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Bellis A, Mauro C, Barbato E, Ceriello A, Cittadini A, Morisco C. Stress-Induced Hyperglycaemia in Non-Diabetic Patients with Acute Coronary Syndrome: From Molecular Mechanisms to New Therapeutic Perspectives. Int J Mol Sci 2021; 22:E775. [PMID: 33466656 PMCID: PMC7828822 DOI: 10.3390/ijms22020775] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/08/2021] [Accepted: 01/10/2021] [Indexed: 01/08/2023] Open
Abstract
Stress-induced hyperglycaemia (SIH) at hospital admission for acute coronary syndrome is associated with poor outcome, especially in patients without known diabetes. Nevertheless, insulin treatment in these subjects was not correlated with the reduction of mortality. This is likely due to the fact that SIH in the context of an acute coronary syndrome, compared to that in known diabetes, represents an epiphenomenon of other pathological conditions, such as adrenergic and renin-angiotensin system over-activity, hyperglucagonaemia, increase of circulating free fatty acids and pancreatic beta-cell dysfunction, which are not completely reversed by insulin therapy and so worsen the prognosis. Thus, SIH may be considered not only as a biomarker of organ damage, but also as an indicator of a more complex therapeutic strategy in these subjects. The aim of this review is to analyse the molecular mechanisms by which SIH may favour a worse prognosis in non-diabetic patients with acute coronary syndrome and identify new therapeutic strategies, in addition to insulin therapy, for a more appropriate treatment and improved outcomes.
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Affiliation(s)
- Alessandro Bellis
- Unità Operativa Complessa Cardiologia con UTIC ed Emodinamica-Dipartimento Emergenza Accettazione, Azienda Ospedaliera “Antonio Cardarelli”, 80131 Napoli, Italy; (A.B.); (C.M.)
| | - Ciro Mauro
- Unità Operativa Complessa Cardiologia con UTIC ed Emodinamica-Dipartimento Emergenza Accettazione, Azienda Ospedaliera “Antonio Cardarelli”, 80131 Napoli, Italy; (A.B.); (C.M.)
| | - Emanuele Barbato
- Dipartimento di Scienze Biomediche Avanzate, Università Federico II, 80131 Napoli, Italy;
| | - Antonio Ceriello
- Department of Cardiovascular and Metabolic Diseases, IRCCS Multimedica, Sesto San Giovanni, 20099 Milan, Italy;
| | - Antonio Cittadini
- Dipartimento di Scienze Mediche Traslazionali, Università Federico II, 80131 Napoli, Italy;
| | - Carmine Morisco
- Dipartimento di Scienze Biomediche Avanzate, Università Federico II, 80131 Napoli, Italy;
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Propofol cardioprotection for on-pump aortocoronary bypass surgery in patients with type 2 diabetes mellitus (PRO-TECT II): a phase 2 randomized-controlled trial. Can J Anaesth 2015; 63:442-53. [DOI: 10.1007/s12630-015-0580-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 09/30/2015] [Accepted: 12/22/2015] [Indexed: 01/10/2023] Open
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Huber AH, Kampf JP, Kwan T, Zhu B, Adams J, Kleinfeld AM. Usefulness of serum unbound free fatty acid levels to predict death early in patients with ST-segment elevation myocardial infarction (from the Thrombolysis In Myocardial Infarction [TIMI] II trial). Am J Cardiol 2014; 113:279-84. [PMID: 24176067 DOI: 10.1016/j.amjcard.2013.08.057] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Revised: 08/28/2013] [Accepted: 08/28/2013] [Indexed: 12/13/2022]
Abstract
Circulating total free fatty acid (FFA) levels are elevated early in myocardial infarction (MI) and have been associated with an increase in mortality. We investigated the association of serum unbound FFA (FFAu) levels with mortality in patients presenting with ST-segment elevation MI in the Thrombolysis In Myocardial Infarction II trial. The Thrombolysis In Myocardial Infarction II trial enrolled patients within 4 hours of chest pain onset. The patients were treated with a recombinant tissue plasminogen activator within 1 hour of enrollment. The FFAu concentration was evaluated in serum samples from 1,834 patients obtained at baseline, before therapy. The FFAu level was an independent risk factor for death as early as at 1 day of hospitalization and continued to be an independent risk factor for the >3.8 years of follow-up. When adjusted for other cardiovascular risk factors, the FFAu levels in the fourth versus the first quartile remained an independent risk factor for death from MI (hazard ratio 5.0, 95% confidence interval 1.9 to 13.0), all cardiac death (hazard ratio 2.4, 95% confidence interval 1.3 to 4.4), and all-cause death (hazard ratio 1.9, 95% confidence interval 1.2 to 3.1). Women were twice as likely to be in the upper 2 FFAu quartiles and had approximately twice the rate of death as men. In conclusion, FFAu elevation is 1 of the earliest molecular biomarkers of mortality in patients with ST-segment elevation MI and was independent of other risk factors known to affect the outcomes after ST-segment elevation MI.
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Grossman AN, Opie LH, Beshansky JR, Ingwall JS, Rackley CE, Selker HP. Glucose-insulin-potassium revived: current status in acute coronary syndromes and the energy-depleted heart. Circulation 2013; 127:1040-8. [PMID: 23459576 DOI: 10.1161/circulationaha.112.130625] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
CONTEXT Recent studies on mediators of inflammation, experimental models of atherosclerosis, and acute ischemia have identified novel mechanisms through which insulin may exert cardiovascular protective effects. This review aims to summarize current knowledge regarding the cardiovascular, antiinflammatory, and antiatherogenic effects of insulin, and the effect of intensive glycemic control in acute cardiovascular disease. EVIDENCE ACQUISITION Publications of interest were identified using preselected MeSH terminology and keywords to search online databases such as PubMed and OVID for the period January 1988 to February 2012. Relevant publications were obtained and reviewed by two independent observers, then evaluated a priori against the following criteria: study quality, main clinical outcomes, and applicability to clinical practice. EVIDENCE SYNTHESIS Insulin has been shown to exert vasodilatory, antiinflammatory, and antiatherogenic effects in experimental models, independent of its glucose-lowering effects. Additionally, glucose is known to exert potent proinflammatory, prothrombotic, and proapoptotic effects during myocardial infarct, indicative that hyperglycemia is likely to be injurious to the heart. In this context, through its nonmetabolic and metabolic (glucose-lowering) effects, insulin is likely to be cardioprotective and to improve clinical outcomes in acute myocardial infarction. CONCLUSIONS Despite promising experimental data and evidence of benefit from single-center randomized clinical trials, clinical evidence supporting the cardioprotective effects of insulin from a multicenter randomized clinical trial is still lacking. Future prospective studies with insulin infused at adequate concentrations, individually titrated to achieve and maintain euglycemia (blood glucose < 140 mg/dl) and minimize hypoglycemia, are required to investigate the role of insulin in the management of patients with acute cardiovascular disease.
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Affiliation(s)
- Ajay Chaudhuri
- Diabetes-Endocrinology Center of Western New York, Division of Endocrinology, Kaleida Health/Millard Fillmore Hospital, Buffalo, New York, USA
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Dyslipidemia: a prospective controlled randomized trial of intensive glycemic control in sepsis. Intensive Care Med 2012; 38:634-41. [DOI: 10.1007/s00134-011-2458-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Accepted: 12/20/2011] [Indexed: 02/04/2023]
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de Mulder M, Umans VA, Stam F, Cornel JH, Oemrawsingh RM, Boersma E. Intensive management of hyperglycaemia in acute coronary syndromes. Study design and rationale of the BIOMArCS 2 glucose trial. Diabet Med 2011; 28:1168-75. [PMID: 21480974 DOI: 10.1111/j.1464-5491.2011.03307.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Elevated admission plasma glucose is associated with increased mortality in patients who are admitted with an acute coronary syndrome. This may be mediated by increased inflammation, apoptosis and coagulation, and by a disturbed endothelial function that can be found in hyperglycaemic patients. Insulin has several characteristics that may potentially counteract these mechanisms. METHODS The BIOMArCS programme is a multi-centre initiative and currently consists of three different studies. The effects of acute coronary syndrome on acute biomarkers washout are studied in the BIOMArCS pilot and the value of biomarkers in predicting upcoming acute coronary syndrome events is studied in BIOMArCS 1. The third study (BIOMArCS 2 glucose), which will be presented here, investigates the effectiveness and safety of intensive glucose level control compared with conventional glucose management in patients with acute coronary syndrome and an admission plasma glucose of 7.8-16 mmol/l. In BIOMArCS 2 glucose, a total of 300 patients without insulin-treated diabetes mellitus will be randomized in a 1:1 ratio to either intensive or conventional glucose management on top of standard medical care. The primary endpoint is infarct size as expressed by the cardiac troponin T level 72 h after admission. To study the metabolic effects of insulin administration, we will investigate biomarker washout patterns of various metabolic mechanisms up to 7 days after admission. These markers will address inflammation, oxidative stress, hypercoagulability, endothelial activation and vasodilatation. IMPLICATIONS Current acute coronary syndrome guidelines lack a clear strategy for hyperglycaemia treatment. This study will extend our knowledge on this matter as it may clarify mechanisms and generate hypotheses of if and how myocardial infarct size may be limited by glucose management at admission.
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Affiliation(s)
- M de Mulder
- Department of Cardiology, Medical Centre Alkmaar, Alkmaar, The Netherlands
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Scherer T, O'Hare J, Diggs-Andrews K, Schweiger M, Cheng B, Lindtner C, Zielinski E, Vempati P, Su K, Dighe S, Milsom T, Puchowicz M, Scheja L, Zechner R, Fisher SJ, Previs SF, Buettner C. Brain insulin controls adipose tissue lipolysis and lipogenesis. Cell Metab 2011; 13:183-94. [PMID: 21284985 PMCID: PMC3061443 DOI: 10.1016/j.cmet.2011.01.008] [Citation(s) in RCA: 152] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Revised: 09/14/2010] [Accepted: 12/06/2010] [Indexed: 01/14/2023]
Abstract
White adipose tissue (WAT) dysfunction plays a key role in the pathogenesis of type 2 diabetes (DM2). Unrestrained WAT lipolysis results in increased fatty acid release, leading to insulin resistance and lipotoxicity, while impaired de novo lipogenesis in WAT decreases the synthesis of insulin-sensitizing fatty acid species like palmitoleate. Here, we show that insulin infused into the mediobasal hypothalamus (MBH) of Sprague-Dawley rats increases WAT lipogenic protein expression, inactivates hormone-sensitive lipase (Hsl), and suppresses lipolysis. Conversely, mice that lack the neuronal insulin receptor exhibit unrestrained lipolysis and decreased de novo lipogenesis in WAT. Thus, brain and, in particular, hypothalamic insulin action play a pivotal role in WAT functionality.
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Affiliation(s)
- Thomas Scherer
- Department of Medicine, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1055, New York, NY 10029-6574, USA
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Dandona P, Chaudhuri A, Ghanim H, Mohanty P. Insulin as an anti-inflammatory and antiatherogenic modulator. J Am Coll Cardiol 2009; 53:S14-20. [PMID: 19179212 DOI: 10.1016/j.jacc.2008.10.038] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Revised: 10/03/2008] [Accepted: 10/07/2008] [Indexed: 01/08/2023]
Abstract
Data demonstrate the anti-inflammatory effects of insulin and proinflammatory effects of glucose. These data provide a mechanistic justification for the benefits of maintaining euglycemia with insulin infusions in hospitalized patients. Regimens that infuse fixed doses of insulin with high rates of glucose are usually associated with hyperglycemia, which may neutralize the beneficial effects of insulin. Therefore, we propose that such regimens should be avoided and instead replaced by insulin infusions that normalize and maintain blood glucose at a reasonably low level and ensure that plasma insulin is maintained at levels high enough to provide clinically relevant anti-inflammatory and cardioprotective effects. Trials to test this hypothesis are in progress.
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Catalyurek H, Oktay G, Guzeloglu M, Çavdar Z, Acikel U, Silistreli E, Hazan E. Insulin—Blood Cardioplegia Decreases Matrix Metalloproteinase Activity in Ischaemia-reperfusion Injury during Coronary Artery Bypass Surgery. J Int Med Res 2008; 36:551-8. [DOI: 10.1177/147323000803600321] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Reperfusion of myocardium during coronary bypass activates matrix metalloproteinases (MMPs) with changes occurring in the levels of tissue inhibitors of metalloproteinases (TIMPs) in the myocardium. This study investigated the effects of insulin-blood cardioplegia on MMP activity and TIMP levels during reperfusion. Non-diabetic patients undergoing coronary artery bypass graft with cardiopulmonary bypass were randomized into a control group ( n = 12) or an insulin group ( n = 12). Blood cardioplegia was used for both groups; insulin and glucose were added to the insulin group. Blood samples were obtained from the coronary sinus just before aortic cross clamping and after 1 and 30 min of reperfusion. Plasma proenzyme MMPs (proMMP-2 and −9) and TIMPs (TIMP-1 and TIMP-2) levels were measured. There were no differences between groups for MMP-2 and TIMP-2 levels. However, insulin diminished proMMP-9 activation, although some still occurred. TIMP-1 consumption lessened during reperfusion which, we conclude, was as a result of the diminished MMP activation. This is the first open heart surgery study in which diminished MMP activation was achieved via a metabolic change.
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Affiliation(s)
- H Catalyurek
- Department of Cardiovascular Surgery, Dokuz Eylül University Medical School, Balcova, Izmir, Turkey
| | - G Oktay
- Department of Biochemistry, Dokuz Eylül University Medical School, Balcova, Izmir, Turkey
| | - M Guzeloglu
- Department of Cardiovascular Surgery, Dokuz Eylül University Medical School, Balcova, Izmir, Turkey
| | - Z Çavdar
- Department of Biochemistry, Dokuz Eylül University Medical School, Balcova, Izmir, Turkey
| | - U Acikel
- Department of Cardiovascular Surgery, Dokuz Eylül University Medical School, Balcova, Izmir, Turkey
| | - E Silistreli
- Department of Cardiovascular Surgery, Dokuz Eylül University Medical School, Balcova, Izmir, Turkey
| | - E Hazan
- Department of Cardiovascular Surgery, Dokuz Eylül University Medical School, Balcova, Izmir, Turkey
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Dandona P, Chaudhuri A, Ghanim H, Mohanty P. Potential use of insulin as an anti-inflammatory drug. Drug Dev Res 2008. [DOI: 10.1002/ddr.20233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Opie LH. Metabolic Management of Acute Myocardial Infarction Comes to the Fore and Extends Beyond Control of Hyperglycemia. Circulation 2008; 117:2172-7. [DOI: 10.1161/circulationaha.108.780999] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Lionel H. Opie
- From the Hatter Cardiovascular Research Institute, Department of Medicine, University of Cape Town, South Africa
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Dandona P, Chaudhuri A, Ghanim H, Mohanty P. Use of insulin to improve glycemic control in diabetes mellitus. Cardiovasc Drugs Ther 2008; 22:241-51. [PMID: 18347965 DOI: 10.1007/s10557-008-6101-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2008] [Accepted: 02/19/2008] [Indexed: 01/08/2023]
Abstract
BACKGROUND The restoration of normoglycemia ensures the control of diabetic symptoms and reduction in microangiopathic complications in type 1 and type 2 diabetes. However, there is no conclusive evidence that intensive glycemic control alone will prevent macrovascular disease, the commonest cause of morbidity and mortality in type 2 diabetes. As atherosclerosis is an inflammatory condition, it is relevant that the two common insulin resistant states of obesity and type 2 diabetes have significant inflammatory processes, which promote atherosclerosis. It is also relevant that glucose has been shown to have profound effects on the endothelial cell, the leukocyte and the platelet. These effects include the induction of acute oxidative and inflammatory stress and a prothrombotic and pro-apoptotic effect following glucose intake. In contrast insulin has been shown to exert several biological effects at physiologically relevant concentrations, in relation to the endothelial cell, the platelet and leucocyte function, which may be cardioprotective and potentially anti-atherosclerotic. CONCLUSION These findings are of great interest as it is possible that the prevention of macrovascular complications in type 2 diabetes may require the use of those glucose lowering drugs which have additional anti-inflammatory effects in addition to the control of comorbid conditions (hypertension and dyslipidemia) associated with this disease. Results of future clinical trials are awaited to confirm the benefits of this approach in the primary and secondary prevention of macrovascular complications in type 2 diabetes.
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Affiliation(s)
- Paresh Dandona
- Division of Endocrinology, Diabetes and Metabolism, State University of New York at Buffalo, Buffalo, NY 14209, USA.
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