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Li G, Zhong S, Wang X, Zhuge F. Association of hypoglycaemia with the risks of arrhythmia and mortality in individuals with diabetes - a systematic review and meta-analysis. Front Endocrinol (Lausanne) 2023; 14:1222409. [PMID: 37645418 PMCID: PMC10461564 DOI: 10.3389/fendo.2023.1222409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 07/24/2023] [Indexed: 08/31/2023] Open
Abstract
Background Hypoglycaemia has been linked to an increased risk of cardiac arrhythmias by causing autonomic and metabolic alterations, which may be associated with detrimental outcomes in individuals with diabetes(IWD), such as cardiovascular diseases (CVDs) and mortality, especially in multimorbid or frail people. However, such relationships in this population have not been thoroughly investigated. For this reason, we conducted a systematic review and meta-analysis. Methods Relevant papers published on PubMed, Embase, Cochrane, Web of Knowledge, Scopus, and CINHAL complete from inception to December 22, 2022 were routinely searched without regard for language. All of the selected articles included odds ratio, hazard ratio, or relative risk statistics, as well as data for estimating the connection of hypoglycaemia with cardiac arrhythmia, CVD-induced death, or total death in IWD. Regardless of the heterogeneity assessed by the I2 statistic, pooled relative risks (RRs) and 95% confidence intervals (CI) were obtained using random-effects models. Results After deleting duplicates and closely evaluating all screened citations, we chose 60 studies with totally 5,960,224 participants for this analysis. Fourteen studies were included in the arrhythmia risk analysis, and 50 in the analysis of all-cause mortality. Hypoglycaemic patients had significantly higher risks of arrhythmia occurrence (RR 1.42, 95%CI 1.21-1.68), CVD-induced death (RR 1.59, 95% CI 1.24-2.04), and all-cause mortality (RR 1.68, 95% CI 1.49-1.90) compared to euglycaemic patients with significant heterogeneity. Conclusion Hypoglycaemic individuals are more susceptible to develop cardiac arrhythmias and die, but evidence of potential causal linkages beyond statistical associations must await proof by additional specifically well planned research that controls for all potential remaining confounding factors.
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Affiliation(s)
- Gangfeng Li
- Clinical Laboratory Center, Shaoxing People’s Hospital, Shaoxing, Zhejiang, China
| | - Shuping Zhong
- Department of Hospital Management, Shaoxing People’s Hospital, Shaoxing, Zhejiang, China
| | - Xingmu Wang
- Clinical Laboratory Center, Shaoxing People’s Hospital, Shaoxing, Zhejiang, China
| | - Fuyuan Zhuge
- Department of Endocrine and Metabolism, Shaoxing People’s Hospital, Shaoxing, Zhejiang, China
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Katsiki N, Kotsa K, Stoian AP, Mikhailidis DP. Hypoglycaemia and Cardiovascular Disease Risk in Patients with Diabetes. Curr Pharm Des 2021; 26:5637-5649. [PMID: 32912117 DOI: 10.2174/1381612826666200909142658] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 08/09/2020] [Indexed: 12/12/2022]
Abstract
Hypoglycaemia represents an important side effect of insulin therapy and insulin secretagogues. It can occur in both type 1 and type 2 diabetes mellitus patients. Also, some associations between hypoglycaemia and cardiovascular (CV) risk have been reported. Several mechanisms may be involved, including the sympathoadrenal system, hypokalaemia, endothelial dysfunction, coagulation, platelets, inflammation, atherothrombosis and impaired autonomic cardiac reflexes. This narrative review discusses the associations of hypoglycaemia with CV diseases, including coronary heart disease (CHD), cardiac arrhythmias, stroke, carotid disease and peripheral artery disease (PAD), as well as with dementia. Severe hypoglycaemia has been related to CHD, CV and all-cause mortality. Furthermore, there is evidence supporting an association between hypoglycaemia and cardiac arrhythmias, potentially predisposing to sudden death. The data linking hypoglycaemia with stroke, carotid disease and PAD is limited. Several factors may affect the hypoglycaemia-CV relationships, such as the definition of hypoglycaemia, patient characteristics, co-morbidities (including chronic kidney disease) and antidiabetic drug therapy. However, the association between hypoglycaemia and dementia is bilateral. Both the disorders are more common in the elderly; thus, glycaemic goals should be carefully selected in older patients. Further research is needed to elucidate the impact of hypoglycaemia on CV disease.
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Affiliation(s)
- Niki Katsiki
- Division of Endocrinology and Metabolism, Diabetes Center, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Kalliopi Kotsa
- Division of Endocrinology and Metabolism, Diabetes Center, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Anca P Stoian
- Diabetes, Nutrition and Metabolic diseases Department, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, United Kingdom
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3
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Shacham EC, Nitzan R, Schwartz N, Ishay A. Effects of Recommendations for Diabetes Management at Hospital Discharge on Long-Term Diabetes Control. Endocr Pract 2021; 27:118-123. [PMID: 33616045 DOI: 10.1016/j.eprac.2020.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 08/28/2020] [Accepted: 09/17/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To determine the impact of diabetes-specific recommendations at 1 year after hospital discharge on glycemic control and diabetes care in an outpatient setting. METHODS A total of 139 patients with type 2 diabetes on a basal-bolus insulin regimen during hospitalization were included in the statistical analysis. We gathered data on treatment regimens after 12 to 16, 26 to 30, and 52 to 56 weeks following discharge as well as glycosylated hemoglobin (HbA1c) levels for all patients. Prescriptions for diabetes therapy were retrieved. All changes in insulin or oral/noninsulin injectable drug regimens were recorded. RESULTS Half of the patients (n = 69) were discharged on their preadmission regimen (no change), and a change in the home treatment was recommended in the other half (n = 70). In the group of patients whose preadmission therapy was adjusted, HbA1c decreased from 9.6% (80 mmol/mol) to 8.5% (69 mmol/mol) (P = .0004) 1 year after discharge. In the group of patients discharged on their preadmission regimen, no significant changes in HbA1c levels during the study were observed. At follow-ups occurring 12 to 16 weeks after discharge, 52% (95% CI: 37.4%-66.3%) of patients in the change group had their treatment modified, compared with 18.6% (95% CI: 9.7%-30.9%) in the no-change group. In the group of patients discharged on their preadmission regimen, no significant change was observed. At the beginning of the study, patients in the change treatment group had higher HbA1c levels than patients in the no-change group (9.6 ± 2.0 vs 8.6 ± 1.7, P < .001). At the end of the study, no significant changes in terms of HbA1c levels were found between the groups (8.8 ± 1.9 vs 8.5 ± 1.9, P = .2). CONCLUSIONS Significant improvement in diabetes control occurred 1 year after hospital discharge in patients who underwent modifications in their treatment. This supports the relevance of providing and implementing proper care recommendations at transition.
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Affiliation(s)
- Elena Chertok Shacham
- Endocrinology Unit; Internal Medicine Department E, Haemek Medical Center, Afula, Israel.
| | | | - Naama Schwartz
- Statistics Department, Carmel Medical Center, Haifa, Israel
| | - Avraham Ishay
- Endocrinology Unit; Technion - Ruth & Bruce Rappaport Faculty of Medicine, Haifa, Israel
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Koraćević G, Mićić S, Stojanović M, Tomašević M, Kostić T, Koraćević M, Janković I. Single prognostic cut-off value for admission glycemia in acute myocardial infarction has been used although high-risk stems from hyperglycemia as well as from hypoglycemia (a narrative review). Prim Care Diabetes 2020; 14:594-604. [PMID: 32988774 DOI: 10.1016/j.pcd.2020.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/30/2020] [Accepted: 09/10/2020] [Indexed: 01/08/2023]
Abstract
All original articles and meta-analysis use the single cut-off value to distinguish high-risk hyperglycemic from other acute myocardial infarction (AMI) patients. The mortality rate is 3.9 times higher in non-diabetic AMI patients with admission glycemia ≥6.1mmol compared to normoglycemic non-diabetic AMI patients. On the other hand, admission hypoglycemia in AMI is an important predictor of mortality. Because both admission hypo- and hyperglycemia correspond to higher in-hospital mortality, this graph is recognized as "J or U shaped curve". The review suggests two cut-off values for admission glycemia for risk assessment in AMI instead of single one because hypoglycemia as well as hyperglycemia represents a high-risk factor.
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Affiliation(s)
- Goran Koraćević
- Department for Cardiovascular Diseases, Clinical Center Niš, Serbia; Faculty of Medicine, University of Niš, Serbia
| | | | | | - Miloje Tomašević
- Faculty of Medicine, University of Belgrade, Department of Cardiology, Clinical Center Serbia, Belgrade, Serbia
| | - Tomislav Kostić
- Department for Cardiovascular Diseases, Clinical Center Niš, Serbia; Faculty of Medicine, University of Niš, Serbia
| | - Maja Koraćević
- Faculty of Medicine, University of Niš, Serbia; Innovation Center, University of Niš, Serbia
| | - Irena Janković
- Faculty of Medicine, University of Niš, Serbia; Clinic of Plastic and Reconstructive Surgery, Clinical Center Niš, Serbia
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Zaccardi F, Nystrup Husemoen LL, Thorsted BL, Webb DR, Paul SK, Davies MJ, Khunti K. Selectivity of beta-blockers, cardiovascular and all-cause mortality in people with hypoglycaemia: An observational study. Nutr Metab Cardiovasc Dis 2019; 29:481-488. [PMID: 30940488 DOI: 10.1016/j.numecd.2019.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/16/2019] [Accepted: 01/17/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND AIMS The association of beta-blockers and their selectivity with mortality and cardiovascular events in patients with and without hypoglycaemia is unknown. METHODS AND RESULTS Insulin-treated patients with diabetes were identified within the UK CPRD database. All-cause deaths, cardiovascular events, and hypoglycaemic episodes were captured to assess the interaction between beta-blocker therapy and selectivity with hypoglycaemia. 13,682 patients, of which 2036 (14.9%) with at least one hypoglycaemic episode, were included; 3148 deaths and 1235 cardiovascular events were recorded during a median of 2.3 and 4.7 years in patients with and without incident hypoglycaemia, respectively. Treatment with any beta-blocker was not associated with risk of death in both patients with and without hypoglycaemia, without significant interaction. Compared to no therapy, non-selective beta-blockers were associated with higher risk of death in patients without hypoglycaemia (hazard ratio (HR) 2.93 [1.26-6.83] in the fully adjusted model) but not in those with hypoglycaemia; interactions was not significant. For beta1-selective beta-blockers, there was no association with mortality in both patients with and without hypoglycaemia, without significant interaction. After missing data imputation, results were consistent for non-selective beta-blockers (HR in patients without hypoglycaemia 1.59 [1.22-2.08]) while indicated a reduced risk of death for beta1-selective beta-blockers in patients with hypoglycaemia (HR 0.76 [0.61-0.94]). Due to few cardiovascular events, complete-case analysis compared only any vs no beta-blocker therapy and indicated no associations with therapy or interaction by hypoglycaemia. CONCLUSION In patients with hypoglycaemic episodes, treatment with beta1-selective beta-blockers may potentially reduce the risk of death. These explorative findings and the potential role of confounding by indication need to be evaluated in other studies.
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Affiliation(s)
- F Zaccardi
- Diabetes Research Centre, University of Leicester, Gwendolen Rd, Leicester, LE5 4PW, UK.
| | | | - B L Thorsted
- Novo Nordisk A/S, Vandtårnsvej a08, b860, Søborg, Denmark
| | - D R Webb
- Diabetes Research Centre, University of Leicester, Gwendolen Rd, Leicester, LE5 4PW, UK
| | - S K Paul
- Melbourne EpiCentre, University of Melbourne and Melbourne Health, Level 7, East, c00 Grattan Street, Parkville Victoria, Melbourne, Australia
| | - M J Davies
- Diabetes Research Centre, University of Leicester, Gwendolen Rd, Leicester, LE5 4PW, UK
| | - K Khunti
- Diabetes Research Centre, University of Leicester, Gwendolen Rd, Leicester, LE5 4PW, UK
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Pieber TR, Marso SP, McGuire DK, Zinman B, Poulter NR, Emerson SS, Pratley RE, Woo V, Heller S, Lange M, Brown-Frandsen K, Moses A, Barner Lekdorf J, Lehmann L, Kvist K, Buse JB. DEVOTE 3: temporal relationships between severe hypoglycaemia, cardiovascular outcomes and mortality. Diabetologia 2018; 61:58-65. [PMID: 28913543 PMCID: PMC6002964 DOI: 10.1007/s00125-017-4422-0] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 08/25/2017] [Indexed: 11/15/2022]
Abstract
AIMS/HYPOTHESIS The double-blind Trial Comparing Cardiovascular Safety of Insulin Degludec vs Insulin Glargine in Patients with Type 2 Diabetes at High Risk of Cardiovascular Events (DEVOTE) assessed the cardiovascular safety of insulin degludec. The incidence and rates of adjudicated severe hypoglycaemia, and all-cause mortality were also determined. This paper reports a secondary analysis investigating associations of severe hypoglycaemia with cardiovascular outcomes and mortality. METHODS In DEVOTE, patients with type 2 diabetes were randomised to receive either insulin degludec or insulin glargine U100 (100 units/ml) once daily (between dinner and bedtime) in an event-driven, double-blind, treat-to-target cardiovascular outcomes trial. The primary outcome was the first occurrence of an adjudicated major adverse cardiovascular event (MACE; cardiovascular death, non-fatal myocardial infarction or non-fatal stroke). Adjudicated severe hypoglycaemia was the pre-specified secondary outcome. In the present analysis, the associations of severe hypoglycaemia with both MACE and all-cause mortality was evaluated in the pooled trial population using time-to-event analyses, with severe hypoglycaemia as a time-dependent variable and randomised treatment as a fixed factor. An investigation with interaction terms indicated that the effect of severe hypoglycaemia on the risk of MACE and all-cause mortality were the same for both treatment arms, and so the temporal association for severe hypoglycaemia with subsequent MACE and all-cause mortality is reported for the pooled population. RESULTS There was a non-significant difference in the risk of MACE for individuals who had vs those who had not experienced severe hypoglycaemia during the trial (HR 1.38, 95% CI 0.96, 1.96; p = 0.080) and therefore there was no temporal relationship between severe hypoglycaemia and MACE. There was a significantly higher risk of all-cause mortality for patients who had vs those who had not experienced severe hypoglycaemia during the trial (HR 2.51, 95% CI 1.79, 3.50; p < 0.001). There was a higher risk of all-cause mortality 15, 30, 60, 90, 180 and 365 days after experiencing severe hypoglycaemia compared with not experiencing severe hypoglycaemia in the same time interval. The association between severe hypoglycaemia and all-cause mortality was maintained after adjustment for the following baseline characteristics: age, sex, HbA1c, BMI, diabetes duration, insulin regimen, hepatic impairment, renal status and cardiovascular risk group. CONCLUSIONS/INTERPRETATION The results from these analyses demonstrate an association between severe hypoglycaemia and all-cause mortality. Furthermore, they indicate that patients who experienced severe hypoglycaemia were particularly at greater risk of death in the short term after the hypoglycaemic episode. These findings indicate that severe hypoglycaemia is associated with higher subsequent mortality; however, they cannot answer the question as to whether severe hypoglycaemia serves as a risk marker for adverse outcomes or whether there is a direct causal effect. TRIAL REGISTRATION ClinicalTrials.gov NCT01959529.
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Affiliation(s)
- Thomas R Pieber
- Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, A-8036, Graz, Austria.
| | | | - Darren K McGuire
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Neil R Poulter
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | | | - Richard E Pratley
- Florida Hospital Translational Research Institute for Metabolism and Diabetes, Orlando, FL, USA
- Sanford Burnham Prebys Medical Discovery Institute, Orlando, FL, USA
| | - Vincent Woo
- University of Manitoba, Winnipeg, MB, Canada
| | - Simon Heller
- Academic Unit of Diabetes, Endocrinology and Metabolism, University of Sheffield, Sheffield, UK
| | | | | | | | | | | | | | - John B Buse
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
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7
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Lee AK, Warren B, Lee CJ, McEvoy JW, Matsushita K, Huang ES, Sharrett AR, Coresh J, Selvin E. The Association of Severe Hypoglycemia With Incident Cardiovascular Events and Mortality in Adults With Type 2 Diabetes. Diabetes Care 2018; 41:104-111. [PMID: 29127240 PMCID: PMC5741158 DOI: 10.2337/dc17-1669] [Citation(s) in RCA: 127] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 10/11/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE There is suggestive evidence linking hypoglycemia with cardiovascular disease, but few data have been collected in a community-based setting. Information is lacking on individual cardiovascular outcomes and cause-specific mortality. RESEARCH DESIGN AND METHODS We conducted a prospective cohort analysis of 1,209 participants with diagnosed diabetes from the Atherosclerosis Risk in Communities (ARIC) study (analytic baseline, 1996-1998). Severe hypoglycemic episodes were identified using first position ICD-9 codes from hospitalizations, emergency department visits, and ambulance calls through 2013. Cardiovascular events and deaths were captured through 2013. We used adjusted Cox regression models with hypoglycemia as a time-varying exposure. RESULTS There were 195 participants with at least one severe hypoglycemic episode during a median fellow-up of 15.3 years. After severe hypoglycemia, the 3-year cumulative incidence of coronary heart disease was 10.8% and of mortality was 28.3%. After adjustment, severe hypoglycemia was associated with coronary heart disease (hazard ratio [HR] 2.02, 95% CI 1.27-3.20), all-cause mortality (HR 1.73, 95% CI 1.38-2.17), cardiovascular mortality (HR 1.64, 95% CI 1.15-2.34), and cancer mortality (HR 2.49, 95% CI 1.46-4.24). Hypoglycemia was not associated with stroke, heart failure, atrial fibrillation, or noncardiovascular and noncancer death. Results were robust within subgroups defined by age, sex, race, diabetes duration, and baseline cardiovascular risk. CONCLUSIONS Severe hypoglycemia is clearly indicative of declining health and is a potent marker of high absolute risk of cardiovascular events and mortality.
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Affiliation(s)
- Alexandra K Lee
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Bethany Warren
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Clare J Lee
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins School of Medicine, Baltimore, MD
| | - John W McEvoy
- Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Kunihiro Matsushita
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Elbert S Huang
- Section of Internal Medicine, University of Chicago Medicine, Chicago, IL
| | - A Richey Sharrett
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Josef Coresh
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Elizabeth Selvin
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Schnell O, Rydén L, Standl E, Ceriello A. Current perspectives on cardiovascular outcome trials in diabetes. Cardiovasc Diabetol 2016; 15:139. [PMID: 27716274 PMCID: PMC5045635 DOI: 10.1186/s12933-016-0456-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 09/23/2016] [Indexed: 12/23/2022] Open
Abstract
Cardiovascular disease (CVD) is one of the most common diabetes-associated complications, as well as a leading cause for death in type 2 diabetes patients (T2D). Despite the well-known correlation between the two, up until the 2008 FDA industry guidance for licensing of new anti-hyperglycemic drugs, which required an investigation of cardiovascular outcomes (CVO) of glucose-lowering agents, only a few studies had looked into the relationship between glucose lowering drugs and cardiovascular (CV) risk. Thereafter, CVOT design has focused on non-inferiority short-term studies on high-risk patient populations aiming at capturing CV safety issues. Despite the wealth of information and useful data provided by CVOTs, this approach still suffers from certain limitations. The present review will condense the main results of the most recently completed CVOTs, reflect on the lessons learned, discuss on the issues presented by current CVOT design and offer some suggestions for improvement.
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Affiliation(s)
- Oliver Schnell
- Forschergruppe Diabetes e.V., Munich, Ingolstaedter Landstrasse 1, 85764, Neuherberg (Munich), Germany.
| | - Lars Rydén
- Cardiology Unit, Department of Medicine K2, Karolinska Institutet, 171 76, Stockholm, Sweden
| | - Eberhard Standl
- Forschergruppe Diabetes e.V., Munich, Ingolstaedter Landstrasse 1, 85764, Neuherberg (Munich), Germany
| | - Antonio Ceriello
- Institut d'Investigacions Biomèdiques August Pi i Sunyer-IDIBAPS, Mallorca, 183, 08036, Barcelona, Spain.,IRCCS MultiMedica, Via Milanese, 300, 20099, Milan, Italy
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