Circulating Cardiac Biomarkers in Diabetes Mellitus: A New Dawn for Risk Stratification-A Narrative Review

A Carrier-Based Quantitative Proteomics Method Applied to Biomarker Discovery in Pericardial Fluid

Data-dependent liquid chromatography tandem mass spectrometry is challenged by the large concentration range of proteins in plasma and related fluids. We adapted the SCoPE method from single-cell proteomics to pericardial fluid, where a myocardial tissue carrier was used to aid protein quantification. The carrier proteome and patient samples were labeled with distinct isobaric labels, which allowed separate quantification. Undepleted pericardial fluid from patients with type 2 diabetes mellitus and/or heart failure undergoing heart surgery was analyzed with either a traditional liquid chromatography tandem mass spectrometry method or with the carrier proteome. In total, 1398 proteins were quantified with a carrier, compared to 265 without, and a higher proportion of these proteins were of myocardial origin. The number of differentially expressed proteins also increased nearly four-fold. For patients with both heart failure and type 2 diabetes mellitus, pathway analysis of upregulated proteins demonstrated the enrichment of immune activation, blood coagulation, and stress pathways. Overall, our work demonstrates the applicability of a carrier for enhanced protein quantification in challenging biological matrices such as pericardial fluid, with potential applications for biomarker discovery. Mass spectrometry data are available via ProteomeXchange with identifier PXD053450.

Paper title: Therapeutic effect of Momordica charantia on cardiomyopathy in a diabetic maternal rat model

Myocardial structural and functional abnormalities are hallmarks of diabetic cardiomyopathy (DCM), a chronic consequence of diabetes mellitus (DM). Maternal DM affects and increases the risk of heart defects in diabetic mothers compared with nondiabetic mothers. Momordica charantia exhibits antidiabetic effects due to various bioactive compounds that are phytochemicals, a broad group that includes phenolic compounds, alkaloids, proteins, steroids, inorganic compounds, and lipids. Pregnant maternal rats were split into four groups: control (C), M. charantia-treated (MC), type 2 diabetes mellitus (T2DM) (DM), and diabetic (MC + DM) groups. Diabetes mothers had increased serum glucose, insulin, total cholesterol, triglyceride, and low-density lipoprotein cholesterol levels and reduced high-density lipoprotein cholesterol levels. Cardiac biomarkers such as cardiac troponin T (cTnT), creatine kinase-myocardial band (CK-MB), and lactate dehydrogenase were increased. Hormone levels of follicle-stimulating hormone, luteinizing hormone, progesterone, and estrogen decreased significantly. Inflammatory markers such as interleukin 6 (IL-6), tumor necrosis factor-alpha (TNF-α), and vascular adhesion molecule-1 (VCAM-1) were elevated in diabetic mothers. Oxidative stress markers indicated increased malondialdehyde and nitric oxide levels, while antioxidants such as glutathione, superoxide dismutase, and catalase were decreased in maternal heart tissue. The levels of apoptotic markers such as tumor suppressor 53 (P53) and cysteine aspartic protease-3 (caspase-3) were significantly greater in diabetic maternal heart tissue. Histopathological analysis revealed heart tissue abnormalities in diabetic maternal rats. M. charantia extract improved maternal diabetes-induced changes in inflammation, antioxidant levels, and heart tissue structure.

Global longitudinal strain and plasma biomarkers for prognosis in heart failure complicated by diabetes: a prospective observational study

BACKGROUND

Heart failure (HF) and diabetes are associated with increased incidence and worse prognosis of each other. The prognostic value of global longitudinal strain (GLS) measured by cardiovascular magnetic resonance (CMR) has not been established in HF patients with diabetes.

METHODS

In this prospective, observational study, consecutive patients (n = 315) with HF underwent CMR at 3T, including GLS, late gadolinium enhancement (LGE), native T1, and extracellular volume fraction (ECV) mapping. Plasma biomarker concentrations were measured including: N-terminal pro B-type natriuretic peptide(NT-proBNP), high-sensitivity troponin T(hs-TnT), growth differentiation factor 15(GDF-15), soluble ST2(sST2), and galectin 3(Gal-3). The primary outcome was a composite of all-cause mortality or HF hospitalisation.

RESULTS

Compared to those without diabetes (n = 156), the diabetes group (n = 159) had a higher LGE prevalence (76 vs. 60%, p < 0.05), higher T1 (1285±42 vs. 1269±42ms, p < 0.001), and higher ECV (30.5±3.5 vs. 28.8±4.1%, p < 0.001). The diabetes group had higher NT-pro-BNP, hs-TnT, GDF-15, sST2, and Gal-3. Diabetes conferred worse prognosis (hazard ratio (HR) 2.33 [95% confidence interval (CI) 1.43-3.79], p < 0.001). In multivariable Cox regression analysis including clinical markers and plasma biomarkers, sST2 alone remained independently associated with the primary outcome (HR per 1 ng/mL 1.04 [95% CI 1.02-1.07], p = 0.001). In multivariable Cox regression models in the diabetes group, both GLS and sST2 remained prognostic (GLS: HR 1.12 [95% CI 1.03-1.21], p = 0.01; sST2: HR per 1 ng/mL 1.03 [95% CI 1.00-1.06], p = 0.02).

CONCLUSIONS

Compared to HF patients without diabetes, those with diabetes have worse plasma and CMR markers of fibrosis and a more adverse prognosis. GLS by CMR is a powerful and independent prognostic marker in HF patients with diabetes.

Predictive value of serum irisin for chronic heart failure in patients with type 2 diabetes mellitus

We hypothesize that serum irisin can have additional discriminative potency for heart failure (HF) in individuals with type 2 diabetes mellitus (T2DM). The study group comprised 226 consecutive T2DM patients (153 patients with any HF phenotypes and 30 patients without HF) aged 41 to 65 years. The plasma levels N-terminal brain natriuretic pro-peptide (NT-proBNP) and irisin were detected by ELISA at the baseline of the study. We found that the most appropriate cut-off value of irisin (HF versus non-HF) were 10.4 ng/mL (area under curve [AUC] = 0.96, sensitivity = 81.0%, specificity = 88.0%; P = 0.0001). Cutoff point of NT-proBNP that distinguished patients with HF and without it was 750 pmol/L (AUC = 0.78; sensitivity = 72.7%, specificity 76.5%, p = 0.0001). Using multivariate comparative analysis we established that concentrations of irisin < 10.4 ng/mL (odds ration [OR] = 1.30; P = 0.001) and NT-proBNP > 750 pmol/mL (OR = 1.17; P = 0.042), left atrial volume index (LAVI) > 34 mL/m² (OR = 1.06; P = 0.042) independently predicted HF. Irisin being added to NT-proBNP improved predictive modality for HF, whereas combination of NT-proBNP and LAVI > 34 mL/m² did not. In conclusion, we established that irisin had independent predicted potency for HF in patients with established T2DM.

Discriminative Value of Serum Irisin in Prediction of Heart Failure with Different Phenotypes among Patients with Type 2 Diabetes Mellitus

Recent studies have shown that circulating levels of irisin are prognostic factors in heart failure (HF), but no data are available on the predictive role of irisin in patients with type 2 diabetes mellitus (T2DM) and different phenotypes of HF. The aim of the study was to investigate whether serum levels of irisin predict HF in T2DM patients. We prospectively included 183 participants with T2DM aged 41 to 62 years (30 non-HF patients and 153 HF patients) and 25 healthy volunteers in the study and evaluated clinical data, hemodynamics and biomarkers (N-terminal pro-brain natriuretic peptide (NT-proBNP) and irisin). Serum levels of irisin < 8.30 ng/mL were found to be a better indicator of HF with reduced ejection fraction (HFrEF) than irisin ≥ 8.30 ng/mL, but the predictive cut-off point for NT-proBNP remained the same as for HF with mildly reduced ejection fraction (HFmrEF). Serum levels of irisin < 10.4 ng/mL significantly improved the predictive ability of NT-proBNP for HF with preserved ejection fraction (HFpEF). In conclusion, we found that decreased serum levels of irisin significantly predicted HFpEF, rather than HFmrEF and HFrEF, in T2DM patients. This finding may open a new approach to HF risk stratification in T2DM patients.

Salidroside attenuates cardiac dysfunction in a rat model of diabetes

AIM

This study aimed to investigate the therapeutic effects of salidroside on diabetes-induced cardiovascular disease.

METHODS

Sprague-Dawley rats treated with 65 mg/kg of streptozotocin (STZ) on a daily basis were used to establish the diabetic rat model (blood glucose levels >13.9 mmol/L). Cardiac functions of diabetic rats were evaluated by their haemodynamic alterations. Western blot assay was performed to evaluate the protein levels of multiple signalling pathway factors. Quantitative real-time PCR assay was performed to investigate the inflammation and oxidative stress of diabetic rats.

RESULTS

Salidroside treatment improved the cardiac functions of diabetic rats. In addition, salidroside therapy attenuated the cardiac oxidative stress induced by diabetes. Salidroside inhibited the diabetes-induced inflammation in diabetic rat hearts. The apoptosis of cardiomyocytes was also alleviated by the treatment of salidroside. Salidroside also upregulated the phosphorylation levels of AMPK, ACC, TSC2 and RAPTOR.

CONCLUSION

Salidroside exerts protective effects against diabetes-induced cardiac dysfunction by modulating the mTOR and AMPK signalling pathways.

Discriminative Utility of Apelin-to-NT-Pro-Brain Natriuretic Peptide Ratio for Heart Failure with Preserved Ejection Fraction among Type 2 Diabetes Mellitus Patients

BACKGROUND

Apelin is a regulatory vasoactive peptide, which plays a pivotal role in adverse cardiac remodeling and heart failure (HF) with reduced ejection fraction. The purpose of the study was to investigate whether serum levels of apelin is associated with HF with preserved election fraction (HFpEF) in patients with T2DM.

METHODS

The study retrospectively involved 101 T2DM patients aged 41 to 62 years (48 patients with HFpEF and 28 non-HFpEF patients). The healthy control group consisted of 25 individuals with matched age and sex. Data collection included demographic and anthropometric information, hemodynamic performances and biomarkers of the disease. Transthoracic B-mode echocardiography, Doppler and TDI were performed at baseline. Serum levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) and apelin were measured by ELISA in all patients at the study entry.

RESULTS

Unadjusted multivariate logistic model yielded the only apelin to NT-proBNP ratio (OR = 1.44; p = 0.001), BMI > 34 кг/м2 (OR = 1.07; p = 0.036), NT-proBNP > 458 pmol/mL (OR = 1.17; p = 0.042), LAVI > 34 mL/m2 (OR = 1.06; p = 0.042) and E/e' > 11 (OR = 1.04; p = 0.044) remained to be strong predictors for HFpEF. After obesity adjustment, multivariate logistic regression showed that the apelin to NT-proBNP ratio < 0.82 × 10-2 units remained sole independent predictor for HFpEF (OR = 1.44; 95% CI: 1.18-2.77; p = 0.001) HFpEF in T2DM patients. In conclusion, we found that apelin to NT-proBNP ratio < 0.82 × 10-2 units better predicted HFpEF in T2DM patients than apelin and NT-proBNP alone. This finding could open new approach for CV risk stratification of T2DM at higher risk of HF.

Markedly elevated troponin and NT-proBNP and myocardial dysfunction in an adolescent with severe diabetic ketoacidosis: a case report

Severe diabetic ketoacidosis (DKA), rarely, may be associated with elevated troponin and proBNP levels in adults with a history of diabetes. However, few cases have reported this association in children with severe and complicated DKA. We describe a case of severe DKA (pH: 6.89, HCO3: 6.5) in a 14-yr-old female adolescent in which the symptoms of DKA were presented days before the diagnosis. The patient was under the effect of acidosis (Kussmaul respiration) for 12 h before admission to our hospital, where she was admitted in a critical clinical condition. After successful treatment with DKA with intensive intravenous fluid and regular insulin, the patient presented with abnormal cardiac rhythm, disturbance of interventricular septum motility, a mild decrease in left ventricular systolic function, negative T waves in leads III and aVF, and a marked increase in troponin and brain natriuretic peptide (NT-proBNP) levels. All abnormal findings completely resolved within 8 days after the initiation of DKA treatment. The phenomenon in our case was transient, and the patient had a good long-term outcome. However, it represents a challenge for clinicians; therefore, emphasis should be given to cardiac monitoring during the course of severe and prolonged DKA in children and adolescents.

Association between Markers of Fibrosis and Heart Failure Incidence in Patients with Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (T2DM) and chronic heart failure (HF) have close association, and several biomarkers have been studied to better understand this association and improve prediction of HF in T2DM. Furthermore, in recent clinical trials, sodium glucose cotransporter 2 inhibitors (SGLT2i), glucose-lowering drugs, improved HF outcomes. The objective of the present study was to evaluate association between circulating biomarkers of fibrosis and incidence of HF with preserved ejection fraction (HFpEF) in patients with T2DM receiving sodium glucose cotransporter 2 inhibitors (SGLT2i). Materials and Methods. At baseline, transthoracic echocardiography and laboratory assessment of N-terminal fragment of the brain natriuretic peptide (Nt-proBNP), soluble suppression of tumorigenesis-2 (sST2), galectin-3 (Gal-3), C-terminal propeptide of procollagen type I (PICP), N-terminal propeptide of procollagen type III (PIIINP), matrix metalloproteinase-9 (MMP-9), and tissue inhibitor of matrix proteinase-1 (TIMP-1) were done. After 3 years of follow-up, information about HF events (hospitalization for HF, established HF in outpatient department by a cardiologist) was obtained. Results. Seventy-two patients were included in the study. The mean age was 57 (49.7; 63.2) years; 44% were female. Most patients had T2DM for more than 4 years. All patients were overweight or had obesity, and 93% patients had arterial hypertension (AH). After 3 years of follow-up, HFpEF was established in 21% patients. Patients were divided into two groups according to the presence of HFpEF, and baseline characteristics were compared. Patients with HF were older and had longer diabetes and AH duration and higher Nt-proBNP, Gal-3, PIIINP, and PICP levels at baseline than patients without HF (all p < 0.05). Gal - 3 > 10 ng/ml (OR = 2.25; 95% CI, 1.88-5.66; p = 0.01) and NT - pro - BNP > 80 pg/ml (OR = 2.64; 95% CI, 1.56-4.44; p = 0.001) were associated with increased risk of HF incidence. Age > 60 years, diabetes duration > 10 years, and presence of abdominal obesity were independent predictors of HFpEF as well. Conclusions. T2DM patients treated with SLGT2i, who developed HFpEF after 3 years of follow-up, had higher PICP, PIIINP, Gal-3, and NT-proBNP serum concentrations at baseline, and Gal-3 level was an independent predictor of HFpEF.

Role of novel biomarkers in diabetic cardiomyopathy

Diabetic cardiomyopathy (DCM) is commonly defined as cardiomyopathy in patients with diabetes mellitus in the absence of coronary artery disease and hypertension. As DCM is now recognized as a cause of substantial morbidity and mortality among patients with diabetes mellitus and clinical diagnosis is still inappropriate, various expert groups struggled to identify a suitable biomarker that will help in the recognition and management of DCM, with little success so far. Hence, we thought it important to address the role of biomarkers that have shown potential in either human or animal studies and which could eventually result in mitigating the poor outcomes of DCM. Among the array of biomarkers we thoroughly analyzed, long noncoding ribonucleic acids, soluble form of suppression of tumorigenicity 2 and galectin-3 seem to be most beneficial for DCM detection, as their plasma/serum levels accurately correlate with the early stages of DCM. The combination of relatively inexpensive and accurate speckle tracking echocardiography with some of the highlighted biomarkers may be a promising screening method for newly diagnosed diabetes mellitus type 2 patients. The purpose of the screening test would be to direct affected patients to more specific confirmation tests. This perspective is in concordance with current guidelines that accentuate the importance of an interdisciplinary team-based approach.

Heart Failure and Diabetes Mellitus: Biomarkers in Risk Stratification and Prognostication

Heart failure (HF) and type 2 diabetes mellitus (T2DM) have a synergistic effect on cardiovascular (CV) morbidity and mortality in patients with established CV disease (CVD). The aim of this review is to summarize the knowledge regarding the discriminative abilities of conventional and novel biomarkers in T2DM patients with established HF or at higher risk of developing HF. While conventional biomarkers, such as natriuretic peptides and high-sensitivity troponins demonstrate high predictive ability in HF with reduced ejection fraction (HFrEF), this is not the case for HF with preserved ejection fraction (HFpEF). HFpEF is a heterogeneous disease with a high variability of CVD and conventional risk factors including T2DM, hypertension, renal disease, older age, and female sex; therefore, the extrapolation of predictive abilities of traditional biomarkers on this population is constrained. New biomarker-based approaches are disputed to be sufficient for improving risk stratification and the prediction of poor clinical outcomes in patients with HFpEF. Novel biomarkers of biomechanical stress, fibrosis, inflammation, oxidative stress, and collagen turn-over have shown potential benefits in determining prognosis in T2DM patients with HF regardless of natriuretic peptides, but their role in point-to-care and in routine practice requires elucidation in large clinical trials.

The Interplay Between the Immune System, the Renin-Angiotensin-Aldosterone System (RAAS), and RAAS Inhibitors May Modulate the Outcome of COVID-19: A Systematic Review

Since the discovery of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), numerous research has been undertaken to delineate the various effects of the virus which manifests in many ways all over the body. The association between the SARS-CoV-2 invasion mechanism and the renin-angiotensin-aldosterone system (RAAS) receptors, created many debates about the possible consequences of using RAAS-modulating drugs including angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARBs) during the pandemic. Many clinical studies were conducted to assess the outcomes of coronavirus disease 2019 (COVID-19) in patients who use ACEi/ARBs following the arguments claiming to discontinue these drugs as a precautionary measure. Although several studies mainly analyzed the outcomes of the disease, this review aimed to compare specific blood markers in both groups of COVID-19 patients to gain better insight into the interaction of ACEi/ARBs with different body functions during the infection. Several databases were searched using a combination of keywords followed by screening and data extraction. Only 28 studies met our inclusion criteria, the majority of which showed no significant difference between the inflammation markers of COVID-19 patients who used or did not use ACEi/ARBs. Interestingly, 6 studies reported lower inflammatory markers in COVID-19 patients who used ACEi/ARBs, and 6 studies reported better outcomes among the same group. We therefore concluded that the use of ACEi/ARBs may not lead to worse prognosis of COVID-19 and may even play a protective role against the hyperinflammatory response associated with COVID-19.

Insulin Resistance Indexes as Biomarkers of Lifetime Cardiovascular Risk among Adults from Peru

Background

Cardiovascular disease (CVD) is the most prevalent cause of death from disease and disability in the world. Reliable markers are needed to assess and reduce cardiovascular risk. This study aimed to determine if insulin resistance indexes, triglycerides to HDL-cholesterol ratio (TG/HDL-C), and triglyceride glucose index (TyG) are biomarkers for lifetime cardiovascular risk (CVR).

Methods

This analytical cross-sectional study was performed on health personnel from Huaycan Hospital in Peru. The QRISK model was used to measure lifetime CVR. The association and diagnostic accuracy for TyG calculated as Ln (TG (mg/dL) × glucose (mg/dL)/2) and TG/HDL-C ratio were determined using Poisson regression models and ROC curves with Youden index.

Results

In total, 291 adults (207 women and 84 men) were analyzed. In the adjusted Poisson models, each unit of TG/HDL-C increased 1.22-fold and 1.16-fold the probability of high lifetime CVR in men and women, respectively. However, each unit of TyG increased 1.98-fold in men and 3.25-fold in women the probability of high lifetime CVR. The optimal cutoff values of TG/HDL-C were 2.64 (AUC: 0.77), 3.90 (AUC: 0.80), and 2.64 (AUC: 0.74) for the overall population, men, and women, respectively. Likewise, the optimal cutoff values of TyG were 9.04 (AUC: 0.80), 8.95 (AUC: 0.79), and 9.04 (AUC: 0.80) for the overall population, men, and women, respectively.

Conclusion

TG/HDL-C and TyG presented a significant association with lifetime CVR. However, TyG presented a stronger association than TG/HDL-C. Both TG/HDL-C and TyG are shown to be reliable markers for CVR in adults.

INTERRELATIONS BETWEEN GROWTH DIFFERENTIATION FACTOR 15, P-SELECTIN AND GALECTIN-3 AND CLINICAL COURSE IN PATIENTS WITH ARTERIAL HYPERTENSION AND TYPE 2 DIABETES MELLITUS

The aim of our study was to determine the base levels of Growth Differentiation Factor 15, P-selectin and Galectin-3 in blood plasma in patients with AH and T2DM and to assess their association with the diseases clinical course. Materials and methods. A total of 121 patients were included in our study (60 female and 61 male, mean age 64.7±10.6 years, with AH and/or T2DM). Patients were divided into three groups: 1st group with AH only (51 patient), 2nd group with AH and T2DM (57 patients) and 3rd group with T2DM only (13 patients, control group). GDF-15, Galectin-3 and P-selectin tests were performed using standard enzyme-linked immunosorbent assay kits (ELISA). Results. Compared with AH without T2DM and T2DM only groups, AH with T2DM group had a statistically significant higher level of GDF-15. Grade 3 hypertension group had a significantly lower level of GDF-15 compared with Grade 1&2 hypertension groups. P-selectin mean level was significantly higher in Grade 3 hypertension group GDF-15 compared with Grade 1&2 hypertension groups. We observed weak correlation between Galectin-3 and GDF-15 in blood plasma, which was confirmed by linear regression analysis. Conclusions. A combination of hypertension and type 2 diabetes mellitus revealed a significant increase of GDF-15 levels in compare with patients with only hypertension or type 2 diabetes mellitus, which may be due to a greater response to oxidative stress and low-intensity systemic inflammation. P-selectin mean level was higher in patients with grade 3 hypertension, which reflects a greater platelet activation as a part of the systemic inflammatory response. Galectin-3 mean level was higher in patients with stage 3 hypertension compared with patients with stages 1 and 2 due to possibly more pronounced fibrosis progression.