Insulin resistance and atrial fibrillation (from the Framingham Heart Study)

Association between estimated glucose disposal rate and atrial fibrillation recurrence in patients undergoing radiofrequency catheter ablation: a retrospective study

OBJECTIVE

Previous studies have shown a clear link between insulin resistance (IR) and an elevated risk of atrial fibrillation (AF). However, the relationship between the estimated glucose disposal rate (eGDR), which serves as a marker for IR, and the risk of AF recurrence after radiofrequency catheter ablation (RFCA) remains uncertain. Therefore, this study aimed to examine the potential association between the eGDR and the risk of AF recurrence following RFCA.

METHODS

This retrospective study was conducted at Nanchang University Affiliated Second Hospital. The study enrolled 899 patients with AF who underwent RFCA between January 2015 and January 2022. The formula used to calculate the eGDR was as follows: 19.02 - (0.22 * body mass index) - (3.26 * hypertension) - (0.61 * HbA1c). Cox proportional hazard regression models and exposure-effect curves were used to explore the correlation between the baseline eGDR and AF recurrence. The ability of the eGDR to predict AF recurrence was evaluated using the area under the receiver operating characteristic curve (AUROC).

RESULTS

The study observed a median follow-up period of 11.63 months, during which 296 patients experienced AF recurrence. K‒M analyses revealed that the cumulative incidence AF recurrence rate was significantly greater in the group with the lowest eGDR (log-rank p < 0.01). Participants with an eGDR ≥ 8 mg/kg/min had a lower risk of AF recurrence than those with an eGDR < 4 mg/kg/min, with a hazard ratio (HR) of 0.28 [95% confidence interval (CI) 0.18, 0.42]. Additionally, restricted cubic spline analyses demonstrated a linear association between the eGDR and AF recurrence (p nonlinear = 0.70). The area under the curve (AUC) for predicting AF recurrence using the eGDR was 0.75.

CONCLUSIONS

The study revealed that a decrease in the eGDR is associated with a greater AF recurrence risk after RFCA. Hence, the eGDR could be used as a novel biomarker for assessing AF recurrence risk.

Mendelian randomization study on insulin resistance and risk of hypertension and cardiovascular disease

Observational studies have suggested that insulin resistance (IR) is associated with hypertension and various cardiovascular diseases. However, the presence of a causal relationship between IR and cardiovascular disease remains unclear. Here, we applied Mendelian randomization (MR) approaches to address the causal association between genetically determined IR and the risk of cardiovascular diseases. Our primary genetic instruments comprised 53 SNPs associated with IR phenotype from a GWAS of up to 188,577 participants. Genetic association estimates for hypertension and venous thromboembolism (VTE) were extracted from UK Biobank, estimates for atrial fibrillation (AF) were extracted from the hitherto largest GWAS meta-analysis on AF, estimates for heart failure were extracted from HERMES Consortium, estimates for peripheral artery disease (PAD) and aortic aneurysm were extracted from the FinnGen Study. The main analyses were performed using the random-effects inverse-variance weighted approach, and complemented by sensitivity analyses and multivariable MR analyses. Corresponding to 55% higher fasting insulin adjusted for body mass index, 0.46 mmol/L lower high-density lipoprotein cholesterol and 0.89 mmol/L higher triglyceride, one standard deviation change in genetically predicted IR was associated with increased risk of hypertension (odds ratio (OR) 1.06, 95% CI 1.04-1.08; P = 1.91 × 10-11) and PAD (OR 1.90, 95% CI 1.43-2.54; P = 1.19 × 10-5). Suggestive evidence was obtained for an association between IR and heart failure (OR per SD change in IR: 1.19, 95% CI 1.01-1.41, P = 0.041). There was no MR evidence for an association between genetically predicted IR and atrial fibrillation, VTE, and aortic aneurysm. Results were widely consistent across all sensitivity analyses. In multivariable MR, the association between IR and PAD was attenuated after adjustment for lipids (P = 0.347) or BMI (P = 0.163). Our findings support that genetically determined IR increases the risk of hypertension and PAD.

Non-insulin-based insulin resistance indexes in predicting atrial fibrillation recurrence following ablation: a retrospective study

BACKGROUND

Insulin resistance (IR) is involved in the pathophysiological processes of arrhythmias. Increasing evidence suggests triglyceride and glucose (TyG) index, metabolic score for insulin resistance (METS-IR), triglyceride glucose-body mass index (TyG-BMI), and triglyceride to high-density lipoprotein cholesterol (TG/HDL-C) ratio are simple and reliable surrogates for IR. Although they have been associated with atrial fibrillation (AF), evidence supporting this is limited. Here, this is the first study to investigate the association between TyG-BMI index and AF recurrence following radiofrequency catheter ablation (RFCA). The performance of the four non-insulin-based IR indexes in predicting AF recurrence after ablation was explored.

METHODS

A total of 2242 AF patients who underwent a de novo RFCA between June 2018 to January 2022 at two hospitals in China were included in this retrospective study. The predictive values of IR indexes for AF recurrence after ablation were assessed.

RESULTS

During 1-year follow-up, 31.7% of patients experienced AF recurrence. The multivariable analysis revealed that TyG index, METS-IR, and TyG-BMI index were independent risk factors for AF recurrence. Restricted cubic spline analysis revealed a connection between METS-IR, TyG-BMI index, and AF recurrence (P < 0.001). Furthermore, incorporating the METS-IR or TyG-BMI index to the basic risk model with fully adjusted factors considerably enhanced the forecast of AF recurrence, as demonstrated by the C-statistic, continuous net reclassification improvement, and integrated discrimination improvement.

CONCLUSIONS

TyG index, METS-IR, and TyG-BMI index were independently associated with AF recurrence following ablation. Among the four non-insulin-based IR indexes, TyG-BMI had the highest predictive value, followed by METS-IR.

Assessing the association between triglyceride-glucose index and atrial fibrillation: a systematic review and meta-analysis

BACKGROUND

An essential relationship between insulin resistance (IR) and atrial fibrillation (AF) has been demonstrated. Among the methods used to assess IR, the triglyceride-glucose (TyG) index is the more straightforward, dimensionless, and low-cost tool. However, the possible usage of this index in clinical practice to predict and diagnose AF has yet to be determined and consolidated.

OBJECTIVE AND RATIONALE

Herein, we performed a systematic review and meta-analysis to assess the association between the TyG index and AF.

METHODS

Databases (PubMed, Embase, Scopus, and Web of Science) were systematically searched for studies evaluating the TyG index in AF. The inclusion criteria were observational studies investigating AF and TyG index correlation in individuals older than 18 years, while preclinical studies and those without the relevant data were excluded. Random effect meta-analyses comparing TyG levels between AF and non-AF cases, AF recurrence after radiofrequency ablation, and post-procedural AF were performed using standardized mean differences (SMD) with their matching 95% confidence intervals (CIs).

RESULTS

Our screening identified nine studies to be analyzed, including 6,171 participants including 886 with AF. The meta-analysis demonstrated that the TyG index resulted higher in patients with AF than non-AF counterparts (SMD 1.23, 95% CI 0.71 to 1.75, I2 98%, P < 0.001). Subgroup analysis showed the same results for post-procedure AF (SMD 0.99, 95% CI 0.78 to 1.20, I2 10%, P < 0.001) and post-ablation AF (SMD 1.25, 95% CI 1.07 to 1.43, I2 46%, P < 0.001), while no difference was found in population-based cohorts (SMD 1.45, 95% CI - 0.41 to 3.31, I2 100%, P = 0.13). Publication year (P = 0.036) and sample size (P = 0.003) showed significant associations with the effect size, using multivariable meta-regression.

CONCLUSION

The TyG index is an easy-to-measure surrogate marker of IR in patients with AF. Further clinical studies are warranted to demonstrate its ability for routine clinical use and as a screening tool.

The association between triglyceride glucose-body mass index and all-cause mortality in critically ill patients with atrial fibrillation: a retrospective study from MIMIC-IV database

BACKGROUND

The TyG-BMI index, which is a reliable indicator of insulin resistance (IR), has been found to have a significant correlation with the occurrence of cardiovascular events. However, there still lacks study on the TyG-BMI index and prognosis in patients with atrial fibrillation (AF). The objective of the present study was to evaluate the relationship between TyG-BMI index at admission to ICU and all-cause mortality in critically ill patients with AF.

METHODS

The patient's data were extracted from Medical Information Mart for Intensive Care IV(MIMIC-IV) database. All patients were divided into four groups according to TyG-BMI index. Outcomes include primary and secondary endpoints, with the primary endpoint being the 30-day and 365-day all-cause mortality and the secondary endpoint being the 90-day and 180-day all-cause mortality. TyG-BMI index was quartile and Kaplan-Meier curve was used to compare the outcome of each group. Cox proportional-hazards regression model and restricted cubic splines (RCS) were conducted to assess the relationship between TyG-BMI index and outcomes.

RESULTS

Out of a total of 2509 participants, the average age was 73.26 ± 11.87 years, with 1555 (62.0%) being males. Patients with lower level of TyG-BMI had higher risk of 30-day, 90-day, 180-day and 365-day all-cause mortality, according to the Kaplan-Meier curves (log-rank P < 0.001). In addition, cox proportional-hazards regression analysis revealed that the risk of 30-day, 90-day, 180-day and 365-day all-cause mortality was significantly higher in the lowest quartile of TyG-BMI. Meanwhile, the RCS analysis indicated that L-typed relationships between TyG-BMI index and all-cause mortality, with inflection points at 223.60 for 30-day and 255.02 for 365-day all-cause mortality, respectively. Compared to patients with TyG-BMI levels below the inflection points, those with higher levels had a 1.8% lower risk for 30-day all-cause mortality (hazard ratio [HR] 0.982, 95% confidence interval [CI] 0.9676-0.988) and 1.1% lower risk for 365-day all-cause mortality (HR 0.989, 95% CI 0.986-0.991).

CONCLUSION

In critically ill patients with AF, a lower TyG-BMI level is significantly associated with a higher risk of 30-day, 90-day, 180-day and 365-day all-cause mortality. TyG-BMI index could be used as a valid indicator for grading and treating patients with AF in the ICU.

Metabolic Inflexibility as a Pathogenic Basis for Atrial Fibrillation

Atrial fibrillation (AF), the most common sustained arrhythmia, is closely intertwined with metabolic abnormalities. Recently, a metabolic paradox in AF pathogenesis has been suggested: under different forms of pathogenesis, the metabolic balance shifts either towards (e.g., obesity and diabetes) or away from (e.g., aging, heart failure, and hypertension) fatty acid oxidation, yet they all increase the risk of AF. This has raised the urgent need for a general consensus regarding the metabolic changes that predispose patients to AF. “Metabolic flexibility” aptly describes switches between substrates (fatty acids, glucose, amino acids, and ketones) in response to various energy stresses depending on availability and requirements. AF, characterized by irregular high-frequency excitation and the contraction of the atria, is an energy challenge and triggers a metabolic switch from preferential fatty acid utilization to glucose metabolism to increase the efficiency of ATP produced in relation to oxygen consumed. Therefore, the heart needs metabolic flexibility. In this review, we will briefly discuss (1) the current understanding of cardiac metabolic flexibility with an emphasis on the specificity of atrial metabolic characteristics; (2) metabolic heterogeneity among AF pathogenesis and metabolic inflexibility as a common pathological basis for AF; and (3) the substrate-metabolism mechanism underlying metabolic inflexibility in AF pathogenesis.

The pre-ablation triglyceride-glucose index predicts late recurrence of atrial fibrillation after radiofrequency ablation in non-diabetic adults

Background

Current prognostic risk scoring systems and biomarkers are routinely used as non-invasive methods for assessing late recurrence of atrial fibrillation (AF) in patients who have undergone radiofrequency catheter ablation (RFCA). This study aimed to investigate the predictive value of the triglyceride-glucose (TyG) index for late AF recurrence after RFCA in non-diabetic patients.

Methods

In total, 275 patients with AF who underwent RFCA at the Fuwai hospital (Beijing, China) between January 2016 and December 2018 were enrolled in this study. During follow up, patients were divided into late and non-late AF recurrence groups, based on whether they had experienced late AF recurrence determined by electrocardiography (ECG) examine or 48 h Holter monitoring. The TyG index was calculated using the following equation: ln [fasting triglycerides [mg/dL] × fasting glucose [mg/dL]/2].

Results

During a median follow-up of 26.1 months, late AF recurrence event rates significantly increased in the highest TyG index tertile group (tertile 3) compared to the lowest group (tertile 1) (54% versus 12%, respectively; p < 0.001). The mean TyG index was higher in the late AF recurrence group compared to the non- late AF recurrence group (9.42 ± 0.6 versus 8.68 ± 0.70, respectively; p < 0.001). On multivariate Cox regression analysis, the pre-ablation TyG index was an independent risk factor for late recurrence of AF after RFCA (hazard ratio [HR] 2.015 [95% confidence interval (CI): 1.408–4.117]; p = 0.009). Receiver operating characteristic (ROC) curve analysis revealed that TyG index was a significant predictor of late AF recurrence after RFCA, with an area under the ROC curve (AUC) of 0.737 (95% CI: 0.657–0.816; p < 0.001). In addition, the AUC of left atrial diameter (LAD) was 0.780 (95%CI: 0.703–0.857, p < 0.001). Finally, the TyG index positively correlated with LAD (r = 0.133, p = 0.027), high sensitivity C-reactive protein (r = 0.132, p = 0.028) and N-terminal pro B-type natriuretic peptide (r = 0.291, p < 0.001) levels.

Conclusions

An elevated pre-ablation TyG index was associated with an increased risk of late AF recurrence after RFCA in non-diabetic patients. The TyG index may be potentially useful as a novel biomarker for the risk stratification of late AF recurrence in non-diabetic patients.

Pathophysiological aspects of insulin resistance in Atrial Fibrillation: novel therapeutic approaches

Background

Insulin resistance is associated with metabolic disorders including diabetes, obesity, hypertension, and inflammation which are the risk factors for Atrial Fibrillation. Many studies have reported that type 2 diabetes and AF are related and also their prevalence is increasing globally. Moreover, insulin resistance begins the type 2 diabetes.

Main body

This review explains the pathophysiological aspects of insulin resistance in AF patients and discusses the drugs that are used to manage insulin resistance including Biguanides (metformin), thiazolidinediones (TZDs) [Pioglitazone, rosiglitazone], Sodium-glucose cotransporter 2 (SGLT2) inhibitors, Concentrated Insulin Products, Dipeptidyl peptidase-4 (DPP-4) Inhibitors, Glucagon-like peptide 1 (GLP-1) receptor Agonists, Pramlintide, Sulfonylureas, Meglitinides, α-Glucosidase Inhibitors, Colesevelam, Bromocriptine. This review will highlight a few major drugs that played a significant role in AF patients. For this purpose, many databases were used for reviewing the literature and keywords are used such as Insulin Resistance, Pathophysiology, Atrial Fibrillation, and Drugs.

Conclusion

This review article concludes that insulin resistance is related to AF. It also provides an outlook on the recent pathophysiological aspects of insulin resistance in AF; however, more studies are needed to clarify the management of insulin resistance in AF patients to prevent the development of type 2 diabetes.

Association between triglyceride-glucose index and atrial fibrillation: A retrospective observational study

BACKGROUND

Insulin resistance is associated with atrial remodeling as well as atrial fibrillation (AF). However, there was limited evidence on the relationship of triglyceride-glucose index (TyG) index, a simple, valuable marker of insulin resistance, with AF. Thus, we aimed to investigate the association between TyG index and AF among hospitalized patients.

METHODS

A retrospective observational study was conducted in Daping Hospital, which included 356 hospitalized patients from the Department of Cardiology. Clinical and biochemical parameters were collected from electronic medical records and AF was diagnosed from electrocardiogram (ECG) findings.

RESULTS

We found that the TyG index was significantly higher in the AF group than in the group without AF. Multivariate logistic regression revealed that hypertension (OR = 1.756, 95%CI 1.135-2.717, P = 0.011) and TyG index (OR = 2.092, 95%CI 1.412-3.100, P<0.001) were positively associated with AF. The analysis of the area under the ROC curve was performed and revealed that area under curve (AUC) of TyG index was 0.600 (95%CI, 0.542-0.659, P = 0.001), the optimal critical value was 8.35, the sensitivity was 65.4%, and the specificity was 52.0%. Additional subgroup analyses of diabetic and non-diabetic subjects were also performed and found the TyG index was increased in non-diabetic subjects with AF. Furthermore, a logistic regression analysis showed TyG index was associated with AF (OR = 3.065, 95% CI, 1.819-5.166, P<0.001) in non-diabetic subjects. However, TyG index was not associated with AF in diabetic subjects.

CONCLUSION

Elevated TyG index is an independent risk factor for AF among non-diabetic hospitalized patients.

Association between Atrial Fibrillation and Advanced Liver Fibrosis in Patients with Non-Alcoholic Fatty Liver Disease

PURPOSE

Non-alcoholic fatty liver disease (NAFLD) is independently associated with the development of atrial fibrillation (AF). However, the association of AF with advanced liver fibrosis, which is related to all-cause, cardiovascular, and liver-related mortality, has not been established in NAFLD patients. We aimed to investigate the association between AF and advanced liver fibrosis in NAFLD patients.

MATERIALS AND METHODS

Out of 53704 adults who participated in the health check-up program, 6293 subjects aged 35 years and older were diagnosed as NAFLD using ultrasound. The stage of liver fibrosis was assessed based on the newly adjusted NAFLD fibrosis score (NFS) and Fibrosis-4 (Fib-4) Index, which were used to determine the low and high cut-off values (COVs).

RESULTS

Of 6293 patients with NAFLD, 59 (0.9%) were diagnosed with AF. Patients with AF were older (52.0 vs. 64.6 years, p<0.001), had higher body mass index (25.2 vs. 26.6 kg/m², p<0.001), and had bigger waist circumference (84.0 vs. 89.9 cm, p<0.001) than those without AF. In NAFLD patients, AF was independently associated with advanced liver fibrosis, assessed using both COVs of NFS [low-COV group: final adjusted odds ratios (aORs)=2.85, p=0.004; high-COV group: ORs=12.29, p<0.001). AF was independently associated with advanced liver fibrosis, assessed using both COVs of Fib-4 (low-COV group: aORs=2.49, p<0.001; high-COV group: aORs=3.84, p=0.016).

CONCLUSION

AF is independently associated with advanced liver fibrosis in patients with NAFLD.

Chronic kidney disease and undiagnosed atrial fibrillation in individuals with diabetes

Background

Diabetes is an independent risk factor for atrial fibrillation (AF), which is associated with increases in mortality and morbidity, as well as a diminished quality of life. Renal involvement in diabetes is common, and since chronic kidney disease (CKD) shares several of the same putative mechanisms as AF, it may contribute to its increased risk in individuals with diabetes. The objective of this study is to identify the relationship between CKD and the rates of newly-diagnosed AF in individuals with diabetes taking part in a screening program using a self-applied wearable electrocardiogram (ECG) patch.

Materials and methods

The study included 608 individuals with a diagnosis of diabetes among 1738 total actively monitored participants in the prospective mHealth Screening to Prevent Strokes (mSToPS) trial. Participants, without a prior diagnosis of AF, wore an ECG patch for 2 weeks, twice, over a 4-months period and followed clinically through claims data for 1 year. Definitions of CKD included ICD-9 or ICD-10 chronic renal failure diagnostic codes, and the Health Profile Database algorithm. Individuals requiring dialysis were excluded from trial enrollment.

Results

Ninety-six (15.8%) of study participants with diabetes also had a diagnosis of CKD. Over 12 months of follow-up, 19 new cases of AF were detected among the 608 participants. AF was newly diagnosed in 7.3% of participants with CKD and 2.3% in those without (P < 0.05) over 12 months of follow-up. In a univariate Cox proportional hazard regression analysis, the risk of incident AF was 3 times higher in individuals with CKD relative to those without CKD: hazard ratios (HR) 3.106 (95% CI 1.2–7.9). After adjusting for the effect of age, sex, and hypertension, the risk of incident AF was still significantly higher in those with CKD: HR 2.886 (95% CI 1.1–7.5).

Conclusion

Among individuals with diabetes, CKD significantly increases the risk of incident AF. Identification of AF prior to clinical symptoms through active ECG screening could help to improve the clinical outcomes in individuals with CKD and diabetes.

Association between insulin resistance and risk of atrial fibrillation in non-diabetics

AIMS

Previous studies from Western countries have been unable to demonstrate a relationship between insulin resistance and new-onset atrial fibrillation. We aimed to evaluate this relationship in the nondiabetic Asian population.

METHODS

Between 2001-2003, 8175 adults (mean age 51.5 years, 53% women) without both existing atrial fibrillation and diabetes and with insulin resistance measures at baseline were enrolled and were followed by biennial electrocardiograms thereafter until 2014. We constructed multivariable-adjusted Cox proportional hazard models for risk of incident atrial fibrillation.

RESULTS

Over a median follow-up of 12.3 years, 136 participants (1.89/1000 person-years) developed atrial fibrillation. Higher homeostasis model assessment of insulin resistance (HOMA-IR) was independently associated with newly developed atrial fibrillation (hazard ratio 1.61, 95% confidence interval 1.14-2.28). Atrial fibrillation development increased at the HOMA-IR levels approximately between 1-2.5, and then plateaued afterwards (p = 0.031).

CONCLUSION

There is a significant relationship between insulin resistance and atrial fibrillation development independent of other known risk factors, including obesity in a nondiabetic Asian population.

Porcine models for studying complications and organ crosstalk in diabetes mellitus

The worldwide prevalence of diabetes mellitus and obesity is rapidly increasing not only in adults but also in children and adolescents. Diabetes is associated with macrovascular complications increasing the risk for cardiovascular disease and stroke, as well as microvascular complications leading to diabetic nephropathy, retinopathy and neuropathy. Animal models are essential for studying disease mechanisms and for developing and testing diagnostic procedures and therapeutic strategies. Rodent models are most widely used but have limitations in translational research. Porcine models have the potential to bridge the gap between basic studies and clinical trials in human patients. This article provides an overview of concepts for the development of porcine models for diabetes and obesity research, with a focus on genetically engineered models. Diabetes-associated ocular, cardiovascular and renal alterations observed in diabetic pig models are summarized and their similarities with complications in diabetic patients are discussed. Systematic multi-organ biobanking of porcine models of diabetes and obesity and molecular profiling of representative tissue samples on different levels, e.g., on the transcriptome, proteome, or metabolome level, is proposed as a strategy for discovering tissue-specific pathomechanisms and their molecular key drivers using systems biology tools. This is exemplified by a recent study providing multi-omics insights into functional changes of the liver in a transgenic pig model for insulin-deficient diabetes mellitus. Collectively, these approaches will provide a better understanding of organ crosstalk in diabetes mellitus and eventually reveal new molecular targets for the prevention, early diagnosis and treatment of diabetes mellitus and its associated complications.

Atrial fibrillation and its arrhythmogenesis associated with insulin resistance

Background

Insulin resistance (IR) is considered as a risk factor for atrial fibrillation (AF) even before diabetes develops. The pathophysiology and underlying mechanism are largely unclear.

Methods

We investigated the corresponding mechanism in two IR models of rats fed 15-week high-fat (HFa) and high-fructose/cholesterol (HFr) diets. AF was evaluated and induced by burst atrial pacing. Isolated atrial myocytes were used for whole-cell patch clamp and calcium assessment. Ex vivo whole heart was used for optical mapping. Western blot and immunofluorescence were used for quantitative protein evaluation.

Results

Both HFa and HFr rat atria were vulnerable to AF evaluated by burst atrial pacing. Isolated atrial myocytes from HFa and HFr rats revealed significantly increased sarcoplasmic reticulum calcium content and diastolic calcium sparks. Whole-heart mapping showed prolonged calcium transient duration, conduction velocity reduction, and repetitive ectopic focal discharge in HFa and HFr atria. Protein analysis revealed increased TGF-β1 and collagen expression; increased superoxide production; abnormal upregulation of calcium-homeostasis-related proteins, including oxidized CaMKIIδ, phosphorylated-phospholamban, phosphorylated-RyR-2, and sodium-calcium exchanger; and increased Rac1 activity in both HFa and HFr atria. We observed that inhibition of CaMKII suppressed AF in both HF and HFr diet-fed rats. In vitro palmitate-induced IR neonatal cardiomyocytes and atrial fibroblasts expressed significantly more TGF-β1 than did controls, suggesting paracrine and autocrine effects on both myocytes and fibroblasts.

Conclusions

IR engenders both atrial structural remodeling and abnormal intracellular calcium homeostasis, contributing to increased AF susceptibility. The inhibition of CaMKII may be a potential therapeutic target for AF in insulin resistance.

Insulin Resistance in Children

Insulin resistance (IR) is a pathological condition strongly associated with obesity. However, corticosteroids or growth hormone therapy and genetic diseases may affect insulin sensitivity lifelong. In obese children and adolescents of any age there is an evident association between IR and an increased prevalence of type 2 diabetes (T2D) and other elements contributing to the metabolic syndrome, leading to a higher cardiovascular risk. Therefore, early diagnosis and interventions in the attempt to prevent T2D when glycemia values are still normal is fundamental. The gold standard technique used to evaluate IR is the hyperinsulinemic euglycemic clamp, however it is costly and difficult to perform in clinical and research sets. Therefore, several surrogate markers have been proposed. Although the treatment of insulin resistance in children is firstly targeted to lifestyle interventions, in selected cases the integration of a pharmacological intervention might be taken into consideration. The aim of this review is to present the current knowledge on IR in children, starting with an outline of the recent evidences about the congenital forms of deficiency in insulin functioning and therefore focusing on the physiopathology of IR, its appropriate measurement, consequences, treatment options and prevention strategies.

The Association Between Diabetes Mellitus and Atrial Fibrillation: Clinical and Mechanistic Insights

A number of clinical studies have reported that diabetes mellitus (DM) is an independent risk factor for Atrial fibrillation (AF). After adjustment for other known risk factors including age, sex, and cardiovascular risk factors, DM remains a significant if modest risk factor for development of AF. The mechanisms underlying the increased susceptibility to AF in DM are incompletely understood, but are thought to involve electrical, structural, and autonomic remodeling in the atria. Electrical remodeling in DM may involve alterations in gap junction function that affect atrial conduction velocity due to changes in expression or localization of connexins. Electrical remodeling can also occur due to changes in atrial action potential morphology in association with changes in ionic currents, such as sodium or potassium currents, that can affect conduction velocity or susceptibility to triggered activity. Structural remodeling in DM results in atrial fibrosis, which can alter conduction patterns and susceptibility to re-entry in the atria. In addition, increases in atrial adipose tissue, especially in Type II DM, can lead to disruptions in atrial conduction velocity or conduction patterns that may affect arrhythmogenesis. Whether the insulin resistance in type II DM activates unique intracellular signaling pathways independent of obesity requires further investigation. In addition, the relationship between incident AF and glycemic control requires further study.

Clinical Overview of Obesity and Diabetes Mellitus as Risk Factors for Atrial Fibrillation and Sudden Cardiac Death

The epidemics of obesity and diabetes mellitus are associated with an increased incidence of both atrial fibrillation (AF), the most common sustained arrhythmia in adults, and sudden cardiac death (SCD). Obesity and DM are known to have adverse effects on cardiac structure and function. The pathologic mechanisms are thought to involve cardiac tissue remodeling, metabolic dysregulation, inflammation, and oxidative stress. Clinical data suggest that left atrial size, epicardial fat pad thickness, and other modifiable risk factors such as hypertension, glycemic control, and obstructive sleep apnea may mediate the association with AF. Data from human atrial tissue biopsies demonstrate alterations in atrial lipid content and evidence of mitochondrial dysfunction. With respect to ventricular arrhythmias, abnormalities such as long QT syndrome, frequent premature ventricular contractions, and left ventricular hypertrophy with diastolic dysfunction are commonly observed in obese and diabetic humans. The increased risk of SCD in this population may also be related to excessive cardiac lipid deposition and insulin resistance. While nutritional interventions have had limited success, perhaps due to poor long-term compliance, weight loss and improved cardiorespiratory fitness may reduce the frequency and severity of AF.

Diabetes and Arrhythmias: Pathophysiology, Mechanisms and Therapeutic Outcomes

The prevalence of diabetes is rapidly increasing and closely associated with cardiovascular morbidity and mortality. While the major cardiovascular complication associated with diabetes is coronary artery disease, it is becoming increasingly apparent that diabetes impacts the electrical conduction system in the heart, resulting in atrial fibrillation, and ventricular arrhythmias. The relationship between diabetes and arrhythmias is complex and multifactorial including autonomic dysfunction, atrial and ventricular remodeling and molecular alterations. This review will provide a comprehensive overview of the link between diabetes and arrhythmias with insight into the common molecular mechanisms, structural alterations and therapeutic outcomes.

A Machine Learning Aided Systematic Review and Meta-Analysis of the Relative Risk of Atrial Fibrillation in Patients With Diabetes Mellitus

Background: Meta-analysis is a widely used tool in which weighted information from multiple similar studies is aggregated to increase statistical power. However, the exponential growth of publications in key areas of medical science has rendered manual identification of relevant studies increasingly time-consuming. The aim of this work was to develop a machine learning technique capable of robust automatic study selection for meta-analysis. We have validated this approach with an up-to-date meta-analysis to investigate the association between diabetes mellitus (DM) and new-onset atrial fibrillation (AF). Methods: The PubMed online database was searched from 1960 to September 2017 where 4,177 publications that mentioned both DM and AF were identified. Relevant studies were selected as follows. First, publications were clustered based on common text features using an unsupervised K-means algorithm. Clusters that best matched the selected set of potentially relevant studies (a "training" set of 139 articles) were then identified by using maximum entropy classification. The 139 articles selected automatically on this basis were screened manually to identify potentially relevant studies. To determine the validity of the automated process, a parallel set of studies was also assembled by manually screening all initially searched publications. Finally, detailed manual selection was performed on the full texts of the studies in both sets using standard criteria. Quality assessment, meta-regression random-effects models, sensitivity analysis and publication bias assessment were then conducted. Results: Machine learning-assisted screening identified the same 29 studies for meta-analysis as those identified by using manual screening alone. Machine learning enabled more robust and efficient study selection, reducing the number of studies needed for manual screening from 4,177 to 556 articles. A pooled analysis using the most conservative estimates indicated that patients with DM had ~49% greater risk of developing AF compared with individuals without DM. After adjusting for three additional risk factors i.e., hypertension, obesity and heart disease, the relative risk was 23%. Using multivariate adjusted models, the risk for developing AF in patients with DM was similar for all DM subtypes. Women with DM were 24% more likely to develop AF than men with DM. The risk for new-onset AF in patients with DM has also increased over the years. Conclusions: We have developed a novel machine learning method to identify publications suitable for inclusion in meta-analysis.This approach has the capacity to provide for a more efficient and more objective study selection process for future such studies. We have used it to demonstrate that DM is a strong, independent risk factor for AF, particularly for women.

Fasting and post-glucose load measures of insulin resistance and risk of incident atrial fibrillation: The Cardiovascular Health Study

BACKGROUND AND AIMS

Existing literature in individuals without diabetes has not demonstrated a relationship between IR and incident AF; however, data are limited and only fasting glucose measures of IR were assessed. We evaluated the relationship of both fasting and post-glucose load IR measures with the development of atrial fibrillation in nondiabetic older adults.

METHODS AND RESULTS

Among Cardiovascular Health Study participants, a population-based cohort of 5888 adults aged 65 years or older enrolled in two waves (1989-1990 and 1992-1993), those without prevalent AF or diabetes and with IR measures at baseline were followed for the development of AF, identified by follow-up visit electrocardiograms, hospital discharge diagnosis coding, or Medicare claims data, through 2014. Fasting IR was determined by the homeostatic model of insulin resistance (HOMA-IR) and post-glucose load IR was determined by the Gutt index. Cox proportional hazards models were used to determine the association of IR with risk of AF. Analyses included 3601 participants (41% men) with a mean age of 73 years. Over a median follow-up of 12.3 years, 1443 (40%) developed AF. After multivariate adjustment, neither HOMA-IR nor the Gutt index was associated with risk of developing AF [hazard ratios (95% confidence intervals): 0.96 (0.90, 1.03) for 1-SD increase in HOMA-IR and 1.03 (0.97, 1.10) for 1-SD decrease in the Gutt index].

CONCLUSIONS

We found no evidence of an association between either fasting or post-glucose load IR measures and incident AF.

Linking atrial fibrillation with non-alcoholic fatty liver disease: potential common therapeutic targets

Non-alcoholic fatty liver disease (NAFLD) and atrial fibrillation (AF) are common chronic non-infectious diseases with rising incidences. NAFLD is an independent risk factor for the onset of AF, after adjusting potentially related factors. The pathogenesis of these diseases share several mechanisms including reduced adiponectin level, insulin resistance, and renin angiotensin aldosterone system (RAAS) activation, in addition to activation of common disease pathways that promote inflammation, oxidative stress, and fibrosis. Furthermore, statins and RAAS blockers exert therapeutic effects concurrently on NAFLD and AF. The common pathogenesis of NAFLD and AF may serve as a potential therapeutic target in the future.

Antihyperglycemic drugs use and new-onset atrial fibrillation in elderly patients

BACKGROUND

Antihyperglycemic drugs have been linked to new-onset atrial fibrillation (NAF). However, the effect of the different classes of antihyperglycemic drugs on the development of NAF in elderly patients has not been well studied. In this study, we investigated the association between different classes of antihyperglycemic drugs and NAF in elderly patients.

MATERIALS AND METHODS

This was a nested case-control study performed using the database of National Health Insurance programme in Taiwan. Each participant aged 65 years and older who were NAF from 2005 to 2012 were assigned to the NAF group, whereas case was sex-, age-, diabetes duration-, index date-matched, and Charlson Comorbidity Index score-matched randomly selected participant without NAF were assigned to the non-NAF group. Multivariable logistic regression model was used for the estimation of odds ratios (ORs) and 95% confidence intervals (CIs) of NAF associated with use of different classes of antihyperglycemic agents. Nonusers served as the reference group.

RESULTS

We identified 1958 cases and 7832 controls. The risk of NAF after adjusting for sex, age, comorbidities and concurrent medication was higher among the users of insulin than among the nonusers (OR, 1·58; 95% CI, 1·37-1·82). Patients who took dipeptidyl peptidase 4 inhibitors were at lower risk of developing NAF than the nonusers (OR, 0·65; 95% CI, 0·45-0·93).

CONCLUSIONS

In this population, use of dipeptidyl peptidase 4 inhibitor was associated with a low risk of NAF. Insulin use was associated with a significant increase in the risk of NAF during the long-term follow-up.

Diabetes mellitus is an independent risk factor for atrial fibrillation in a general Chinese population

Aims/Introduction

To explore the association between atrial fibrillation (AF) and diabetes mellitus in a general Chinese population, and the influence of hypertension.

Materials and Methods

From January 2013 to August 2013, we carried out a cross‐sectional study involving 11,956 permanent residents aged ≥35 years from the general population in the Liaoning province of China (response rate 85.3%). Each participant completed a questionnaire, had a physical examination, and underwent an electrocardiogram and echocardiogram. AF was diagnosed on the basis of the electrocardiogram findings. Logistic regression analyses were carried out to estimate the associations between diabetes mellitus and AF. The associations were also analyzed in hypertensive and normotensive subgroups.

Results

There was a higher prevalence of AF in participants with diabetes mellitus than those without diabetes mellitus (1.2 vs 0.5%; P = 0.004). In the hypertensive subgroup, the prevalence of AF in participants with diabetes mellitus was significantly higher than in participants without diabetes mellitus (1.5 vs 0.6%; P = 0.008); however, the prevalences were similar in the normotensive subgroup (0.3 vs 0.4%; P = 1.000). Similar trends were present in both men and women. After adjustment for cardiovascular risk factors, the independent association between diabetes mellitus and AF remained in the total sample (odds ratio 2.33, 95% confidence interval 1.20–4.54) and hypertensive subgroup (odds ratio 3.15, 95% confidence interval 1.52–6.56), but not in the normotensive subgroup (odds ratio 0.64, 95% confidence interval 0.08–5.31).

Conclusions

Diabetes mellitus is an independent risk factor for AF in the general population in China, this association was present in total and hypertensive participants, but not in normotensive participants.

Obesity, metabolic syndrome and risk of atrial fibrillation: a Swedish, prospective cohort study

Aim

We aimed to investigate whether different measures of obesity could similarly predict atrial fibrillation, and whether the atrial fibrillation risk associated with obesity is dependent on presence of metabolic syndrome.

Material and Methods

We performed our study in a population-based longitudinal cardiovascular study, comprising 1 924 men and 2 097 women, aged 60 years, from Stockholm. Body mass index, waist circumference, sagittal abdominal diameter and components of metabolic syndrome (systolic- and diastolic blood pressure, fasting glucose, triglycerides, high-density lipoprotein-cholesterol) were recorded at baseline. Participants were classified by their body mass index (normal weight, overweight or obese), waist circumference (normal, semi-elevated or elevated), and according to presence of metabolic syndrome. Atrial fibrillation risk was estimated by Cox proportional hazards regression models, adjusted for common atrial fibrillation risk factors, expressed as HR and 95% CI.

Results

During a mean follow-up of 13.6 years, 285 incident atrial fibrillation cases were recorded. One standard deviation increment of each obesity measure was associated with increased atrial fibrillation risk as: body mass index 1.25 (1.12 – 1.40), waist circumference 1.35 (1.19 – 1.54) and sagittal abdominal diameter 1.28 (1.14 – 1.44). Compared to normal weight subjects without metabolic syndrome, increased atrial fibrillation risk was noted for overweight subjects with metabolic syndrome, 1.67 (1.16 – 2.41), obese subjects without metabolic syndrome, 1.75 (1.11 – 2.74) and obese subjects with metabolic syndrome, 1.92 (1.34 – 2.74). Compared to subjects with normal waist circumference without metabolic syndrome, subjects with elevated waist circumference and metabolic syndrome suffered increased atrial fibrillation risk, 2.03 (1.44 – 2.87).

Conclusions

Body mass index, waist circumference and sagittal abdominal diameter could similarly predict atrial fibrillation. Obesity was associated with an increased atrial fibrillation risk regardless of metabolic syndrome, whereas overweight and elevated waist circumference was associated with increased atrial fibrillation risk only if metabolic syndrome was present.

Diabetes mellitus and atrial fibrillation: Pathophysiological mechanisms and potential upstream therapies

Diabetes mellitus (DM) represents one of the most important risk factors for atrial fibrillation (AF) while AF is a strong and independent marker of overall mortality and cardiovascular morbidity in diabetic patients. Autonomic, electrical, electromechanical, and structural remodeling, including oxidative stress, connexin remodeling and glycemic fluctuations seem to be implicated in AF pathophysiology in the setting of DM. The present review highlights the association between DM and AF, provides a comprehensive overview of the responsible pathophysiological mechanisms and briefly discusses potential upstream therapies for DM-related atrial remodeling.

Low fasting plasma insulin is associated atrial fibrillation in men from a cohort study--the Malmö preventive project

Background

Type 2 diabetes has been associated with increased incidence of atrial fibrillation (AF) and cardiovascular disease. Controversy remains regarding the role of insulin in the epidemiology of AF risk. The aim of the present study was to study the association between fasting plasma insulin (FPI) and incidence of AF, as well as any effect modification by fasting blood glucose (FBG) or 2 h post-load blood glucose and body mass index (BMI).

Methods

The study population consisted of 6052 men and 1014 women followed for an average of 26.2 years. There were 983 cases of incident AF. Analysis was performed using Cox regression and competing risks regression approaches. The population was analysed as a whole, and by subgroups according to glucose levels and BMI.

Results

After adjustment for age, height, weight, systolic blood pressure and smoking there was a significant inverse association between FPI and AF (hazard ratio; HR) for 4th vs. 1st quartile: 0.69 (95% confidence interval (CI): 0.57-0.83, p < 0.0001) in the cohort as a whole. Among men the corresponding values were HR 0.64 (95% CI 0.52-0.78, p < 0.001) and among women HR 1.16 (95% CI 0.69-1.93, p = 0.58); p-value for interaction 0.06. The protective effects of insulin tended to be weaker in subjects with elevated fasting glucose, implying that the relation between FPI and incident AF could be dependent on the status of individual’s glucose metabolism.

Conclusions

High levels of FPI are associated with lower risk of incident AF in a middle-aged population with a long follow-up.

Cardiac aging and insulin resistance: could insulin/insulin-like growth factor (IGF) signaling be used as a therapeutic target?

Intrinsic cardiac aging is an independent risk factor for cardiovascular disease and is associated with structural and functional changes that impede cardiac responses to stress and to cardio-protective mechanisms. Although systemic insulin resistance and the associated risk factors exacerbate cardiac aging, cardiac-specific insulin resistance without confounding systemic alterations, could prevent cardiac aging. Thus, strategies aimed to reduce insulin/insulin-like growth factor (IGF) signaling in the heart prevent cardiac aging in lower organisms and in mammals but the mechanisms underlying this protection are not fully understood. In this review, we describe the impact of aging on the cardiovascular system and discuss the mounting evidence that reduced insulin/IGF signaling in the heart could alleviate age-associated alterations and preserve cardiac performance.

Atrial Fibrillation and Its Association with Endocrine Disorders

Atrial Fibrillation (AF) is the most common arrhythmia affecting millions of people and the number is rising, it is therefore important to understand the risk factors causing AF. Risk factors such as hypertension, heart failure, coronary heart disease, and type 2 diabetes mellitus increase the risk of AF, however, the underlying etiology in a majority of patients remains elusive. Many of the endocrine disorders have been implicated in causing AF and an in depth knowledge of these disorders helps in early diagnosis and treatment. Due to the high prevalence of AF and its complications, it is therefore important to recognize these risk factors and have a low threshold for suspicion while other common causes are being excluded. In this review we summarize the issues related to AF and endocrine disorders. A better understanding of the relationship may lead to the development of the primary preventive strategies, fostering a more preventive and predictive approach that may result in decreased incidence of AF and its associated complications and provide personalized treatment options. For this review we carried out a search of Pubmed, the words or combination of words we used for our search include Endocrine disorders, metabolic disorders, Dyslipidemia, Diabetes mellitus type 2, Vitamin D, Hyperthyroidism, Primary aldosteronism, Pheochromocytoma, Obesity, Hypercalcemia, Hypogonadism, Medications, and Atrial fibrillation. We also retrieved articles from the references of retrieved articles.

Diabetes, Obesity and Atrial Fibrillation: Epidemiology, Mechanisms and Interventions

Body mass index (BMI) is a powerful predictor of death, type 2 diabetes (T2DM) and cardiovascular (CV) morbidity and mortality. Over the last few decades, we have witnessed a global rise in adult obesity of epidemic proportions. Similarly, there has been a parallel increase in the incidence of atrial fibrillation (AF), itself a significant cause of cardiovascular morbidity and mortality. This may be partly attributable to advances in the treatment of coronary heart disease (CHD) and heart failure (HF) improving life expectancy, however, epidemiological studies have demonstrated an independent association between obesity, diabetes and AF, suggesting possible common pathophysiological mechanisms and risk factors. Indeed, cardiac remodeling, haemodynamic alterations, autonomic dysfunction, and diastolic dysfunction have been reported in obese and diabetic cohorts. Moreover, diabetic cardiomyopathy is characterized by an adverse structural and functional cardiac phenotype, which may predispose to the development of AF. In this review, we discuss the pathophysiological and mechanistic relationships between obesity, diabetes and AF, and some of the challenges posed in the management of this high-risk group of individuals.

What do we currently know about metabolic syndrome and atrial fibrillation?

Metabolic syndrome represents a cluster of atherogenic risk factors including hypertension, insulin resistance, obesity, and dyslipidemia. Considering that all of these risk factors could influence the development of atrial fibrillation, an association between atrial fibrillation and the metabolic syndrome has been suggested. Additionally, oxidative stress and inflammation have been involved in the pathogenesis of both metabolic syndrome and atrial fibrillation. The mechanisms that relate metabolic syndrome to the increased risk of atrial fibrillation occurrence are not completely understood. Metabolic syndrome and atrial fibrillation are associated with increased cardiovascular morbidity and mortality. Because atrial fibrillation is the most common arrhythmia, and along with the prevalence of metabolic syndrome constantly increasing, it would be very important to determine the relationship between these 2 entities, especially due to the fact that the risk factors of metabolic syndrome are mainly correctable. This review focused on the available evidence supporting the association between metabolic syndrome components and metabolic syndrome as a clinical entity with atrial fibrillation.

Obesity, diabetes and atrial fibrillation; epidemiology, mechanisms and interventions

The last few decades have witnessed a global rise in adult obesity of epidemic proportions. The potential impact of this is emphasized when one considers that body mass index (BMI) is a powerful predictor of death, type 2 diabetes (T2DM) and cardiovascular (CV) morbidity and mortality [1, 2]. Similarly we have witnessed a parallel rise in the incidence of atrial fibrillation (AF), the commonest sustained cardiac arrhythmia, which is also a significant cause of cardiovascular morbidity and mortality. Part of this increase is attributable to advances in the treatment of coronary heart disease (CHD) and heart failure (HF) improving life expectancy and consequently the prevalence of AF. However, epidemiological studies have demonstrated an independent association between obesity and AF, possibly reflecting common pathophysiology and risk factors for both conditions. Indeed, weight gain and obesity are associated with structural and functional changes of the cardiovascular system including left atrial and ventricular remodeling, haemodynamic alterations, autonomic dysfunction, and diastolic dysfunction. Moreover, diabetic cardiomyopathy is characterized by an adverse structural and functional cardiac phenotype which may predispose to the development of AF [3]. In this review, we discuss the pathophysiological and mechanistic relationships between obesity, diabetes and AF, and the challenges posed in the management of this high-risk group of individuals.

Impact of Metabolic Syndrome on Ablation-Outcome in Patients with Atrial Fibrillation: A Systematic Review

Metabolic syndrome (MS), a pro-inflammatory state with hypertension, diabetes, dyslipidemia and obesity is presumed to be a close associate of atrial fibrillation (AF). However, the exact mechanism by which MS facilitates perpetuation of AF is yet to be fully understood. Moreover, the impact of the components of MS as well as MS as a group, on ablation-outcome in AF is not clearly elucidated until now. This review has compiled the results from major studies that have looked into those risk factors and defined their significance in influencing ablation-outcome in AF. It has also overviewed the impact of life-style changes that might improve the success rate of AF-ablation by effectively addressing the different constituents of MS.

Type 2 diabetes mellitus and risk of incident atrial fibrillation in women

OBJECTIVES

The purpose of this study was to assess whether changes of major atrial fibrillation (AF) risk factors and/or intercurrent cardiovascular events could explain the relationship between type 2 diabetes mellitus (T2D) and incident AF.

BACKGROUND

Previous studies found an increased risk of incident AF among individuals with T2D, but few, if any, of these studies took into account changes of AF risk factors over time.

METHODS

A total of 34,720 female health professionals who participated in the Women's Health Study, and who were free of cardiovascular disease and AF at baseline were followed for a median of 16.4 years. Cox proportional-hazards models were constructed to assess the relationship between T2D and incident AF, using either information at baseline or time-varying covariates for both T2D and potential confounders.

RESULTS

At baseline, 937 (2.7 %) women had T2D. Compared with women without T2D, women with T2D had an age-adjusted hazard ratio (HR) for new-onset AF of 1.95 (95% confidence interval [CI]: 1.49 to 2.56; p<0.0001). In multivariable analyses adjusting for baseline confounders, this HR was substantially attenuated, but baseline T2D remained a significant predictor of incident AF (HR: 1.37, 95% CI: 1.03 to 1.83; p=0.03). In time-updated models that adjusted for changes in AF risk factors and intercurrent cardiovascular events, the HR for T2D was attenuated further and became nonsignificant (HR: 1.14; 95% CI: 0.93 to 1.40; p=0.20).

CONCLUSIONS

Although this study confirms a significant relationship between baseline T2D and incident AF, our data suggest that the increased risk associated with T2D is mainly mediated by changes of other AF risk factors.

The Relationship Between Atrial Fibrillation and Chronic Kidney Disease : Epidemiologic and Pathophysiologic Considerations for a Dual Epidemic

Atrial fibrillation (AF) presently affects over 2 million Americans, and the magnitude and population burden from AF continues to increase concomitant with the aging of the U.S.

POPULATION

Chronic kidney disease (CKD) is present in 13% of individuals in the U.S., and the prevalence of CKD is also rapidly increasing. The increasing population burden of CKD and AF will profoundly affect the clinical and public health, since CKD and AF are both associated with lower quality of life, increased hospitalization rates, and a greater risk of heart failure, stroke, and total mortality. AF and CKD often co-exist, each condition predisposes to the other, and the co-occurrence of these disorders worsens prognosis relative to either disease alone. The shared epidemiology of CKD and AF may be explained by the strong pathophysiologic connections between these diseases. In order to promote a better understanding of CKD and AF, we have reviewed their shared epidemiology and pathophysiology and described the natural history of patients affected by both diseases.

Insulin resistance and risk of venous thromboembolism: results of a population-based cohort study

BACKGROUND

Obesity is an established risk factor for venous thromboembolism (VTE), but it is uncertain how this is mediated. Insulin resistance has a central role in the pathophysiology of the metabolic effects of obesity.

OBJECTIVE

We aimed to investigate whether insulin resistance is a risk factor for VTE.

METHODS

For this analysis we used the PREVEND prospective community-based observational cohort study. Insulin resistance was measured as HOMA-IR (homeostasis model assessment of insulin resistance) and fasting insulin. VTE was assessed using databases of the national registries of hospital discharge diagnoses, death certificates and the regional anticoagulation clinic.

RESULTS

Out of 7393 subjects, 114 developed VTE during a median follow-up of 10.5 years. High HOMA-IR was associated with increased risk of VTE after adjustment for traditional cardiovascular risk factors, CRP and markers of endothelial dysfunction (hazard ratio [HR], 1.38; 95% confidence interval [95% CI], 1.09-1.75; P=0.007). When body mass index (BMI) was added to the model, BMI was a strong risk predictor for VTE (HR, 1.53; 95% CI, 1.24-1.88; P<0.001) whereas HOMA-IR no longer showed such an association (HR, 1.11; 95% CI, 0.85-1.43; P=0.45). Results were similar for fasting insulin.

CONCLUSION

Our population-based cohort study shows an increased risk of VTE in subjects with increasing insulin resistance but not independently of BMI.