1.01-1.08), compared to individuals without diabetes. CONCLUSION AF and diabetes coexist among hospitalized patients, with rising trends over the last decade. Diabetes is associated with lower rates in-hospital adverse AF outcomes, but a higher 30-day readmission risk.
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Affiliation(s)
- Nilay Kumar
- Division of Hospital Medicine, Department of MedicineUniversity of Wisconsin School of MedicineMadisonWisconsinUSA
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232
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Bonora BM, Raschi E, Avogaro A, Fadini GP. SGLT-2 inhibitors and atrial fibrillation in the Food and Drug Administration adverse event reporting system. Cardiovasc Diabetol 2021; 20:39. [PMID: 33573667 PMCID: PMC7879696 DOI: 10.1186/s12933-021-01243-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 02/08/2021] [Indexed: 02/07/2023] Open
Abstract
Background Sodium glucose cotransporter-2 inhibitors (SGLT2i) reduce the risk of heart failure and new data show they can prevent atrial fibrillation (AF). We examined the association between SGLT2i and AF in the Food and Drug Administration adverse event reporting system (FAERS). Methods We mined the FAERS from 2014q1 to 2019q4 to compare AF reporting for SGLT-2 i versus reports for other glucose lowering medications (ATC10 class). Several exclusions were sequentially applied for: concomitant medications; diabetes, cardiovascular or renal disease indication; reports for competing adverse events (genitourinary tract infections, ketoacidosis, Fournier’s gangrene, amputation). We provide descriptive statistics and calculated proportional reporting ratios (PRR). Results There were 62,098 adverse event reports for SGLT2i and 642,031 reports for other ATC10 drugs. The reporting of AF was significantly lower with SGLT2i than with other ATC10 drugs (4.8 versus 8.7/1000; p < 0.001) with a PRR of 0.55 (0.49–0.62). Results did not change substantially after excluding reports listing insulin (PRR 0.49) or anti-arrhythmics (PRR 0.59) as suspect or concomitant drugs, excluding reports with indications for cardiovascular disease (PRR 0.49) or renal disease (PRR 0.55), and those filed for competing adverse events (PRR 0.63). Results were always statistically significant whether the diabetes indication was specified. Negative and positive controls confirmed internal validity of the database. Conclusions In a large pharmacovigilance database, AF was robustly and consistently reported more frequently for diabetes medications other than SGLT2i. This finding complements available evidence from trials supporting a protective role of SGLT2i against the occurrence of AF.
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Affiliation(s)
| | - Emanuel Raschi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Gian Paolo Fadini
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padova, Italy.
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Ostropolets A, Elias PA, Reyes MV, Wan EY, Pajvani UB, Hripcsak G, Morrow JP. Metformin Is Associated With a Lower Risk of Atrial Fibrillation and Ventricular Arrhythmias Compared With Sulfonylureas: An Observational Study. Circ Arrhythm Electrophysiol 2021; 14:e009115. [PMID: 33554609 DOI: 10.1161/circep.120.009115] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
[Figure: see text].
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MESH Headings
- Administration, Oral
- Atrial Fibrillation/diagnosis
- Atrial Fibrillation/etiology
- Atrial Fibrillation/physiopathology
- Atrial Fibrillation/prevention & control
- Databases, Factual
- Diabetes Mellitus, Type 2/complications
- Diabetes Mellitus, Type 2/diagnosis
- Diabetes Mellitus, Type 2/drug therapy
- Drug Therapy, Combination
- Humans
- Hypoglycemic Agents/administration & dosage
- Metformin/administration & dosage
- Retrospective Studies
- Risk Assessment
- Risk Factors
- Sulfonylurea Compounds/administration & dosage
- Tachycardia, Ventricular/diagnosis
- Tachycardia, Ventricular/etiology
- Tachycardia, Ventricular/physiopathology
- Tachycardia, Ventricular/prevention & control
- Time Factors
- Treatment Outcome
- Ventricular Fibrillation/diagnosis
- Ventricular Fibrillation/etiology
- Ventricular Fibrillation/physiopathology
- Ventricular Fibrillation/prevention & control
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Affiliation(s)
- Anna Ostropolets
- Department of Biomedical Informatics (A.O., G.H.), College of Physicians and Surgeons of Columbia University, NY
| | - Pierre A Elias
- Department of Medicine (P.A.E., M.V.R., E.Y.W., U.B.P., G.H., J.P.M.), College of Physicians and Surgeons of Columbia University, NY
| | - Michael V Reyes
- Department of Medicine (P.A.E., M.V.R., E.Y.W., U.B.P., G.H., J.P.M.), College of Physicians and Surgeons of Columbia University, NY
| | - Elain Y Wan
- Department of Medicine (P.A.E., M.V.R., E.Y.W., U.B.P., G.H., J.P.M.), College of Physicians and Surgeons of Columbia University, NY
| | - Utpal B Pajvani
- Department of Medicine (P.A.E., M.V.R., E.Y.W., U.B.P., G.H., J.P.M.), College of Physicians and Surgeons of Columbia University, NY
| | - George Hripcsak
- Department of Biomedical Informatics (A.O., G.H.), College of Physicians and Surgeons of Columbia University, NY
- Department of Medicine (P.A.E., M.V.R., E.Y.W., U.B.P., G.H., J.P.M.), College of Physicians and Surgeons of Columbia University, NY
| | - John P Morrow
- Department of Medicine (P.A.E., M.V.R., E.Y.W., U.B.P., G.H., J.P.M.), College of Physicians and Surgeons of Columbia University, NY
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Lee TW, Lee TI, Lin YK, Chen YC, Kao YH, Chen YJ. Effect of antidiabetic drugs on the risk of atrial fibrillation: mechanistic insights from clinical evidence and translational studies. Cell Mol Life Sci 2021; 78:923-934. [PMID: 32965513 PMCID: PMC11072414 DOI: 10.1007/s00018-020-03648-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 08/18/2020] [Accepted: 09/12/2020] [Indexed: 12/13/2022]
Abstract
Diabetes mellitus (DM) is an independent risk factor for atrial fibrillation (AF), which is the most common sustained arrhythmia and is associated with substantial morbidity and mortality. Advanced glycation end product and its receptor activation, cardiac energy dysmetabolism, structural and electrical remodeling, and autonomic dysfunction are implicated in AF pathophysiology in diabetic hearts. Antidiabetic drugs have been demonstrated to possess therapeutic potential for AF. However, clinical investigations of AF in patients with DM have been scant and inconclusive. This article provides a comprehensive review of research findings on the association between DM and AF and critically analyzes the effect of different pharmacological classes of antidiabetic drugs on AF.
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Affiliation(s)
- Ting-Wei Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Ting-I Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of General Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yung-Kuo Lin
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yao-Chang Chen
- Department of Biomedical Engineering, National Defense Medical Center, Taipei, Taiwan
| | - Yu-Hsun Kao
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Medical Education and Research, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yi-Jen Chen
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
- Cardiovascular Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan.
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235
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Atrial Dysfunction in Patients With Heart Failure With Preserved Ejection Fraction and Atrial Fibrillation. J Am Coll Cardiol 2021; 76:1051-1064. [PMID: 32854840 DOI: 10.1016/j.jacc.2020.07.009] [Citation(s) in RCA: 215] [Impact Index Per Article: 71.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/30/2020] [Accepted: 07/02/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Paroxysmal and permanent atrial fibrillation (AF) are common in heart failure with preserved ejection fraction (HFpEF). OBJECTIVES This study sought to determine the implications of left atrial (LA) myopathy and dysrhythmia across the spectrum of AF burden in HFpEF. METHODS Consecutive patients with HFpEF (n = 285) and control subjects (n = 146) underwent invasive exercise testing and echocardiographic assessment of cardiac structure, function, and pericardial restraint. RESULTS Patients with HFpEF were categorized into stages of AF progression: 181 (65%) had no history of AF, 49 (18%) had paroxysmal AF, and 48 (17%) had permanent AF. Patients with permanent AF were more congested with greater pulmonary vascular disease and lower cardiac output. LA volumes increased, while LA compliance, LA reservoir strain, and right ventricular function decreased with increasing AF burden. The presence of permanent AF was characterized by a distinct pathophysiology, with greater total heart volume caused by atrial dilatation, leading to elevated filling pressures through heightened pericardial restraint. Survival decreased with increasing AF burden. Ten-year progression to permanent AF was common, particularly in paroxysmal AF (52%), and the likelihood of AF progression increased with higher AF stage, poorer LA compliance, and lower LA strain. CONCLUSIONS LA compliance and mechanics progressively decline with increasing AF burden in HFpEF, increasing risk for new onset AF and progressive AF. These changes promote development of a unique phenotype of HFpEF characterized by heightened ventricular interaction, right heart failure, and worsening pulmonary vascular disease. Further study is required to identify therapeutic interventions targeting LA myopathy to improve outcomes in HFpEF.
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236
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Bisson A, Bodin A, Fauchier G, Herbert J, Angoulvant D, Ducluzeau PH, Lip GYH, Fauchier L. Sex, age, type of diabetes and incidence of atrial fibrillation in patients with diabetes mellitus: a nationwide analysis. Cardiovasc Diabetol 2021; 20:24. [PMID: 33482830 PMCID: PMC7821402 DOI: 10.1186/s12933-021-01216-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 01/09/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND There remain uncertainties regarding diabetes mellitus and the incidence of atrial fibrillation (AF), in relation to type of diabetes, and the interactions with sex and age. We investigated whether diabetes confers higher relative rates of AF in women compared to men, and whether these sex-differences depend on type of diabetes and age. METHODS All patients aged ≥ 18 seen in French hospitals in 2013 with at least 5 years of follow-up without a history of AF were identified and categorized by their diabetes status. We calculated overall and age-dependent incidence rates, hazard ratios, and women-to-men ratios for incidence of AF in patients with type 1 and type 2 diabetes (compared to no diabetes). RESULTS In 2,921,407 patients with no history of AF (55% women), 45,389 had prevalent type 1 diabetes and 345,499 had prevalent type 2 diabetes. The incidence rates (IRs) of AF were higher in type 1 or type 2 diabetic patients than in non-diabetics, and increased with advancing age. Among individuals with diabetes, the absolute rate of AF was higher in men than in women. When comparing individuals with and without diabetes, women had a higher adjusted hazard ratio (HR) of AF than men: adjusted HR 1.32 (95% confidence interval 1.27-1.37) in women vs. 1.12(1.08-1.16) in men for type 1 diabetes, adjusted HR 1.17(1.16-1.19) in women vs. 1.10(1.09-1.12) in men for type 2 diabetes. CONCLUSION Although men have higher absolute rates for incidence of AF, the relative rates of incident AF associated with diabetes are higher in women than in men for both type 1 and type 2 diabetes.
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Affiliation(s)
- Arnaud Bisson
- Service de Cardiologie, Centre Hospitalier Universitaire Et Faculté de Médecine, Université de Tours, Hôpital Trousseau, 37044, Tours, France
| | - Alexandre Bodin
- Service de Cardiologie, Centre Hospitalier Universitaire Et Faculté de Médecine, Université de Tours, Hôpital Trousseau, 37044, Tours, France
| | - Grégoire Fauchier
- Service de Médecine Interne, Unité D'Endocrinologie Diabétologie Et Nutrition, Centre Hospitalier Universitaire Et Faculté de Médecine, Université de Tours, Tours, France
| | - Julien Herbert
- Service de Cardiologie, Centre Hospitalier Universitaire Et Faculté de Médecine, Université de Tours, Hôpital Trousseau, 37044, Tours, France
- Service D'information Médicale, D'épidémiologie Et D'économie de La Santé, Centre Hospitalier Universitaire Et Faculté de Médecine, Université de Tours, EA7505, Tours, France
| | - Denis Angoulvant
- Service de Cardiologie, Centre Hospitalier Universitaire Et Faculté de Médecine, Université de Tours, Hôpital Trousseau, 37044, Tours, France
- EA4245 T2i, Université de Tours, Tours, France
| | - Pierre Henri Ducluzeau
- Service de Médecine Interne, Unité D'Endocrinologie Diabétologie Et Nutrition, Centre Hospitalier Universitaire Et Faculté de Médecine, Université de Tours, Tours, France
- INRAE (Institut National de Recherche Pour L'Agriculture, l'Alimentation Et L'Environnement), Unité Mixte de Recherche Physiologie de La Reproduction Et Des Comportements, 37380, Nouzilly, France
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Et Faculté de Médecine, Université de Tours, Hôpital Trousseau, 37044, Tours, France.
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237
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Mesubi OO, Rokita AG, Abrol N, Wu Y, Chen B, Wang Q, Granger JM, Tucker-Bartley A, Luczak ED, Murphy KR, Umapathi P, Banerjee PS, Boronina TN, Cole RN, Maier LS, Wehrens XH, Pomerantz JL, Song LS, Ahima RS, Hart GW, Zachara NE, Anderson ME. Oxidized CaMKII and O-GlcNAcylation cause increased atrial fibrillation in diabetic mice by distinct mechanisms. J Clin Invest 2021; 131:95747. [PMID: 33151911 PMCID: PMC7810480 DOI: 10.1172/jci95747] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 11/03/2020] [Indexed: 12/21/2022] Open
Abstract
Diabetes mellitus (DM) and atrial fibrillation (AF) are major unsolved public health problems, and diabetes is an independent risk factor for AF. However, the mechanism(s) underlying this clinical association is unknown. ROS and protein O-GlcNAcylation (OGN) are increased in diabetic hearts, and calmodulin kinase II (CaMKII) is a proarrhythmic signal that may be activated by ROS (oxidized CaMKII, ox-CaMKII) and OGN (OGN-CaMKII). We induced type 1 (T1D) and type 2 DM (T2D) in a portfolio of genetic mouse models capable of dissecting the role of ROS and OGN at CaMKII and global OGN in diabetic AF. Here, we showed that T1D and T2D significantly increased AF, and this increase required CaMKII and OGN. T1D and T2D both required ox-CaMKII to increase AF; however, we did not detect OGN-CaMKII or a role for OGN-CaMKII in diabetic AF. Collectively, our data affirm CaMKII as a critical proarrhythmic signal in diabetic AF and suggest ROS primarily promotes AF by ox-CaMKII, while OGN promotes AF by a CaMKII-independent mechanism(s). These results provide insights into the mechanisms for increased AF in DM and suggest potential benefits for future CaMKII and OGN targeted therapies.
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Affiliation(s)
- Olurotimi O. Mesubi
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Adam G. Rokita
- Division of Cardiovascular Medicine and Cardiovascular Research Center, Carver College of Medicine, Iowa City, Iowa, USA
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Neha Abrol
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yuejin Wu
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Biyi Chen
- Division of Cardiovascular Medicine and Cardiovascular Research Center, Carver College of Medicine, Iowa City, Iowa, USA
| | - Qinchuan Wang
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jonathan M. Granger
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anthony Tucker-Bartley
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth D. Luczak
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kevin R. Murphy
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Priya Umapathi
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Partha S. Banerjee
- Department of Biological Chemistry, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tatiana N. Boronina
- Department of Biological Chemistry, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Robert N. Cole
- Department of Biological Chemistry, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lars S. Maier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Xander H. Wehrens
- Department of Molecular Physiology and Biophysics, Department of Medicine (Cardiology), Department of Pediatrics, and Center for Space Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Joel L. Pomerantz
- Department of Biological Chemistry, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Institute for Cell Engineering
| | - Long-Sheng Song
- Division of Cardiovascular Medicine and Cardiovascular Research Center, Carver College of Medicine, Iowa City, Iowa, USA
| | - Rexford S. Ahima
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine
| | - Gerald W. Hart
- Department of Biological Chemistry, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Natasha E. Zachara
- Department of Biological Chemistry, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mark E. Anderson
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, and
- Department of Physiology and Program in Cellular and Molecular Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Higa S, Maesato A, Ishigaki S, Suenari K, Chen YJ, Chen SA. Diabetes and Endocrine Disorders (Hyperthyroidism/Hypothyroidism) as Risk Factors for Atrial Fibrillation. Card Electrophysiol Clin 2021; 13:63-75. [PMID: 33516408 DOI: 10.1016/j.ccep.2020.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Risk factors including cardiometabolic and endocrine disorders have a significant impact on atrial remodeling causing atrial fibrillation (AF). Diabetes mellitus and hyperthyroidism are strong independent risk factors for AF and worsen outcomes of rhythm control strategies. An early diagnosis and intervention for these risk factors combined with rhythm control strategies may improve the overall cardiovascular mortality and morbidity. This review summarizes the current state of knowledge about the AF risk factors diabetes mellitus and thyroid disease, and discusses the impact of the modification of these risk factors on primary and secondary prevention of AF.
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Affiliation(s)
- Satoshi Higa
- Cardiac Electrophysiology and Pacing Laboratory, Division of Cardiovascular Medicine, Makiminato Central Hospital, 1199 Makiminato, Urasoe City, Okinawa 901-2131, Japan.
| | - Akira Maesato
- Cardiac Electrophysiology and Pacing Laboratory, Division of Cardiovascular Medicine, Makiminato Central Hospital, 1199 Makiminato, Urasoe City, Okinawa 901-2131, Japan
| | - Sugako Ishigaki
- Cardiac Electrophysiology and Pacing Laboratory, Division of Cardiovascular Medicine, Makiminato Central Hospital, 1199 Makiminato, Urasoe City, Okinawa 901-2131, Japan
| | - Kazuyoshi Suenari
- Department of Cardiology, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-ku, Hiroshima City, Hiroshima 703-8518, Japan
| | - Yi-Jen Chen
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, 111 Hsin-Lung Road, Section 3, Taipei 116, Taiwan
| | - Shih-Ann Chen
- Division of Cardiology and Cardiovascular Research Center, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan
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239
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Bode D, Semmler L, Wakula P, Hegemann N, Primessnig U, Beindorff N, Powell D, Dahmen R, Ruetten H, Oeing C, Alogna A, Messroghli D, Pieske BM, Heinzel FR, Hohendanner F. Dual SGLT-1 and SGLT-2 inhibition improves left atrial dysfunction in HFpEF. Cardiovasc Diabetol 2021; 20:7. [PMID: 33413413 PMCID: PMC7792219 DOI: 10.1186/s12933-020-01208-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/27/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Sodium-glucose linked transporter type 2 (SGLT-2) inhibition has been shown to reduce cardiovascular mortality in heart failure independently of glycemic control and prevents the onset of atrial arrhythmias, a common co-morbidity in heart failure with preserved ejection fraction (HFpEF). The mechanism behind these effects is not fully understood, and it remains unclear if they could be further enhanced by additional SGLT-1 inhibition. We investigated the effects of chronic treatment with the dual SGLT-1&2 inhibitor sotagliflozin on left atrial (LA) remodeling and cellular arrhythmogenesis (i.e. atrial cardiomyopathy) in a metabolic syndrome-related rat model of HFpEF. METHODS 17 week-old ZSF-1 obese rats, a metabolic syndrome-related model of HFpEF, and wild type rats (Wistar Kyoto), were fed 30 mg/kg/d sotagliflozin for 6 weeks. At 23 weeks, LA were imaged in-vivo by echocardiography. In-vitro, Ca2+ transients (CaT; electrically stimulated, caffeine-induced) and spontaneous Ca2+ release were recorded by ratiometric microscopy using Ca2+-sensitive fluorescent dyes (Fura-2) during various experimental protocols. Mitochondrial structure (dye: Mitotracker), Ca2+ buffer capacity (dye: Rhod-2), mitochondrial depolarization (dye: TMRE) and production of reactive oxygen species (dye: H2DCF) were visualized by confocal microscopy. Statistical analysis was performed with 2-way analysis of variance followed by post-hoc Bonferroni and student's t-test, as applicable. RESULTS Sotagliflozin ameliorated LA enlargement in HFpEF in-vivo. In-vitro, LA cardiomyocytes in HFpEF showed an increased incidence and amplitude of arrhythmic spontaneous Ca2+ release events (SCaEs). Sotagliflozin significantly reduced the magnitude of SCaEs, while their frequency was unaffected. Sotagliflozin lowered diastolic [Ca2+] of CaT at baseline and in response to glucose influx, possibly related to a ~ 50% increase of sodium sodium-calcium exchanger (NCX) forward-mode activity. Sotagliflozin prevented mitochondrial swelling and enhanced mitochondrial Ca2+ buffer capacity in HFpEF. Sotagliflozin improved mitochondrial fission and reactive oxygen species (ROS) production during glucose starvation and averted Ca2+ accumulation upon glycolytic inhibition. CONCLUSION The SGLT-1&2 inhibitor sotagliflozin ameliorated LA remodeling in metabolic HFpEF. It also improved distinct features of Ca2+-mediated cellular arrhythmogenesis in-vitro (i.e. magnitude of SCaEs, mitochondrial Ca2+ buffer capacity, diastolic Ca2+ accumulation, NCX activity). The safety and efficacy of combined SGLT-1&2 inhibition for the treatment and/or prevention of atrial cardiomyopathy associated arrhythmias should be further evaluated in clinical trials.
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MESH Headings
- Animals
- Arrhythmias, Cardiac/etiology
- Arrhythmias, Cardiac/metabolism
- Arrhythmias, Cardiac/physiopathology
- Arrhythmias, Cardiac/prevention & control
- Atrial Function, Left/drug effects
- Atrial Remodeling/drug effects
- Calcium Signaling/drug effects
- Disease Models, Animal
- Glycosides/pharmacology
- Heart Atria/drug effects
- Heart Atria/metabolism
- Heart Atria/physiopathology
- Heart Failure/drug therapy
- Heart Failure/etiology
- Heart Failure/metabolism
- Heart Failure/physiopathology
- Metabolic Syndrome/complications
- Mitochondria, Heart/drug effects
- Mitochondria, Heart/metabolism
- Mitochondria, Heart/pathology
- Mitochondrial Dynamics/drug effects
- Mitochondrial Swelling/drug effects
- Rats, Inbred WKY
- Rats, Zucker
- Reactive Oxygen Species/metabolism
- Sodium-Calcium Exchanger/metabolism
- Sodium-Glucose Transporter 1/antagonists & inhibitors
- Sodium-Glucose Transporter 1/metabolism
- Sodium-Glucose Transporter 2/metabolism
- Sodium-Glucose Transporter 2 Inhibitors/pharmacology
- Rats
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Affiliation(s)
- David Bode
- Department of Internal Medicine and Cardiology, Charité University Medicine, Campus Virchow-Klinikum, Augustenburgerplatz 1, 13353, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Lukas Semmler
- Department of Internal Medicine and Cardiology, Charité University Medicine, Campus Virchow-Klinikum, Augustenburgerplatz 1, 13353, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Paulina Wakula
- Department of Internal Medicine and Cardiology, Charité University Medicine, Campus Virchow-Klinikum, Augustenburgerplatz 1, 13353, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Niklas Hegemann
- Department of Internal Medicine and Cardiology, Charité University Medicine, Campus Virchow-Klinikum, Augustenburgerplatz 1, 13353, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Uwe Primessnig
- Department of Internal Medicine and Cardiology, Charité University Medicine, Campus Virchow-Klinikum, Augustenburgerplatz 1, 13353, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Nicola Beindorff
- Berlin Experimental Radionuclide Imaging Center (BERIC), Charité-Universitaetsmedizin Berlin, Berlin, Germany
| | - David Powell
- Lexicon Pharmaceuticals, Metabolism Research, Houston, TX, USA
| | - Raphael Dahmen
- Sanofi-Aventis Deutschland GmbH, Research & Development, 65926, Frankfurt am Main, Germany
| | - Hartmut Ruetten
- Sanofi-Aventis Deutschland GmbH, Research & Development, 65926, Frankfurt am Main, Germany
| | - Christian Oeing
- Department of Internal Medicine and Cardiology, Charité University Medicine, Campus Virchow-Klinikum, Augustenburgerplatz 1, 13353, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Alessio Alogna
- Department of Internal Medicine and Cardiology, Charité University Medicine, Campus Virchow-Klinikum, Augustenburgerplatz 1, 13353, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Daniel Messroghli
- Department of Internal Medicine and Cardiology, Charité University Medicine, Campus Virchow-Klinikum, Augustenburgerplatz 1, 13353, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Department of Internal Medicine and Cardiology, German Heart Center Berlin, 13353, Berlin, Germany
| | - Burkert M Pieske
- Department of Internal Medicine and Cardiology, Charité University Medicine, Campus Virchow-Klinikum, Augustenburgerplatz 1, 13353, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Department of Internal Medicine and Cardiology, German Heart Center Berlin, 13353, Berlin, Germany
| | - Frank R Heinzel
- Department of Internal Medicine and Cardiology, Charité University Medicine, Campus Virchow-Klinikum, Augustenburgerplatz 1, 13353, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Felix Hohendanner
- Department of Internal Medicine and Cardiology, Charité University Medicine, Campus Virchow-Klinikum, Augustenburgerplatz 1, 13353, Berlin, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.
- Berlin Institute of Health (BIH), Berlin, Germany.
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240
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Association of type 2 diabetes mellitus with the development of new-onset atrial fibrillation in patients with non-ischemic dilated cardiomyopathy: impact of SGLT2 inhibitors. Int J Cardiovasc Imaging 2021; 37:1333-1341. [PMID: 33392879 DOI: 10.1007/s10554-020-02122-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 11/24/2020] [Indexed: 01/06/2023]
Abstract
The aim of this study was to investigate the association of type 2 diabetes mellitus (T2DM) with the development of new-onset atrial fibrillation (AF) for non-ischemic dilated cardiomyopathy (DCM) patients. We also tested the hypothesis that sodium glucose cotransporter type 2 (SGLT2) inhibitors reduce the risk of development of new-onset AF for non-ischemic DCM patients. We retrospectively studied 210 patients with non-ischemic DCM and sinus rhythm, mean age of 59.0 ± 16.7 years and left ventricular ejection fraction of 31.0 ± 8.2% (all < 45%). T2DM was identified in 60 patients (28.6%), and the remaining 150 patients (71.4%) were classified as non-T2DM patients. New-onset AF occurred in 21 patients (10.0%) over a median follow-up of 6.1 years. Kaplan-Meier curve analysis showed that non-ischemic DCM patients without T2DM experienced fewer occurrences of the development of new-onset AF compared with those with T2DM (log-rank p = 0.0003). Furthermore, global longitudinal strain in patients who showed development of new-onset AF was significantly lower than that in those whose sinus rhythm was preserved (6.4 ± 1.4% vs. 7.7 ± 2.2%, p = 0.01). Of the 60 non-ischemic DCM patients with T2DM, those treated with SGLT2 inhibitors experienced fewer occurrences of the development of new-onset AF than did those not treated with SGLT2 inhibitors (log-rank p = 0.040). T2DM is associated with the development of new-onset AF in non-ischemic DCM patients, and treatment with SGLT2 inhibitors can significantly reduce the development of new-onset AF. Our findings may thus offer a new insight into the management of non-ischemic DCM patients with T2DM.
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241
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Okunrintemi V, Mishriky BM, Powell JR, Cummings DM. Sodium-glucose co-transporter-2 inhibitors and atrial fibrillation in the cardiovascular and renal outcome trials. Diabetes Obes Metab 2021; 23:276-280. [PMID: 33001548 DOI: 10.1111/dom.14211] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 09/26/2020] [Accepted: 09/26/2020] [Indexed: 12/16/2022]
Abstract
Dapagliflozin is a sodium-glucose co-transporter-2 (SGLT2) inhibitor that has recently been shown to reduce the incidence of reported episodes of atrial fibrillation (AF)/atrial flutter in the DECLARE-TIMI 58 trial. This raises the question regarding whether SGLT2 inhibitors can reduce the incidence of AF in a high-risk population. We searched for trials comparing SGLT2 inhibitors to placebo in high-risk individuals with or without diabetes (ie, cardiovascular and renal outcome trials) and that reported the incidence of AF as a serious adverse event. The EMPA-REG OUTCOME trial, CANVAS, CANVAS-R, the DECLARE-TIMI 58 trial, CREDENCE, DAPA-HF, VERTIS-CV and DAPA-CKD were included. The incidence of AF, reported as a serious adverse event, was 0.9% in individuals who received an SGLT2 inhibitor compared to 1.1% in those who received placebo. Pooled results showed a significantly lower incidence of AF in individuals with and without diabetes (relative risk 0.79, 95% confidence interval 0.67,0.93). This review suggests that there is a significantly lower risk of incident AF for individuals on SGLT2 inhibitors versus placebo. While there was a statistically significant lower incidence of AF, reported as a serious adverse event, more research is needed to evaluate its clinical significance.
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Affiliation(s)
- Victor Okunrintemi
- Department of Internal Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Basem M Mishriky
- Department of Internal Medicine, East Carolina University, Greenville, North Carolina, USA
| | - James R Powell
- Department of Internal Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Doyle M Cummings
- Department of Family Medicine, East Carolina University, Greenville, North Carolina, USA
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Kohsaka S, Takeda M, Bodegård J, Thuresson M, Kosiborod M, Yajima T, Wittbrodt E, Fenici P. Sodium-glucose cotransporter 2 inhibitors compared with other glucose-lowering drugs in Japan: Subanalyses of the CVD-REAL 2 Study. J Diabetes Investig 2021; 12:67-73. [PMID: 32530554 PMCID: PMC7779275 DOI: 10.1111/jdi.13321] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 05/21/2020] [Accepted: 06/04/2020] [Indexed: 12/17/2022] Open
Abstract
There are limited data on cardiovascular efficacy and safety of type 2 diabetes therapies in Japan, where treatments are characterized by lower metformin use and higher dipeptidyl peptidase-4 inhibitor (DPP4i) use versus other countries. We investigated the cardiovascular outcomes in Japanese patients with type 2 diabetes initiating sodium-glucose cotransporter 2 inhibitors (SGLT2i) matched 1:1 to patients initiating other glucose-lowering drugs (33,890 patients/group) or DPP4i (9,876 patients/group). SGLT2i initiation was associated with lower risks (hazard ratio of in-hospital death [death] 0.56, 95% confidence interval [CI] 0.47-0.67; hospitalization for heart failure 0.75, 95% CI 0.64-0.89; composite of hospitalization for heart failure or death 0.65, 95% CI 0.58-0.74 and stroke 0.66, 95% CI 0.52-0.84 versus other glucose-lowering drugs and lower risks of death 0.52, 95% CI 0.36-0.73) and composite of hospitalization for heart failure or death (0.65, 95% CI 0.51-0.83) versus DPP4i. In conclusion, SGLT2i initiators had lower risks of cardiovascular events versus other glucose-lowering drug initiators and, uniquely, versus DPP4i initiators in Japanese real-world practice.
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Affiliation(s)
- Shun Kohsaka
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | | | | | | | - Mikhail Kosiborod
- Department of Cardiovascular DiseaseSaint Luke’s Mid America Heart Institute and University of Missouri‐Kansas CityKansas CityMissouriUSA
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Kreutz R, Camm AJ, Rossing P. Concomitant diabetes with atrial fibrillation and anticoagulation management considerations. Eur Heart J Suppl 2020; 22:O78-O86. [PMID: 33380946 PMCID: PMC7753879 DOI: 10.1093/eurheartj/suaa182] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Atrial fibrillation is a highly prevalent cardiac arrhythmia. It is associated with numerous co mobilities. Approximately 30% of diabetic patients have atrial fibrillation and 15% of atrial fibrillation regulation patients have diabetes mellitus. Diabetes increases the likelihood of the development of atrial fibrillation and contributes to the high risk of thromboembolism seen in patients with both diabetes and atrial fibrillation. Chronic kidney disease is often a consequence of diabetes and presents an additional challenge to the management of patients with both atrial fibrillation and diabetes. All non-vitamin K oral anticoagulants are partially eliminated via the kidney and must be carefully prescribed according to strict dosing schedules to avoid anticoagulation overdose. However, NOACs have the advantage of being associated with less progressive impairment of renal function compared with vitamin K antagonist therapy in both diabetics and non-diabetics. Otherwise, diabetic patients benefit from NOAC therapy as opposed to vitamin K antagonists to a similar extent as patients without diabetes. This review deals with anticoagulation treatment in patients with fibrillation and diabetes mellitus, often complicated by progressive renal impairment.
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Affiliation(s)
- Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Institut für Klinische Pharmakologie und Toxikologie, Berlin, Germany
| | - A John Camm
- Cardiac Clinical Academic Group, St George’s University of London, Cranmer Terrace, London SW19 0RE, UK
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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McGuire DK, Zinman B, Inzucchi SE, Wanner C, Fitchett D, Anker SD, Pocock S, Kaspers S, George JT, von Eynatten M, Johansen OE, Jamal W, Mattheus M, Elsasser U, Hantel S, Lund SS. Effects of empagliflozin on first and recurrent clinical events in patients with type 2 diabetes and atherosclerotic cardiovascular disease: a secondary analysis of the EMPA-REG OUTCOME trial. Lancet Diabetes Endocrinol 2020; 8:949-959. [PMID: 33217335 DOI: 10.1016/s2213-8587(20)30344-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 09/22/2020] [Accepted: 09/22/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Patients with type 2 diabetes and atherosclerotic cardiovascular disease are at high clinical risk. We assessed the effect of the sodium-glucose co-transporter-2 inhibitor, empagliflozin, on total cardiovascular events and admissions to hospital in the EMPA-REG OUTCOME trial. METHODS The EMPA-REG OUTCOME trial was a randomised, double-blind, non-inferiority trial of patients (aged ≥18 years) with type 2 diabetes and atherosclerotic cardiovascular disease done between August, 2010, and April, 2015. Participants were randomly assigned (1:1:1) to empagliflozin 10 mg or 25 mg, or placebo. The primary outcome was major adverse cardiovascular events: a composite of cardiovascular death, non-fatal stroke, or non-fatal myocardial infarction. As prespecified, the effects of pooled empagliflozin versus placebo were assessed on total (first plus recurrent) events of major adverse cardiovascular events, fatal or non-fatal myocardial infarction, fatal or non-fatal stroke, and admission to hospital for heart failure. We also did post-hoc analyses on additional cardiovascular and admission to hospital outcomes. We used statistical models that preserve randomisation and account for correlation of recurrent events, including negative binomial regression, as prespecified for the primary analyses. The EMPA-REG OUTCOME trial is registered with ClinicalTrials.gov, NCT01131676, and is closed to accrual. FINDINGS In the EMPA-REG OUTCOME trial, 7020 patients were randomly assigned and treated with empagliflozin 10 mg (n=2345), empagliflozin 25 mg (n=2342), or placebo (n=2333) and followed up for a median of 3·2 years (IQR 2·2 to 3·6) in the pooled empagliflozin group and 3·1 years (2·2 to 3·5) in the placebo group. Analysing total (first plus recurrent) events, empagliflozin versus placebo reduced the risk of major adverse cardiovascular events (rate ratio [RR] 0·78 [95% CI 0·67 to 0·91]; p=0·0020; 12·88 [95% CI 3·74 to 22·02] events prevented per 1000 patient-years); fatal or non-fatal myocardial infarction (0·79 [0·62 to 0·998]; p=0·049; 4·97 [-0·68 to 10·61] events prevented per 1000 patient-years); the composite of fatal or non-fatal myocardial infarction, or coronary revascularisation (0·80 [0·67 to 0·95]; p=0·012; 11·65 [1·25 to 22·05] events prevented per 1000 patient-years); admission to hospital for heart failure (0·58 [0·42 to 0·81]; p=0·0012; 9·67 [3·07 to 16·28] events prevented per 1000 patient-years); and all-cause admission to hospital (0·83 [0·76 to 0·91]; p<0·0001; 50·41 [26·20 to 74·63] events prevented per 1000 patient-years). For outcomes significantly reduced with empagliflozin, risk reductions were numerically larger for total events than for first events. Total fatal or non-fatal stroke was not significantly different between treatment groups (RR 1·10 [95% CI 0·82 to 1·49]; p=0·52). INTERPRETATION Empagliflozin reduced the total burden of cardiovascular complications and all-cause admission to hospital in patients with type 2 diabetes and atherosclerotic cardiovascular disease. FUNDING The Boehringer Ingelheim and Lilly Alliance.
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Affiliation(s)
- Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX, USA.
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, CT, USA
| | | | - David Fitchett
- St Michael's Hospital, Division of Cardiology, University of Toronto, Toronto, ON, Canada
| | - Stefan D Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | | | - Waheed Jamal
- Boehringer Ingelheim International, Ingelheim, Germany
| | | | | | | | - Søren S Lund
- Boehringer Ingelheim International, Ingelheim, Germany
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245
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Ling AWC, Chan CC, Chen SW, Kao YW, Huang CY, Chan YH, Chu PH. The risk of new-onset atrial fibrillation in patients with type 2 diabetes mellitus treated with sodium glucose cotransporter 2 inhibitors versus dipeptidyl peptidase-4 inhibitors. Cardiovasc Diabetol 2020; 19:188. [PMID: 33158436 PMCID: PMC7648323 DOI: 10.1186/s12933-020-01162-w] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 10/27/2020] [Indexed: 12/17/2022] Open
Abstract
Background Sodium glucose cotransporter 2 inhibitor (SGLT2i) reduces the risk of hard cardiovascular endpoints in type 2 diabetes mellitus (T2DM) patients with/without established cardiovascular diseases. Whether SGLT2i is associated with a lower risk of new-onset atrial fibrillation (AF) in T2DM patients is unclear. We aimed to evaluate the risk of new-onset AF associated with the use of SGLT2i compared to dipeptidyl peptidase-4 inhibitor (DPP4i) among a longitudinal cohort of diabetic patients. Methods We used medical data from a multi-center healthcare provider in Taiwan, which included a total of 15,606 and 12,383 patients treated with SGLT2i and DPP4i, respectively, from June 1, 2016 to December 31, 2018. We used propensity-score weighting to balance covariates across study groups. Patients were followed up from the drug index date until the occurrence of new-onset AF, discontinuation of the index drug, or the end of the study period, whichever occurred first. Results Overall, 55%, 45%, and 0% of the patients were treated with empagliflozin, dapagliflozin, and canagliflozin, respectively. Most patients in the DPP4i group were prescribed with linagliptin (51%), followed by sitagliptin (24%), saxagliptin (13%), vildagliptin (8%) and alogliptin (5%). The use of SGLT2i was associated with a lower risk of new-onset AF compared with DPP4i after propensity-score weighting [hazard ratio: 0.61; 95% confidential interval: 0.50–0.73; P < 0.001]. Subgroup analysis revealed that the use of SGLT2i was associated with a lower risk of new-onset AF compared with DPP4i across several subgroups including old age, female in gender, the presence of cardiovascular disease, hemoglobin A1c \documentclass[12pt]{minimal}
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\begin{document}$$\ge$$\end{document}≥ 8%, and chronic kidney disease. The advantage of SGLT2i over DPP4i persisted with different SGLT2i (dapagliflozin or empagliflozin) and either low- or standard-dose SGLT2i. Conclusions SGLT2i was associated with a lower risk of new-onset AF compared with DPP4i among T2DM patients in real-world practice.
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Affiliation(s)
- Ann Wan-Chin Ling
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan
| | - Cze-Ci Chan
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan
| | - Shao-Wei Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan.,Center for Big Data Analytics and Statistics, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Yi-Wei Kao
- Graduate Institute of Business Administration, College of Management, Fu Jen Catholic University, Taipei, Taiwan
| | - Chien-Ying Huang
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan
| | - Yi-Hsin Chan
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan. .,Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.
| | - Pao-Hsien Chu
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.
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Musat DL, Milstein NS, Pimienta J, Bhatt A, Preminger MW, Sichrovsky TC, Flynn L, Pistilli C, Shaw RE, Mittal S. Incidence, duration, pattern, and burden of de novo atrial arrhythmias detected by continuous ECG monitoring using an implantable loop recorder following ablation of the cavotricuspid isthmus. CARDIOVASCULAR DIGITAL HEALTH JOURNAL 2020; 1:114-122. [PMID: 35265883 PMCID: PMC8890330 DOI: 10.1016/j.cvdhj.2020.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Following cavotricuspid isthmus (CTI) ablation, many patients with atrial flutter (AFL) are diagnosed with atrial fibrillation (AF). The incidence, duration, pattern, and burden of AF remain undefined. These may have implications for the management of these patients. Objective To classify the incidence, duration, pattern, and burden of AF/AFL using an implantable loop recorder (ILR) after CTI ablation. Methods We enrolled consecutive patients with CTI-dependent AFL, no known history of AF, and CHA2DS2-VASc ≥ 2. An ILR was implanted before or within 90 days of ablation. The time to first AF/AFL, pattern, duration, and burden of longest AF/AFL were determined. Five distinct AF/AFL cohorts were identified: no AF/AFL and those with recurrences of isolated, clustered, frequent, or persistent AF/AFL. Results Fifty-two patients (81% male; 73 ± 9 years; CHA2DS2-VASc 3.7 ± 1.2) were followed for 784 (interquartile range [IQR] 263, 1150) days. AF/AFL occurred in 44 (85%) patients at 64 (IQR 8, 189) days post-CTI ablation and was paroxysmal in 31 (70%) patients (burden 0.6% [IQR 0.1, 4.8]). AF/AFL was isolated (n = 5, 11%), clustered (n =7, 16%), frequent (n =19, 43%), and persistent (n =13, 30%). The longest AF episode was <24 hours in 27 (61%) patients. Conclusion Following CTI ablation in AFL patients, although AF/AFL occurs in most patients, the burden is low and episodes were <24 hours in the majority of patients. Additional studies are needed to determine whether long-term electrocardiographic monitoring can help guide management of patients undergoing CTI ablation.
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247
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Zelniker TA, Raz I, Sabatine MS, Wiviott SD. Response by Zelniker et al to Letter Regarding Article, "Effect of Dapagliflozin on Atrial Fibrillation in Patients With Type 2 Diabetes Mellitus: Insights From the DECLARE-TIMI 58 Trial". Circulation 2020; 142:e129-e130. [PMID: 32897752 DOI: 10.1161/circulationaha.120.049841] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Thomas A Zelniker
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Austria (T.A.Z.)
| | - Itamar Raz
- The Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Israel (I.R.)
| | - Marc S Sabatine
- TIMI (Thrombolysis in Myocardial Infarction) Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.S.S., S.D.W.)
| | - Stephen D Wiviott
- TIMI (Thrombolysis in Myocardial Infarction) Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.S.S., S.D.W.)
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248
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Chen ZQ, Chen F, Li L. Letter by Chen et al Regarding Article, "Effect of Dapagliflozin on Atrial Fibrillation in Patients With Type 2 Diabetes Mellitus: Insights From the DECLARE-TIMI 58 Trial". Circulation 2020; 142:e127-e128. [PMID: 32897750 DOI: 10.1161/circulationaha.120.046310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Zhi-Qing Chen
- Departments of Cardiology (Z-Q.C., L.L.), The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Feng Chen
- Emergency (F.C.), The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lang Li
- Departments of Cardiology (Z-Q.C., L.L.), The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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Giorgino F, Vora J, Fenici P, Solini A. Cardiovascular protection with sodium-glucose co-transporter-2 inhibitors in type 2 diabetes: Does it apply to all patients? Diabetes Obes Metab 2020; 22:1481-1495. [PMID: 32285611 PMCID: PMC7496739 DOI: 10.1111/dom.14055] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 04/04/2020] [Accepted: 04/05/2020] [Indexed: 12/13/2022]
Abstract
Patients with type 2 diabetes (T2D) are at an increased risk of cardiovascular disease (CVD). Cardiovascular risk in these patients should be considered as a continuum, and comprehensive treatment strategies should aim to target multiple disease risk factors. Large-scale clinical trials of sodium-glucose co-transporter-2 (SGLT2) inhibitors have shown an impact on cardiovascular outcomes, including heart failure hospitalization and cardiovascular death, which appears to be independent of their glucose-lowering efficacy. Reductions in major cardiovascular events appear to be greatest in patients with established CVD, particularly those with prior myocardial infarction, but are independent of heart failure or renal risk. Most large-scale trials of SGLT2 inhibitors predominantly include patients with T2D with pre-existing CVD and high cardiovascular risk at baseline, limiting their applicability to patients typically observed in clinical practice. Real-world evidence from observational studies suggests that there might also be beneficial effects of SGLT2 inhibitors on heart failure hospitalization and all-cause mortality in various cohorts of lower risk patients. The most common adverse events reported in clinical and observational studies are genital infections; however, the overall risk of these events appears to be low and easily managed. Similar safety profiles have been reported for elderly and younger patients. There is still some debate regarding the safety of canagliflozin in patients at high risk of fracture and amputation. Outstanding questions include specific patterns of cardiovascular protection according to baseline risk.
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Affiliation(s)
- Francesco Giorgino
- Department of Emergency and Organ TransplantationUniversity of Bari Aldo MoroBariItaly
| | - Jiten Vora
- Department of Diabetes and EndocrinologyUniversity of Liverpool, LiverpoolUK
| | | | - Anna Solini
- Department of Surgical, MedicalMolecular and Critical Area Pathology, University of PisaPisaItaly
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