Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial

Incidence of heart failure among diabetic patients with ischemic heart disease: a cohort study

BACKGROUND

In population studies of heart failure (HF), diabetes has been shown to be an independent risk factor. However, the evidence evaluating diabetes mellitus (DM) as an independent risk factor in incident HF in patients with ischemic heart disease (IHD) is scarce. Our study aimed to assess the incidence of HF in diabetic IHD patients compared to non-diabetic IHD patients in Ethiopia.

METHODS

A retrospective cohort study was conducted among 306 patients with IHD followed-up at Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia. The IHD patients who did not have HF at baseline were followed for 24 months beginning from November 30, 2015. We assessed the incidence of HF in patients with diabetic IHD versus the non-diabetic IHD. Cox proportional hazards models were used to assess the association between diabetic IHD and HF after controlling for important covariates. Hypertension was examined as a possible effect modifier as well.

RESULTS

The mean age was 56.8 years, 69% were male, and 31% were diabetic. During the 24 months follow-up period, 196 (64.1%) had incident HF. On multivariate Cox regression, DM was significantly associated with incident HF [Hazard Ratio = 2.04, 95% confidence interval (CI): 1.32-3.14, p = 0.001]. Furthermore, when the patients were stratified by hypertension (HTN), DM was associated with worse prognosis, the strongest association being in those with co-existing DM and HTN [HR = 2.57,95% CI =1.66-3.98, p <  0.0001] followed by the presence of DM without HTN [HR 2.27, 95% CI = 1.38-3.71, p = 0.001] (compared to those with neither).

CONCLUSION

DM is the strongest predictor of incident HF, compared to other traditional risk factors, in Ethiopian patients with IHD. Those with both DM and HTN are at the highest risk.

Circulating IgGs in Type 2 Diabetes with Atrial Fibrillation Induce IP3-Mediated Calcium Elevation in Cardiomyocytes

Higher risk of cardiac arrhythmias including atrial fibrillation (AF) associates with type 2 diabetes mellitus (T2DM) with the underlying mechanism largely unknown. The present study reported a subset of circulating immunoglobulin G autoantibodies (IgGs) from patients with T2DM with AF (T2DM/AF)-induced intracellular calcium elevation in both human induced pluripotent stem cell (iPSC)-derived and mouse atrial cardiomyocytes, whereas (identical concentrations of) IgGs from patients with T2DM without AF could not. The IgG-evoked intracellular calcium elevation was insensitive to verapamil, mibefradil, or BTP-2, indicating calcium source from neither voltage-gated calcium channels nor store-operated calcium entry. On the other hand, pharmacological antagonism or genetic knockdown of inositol triphosphate (IP₃) receptor significantly decreased T2DM/AF IgG-induced intracellular calcium elevation. Furthermore, pharmacological blockage of G protein-coupled receptor (GPCR), heterotrimeric G protein or phospholipase C dampened IgG-induced intracellular calcium elevation. Taken together, circulating IgGs from patients with T2DM/AF stimulated arrhythmogenic intracellular calcium elevation through IP₃ pathway in atrial cardiomyocytes.

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Identification of cardiomyocyte-targeting IgGs in T2DM atrial fibrillation patients

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Induction of arrhythmogenic Ca²⁺ signaling by these IgGs

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Independent of voltage-gated or store-operated Ca²⁺ channels

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Involvement of GPCR-IP₃-IP₃R axis in IgG-evoked intracellular Ca²⁺ elevation

Importance of intensive blood pressure control in type 2 diabetes: Mechanisms, treatments and current guidelines

Observational and interventional studies have shown that intensified blood pressure (BP) reduction can benefit people with diabetes. Because of their special haemodynamic properties, renin-angiotensin-aldosterone system (RAAS) blockers are recommended. The results of the BP arm of the ADVANCE study strongly support the recently updated European Society of Cardiology/European Association of Diabetes recommendations for the treatment of BP in people with diabetes, which recommend a target systolic/diastolic BP of 130/80 mmHg with few exceptions, and a fixed combination of an RAAS blocker with a diuretic or a calcium channel blocker as first-line treatment.

Influence of sex on the incidence of potential coronary artery disease and long-term outcomes in asymptomatic patients with diabetes mellitus

Background

Diabetic patients often have coronary artery disease (CAD) without symptoms. It is known that females tend to have silent or less chest pain and worse prognoses when they develop acute coronary syndrome. Thus, sex differences may impact long-term outcomes in diabetes mellitus (DM) patients with silent myocardial ischemia (SMI). The present study aimed to assess the influence of sex on long-term outcomes in DM patients with SMI.

Methods

A total of 461 consecutive asymptomatic and self-sufficient DM patients seen at our hospital from 2011 to 2017 were prospectively reviewed. Patients underwent an ergometer exercise test. When the exercise test was positive or the patient could not achieve 90% of their target heart rate, coronary angiography was performed. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCEs), including death, non-fatal myocardial infarction, and stroke.

Results

SMI was diagnosed in 81 patients. The median follow-up duration from diagnosis was 35 (15-57) months. The incidence of SMI was similar in females and males [34/170 (20%) vs. 47/291 (16.2%), p = 0.36]. Enrolled patients were divided into four groups according to sex and the presence/absence of SMI. Female patients with SMI showed worse clinical outcomes. After adjustment for age and coronary risk factors, female SMI was independently associated with MACCEs [hazard ratio 2.59, 95% confidence interval 1.07-5.68, p = 0.024], while male SMI was not.

Conclusions

Female SMI was associated with worse long-term outcomes in DM patients. Early diagnosis of potential SMI and appropriate care are required in female DM patients. (UMIN000038340).

Diabetes Mellitus-Related All-Cause and Cardiovascular Mortality in a National Cohort of Adults

Background Diabetes mellitus is a risk factor for cardiovascular disease ( CVD ) and has been associated with 2- to 4-fold higher mortality. Diabetes mellitus-related mortality has not been reassessed in individuals receiving routine care in the United States in the contemporary era of CVD risk reduction. Methods and Results We retrospectively studied 963 648 adults receiving care in the US Veterans Affairs Healthcare System from 2002 to 2014; mean follow-up was 8 years. We estimated associations of diabetes mellitus status and hemoglobin A1c (HbA1c) with all-cause and CVD mortality using covariate-adjusted incidence rates and multivariable Cox proportional hazards regression. Of participants, 34% had diabetes mellitus. Compared with nondiabetic individuals, patients with diabetes mellitus had 7.0 (95% CI , 6.7-7.4) and 3.5 (95% CI, 3.3-3.7) deaths/1000-person-years higher all-cause and CVD mortality, respectively. The age-, sex-, race-, and ethnicity-adjusted hazard ratio for diabetes mellitus-related mortality was 1.29 (95% CI, 1.28-1.31), and declined with adjustment for CVD risk factors (hazard ratio, 1.18 [95% CI, 1.16-1.19]) and glycemia (hazard ratio, 1.03 [95% CI, 1.02-1.05]). Among individuals with diabetes mellitus, CVD mortality increased as HbA1c exceeded 7% (hazard ratios, 1.11 [95% CI, 1.08-1.14], 1.25 [95% CI, 1.22-1.29], and 1.52 [95% CI, 1.48-1.56] for HbA1c 7%-7.9%, 8%-8.9%, and ≥9%, respectively, relative to HbA1c 6%-6.9%). HbA1c 6% to 6.9% was associated with the lowest mortality risk irrespective of CVD history or age. Conclusions Diabetes mellitus remains significantly associated with all-cause and CVD mortality, although diabetes mellitus-related excess mortality is lower in the contemporary era than previously. We observed a gradient of mortality risk with increasing HbA1c >6% to 6.9%, suggesting HbA1c remains an informative predictor of outcomes even if causality cannot be inferred.

Sleep heart rate variability assists the automatic prediction of long-term cardiovascular outcomes

OBJECTIVE

We aimed to investigate the association between sleep HRV and long-term cardiovascular disease (CVD) outcomes, and further explore whether HRV features can assist the automatic CVD prediction.

METHODS

We retrospectively analyzed polysomnography (PSG) data obtained from 2111 participants in the Sleep Heart Health Study, who were followed up for a median of 11.8 years after PSG acquisition. During follow-up, 1252 participants suffered CVD events (CVD group) and 859 participants remained CVD-free (non-CVD group). HRV measures, derived from time-domain and frequency-domain, were calculated. Regression models were created to determine the independent predictor for long-term CVD outcomes, and to explore the association between HRV and CVD latency. Furthermore, based on HRV and other clinical features, a model was trained to automatically predict CVD outcomes using the eXtreme Gradient Boosting algorithm.

RESULTS

Compared with the non-CVD group, decreased HRV during sleep was found in the CVD group. HRV, particularly its component of high frequency (HF), was demonstrated to be independent predictor of CVD outcomes. Moreover, normalized HF was positively correlated with CVD latency. The proposed prediction model achieved a total accuracy of 75.3%, in which sleep HRV features served as a supplement to the well-recognized CVD risk factors, such as aging, adiposity and sleep disorders.

CONCLUSIONS

Association between sleep HRV and long-term CVD outcomes was demonstrated here, suggesting that altered HRV during sleep might occur many years prior to the onset of CVD. Machine learning models, combining sleep HRV and other clinical characteristics, should be promising in the early prediction of CVD outcomes.

Association between IL-1beta and cardiovascular disease risk in patients with newly diagnosed, drug-naïve type 2 diabetes mellitus: a cross-sectional study

Background

To determine whether the pro-inflammatory cytokine interleukin (IL)-1beta, as a marker of the nucleotide binding and oligomerization domain-like receptor family pyrin domain-containing 3 (NLRP3) inflammasome activation, can be used to predict cardiovascular disease (CVD) risk in patients with newly diagnosed, drug-naïve type 2 diabetes mellitus (T2DM).

Methods

A total of 110 subjects with no history of diabetes were enrolled and divided into control subjects (non-DM group, n=52) and patients with newly diagnosed, drug-naïve T2DM (DM group, n=58).

Results

Serum IL-1beta levels were not different between the two groups. The Framingham CVD risk score (F-score) was positively correlated with the serum IL-1beta level in the DM group. Multivariate regression analyses showed that the F-score was independently associated with the serum IL-1beta level in the DM group. Patients with an intermediate to high CVD risk (F-score ≥10%) also had significantly higher serum IL-1beta levels than did those with a low CVD risk (F-score <5%). Smokers in the DM group had higher IL-1beta levels than did those in the non-DM group, regardless of the F-score.

Conclusions

These results suggest that serum IL-1beta levels might be useful as an independent risk factor predicting CVD risk in patients with newly diagnosed, drug naïve T2DM, particularly those who smoke.

Diabetes Mellitus and Long-Term Risk for Heart Failure After Coronary Revascularization

BACKGROUND

The effect of diabetes mellitus (DM) status on the long-term risk for heart failure (HF) in patients undergoing coronary revascularization has not been adequately evaluated.

METHODS AND RESULTS

In this study, 15,231 patients who underwent coronary revascularization in the CREDO-Kyoto Registry Cohort-2 were divided into 2 groups according to DM status (DM group: n=5,999; Non-DM group: n=9,232). The DM group was further divided into 2 groups according to insulin treatment (insulin-treated DM [ITDM]: n=1,353; non-insulin-treated DM [NITDM]: n=4,646). The primary outcome measure was HF hospitalization. The cumulative 5-year incidence of HF hospitalization was significantly higher in the DM than non-DM group (11.0% vs. 6.6%, respectively; log-rank P<0.0001), and in the ITDM than NITDM group (14.6% vs. 10.0%, respectively; log-rank P<0.0001). After adjusting for confounders, the increased risk of HF hospitalization with DM relative to non-DM remained significant (hazard ratio [HR] 1.47, 95% confidence interval [CI] 1.30-1.67, P<0.0001), whereas the risk associated with ITDM relative to NITDM was not significant (HR 1.17, 95% CI 0.96-1.43, P=0.12).

CONCLUSIONS

The adjusted long-term risk for HF hospitalization after coronary revascularization was significantly higher in DM than non-DM patients, regardless of revascularization strategy, but did not differ between ITDM and NITDM patients.

Myocardial Changes in Diabetic and Nondiabetic Nonhuman Primates

Diabetic human patients have increased risk of heart failure compared to healthy subjects. The underlying mechanisms for this are not fully understood, and to help develop improved treatment strategies, well-characterized animal models are essential. To investigate cardiac dysfunction in diabetes, this study evaluated myocardial changes in 10 aging rhesus monkeys with and without diabetes. Based on evaluation of plasma glycosylated hemoglobin and glucose, 7 of 10 rhesus macaques had diabetes for a minimum of 11 months, while 3 of 10 were categorized as nondiabetic. A detailed histological examination of formalin-fixed left ventricular myocardial samples was followed by a semiquantitative evaluation of myocardial fibrosis and fat infiltration; digital quantifications of myocardial collagen, lipofuscin, and nuclear area fractions; and measurements of cardiomyocyte diameter. Histological myocardial evaluation revealed the presence of lipofuscin; large nuclei; interstitial, replacement, and vascular fibrosis; adipocyte infiltration; and vacuolar degeneration with atrophy of cardiomyocytes and fibrosis. However, there were no differences between groups for semiquantitative fat infiltration, fibrosis, cardiomyocyte size, collagen, or nuclear and lipofuscin area fraction. Lipofuscin area fraction correlated with plasma insulin, triglyceride, total cholesterol, and high-density lipoprotein cholesterol concentrations. In conclusion, myocardial pathological changes were found in left ventricular myocardium in aged rhesus macaques, independent of the stage of diabetes. The duration of diabetes might have been too short to cause differences between groups.

SGLT-2 inhibitors and GLP-1 receptor agonists for nephroprotection and cardioprotection in patients with diabetes mellitus and chronic kidney disease. A consensus statement by the EURECA-m and the DIABESITY working groups of the ERA-EDTA

Chronic kidney disease (CKD) in patients with diabetes mellitus (DM) is a major problem of public health. Currently, many of these patients experience progression of cardiovascular and renal disease, even when receiving optimal treatment. In previous years, several new drug classes for the treatment of type 2 DM have emerged, including inhibitors of renal sodium-glucose co-transporter-2 (SGLT-2) and glucagon-like peptide-1 (GLP-1) receptor agonists. Apart from reducing glycaemia, these classes were reported to have other beneficial effects for the cardiovascular and renal systems, such as weight loss and blood pressure reduction. Most importantly, in contrast to all previous studies with anti-diabetic agents, a series of recent randomized, placebo-controlled outcome trials showed that SGLT-2 inhibitors and GLP-1 receptor agonists are able to reduce cardiovascular events and all-cause mortality, as well as progression of renal disease, in patients with type 2 DM. This document presents in detail the available evidence on the cardioprotective and nephroprotective effects of SGLT-2 inhibitors and GLP-1 analogues, analyses the potential mechanisms involved in these actions and discusses their place in the treatment of patients with CKD and DM.

Supporting care for suboptimally controlled type 2 diabetes mellitus in general practice with a clinical decision support system: a mixed methods pilot cluster randomised trial

OBJECTIVES

We developed a complex intervention called DECIDE (ComputeriseD dECisIonal support for suboptimally controlleD typE 2 Diabetes mellitus in Irish General Practice) which used a clinical decision support system to address clinical inertia and support general practitioner (GP) intensification of treatment for adults with suboptimally controlled type2 diabetes mellitus (T2DM). The current study explored the feasibility and potential impact of DECIDE.

DESIGN

A pilot cluster randomised controlled trial.

SETTING

Conducted in 14 practices in Irish General Practice.

PARTICIPANTS

The DECIDE intervention was targeted at GPs. They applied DECIDE to patients with suboptimally controlled T2DM, defined as a glycated haemoglobin (HbA1c) ≥70 mmol/mol and/or blood pressure ≥150/95 mmHg.

INTERVENTION

The intervention incorporated training and a web-based clinical decision support system which supported; (i) medication intensification actions; and (ii) non-pharmacological actions to support care. Control practices delivered usual care.

PRIMARY AND SECONDARY OUTCOME MEASURES

Feasibility and acceptability was determined using thematic analysis of semi-structured interviews with GPs, combined with data from the DECIDE website. Clinical outcomes included HbA1c, medication intensification, blood pressure and lipids.

RESULTS

We recruited 14 practices and 134 patients. At 4-month follow-up, all practices and 114 patients were followed up. GPs reported finding decision support helpful navigating increasingly complex medication algorithms. However, the majority of GPs believed that the target patient group had poor engagement with GP and hospital services for a range of reasons. At follow-up, there was no difference in glycaemic control (-3.6 mmol/mol (95% CI -11.2 to 4.0)) between intervention and control groups or in secondary outcomes including, blood pressure, total cholesterol, medication intensification or utilisation of services. Continuation criteria supported proceeding to a definitive randomised trial with some modifications.

CONCLUSION

The DECIDE study was feasible and acceptable to GPs but wider impacts on glycaemic and blood pressure control need to be considered for this patient population going forward.

TRIAL REGISTRATION NUMBER

ISRCTN69498919.

Prevalence and RIsk factors for Silent Myocardial ischemia (PRISM): A clinico observational study in patients of type 2 diabetes

Objectives

To estimate the prevalence and to identify potential risk factors of silent myocardial ischemia in a cohort of patients with asymptomatic type 2 Diabetes (diabetes) for early detection of coronary risk by employing objective noninvasive clinical screening tools for Subclinical Atherosclerosis.

Methods

The study is a clinic-based observational study on 338 consecutive diabetes patients attending an urban health center from Eastern India. The response rate was 96.57% out of 350 eligible subjects, comprising 176 (52.1%) males and 162 (47.9%) females. Clinical, anthropometric, biochemical parameters were collected in all participants. Both tools, i.e., treadmill test (TMT) to identify subjects with silent myocardial ischemia, and carotid imaging to detect subclinical atherosclerosis by evaluating carotid intima-media thickness (CIMT), were assessed. Significant determinants were predicted by multivariable logistic regression.

Results

The study group was divided into a TMT negative (n = 260), and a TMT positive group (n = 78). These 78 TMT positive subjects (23.1%) were identified to have silent myocardial ischemia. The prevalence of silent myocardial ischemia was more common in males (28.4%) than in females (17.3%). The mean CIMT in our study group was 0.6741 ± 0.034 mm (males – 0.684 ± 0.034 mm and females – 0.663 ± 0.032 mm). Age ≥50 years, CIMT ≥0.70 mm, hypercholesterolemia, and hypertriglyceridemia were significant determinants for identifying asymptomatic diabetics at risk for silent myocardial ischemia.

Conclusion

Silent myocardial ischemia is highly prevalent at about one in four asymptomatic diabetic patients. An increased CIMT can be a surrogate marker of higher coronary risk amongst these asymptomatic diabetics.

Ablating the Rab-GTPase activating protein TBC1D1 predisposes rats to high-fat diet-induced cardiomyopathy

KEY POINTS

Although the role of TBC1D1 within the heart remains unknown, expression of TBC1D1 increases in the left ventricle following an acute infarction, suggesting a biological importance within this tissue. We investigated the mechanistic role of TBC1D1 within the heart, aiming to establish the consequences of attenuating TBC1D1 signalling in the development of diabetic cardiomyopathy, as well as to determine potential sex differences. TBC1D1 ablation increased plasma membrane fatty acid binding protein content and myocardial palmitate oxidation. Following high-fat feeding, TBC1D1 ablation dramatically increased fibrosis and induced end-diastolic dysfunction in both male and female rats in the absence of changes in mitochondrial bioenergetics. Altogether, independent of sex, ablating TBC1D1 predisposes the left ventricle to pathological remodelling following high-fat feeding, and suggests TBC1D1 protects against diabetic cardiomyopathy.

ABSTRACT

TBC1D1, a Rab-GTPase activating protein, is involved in the regulation of glucose handling and substrate metabolism within skeletal muscle, and is essential for maintaining pancreatic β-cell mass and insulin secretion. However, the function of TBC1D1 within the heart is largely unknown. Therefore, we examined the role of TBC1D1 in the left ventricle and the functional consequence of ablating TBC1D1 on the susceptibility to high-fat diet-induced abnormalities. Since mutations within TBC1D1 (R125W) display stronger associations with clinical parameters in women, we further examined possible sex differences in the predisposition to diabetic cardiomyopathy. In control-fed animals, TBC1D1 ablation did not alter insulin-stimulated glucose uptake, or echocardiogram parameters, but increased accumulation of a plasma membrane fatty acid transporter and the capacity for palmitate oxidation. When challenged with an 8 week high-fat diet, TBC1D1 knockout rats displayed a four-fold increase in fibrosis compared to wild-type animals, and this was associated with diastolic dysfunction, suggesting a predisposition to diet-induced cardiomyopathy. Interestingly, high-fat feeding only induced cardiac hypertrophy in male TBC1D1 knockout animals, implicating a possible sex difference. Mitochondrial respiratory capacity and substrate sensitivity to pyruvate and ADP were not altered by diet or TBC1D1 ablation, nor were markers of oxidative stress, or indices of overt heart failure. Altogether, independent of sex, ablation of TBC1D1 not only increased the susceptibility to high-fat diet-induced diastolic dysfunction and left ventricular fibrosis, independent of sex, but also predisposed male animals to the development of cardiac hypertrophy. These data suggest that TBC1D1 may exert cardioprotective effects in the development of diabetic cardiomyopathy.

Diabetes without Manifest Cardiovascular Disease: A Novel Approach in Risk Stratification and Treatment Selection

BACKGROUND

Cardiovascular disease (CVD), the main macro vascular complication of type 2 diabetes (T2D), increases the risk of death significantly in patients with T2D.

INTRODUCTION

Most of the patients with T2D do not have obvious CVD symptoms. Due to the paucity of data, CVD screening in asymptomatic patients with T2D remains highly controversial.

METHODS

This has driven a panel of experts to establish a novel consensus on how to approach patients with T2D at high CVD risk. The panel formulated a stepwise algorithm by which patients with T2D undergo initial risk stratification into low, intermediate and high risk using the ASCVD calculator. In patients with intermediate risk, coronary artery calcium measurement is used to further stratify those patients into new low and high-risk categories.

RESULTS AND CONCLUSION

The panel recommends using standard diabetes care in low risk patients and using SGLT2 inhibitors and GLP1 agonists with cardio protective effect, on top of standard care, in high risk individuals.

From Endothelial Dysfunction to Arterial Stiffness in Diabetes Mellitus

Prevalence of diabetes mellitus has increased drastically over time, especially in more populous countries such as the United States, India, and China. Patients with diabetes have an increased risk of major cardiovascular events such as acute myocardial infarction, cerebrovascular disease, and peripheral vascular disease. Arterial stiffness is a process related to aging and vascular, metabolic, cellular and physiological deterioration. In recent years, it has been described as an independent predictor of cardiovascular mortality and coronary artery disease. Additionally, it plays an important role in the measurement of chronic disease progression. Recent studies have suggested a strong relationship between diabetes mellitus and arterial stiffness since they share a similar pathophysiology involving endothelial dysfunction. The literature has shown that microvascular and macrovascular complications in diabetic patients could be screened and measured with arterial stiffness. Additionally, new evidence proposes that there is a relationship between blood glucose levels, microalbuminuria, and arterial stiffness. Moreover, arterial stiffness predicts cardiovascular risk and is independently associated with mortality in diabetic patients. Abnormal arterial stiffness values in diabetic patients should alert the clinician to the presence of vascular disease, which merits early study and treatment. We await more studies to determine if arterial stiffness could be considered a routine useful non-invasive tool in the evaluation of diabetic patients. There is enough evidence to conclude that arterial stiffness is related to the progression of diabetes mellitus.

Association between mandatory health examination attendance and diabetes treatment initiation among employees being treated for hypertension

OBJECTIVES

It is unclear whether mandatory health examination is effective for employees who are already being treated for chronic diseases. We focused on patients being treated for hypertension and evaluated the association between employer-based health examination attendance and diabetes treatment initiation.

METHODS

Using a database that stores health insurance claims and health examination results of subscribers enrolled in society-managed health insurance plans in Japan, we identified employees aged 40-59 years who were being treated for hypertension when starting diabetes treatment from April 2012 to December 2016. A case-crossover analysis was conducted using 90, 180, and 270 days prior to diabetes treatment initiation as reference points and 90 days after the mandatory health examination as the exposure period. We conducted a subgroup analysis by hemoglobin A1c (HbA1c) level and frequency of outpatient blood glucose testing before the mandatory health examination.

RESULTS

We identified 1464 individuals starting treatment for diabetes while on antihypertensive drugs. The overall odds ratio for starting diabetes treatment within 90 days of the health examination was 1.89 (95% confidence interval: 1.70-2.10). The subgroup analysis showed that this odds ratio increased as HbA1c level increased and as blood glucose testing frequency decreased.

CONCLUSIONS

Among employees starting treatment for diabetes while being treated for hypertension, employer-based mandatory health examination attendance was associated with initiation of diabetes treatment. The health examinations may be functioning as a complement to screening in outpatient settings.

Add-On Therapy with DPP-4 Inhibitors May Improve Renal Function Decline in α-Glucosidase Inhibitor and Metformin Users: A Retrospective Observational Study

PURPOSE

We retrospectively evaluated the long-term effect of dipeptidyl peptidase (DPP)-4 inhibitors on estimated glomerular filtration rate (eGFR) slopes, and then evaluated the beneficial interaction between DPP-4 inhibitor initiation and baseline use of α-glucosidase inhibitor and/or metformin in patients with diabetic kidney disease.

PATIENTS AND METHODS

Altogether, 1512 patients with type 2 diabetes were receiving DPP-4 inhibitor therapy over 1 year and were followed up for a maximum of 2 years before and after 7 years of treatment. The decline in renal function was estimated as the slope of the individual linear regression line of eGFR over 2-year follow-up. Prescription data on medications before and after DPP-4 inhibitor treatment were examined.

RESULTS

The mean length of DPP-4 inhibitor treatment was 5.3 ± 2.6 years. The baseline mean eGFR slope (mL/min/1.73m²/year) was -2.24 ± 6.05. After DPP-4 inhibitor treatment, mean eGFR slope was significantly improved (-1.53 ± 6.36, P < 0.01) in patients with type 2 diabetes. This effect appeared more pronounced for baseline use of α-glucosidase inhibitor and/or metformin in patients with diabetic kidney disease. These non-users showed a trend towards attenuation or no effects.

CONCLUSION

In the present study, patients treated with DPP-4 inhibitors had a significantly slower annual loss of kidney function. The benefit appears pronounced in α-glucosidase inhibitor and metformin users with advanced renal dysfunction. These results suggest that the beneficial effects of DPP-4 inhibitors on kidney function may have occurred in the presence of an α-glucosidase inhibitor and/or metformin.

Worse cardiovascular prognosis after endovascular surgery for intermittent claudication caused by infrainguinal atherosclerotic disease in patients with diabetes

BACKGROUND

Diabetes mellitus (DM) is an established risk factor for intermittent claudication (IC) and other manifestations of atherosclerotic peripheral arterial disease. Indications for surgery in infrainguinal IC are debated, and there are conflicting reports regarding its outcomes in patients with DM. Aims of this study were to compare both short- and long-term effects on total- and cardiovascular (CV) mortality, major adverse cardiovascular events (MACEs), acute myocardial infarction (AMI), stroke, and major amputation following infrainguinal endovascular surgery for IC in patients with and without DM. We also evaluated potential relationships between diabetic control and outcomes in patients with DM.

METHODS

Nationwide observational cohort study of patients registered in the Swedish Vascular Registry and the Swedish National Diabetes Registry. Propensity score adjusted comparison of total and CV mortality, MACE, AMI, stroke, and major amputation after elective infrainguinal endovascular surgery for IC in 626 patients with and 1112 without DM at 30 postoperative days and after median 5.2 [interquartile range (IQR) 4.2-6.3] years of follow-up for patients with DM, and 5.4 (IQR 4.3-6.5) years for those without.

RESULTS

In propensity score adjusted Cox regression after 30 postoperative days, there were no differences between groups in morbidity or mortality. At last follow-up, patients with DM showed higher rates of MACE [hazard ratio (HR) 1.26, confidence interval (CI) 1.07-1.48; p < 0.01], AMI (HR 1.48, CI 1.09-2.00; p = 0.01), and major amputation (HR 2.31, CI 1.24-4.32; p < 0.01). Among patients with DM, higher HbA1c was associated with higher total mortality during follow-up (HR 1.01, CI 1.00-1.03; p = 0.045).

CONCLUSION

Patients with DM have higher rates of MACE, AMI, and major amputation in propensity score adjusted analysis during 5 years of follow-up after infrainguinal endovascular surgery for IC. Furthermore, HbA1c is associated with total mortality in patients with DM. Prevention and treatment of DM is important to improve cardiovascular and limb outcomes.

Systolic Blood Pressure, Cardiovascular Mortality, and All-Cause Mortality in Normoglycemia, Prediabetes, and Diabetes

BACKGROUND

The optimal blood pressure (BP) level for diabetic patients remains controversial, while studies provided limited evidence on BP management for individuals with normoglycemia or prediabetes. We aimed to investigate the associations between systolic blood pressure (SBP) and all-cause and cardiovascular (CVD) mortality among US adults with different glycemic profiles.

METHODS

We used data from the 1999-2014 National Health and Nutrition Examination Survey (NHANES, n=40,046) with comprehensive baseline examination and follow-up assessment. Restricted cubic spline analysis was performed to examine dose-response relationship between SBP and mortality risk. Cox regression models were used to estimate hazard ratios of all-cause mortality and CVD mortality for SBP categories.

RESULTS

U-shaped associations between SBP and all-cause mortality were observed regardless of glucose status. The relationship between SBP and CVD mortality was found to be U-shaped only in normoglycemic participants. The lowest mortality risk of optimal SBP (mmHg) by group was 115-120 (normoglycemia), 120-130 (prediabetes), and 125-135 (diabetes). When compared with the reference group, SBP < 100 mmHg was significantly associated with 49% (HR=1.49, 95% CI: 1.13-1.96), 57% (1.57, 1.07-2.3), and 59% (1.59, 1.12-2.25) higher all-cause mortality risk in people with normoglycemia, prediabetes, and diabetes, respectively. The multivariable-adjusted HRs of all-cause mortality for SBP ≥150 mmHg were 1.51 (1.25-1.82), 1.56 (1.27-1.93), and 1.33 (1.08-1.64), respectively. As for CVD mortality, the multivariable-adjusted HRs were 2.85 (1.29-6.33) for SBP <100 mmHg and 2.71 (1.56-4.69) for SBP ≥150 mmHg in normoglycemia; HR was 1.66 (1.05-2.63) for SBP ≥150 mmHg in diabetic patients.

CONCLUSION

U-shaped relationships between SBP and all-cause mortality were observed regardless of diabetes status. The optimal SBP range was gradually higher with worsening glucose status.

The Role of Physical Therapists in Fighting the Type 2 Diabetes Epidemic

BACKGROUND

In 2014, the total prevalence of diabetes was estimated to be 422 million people worldwide. Due to the aging population and continued increase in obesity rates, the prevalence is expected to rise to 592 million by 2035. Diabetes can lead to several complications, including cardiovascular disease, stroke, peripheral arterial disease, nephropathy, neuropathy, retinopathy, lower extremity amputation, and musculoskeletal impairments.

CLINICAL QUESTION

Up to 80% of patients referred for outpatient physical therapy have diabetes or are at risk for diabetes, providing an opportunity for physical therapists to intervene. Therefore, we asked, "What is the role of physical therapists in fighting the diabetes epidemic?"

KEY RESULTS

Physical therapists commonly prescribe physical activity for the treatment of diabetes and other chronic diseases, such as cardiovascular disease and osteoarthritis. Physical therapists may also screen for risk factors for diabetes and diabetes-related complications and modify traditional musculoskeletal exercise prescription accordingly. Physical therapists must advocate for regular physical activity as a key component of the treatment of chronic diseases in all patient interactions.

CLINICAL APPLICATION

This commentary (1) describes the diabetes epidemic and the health impact of diabetes and diabetes-related complications, (2) highlights the physical therapist's role as front-line provider, and (3) provides recommendations for physical therapists in screening for diabetes risk factors and diabetes-related complications and considerations for patient management. We focus on type 2 diabetes. J Orthop Sports Phys Ther 2020;50(1):5-16. Epub 28 Nov 2019. doi:10.2519/jospt.2020.9154.

Development of an algorithm to link electronic health record prescriptions with pharmacy dispense claims

Objective

Medication adherence is an important aspect of chronic disease management. Electronic health record (EHR) data are often not linked to dispensing data, limiting clinicians' understanding of which of their patients fill their medications, and how to tailor care appropriately. We aimed to develop an algorithm to link EHR prescribing to claims-based dispensing data and use the results to quantify how often patients with diabetes filled prescribed chronic disease medications.

Materials and Methods

We developed an algorithm linking EHR prescribing data (RxNorm terminology) to claims-based dispensing data (NDC terminology), within sample of adult (19-64) community health center (CHC) patients with diabetes from a network of CHCs across 12 states. We demonstrate an application of the method by calculating dispense rates for a set of commonly prescribed diabetes and cardio-protective medications. To further inform clinical care, we computed adjusted odds ratios of dispense by patient-, encounter-, and clinic-level characteristics.

Results

Seventy-six percent of cardio-protective medication prescriptions and 74% of diabetes medications were linked to a dispensing record. Age, income, ethnicity, insurance, assigned primary care provider, comorbidity, time on EHR, and clinic size were significantly associated with odds of dispensing.

Discussion

EHR prescriptions and pharmacy dispense data can be linked at the record level across different terminologies. Dispensing rates in this low-income population with diabetes were similar to other populations.

Conclusion

Record linkage resulted in the finding that CHC patients with diabetes largely had their chronic disease medications dispensed. Understanding factors associated with dispensing rates highlight barriers and opportunities for optimal disease management.

Diabetes and Cardiovascular Disease: an Update

PURPOSE OF REVIEW

Cardiovascular disease (CVD) is the leading cause of mortality in people with diabetes. Our aim was to review the pathophysiology of CVD in diabetes, review related landmark trials, and discuss the cardiovascular benefit of glucose-lowering agents. We have also discussed the role of controversial anti-platelet therapy.

RECENT FINDINGS

Recent studies have shown the impact of glucose-lowering agents on CVD in people with diabetes. Statins are now recommended for all patients with diabetes over the age of 40 regardless of the LDL level given the cardiovascular benefit of these drugs. Current recommendations suggest a blood pressure < 130/80 for individuals with high cardiovascular risk. Cardiovascular risk reduction should be an important part of the management of diabetes. Focusing solely on glycemic control may not be the best therapeutic strategy. Multifactorial risk reduction should be taken into account. Lipid-lowering agents and anti-hypertensives should be a corner stone of treatment of diabetes. With currently available data, glucose-lowering agents with cardiovascular benefit should be started early in the disease process.

Risk factor reduction in type 2 diabetes demands a multifactorial approach

Dysglycaemia (i.e. type 2 diabetes mellitus or impaired glucose tolerance) is not only common in patients with cardiovascular disease but increases the risk for future cardiovascular complications. Hyperglycaemia, the hallmark of diabetes, has since long been considered to be the link between diabetes and cardiovascular disease. Diabetes is, however, a complex, multifactorial disorder to which, for example, insulin resistance, endothelial dysfunction and factors such as increased thrombogenicity, hypertension and dyslipidaemia contribute. Thus, treatment needs to be multifactorial and to take cardiovascular aspects into account. Life-style adjustments are, together with blood pressure, lipid and glucose control, important parts of such management. Recent trial data reveal a beneficial effect on cardiovascular prognosis and mortality of blood glucose lowering agents belonging to the classes: sodium-glucose-transporter 2 inhibitors and glucagon-like peptide 1 agonists. The precise mechanisms by which certain sodium-glucose-transporter 2 inhibitors and glucagon-like peptide receptor agonists lead to these beneficial effects are only partly understood. An important impact of the benefits of sodium-glucose-transporter 2 inhibitors is a reduction in heart failure while glucagon-like peptide receptor agonists may retard the development of atherosclerotic vascular disease or stabilising plaques. Although there has been a considerable improvement in the prognosis for people with atherosclerotic diseases over the last decades there is still a gap between those with dysglycaemia, who are at higher risk, than those without dysglycaemia. This residual risk is reasonably related to two major factors: a demand for improved management and a need for new and improved therapeutic opportunities of type 2 diabetes, both routes to an improved prognosis that are at hands. This review is a comprehensive description of the possibilities to improve the prognosis for patients with dysglycaemia by a multifactorial management according to the most recent European guidelines issued in 2019 by the European Society of Cardiology in collaboration with the European Association for the Study of Diabetes.

Achievement of glycaemic control is associated with improvements in lipid profile with iGlarLixi versus iGlar: A post hoc analysis of the LixiLan-L trial

Diabetic dyslipidaemia is a major risk factor for accelerated atherosclerosis. Glycaemic treatments that improve dyslipidaemia may help reduce the burden of atherosclerosis. This analysis investigated the effect of iGlarLixi [insulin glargine U100 (iGlar) and lixisenatide] versus iGlar on lipid profiles in patients with type 2 diabetes uncontrolled on basal insulin. Data from LixiLan-L were used to estimate changes in fasting lipid levels from baseline to week 30, overall and in patients stratified by achievement of glycaemic targets {2-hour postprandial glucose [≤10, >10 mmoL/L], fasting plasma glucose [≤6.1, >6.1 mmoL/L], HbA1c [≤7, >7% (≤53, >53 mmol/mol)]}. At week 30, median percentage change in triglycerides remained nearly unchanged (0.3% increase) with iGlarLixi versus a 6.5% increase with iGlar (P = 0.035; overall); similarly, trends towards better total and LDL cholesterol levels were observed with iGlarLixi versus iGlar. In patient subgroups achieving glycaemic targets, all lipid variables except for HDL cholesterol improved with iGlarLixi but not with iGlar. In summary, patients with type 2 diabetes uncontrolled on basal insulin showed improved fasting lipid profiles with iGlarLixi compared with iGlar, particularly when achieving glycaemic targets.

Insulin Resistance and Atherosclerosis: Implications for Insulin-Sensitizing Agents

Patients with type 2 diabetes mellitus (T2DM) are at high risk for macrovascular complications, which represent the major cause of mortality. Despite effective treatment of established cardiovascular (CV) risk factors (dyslipidemia, hypertension, procoagulant state), there remains a significant amount of unexplained CV risk. Insulin resistance is associated with a cluster of cardiometabolic risk factors known collectively as the insulin resistance (metabolic) syndrome (IRS). Considerable evidence, reviewed herein, suggests that insulin resistance and the IRS contribute to this unexplained CV risk in patients with T2DM. Accordingly, CV outcome trials with pioglitazone have demonstrated that this insulin-sensitizing thiazolidinedione reduces CV events in high-risk patients with T2DM. In this review the roles of insulin resistance and the IRS in the development of atherosclerotic CV disease and the impact of the insulin-sensitizing agents and of other antihyperglycemic medications on CV outcomes are discussed.

Exercise and Cardiovascular Risk among Masters Athletes with Type 2 Diabetes

PURPOSE OF REVIEW

This review was designed to provide a scientific and clinical framework for the care of physically active men and women with an emphasis on the management of T2DM.

RECENT FINDINGS

The preventative and therapeutic benefits of physical activity (PA) on adult onset or Type 2 Diabetes Mellitus (T2DM) are well established. Individuals diagnosed with or are at risk for T2DM should be counseled and maximally supported to pursue an active or athletic lifestyle. Optimally, this translates into the adoption of an athletic lifestyle. "Masters athletes", men and women above the age of 35 who regularly train for and/or participate in competitive sport, represent a rapidly growing segment of the population. Although the high level of exercise characteristic of this population has numerous health benefits, it does not confer immunity from T2DM or cardiovascular (CV) disease. Providing effective care for men and women above the age of 35 who regularly train for and/or participate in competitive sport requires an understanding of the interplay between basic exercise physiology and the pathogenesis of insulin resistance.

A data-driven approach to predicting diabetes and cardiovascular disease with machine learning

Background

Diabetes and cardiovascular disease are two of the main causes of death in the United States. Identifying and predicting these diseases in patients is the first step towards stopping their progression. We evaluate the capabilities of machine learning models in detecting at-risk patients using survey data (and laboratory results), and identify key variables within the data contributing to these diseases among the patients.

Methods

Our research explores data-driven approaches which utilize supervised machine learning models to identify patients with such diseases. Using the National Health and Nutrition Examination Survey (NHANES) dataset, we conduct an exhaustive search of all available feature variables within the data to develop models for cardiovascular, prediabetes, and diabetes detection. Using different time-frames and feature sets for the data (based on laboratory data), multiple machine learning models (logistic regression, support vector machines, random forest, and gradient boosting) were evaluated on their classification performance. The models were then combined to develop a weighted ensemble model, capable of leveraging the performance of the disparate models to improve detection accuracy. Information gain of tree-based models was used to identify the key variables within the patient data that contributed to the detection of at-risk patients in each of the diseases classes by the data-learned models.

Results

The developed ensemble model for cardiovascular disease (based on 131 variables) achieved an Area Under - Receiver Operating Characteristics (AU-ROC) score of 83.1% using no laboratory results, and 83.9% accuracy with laboratory results. In diabetes classification (based on 123 variables), eXtreme Gradient Boost (XGBoost) model achieved an AU-ROC score of 86.2% (without laboratory data) and 95.7% (with laboratory data). For pre-diabetic patients, the ensemble model had the top AU-ROC score of 73.7% (without laboratory data), and for laboratory based data XGBoost performed the best at 84.4%. Top five predictors in diabetes patients were 1) waist size, 2) age, 3) self-reported weight, 4) leg length, and 5) sodium intake. For cardiovascular diseases the models identified 1) age, 2) systolic blood pressure, 3) self-reported weight, 4) occurrence of chest pain, and 5) diastolic blood pressure as key contributors.

Conclusion

We conclude machine learned models based on survey questionnaire can provide an automated identification mechanism for patients at risk of diabetes and cardiovascular diseases. We also identify key contributors to the prediction, which can be further explored for their implications on electronic health records.

Prevalence and pattern of dyslipidemia in patients with type 2 diabetes mellitus in Zaria, Northwestern Nigeria

INTRODUCTION

Dyslipidemia confers excess atherosclerotic cardiovascular risk in type 2 diabetes mellitus (DM) patients, and this requires prompt identification and management to reduce morbidity and mortality. This study assessed the prevalence and pattern of dyslipidemia in type 2 DM patients in Zaria, Northwestern Nigeria.

METHODS

This was a cross-sectional study of newly diagnosed type 2 DM patients at Ahmadu Bello University Teaching Hospital (ABUTH), Zaria. Demographic, clinical and laboratory data were extracted from the case notes of eligible patients and analyzed using STATA version 14. Continuous variables were presented as mean ± standard deviation (SD), or median and interquartile range (IQR) while categorical variables were as frequencies and percentages. Student t and chi-square tests were used to test for association at p < 0.05.

RESULTS

A total of 322 subjects (161 male, 161 female) with a mean age of 53.5 ± 10.8 years partook in the study. The prevalence of dyslipidemia was 69.3%. Mixed dyslipidemia of high triglyceride (TG) and high low-density lipoprotein cholesterol (LDL-C) was present in 41.0%; high TG and low high-density lipoprotein cholesterol (HDL-C) in 2.8%; and high LDL and low HDL in 2.5%. Atherogenic dyslipidemia, isolated hypercholesterolemia and isolated low HDL-cholesterol were present in 3.4%, 2.5% and 23.6% respectively. Dyslipidemia status was not associated with age, sex, duration of DM or hypertension, obesity, and mean fasting blood sugar (FBS) and 2-hour postprandial glucose.

CONCLUSION

The prevalence of dyslipidemia is high in the newly diagnosed type 2 DM patients and therefore, initial management should incorporate measures to control dyslipidemia.

Diabetic dyslipidemia: evaluation and mechanism

Diabetes is one of the well-established independent risk factors for cardiovascular diseases. Diabetes induces dyslipidemia which is characterized by elevated fasting triglyceride (TG) and reduced high-density lipoprotein-cholesterol (HDL-C), and such diabetic dyslipidemia is a crucial determinant for atherogenesis and atherosclerotic progression in patients with diabetes. Previous measurement methods of lipoproteins have problems including time-consuming (ultracentrifugation) and inaccurate and impossible measurements of TG-rich lipoproteins such as chylomicron, intermediate-density lipoprotein (IDL) and very low-density lipoprotein (VLDL). Our developed anion-exchange high-performance liquid chromatography (AEX-HPLC) can measure all fractions of lipoproteins accurately. Our studies using AEX-HPLC showed that IDL and VLDL in type 2 diabetes were higher than non-diabetic subjects, and IDL and VLDL were higher in the order of type 2 diabetic patients with obesity, type 2 diabetic patients without obesity, and non-diabetic subjects. Here, we also describe the underlying mechanisms for development of diabetic dyslipidemia.

Orexin A-induced inhibition of leptin expression and secretion in adipocytes reducing plasma leptin levels and hypothalamic leptin resistance

Orexin A (OXA) is a neuropeptide associated with plasma insulin and leptin levels involved in body weight and appetite regulation. However, little is known about the effect of OXA on leptin secretion in adipocytes and its physiological roles. Leptin secretion and expression were analysed in 3T3-L1 adipocytes. Plasma leptin, adiponectin and insulin levels were measured by ELISA assay. Phosphorylated signal transducer and activator of transcription 3 (pSTAT3) levels in the hypothalamus were evaluated by western blotting. OXA dose-dependently suppressed leptin secretion from 3T3-L1 adipocytes by inhibiting its gene expression while facilitating adiponectin secretion. The leptin inhibition by OXA was mediated via orexin receptors (OXR1 and OXR2). In addition to the pathway via extracellular signal-regulated kinases, OXA triggered adenylyl cyclase-induced cAMP elevation, which results in protein kinase A-mediated activation of cAMP response element-binding proteins (CREB). Accordingly, CREB inhibition restored the OXA-induced downregulation of leptin gene expression and secretion. Exogenous OXA for 4 weeks decreased fasting plasma leptin levels and increased hypothalamic pSTAT3 levels in high-fat diet-fed mice, regardless of increase in body weight and food intake. These results suggest that high dose of OXA directly inhibits leptin mRNA expression and thus secretion in adipocytes, which may be a peripheral mechanism of OXA for its role in appetite drive during fasting. It may be also critical for lowering basal plasma leptin levels and thus maintaining postprandial hypothalamic leptin sensitivity.

Association of genetic and behavioral characteristics with the onset of diabetes

Background

Prior work has established sociodemographic, lifestyle, and behavioral risk factors for diabetes but the contribution of these factors to the onset of diabetes remains unclear when accounting for genetic propensity for diabetes. We examined the contribution of a diabetes polygenic score (PGS) to the onset of diabetes in the context of modifiable known risk factors for diabetes.

Methods

Our sample consisted of 15,190 respondents in the United States-based Health and Retirement Study, a longitudinal study with up to 22 years of follow-up. We performed multivariate Cox regression models stratified by race (non-Hispanic white and non-Hispanic black) with time-varying covariates.

Results

We observed 4217 (27.76%) cases of incident diabetes over the survey period. The diabetes PGS was statistically significantly associated with diabetes onset for both non-Hispanic whites (hazard ratio [HR] = 1.38, 95% confidence interval [CI] = 1.30, 1.46) and non-Hispanic blacks (HR = 1.22, 95% CI = 1.06, 1.40) after adjusting for a range of known risk factors for diabetes, highlighting the critical role genetic endowment might play. Nevertheless, genetics do not downplay the role that modifiable characteristics could still play in diabetes management; even with the inclusion of the diabetes PGS, several behavioral and lifestyle characteristics remained significant for both race groups.

Conclusions

The effects of genetic and lifestyle characteristics should be taken into consideration for both future studies and diabetes management.

The effect of guideline revisions on vascular complications of type 2 diabetes

BACKGROUND

The aim of this study was to investigate the impact of implementation and revision of the 'Diabetes Mellitus type II' guideline by the Dutch College of General Practitioners (DCGP) on the prevalence and incidence of macrovascular and microvascular complications.

METHODS

The DiaGene study is a case-control study (n = 1886 patients of type 2 diabetes) with extensive, retrospectively collected complication data, as well as prospective follow up of complications. The study incorporates all lines of diabetes care. Cases were divided into categories according to the date of onset of diabetes and publication dates of the DCGP. Logistic regression models were used to investigate the associations between guideline version and complications. To investigate a possible trend between guideline version and complications, the 'guideline category' was also used as a continuous variable. All models were adjusted for clinical covariables.

RESULTS

The 1999 and 2006 guidelines versions were associated with significantly lower risk of retinopathy than the group that started without a guideline [OR 0.32 (95% CI 0.14-0.72, p = 0.006) and 0.31 (95% CI 0.11-0.91, p = 0.034), respectively]. A significant trend in reduction of peripheral artery disease (PAD) over the guideline versions was found, adjusted for age, sex and diabetes duration (odds ratio (OR) 0.70, 95% CI 0.51-0.97, p trend = 0.029) and for retinopathy in all models (OR = 0.52, 95% CI 0.37-0.73, p trend < 0.001).

CONCLUSIONS

The introduction of the first diabetes guideline and subsequent revisions have reduced the risk of macrovascular and microvascular complications of type 2 diabetes, most strongly in diabetic retinopathy. This indicates that real-time diabetes care has improved over time.

Dimethylguanidino Valerate: A Lifestyle-Related Metabolite Associated With Future Coronary Artery Disease and Cardiovascular Mortality

Background

Identification of lifestyle modifiable metabolic pathways related to cardiometabolic disease risk is essential for improvement of primary prevention in susceptible individuals. It was recently shown that plasma dimethylguanidino valerate (DMGV) levels are associated with incident type 2 diabetes mellitus. Our aims were to investigate whether plasma DMGV is related to risk of future coronary artery disease and with cardiovascular mortality and to replicate the association with type 2 diabetes mellitus and pinpoint candidate lifestyle interventions susceptible to modulate DMGV levels.

Methods and Results

Plasma DMGV levels were measured using liquid chromatography‐mass spectrometry in a total of 5768 participants from the MDC (Malmö Diet and Cancer Study—Cardiovascular Cohort), MPP (Malmö Preventive Project), and MOS (Malmö Offspring Study). Dietary intake assessment was performed in the MOS. Baseline levels of DMGV associated with incident coronary artery disease in both the MDC (hazard ratio=1.29; CI=1.16–1.43; P<0.001) and MPP (odds ratio=1.25; CI=1.08–1.44; P=2.4e‐3). In the MDC, DMGV was associated with cardiovascular mortality and incident coronary artery disease, independently of traditional risk factors. Furthermore, the association between DMGV and incident type 2 diabetes mellitus was replicated in both the MDC (hazard ratio=1.83; CI=1.63–2.05; P<0.001) and MPP (odds ratio=1.65; CI=1.38–1.98; P<0.001). Intake of sugar‐sweetened beverages was associated with increased levels of DMGV, whereas intake of vegetables and level of physical activity was associated with lower DMGV.

Conclusions

We discovered novel independent associations between plasma DMGV and incident coronary artery disease and cardiovascular mortality, while replicating the previously reported association with incident type 2 diabetes mellitus. Additionally, strong associations with sugar‐sweetened beverages, vegetable intake, and physical activity suggest the potential to modify DMGV levels using lifestyle interventions.

[Individualising antihypertensive therapy in patients with diabetes. A guideline by the Austrian Diabetes Association (Update 2019)]

Hypertension is one of the most important comorbidities of diabetes, contributing significantly to death and leads to macrovascular and microvascular complications. When assessing the medical priorities for patients with diabetes, treating hypertension should be a primary consideration. In the present review practical approaches to hypertension in diabetes, including individualized targets for preventing specific complications are discussed according to current studies and guidelines. According to recent studies, blood pressure values of about 130/80 mm Hg are associated with the best outcome. Angiotensin converting enzyme inhibitors and angiotensin receptor blockers are the most effective drugs for treating hypertension in diabetes. Calcium antagonists or diuretics are acceptable as second-line agents. Once the target is achieved, antihypertensive drugs should be continued. Newer antidiabetic medications such as SGLT-2-inhibitors or GLP1-receptor agonists have also antihypertensive effects.

Acute cardiovascular complications in patients with diabetes and hypertension: management consideration for minor oral surgery

Objectives

Medically compromised patients often fear required dental surgical procedures that can increase the risk of medical emergency when combined with reduced tolerance for stress. A stress reduction protocol (SRP) helps doctors minimize treatment-related stress and improves patient management with minimum complications. Diabetes and co-morbid hypertension carry 4-fold risk of aggravation of cardiovascular emergencies and 7.2-fold risk of mortality. Diabetic neuropathy can result in difficult diagnosis of myocardial infarction and reduces chances of surviving a myocardial infarction compared with a non-diabetic person. The aim of the study was to assess the feasibility of a protocol for management of patients having both diabetes and hypertension who required minor oral surgery to minimize the rate of cardiovascular emergencies.

Materials and Methods

A prospective study was conducted in 140 patients having both diabetes and hypertension who required minor oral surgical procedures. A systematic approachable protocol was designed for management of such patients.

Results

Among 140 patients, 6 patients (4.3%) had cardiovascular complications, while 3 patients (1 with syncope and 2 with hypertension) did not require any intervention other than observation. Two patients were managed with aspirin and nitroglycerin, and 1 patient had possible myocardial infarction (overall incidence 0.7%) with chest pain, S-T segment elevation on electrocardiogram, and troponin level of 0.60 ng/mL.

Conclusion

The proposed protocol helps to improve management of patients having both diabetes and hypertension. We recommend that patients with uncontrolled diabetes and uncontrolled hypertension and/or patients having history of cardiovascular complication should be treated in a medical facility with a readily available cardiology unit. This facilitates prompt response to emergency and instant implementation of treatment, helping to reduce morbidity and mortality.

Predicting the risk of stroke among patients with type 2 diabetes: a systematic review and meta-analysis of C-statistics

OBJECTIVE

Stroke is a major cause of disability and death worldwide. People with diabetes are at a twofold to fivefold increased risk for stroke compared with people without diabetes. This study systematically reviews the literature on available stroke prediction models specifically developed or validated in patients with diabetes and assesses their predictive performance through meta-analysis.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

A detailed search was performed in MEDLINE, PubMed and EMBASE (from inception to 22 April 2019) to identify studies describing stroke prediction models.

ELIGIBILITY CRITERIA

All studies that developed stroke prediction models in populations with diabetes were included.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently identified eligible articles and extracted data. Random effects meta-analysis was used to obtain a pooled C-statistic.

RESULTS

Our search retrieved 26 202 relevant papers and finally yielded 38 stroke prediction models, of which 34 were specifically developed for patients with diabetes and 4 were developed in general populations but validated in patients with diabetes. Among the models developed in those with diabetes, 9 reported their outcome as stroke, 23 reported their outcome as composite cardiovascular disease (CVD) where stroke was a component of the outcome and 2 did not report stroke initially as their outcome but later were validated for stroke as the outcome in other studies. C-statistics varied from 0.60 to 0.92 with a median C-statistic of 0.71 (for stroke as the outcome) and 0.70 (for stroke as part of a composite CVD outcome). Seventeen models were externally validated in diabetes populations with a pooled C-statistic of 0.68.

CONCLUSIONS

Overall, the performance of these diabetes-specific stroke prediction models was not satisfactory. Research is needed to identify and incorporate new risk factors into the model to improve models' predictive ability and further external validation of the existing models in diverse population to improve generalisability.

Smoking in men and women with type 2 diabetes: A qualitative gender-sensitive exploration of barriers to smoking cessation among people with type 2 diabetes

Objectives

Despite growing evidence of the impact of smoking on diabetes complications, people with type 2 diabetes still smoke at high rates and little is known about the specific barriers to quit smoking in this group. The purpose of this article is to explore the perception of smoking, and motivation and barriers to quit among smokers with type 2 diabetes. This exploratory study will help designing a smoking cessation intervention tailored to the needs of people with type 2 diabetes. We hypothesize both that living with diabetes and gender may raise additional difficulties to quit smoking.

Setting

The qualitative exploratory research included ten in-depth semi-structured individual interviews and five focus groups conducted in an Ambulatory Care University Hospital in Switzerland. The thematic analysis was conducted with a gender-sensitive focus.

Participants

Both current and former smokers recruited from the ambulatory clinic and the community took part in the qualitative interviews. We restricted the analysis to 21 current smokers only.

Results

The sample included 12 men and 9 women with type 2 diabetes, having a mean age of 59.4 years, who had diabetes for an average of 9 years with a mean HbA1c of 7.4%. We found that harmful effects of tobacco were superficially understood, and participants used several patterns of thinking to minimize the risks. The relation between tobacco and diabetes was poorly known. Readiness to change was related to personal self-image and meaningful engagement in life and social relationships. Barriers could be organized into three groups: dependence, psychological habits and social barriers. Barriers were markedly shaped by gender and living with diabetes.

Conclusions

Results suggest that “one -fits-all” smoking cessation interventions do not satisfy the needs of type 2 diabetic smokers. Personalized smoking cessation interventions should be preferred and should pursue positive psychological outcomes addressing contextual factors.

Survival, cardiovascular morbidity, and reinterventions after elective endovascular aortic aneurysm repair in patients with and without diabetes: A nationwide propensity-adjusted analysis

Epidemiological data indicate decreased risk for development and growth of abdominal aortic aneurysm (AAA) among patients with diabetes mellitus (DM). On the other hand, DM adds to increased cardiovascular (CV) morbidity and mortality. In a nationwide observational cohort study of patients registered in the Swedish Vascular Register and the Swedish National Diabetes Register, we evaluated potential effects of DM on total mortality, CV morbidity, and the need for reintervention after elective endovascular aneurysm repair (EVAR) for AAA. We compared 748 patients with and 2630 without DM with propensity score-adjusted analysis, during a median 4.22 years of follow-up for patients with DM, and 4.05 years for those without. In adjusted analysis, diabetic patients showed higher rates of acute myocardial infarction (AMI) during follow-up (relative risk (RR) 1.44, 95% CI 1.06-1.95; p = 0.02), but lower need for reintervention (RR 0.12, CI 0.02-0.91; p = 0.04). There were no differences in total (RR 0.88, CI 0.74-1.05; p = 0.15) or CV (RR 1.58, CI 0.87-2.86; p = 0.13) mortality, or stroke (RR 0.95, CI 0.68-1.32; p = 0.75) during follow-up. In conclusion, patients with DM had higher rates of AMI and lower need for reintervention after elective EVAR than those without DM, whereas neither total nor CV mortality differed between groups. The putative protective effects of DM towards further AAA enlargement and late sac rupture may help explain the lower need for reintervention and absence of excess mortality.

Suppression of Cardiac Autophagy by Hyperinsulinemia in Insulin Receptor-Deficient Hearts Is Mediated by Insulin-Like Growth Factor Receptor Signaling

Aims: Autophagy is a catabolic process required for the maintenance of cardiac health. Insulin and insulin-like growth factor 1 (IGF-1) are potent inhibitors of autophagy and as such, one would predict that autophagy will be increased in the insulin-resistant/diabetic heart. However, autophagy is rather decreased in the hearts of diabetic/insulin-resistant mice. The aim of this study is to determine the contribution of IGF-1 receptor signaling to autophagy suppression in insulin receptor (IR)-deficient hearts. Results: Absence of IRs in the heart was associated with reduced autophagic flux, and further inhibition of autophagosome clearance reduced survival, impaired contractile function, and enhanced myocyte loss. Contrary to the in vivo setting, isolated cardiomyocytes from IR-deficient hearts exhibited unrestrained autophagy in the absence of insulin, whereas addition of insulin was able to suppress autophagy. To investigate the mechanisms involved in the maintenance of the responsiveness to insulin in IR-deficient hearts, we generated mice lacking both IRs and one copy of the IGF-1 receptor (IGF-1R) in cardiac cells and showed that these mice had increased autophagy. Innovation and Conclusion: This study unveils a new mechanism by which IR-deficient hearts can still respond to insulin to suppress autophagy, in part, through activation of IGF-1R signaling. This is a highly significant observation because it is the first to show that systemic hyperinsulinemia can suppress autophagy in IR-deficient hearts through IGF-1R signaling.

Association between diabetes mellitus and the risk for major cardiovascular outcomes and all-cause mortality in women compared with men: a meta-analysis of prospective cohort studies

OBJECTIVE

Previous studies have reported sex differences in associations between diabetes mellitus (DM) and the risk of developing coronary heart disease (CHD) and stroke; however, the risk for cardiac death and all-cause mortality in women compared with men has not been reported. Therefore, this quantitative meta-analysis was performed to provide reliable estimates of sex differences in the effect of DM on major cardiovascular outcomes and all-cause mortality, irrespective of DM type.

DESIGN

Meta-analysis.

DATA SOURCES

The PubMed, Embase and the Cochrane Library databases were systematically searched in April 2018.

ELIGIBILITY CRITERIA

Investigations designed as prospective cohort studies that examined the association between DM and major cardiovascular outcomes and all-cause mortality stratified according to sex were included.

DATA EXTRACTION AND SYNTHESIS

Data extraction and quality assessment were independently performed by 2 of the authors, and the relative risk ratio (RRR) obtained using a random effects model was used to measure sex differences in the associations of DM with major cardiovascular outcomes and all-cause mortality.

RESULTS

Thirty prospective cohort studies that reported data from 1 148 188 individuals were included. The pooled women-to-men RRR suggested that female sex was associated with an increased risk for CHD (RRR 1.52(95% CI 1.32 to 1.76); p<0.001), stroke (RRR 1.23(95% CI 1.09 to 1.39); p=0.001), cardiac death (RRR 1.49(95% CI 1.11 to 2.00); p=0.009) and all-cause mortality (RRR 1.51(95% CI 1.23 to 1.85); p<0.001). In addition, sex differences for the investigated outcomes in the comparison between DM and non-DM patients were variable after stratification of studies according to publication year, country, sample size, assessment of DM, follow-up duration, adjustment for important cardiovascular risk factors and study quality.

CONCLUSIONS

Findings of the present study suggested that women with DM had an extremely high risk for CHD, stroke, cardiac death and all-cause mortality compared with men with DM.

Differential left ventricular and left atrial remodelling in heart failure with preserved ejection fraction patients with and without diabetes

BACKGROUND

Attempts to characterize cardiac structure in heart failure with preserved ejection fraction (HFpEF) in people with type 2 diabetes (T2D) have yielded inconsistent findings. We aimed to determine whether patients with HFpEF and T2D have a distinct pattern of cardiac remodelling compared with those without diabetes and whether remodelling was related to circulating markers of inflammation and fibrosis and clinical outcomes.

METHODS

We recruited 140 patients with HFpEF (75 with T2D and 65 without). Participants underwent comprehensive cardiovascular phenotyping, including echocardiography, cardiac magnetic resonance imaging and plasma biomarker profiling.

RESULTS

Patients with T2D were younger (age 70 ± 9 versus 75 ± 9y, p = 0.002), with evidence of more left ventricular (LV) concentric remodelling (LV mass/volume ratio 0.72 ± 0.15 versus 0.62 ± 0.16, p = 0.024) and smaller indexed left atrial (LA) volumes (maximal LA volume index 48 ± 20 versus 59 ± 29 ml/m2, p = 0.004) than those without diabetes. Plasma biomarkers of inflammation and extracellular matrix remodelling were elevated in those with T2D. Overall, there were 45 hospitalizations for HF and 22 deaths over a median follow-up period of 47 months [interquartile range (IQR) 38-54]. There was no difference in the primary composite endpoint of hospitalization for HF and mortality between groups. On multivariable Cox regression analysis, age, prior HF hospitalization, history of pulmonary disease and LV mass/volume were independent predictors of the primary endpoint.

CONCLUSIONS

Patients with HFpEF and T2D have increased concentric LV remodelling, smaller LA volumes and evidence of increased systemic inflammation compared with those without diabetes. This suggests the underlying pathophysiology for the development of HFpEF is different in patients with and without T2D.

CLINICALTRIALSGOV IDENTIFIER

NCT03050593.