[Diabetes mellitus and cardiovascular risk: Working group recommendations of Diabetes and Cardiovascular Disease of the Spanish Society of Diabetes (SED, 2015)]

Discriminant Model for Insulin Resistance in Type 2 Diabetic Patients

Introduction: Patients with type 2 diabetes mellitus tend to have insulin resistance, a condition that is evaluated using expensive methods that are not easily accessible in routine clinical practice. Objective: To determine the anthropometric, clinical, and metabolic parameters that allow for the discrimination of type 2 diabetic patients who have insulin resistance from those who do not. Methods: A cross-sectional analytical observational study was carried out in 92 type 2 diabetic patients. A discriminant analysis was applied using the SPSS statistical package to establish the characteristics that differentiate type 2 diabetic patients with insulin resistance from those without it. Results: Most of the variables analyzed in this study have a statistically significant association with the HOMA-IR. However, only HDL-c, LDL-c, glycemia, BMI, and tobacco exposure time allow for the discrimination of type 2 diabetic patients who have insulin resistance from those who do not, considering the interaction between them. According to the absolute value of the structure matrix, the variable that contributes most to the discriminant model is HDL-c (-0.69). Conclusions: The association between HDL-c, LDL-c, glycemia, BMI, and tobacco exposure time allows for the discrimination of type 2 diabetic patients who have insulin resistance from those who do not. This constitutes a simple model that can be used in routine clinical practice.

Abnormal glucose regulation in Chinese patients with coronary artery disease: a gender analysis

BACKGROUND

Diabetes and impaired glucose regulation are very common in patients with coronary artery disease (CAD). In this study, we aim to investigate the prevalence of abnormal glucose regulation in men and women in Chinese CAD patients.

METHODS

In this retrospective study, 4100 patients (male, n = 2873; female, n = 1227)with CAD were enrolled. The mean age of these patients was 63 years. The demographic data, medical history, echocardiography findings and blood investigations were collected and analyzed.

RESULTS

In this population, 953 (24%) patients had definite diagnosis of type 2 diabetes mellitus, including 636 males (23%) and 317 females (27%). There was a higher prevalence of diabetes in females than men (p < 0.05). For the remaining patients, 48% (n = 959) undergone an oral glucose tolerance test (OGTT), which revealed that 83 male patients (12%) and 41 female patients (16%) suffered from the type 2 diabetes (p > 0.05). 283 men (40%) and 105 women (41%) had impaired glucose regulation (IGR) (p > 0.05). Only 338 men (25%) and 109 women (19%) showed the normal glucose regulation, implying a higher prevalence of abnormal glucose regulation in females (p < 0.01). The odd ratio (OR) showed that women were more prone to have diabetes mellitus or IGT than men and the OR was 1.44 and 1.43 respectively.

CONCLUSION

Abnormal glucose regulation is highly prevalent in CAD patients. The women are more prone to have diabetes mellitus or IGT than men.

Diabetes mellitus and cardiovascular risk: an update of the recommendations of the Diabetes and Cardiovascular Disease Working Group of the Spanish Society of Diabetes (SED, 2021)

This document is an update to the clinical practice recommendations for the management of cardiovascular risk factors (CVRF) in diabetes mellitus. The consensus has been developed by a multidisciplinary team made up of members of the Cardiovascular Risk Group of the Spanish Diabetes Society (SED). The work is a necessary update as, since the last review three years ago, there have been many clinical trials that have studied the cardiovascular outcomes of numerous drugs in the diabetic population. We believe that this guideline update may be of interest to all clinicians treating patients with diabetes.

Analysis of the Adherence and Safety of Second Oral Glucose-Lowering Therapy in Routine Practice From the Mediterranean Area: A Retrospective Cohort Study

The aims of our study was compare adherence measured by the medical possession ratio (MPR), time until discontinuation and describe adverse events after adding a DPP-4i, SGLT-2i, or sulfonylureas (SU) to metformin in a primary care population with insufficient glycemic control. We used routinely-collected health data from the SIDIAP database. The included subjects were matched by propensity score. The follow-up period was up to 24 months or premature discontinuation. The primary outcomes were the percentage of subjects with good adherence, treatment discontinuation and adverse events among treatment groups. The proportion of patients with good adherence (MPR> 0.8) after the addition of DPP-4i, SGLT-2i or SU was 53.6%, 68.7%, and 43.0%, respectively. SGLT-2i users were 1.7 times more likely to achieve good adherence compared with DPP-4i users (odds ratio [OR]:1.72, 98% confidence interval [CI]:1.51, 1.96), and 2.8 times more likely compared with SU users (OR: 0.35, 98% CI: 0.07, 0.29). The discontinuation hazard ratios were 1.43 (98%CI: 1.26; 1.62) and 1.60 (98%CI: 1.42; 1.81) times higher among SGLT-2i and SU users than DPP-4i users during the follow-up period. No differences were observed for adverse events among the treatment groups. In conclusion, in our real-world setting, the combination of SGLT-2i with metformin was associated with better adherence. The mean time until discontinuation was longer in the SGLT-2i group in comparison with the DPP-4i or SU groups.

Specific model for the coordination of primary and hospital care for patients with diabetes mellitus. Evaluation of two-year results (2015-2017)

INTRODUCTION

Diabetes mellitus (DM) is one of the most prevalent chronicdiseases and has a significant health and social impact. Strict control of blood glucose levels and other risk factors for vascular disease (VD) reduces complications and mortality and is related to the quality of care received. Although care should be interdisciplinary, based on the coordination of primary care (PC) and hospital care (HC), little information is available on the effectiveness of the different existing intervention models.

OBJECTIVE

To assess, in a population with DM from a healthcare area, the impact on health, quality of care, and effectiveness in the use of resources of a specific model of shared management of patients with DM (Instrument for Evaluation of Models of Chronic Care in Diabetes Mellitus; IEMAC-DM).

PATIENTS AND METHODS

A quasi-experimental before-after intervention study in patients with DM in the Cádiz-San Fernando Healthcare Area (Andalusia, Spain) that allows for identifying the capacity of the program to improve the quality indicators both in the whole population with DM and in that referred to HC. For this, a working group consisting of healthcare professionals of different profiles and care levels was set up. An initial self-assessment was done using the IEMAC-DM tool and, after analysis of the preliminary results, improvement strategies were established and implemented. Finally, the clinical and resource management results were assessed before and two years after the implementation of the model.

RESULTS

During the study period, no significant changes were seen in process indicators related to laboratory practices or examinations in the health area. The proportion of patients with acceptable metabolic control [glycosylated hemoglobin (HbA1c) level < 8%] was 49% in 2015 and 45% in 2017. The number of admissions related to acute myocardial infarction (AMI) and stroke remained constant, but there was an increase in the standardized ratio of major lower limb amputations (1.5 vs. 1.9). Of the 295 patients referred from PC to HC, the proportion of adequate referrals increased from 40% in 2015 to 76% in 2017 (P = .001). In the referred patients, a significant improvement was seen in the mean difference in glycosylated hemoglobin levels (HbA1c; 1.14 ± 1.73%; 95% CI: 0.73-1.55; P = .0001) and cholesterol (11.28 ± 40 mg/dL; 95% CI: 2.07-20.48; P = .012).

CONCLUSIONS

This study shows that an intervention based on a chronicity care model adapted to patients with DM improves certain aspects related to the quality of care and the degree of metabolic control. Improving health outcomes will require long-term evaluation and, probably, other additional interventions.

Assessment of Thoracic Pain Using Machine Learning: A Case Study from Baja California, Mexico

Thoracic pain is a shared symptom among gastrointestinal diseases, muscle pain, emotional disorders, and the most deadly: Cardiovascular diseases. Due to the limited space in the emergency department, it is important to identify when thoracic pain is of cardiac origin, since being a symptom of CVD (Cardiovascular Disease), the attention to the patient must be immediate to prevent irreversible injuries or even death. Artificial intelligence contributes to the early detection of pathologies, such as chest pain. In this study, the machine learning techniques were used, performing an analysis of 27 variables provided by a database with information from 258 geriatric patients with 60 years old average age from Medical Norte Hospital in Tijuana, Baja California, Mexico. The objective of this analysis is to determine which variables are correlated with thoracic pain of cardiac origin and use the results as secondary parameters to evaluate the thoracic pain in the emergency rooms, and determine if its origin comes from a CVD or not. For this, two machine learning techniques were used: Tree classification and cross-validation. As a result, the Logistic Regression model, using the characteristics proposed as second factors to consider as variables, obtained an average accuracy (μ) of 96.4% with a standard deviation (σ) of 2.4924, while for F1 a mean (μ) of 91.2% and a standard deviation (σ) of 6.5640. This analysis suggests that among the main factors related to cardiac thoracic pain are: Dyslipidemia, diabetes, chronic kidney failure, hypertension, smoking habits, and troponin levels at the time of admission, which is when the pain occurs. Considering dyslipidemia and diabetes as the main variables due to similar results with machine learning techniques and statistical methods, where 61.95% of the patients who suffer an Acute Myocardial Infarction (AMI) have diabetes, and the 71.73% have dyslipidemia.

Specific model for the coordination of primary and hospital care for patients with diabetes mellitus. Evaluation of two-year results (2015-2017)

INTRODUCTION

Diabetes mellitus (DM) is one of the most prevalent chronic diseases and has a significant health and social impact. Strict control of blood glucose levels and other risk factors for vascular disease reduces complications and mortality and is related to the quality of care received. Although care should be interdisciplinary, based on the coordination of primary care (PC) and hospital care (HC), little information is available on the effectiveness of the different existing intervention models.

OBJECTIVE

To assess, in a population with DM from a healthcare area, the impact on health, quality of care, and effectiveness in the use of resources of a specific model of shared management of patients with DM (Instrument for Evaluation of Models of Chronic Care in Diabetes Mellitus; IEMAC-DM).

PATIENTS AND METHODS

A quasi-experimental before-after intervention study in patients with DM in the Cádiz-San Fernando Healthcare Area (Andalusia, Spain) that allows for identifying the capacity of the program to improve the quality indicators both in the whole population with DM and in that referred to HC. For this, a working group consisting of healthcare professionals of different profiles and care levels was set up. An initial self-assessment was done using the IEMAC-DM tool and, after analysis of the preliminary results, improvement strategies were established and implemented. Finally, the clinical and resource management results were assessed before and two years after the implementation of the model.

RESULTS

During the study period, no significant changes were seen in process indicators related to laboratory practices or examinations in the health area. The proportion of patients with acceptable metabolic control [glycosylated hemoglobin (HbA1c) level<8%] was 49% in 2015 and 45% in 2017. The number of admissions related to acute myocardial infarction and stroke remained constant, but there was an increase in the standardized ratio of major lower limb amputations (1.5 vs. 1.9). Of the 295 patients referred from PC to HC, the proportion of adequate referrals increased from 40% in 2015 to 76% in 2017 (p=0.001). In the referred patients, a significant improvement was seen in the mean difference in glycosylated hemoglobin levels (HbA1c; 1.14±1.73%; 95% CI: 0.73-1.55; p=0.0001) and cholesterol (11.28±40mg/dL; 95% CI: 2.07-20.48; p=0.012).

CONCLUSIONS

This study shows that an intervention based on a chronicity care model adapted to patients with DM improves certain aspects related to the quality of care and the degree of metabolic control. Improving health outcomes will require long-term evaluation and, probably, other additional interventions.

[ESCRYTO study. Diabetes without cardiovascular disease and level of control]

BACKGROUND AND OBJECTIVES

Diabetes is a significant risk factor for the development of cardiovascular disease, which is the main cause of death. The purpose of this study was to determine the level of glycaemic control in patients with type 2 diabetes without cardiovascular disease in Spain. The data used includes the most recent determination of glycosylated haemoglobin, as well as the pattern of antidiabetic treatment, the incidence of episodes of severe hypoglycaemia in the last 6 months, and the level of control of cardiovascular risk factors, and gender.

PATIENTS AND METHODS

A national, multicentre, and cross-sectional epidemiological study in which 800 doctors associated with the GDPS network participated.

RESULTS

Of the total of 1,059 patients, 57% male, with a mean age of 62.7 years in men vs. 65.2 in women (P<.001). The mean onset of diabetes was 9.4±7.5 years. The mean HbA1C was 7.0% in men vs. 7.1% in women (P=.039), with the control objective of <7% being observed in 47.2%. There were 65% patients on treatment with metformin, and 62.4% on DPP-4 inhibitors, and basal insulin: 14.2%. Incidence of severe hypoglycemias in the last 6 months was 1.9%. The women had worse glycaemic control, total cholesterol, LDL cholesterol, abdominal obesity, and glomerular filtration levels.

CONCLUSIONS

The glycaemic control is worse in women even if adjusted for age and time of onset of diabetes (P=.043), and for the number of hypoglycaemic agents (P=.015). The level of control is also worse in women for dyslipidaemia, abdominal obesity, and glomerular filtration. A preventive strategy promoted from Primary care on healthy lifestyles and controlling all vascular risk factors is essential.

Clinical Inertia in Poorly Controlled Type 2 Diabetes Mellitus Patients with Obesity: An Observational Retrospective Study

INTRODUCTION

To evaluate clinical inertia in patients with type 2 diabetes mellitus (T2DM), obesity and poor glycaemic control in routine clinical practice.

METHODS

This was a retrospective, observational study based on the analysis of medical records from the BIG-PAC® database. Subjects who required medical care in 2013 with the following characteristics were enrolled in the study: age ≥ 30 years, diagnosis of T2DM, glycosylated haemoglobin (HbA1c) ≥ 8%, obesity (body mass index [BMI] ≥ 30 kg/m²) and treatment with ≥ 2 oral antidiabetic drugs (OADs). Inertia was evaluated by time (days) to the first intensification during the period while HbA1c levels were ≥ 8% and percentage of patients whose treatment was not intensified at 6 months, 1, 2 and 3 years and the end of follow-up. The minimum length of follow-up was 4 years. Descriptive analyses and Kaplan-Meier survival curves were performed.

RESULTS

A total of 13,824 patients with T2DM receiving ≥ 2 OADs were identified; of these 2709 (19.6%) had HbA1c ≥ 8% and BMI ≥ 30 kg/m², thus fulfilling the inclusion criteria. Of these 2709 patients, the mean age was 65.5 (standard deviation [SD] 12.0) years; 54.9% were male, mean HbA1c level was 9.2% (SD 1.3%); mean BMI was 32.1 (SD 0.9) kg/m²; and mean time from diagnosis was 8.2 (SD 3.0) years. HbA1c remained ≥ 8% for a median of 440 (95% confidence interval [CI] 421-459) days. The median time to first intensification was 456 (95% CI 429-483) days. No intensification had occurred in 77.8, 59.5, 41.5, 28.1 and 22.4% of patients at 6 months, 1, 2, 3 years and the end of follow-up, respectively.

CONCLUSIONS

The patients with T2DM analysed in this study had a mean HbA1c of 9.2% at baseline, and this remained at ≥ 8% for > 1 year. The time to the first treatment intensification was longer than that recommended by guidelines. Treatment was not intensified in a large percentage of patients, with almost 60% of patients not receiving intensification at 1 year of follow-up.

[Blood glucose control and cardiovascular risk factors in type 2 diabetic patients with cardiovascular disease in Spain, and its treatment pattern, according to gender: CODICE study]

INTRODUCTION AND OBJECTIVES

With the implementation of the Strategy of Health Promotion and Prevention in Spain, the scenario reflected in previous studies of low control of cardiovascular risk factors (CVRF) in patients with type 2 diabetes (DM2) and cardiovascular disease (CVD) can be modified. This study intends to determine the level of blood glucose control and other CVRF in patients with DM2 and CVD currently seen in clinics in Spain, as well as the pattern of antidiabetic treatment, and differences according to gender.

MATERIALS AND METHODS

An epidemiological, observational, cross-sectional, nationwide study was conducted in patients of both genders diagnosed with DM2 and established CVD.

RESULTS

The study included 3,143 patients with a mean age 69.0±10 years. The mean HbA1c was 7.4±1.1% in females vs 7.3±1.2% in males (P<.05) and systolic blood pressure was 137±15.0mmHg in females vs 135.6±14.7mmHg in males (P<.05). The mean LDL-cholesterol was 101.5±38.1mg/dl in females vs 91.1±37.5mg/dl in males; P<.001) and the mean body mass index (30.7±5.4kg/m² in females vs 29.6±4.5kg/m² in males; P<.001). The most used treatments were metformin (68.1%) and/or DPP4 inhibitors (53.7%), with no differences between genders.

CONCLUSIONS

The level of blood glucose control of DM2 patients with CVD in Spain can be improved. The treatment profile does not conform to the recommendations of clinical practice guidelines in general. The differences in the control of CVRF are worse in women for lipids and obesity.

Treatment Patterns of Diabetes in Italy: A Population-Based Study

Background: The steady increase in type 2 diabetes prevalence and the availability of new antidiabetic drugs (AD) have risen the use of these drugs with a change in the patterns of specific drug utilization. The complexity of this treatment is due to successive treatment initiation, switching and addition in order to maintain glycaemic control. The aim of this study was to describe the utilization patterns of ADs at initiation, treatment addition, and switching profiles and to measure factors influencing persistence to therapy.

Methods: Retrospective observational study. Data were retrieved from the Campania Regional Database for Medication Consumption. Population consisted of patients receiving at least one prescription of ADs between January 1 and December 31, 2016. We calculated time to treatment switching or add-on as median number of days and interquartile range (IQR). Persistence rates were estimated using the Kaplan–Meier method. We used Cox regression models to estimate the likelihood of non-persistence over 1 year of follow-up. Hazard ratios and 95% confidence intervals were calculated.

Results: Of 14,679 patients, 86.9% started with monotherapy and 13.1% with combination therapy. Most common initial treatment was metformin in both monotherapy and combination therapy. First-line prescription of sulfonylurea was observed in 6.9% of patients aged 60–79 years and in 10.8% of patients aged ≥80 years. Patients starting with metformin showed fewer treatment modifications (10.4%) compared to patients initiating with sulfonylureas (35.2%). Newer ADs were utilized during treatment progression. Patients who initiated with sulfonylurea were approximately 70% more likely to discontinue treatment compared to those initiated on metformin. Oldest age group (≥80 years) was more likely to be non-persistent, and likelihood of non-persistence was highest in polymedicated patients. Patients changing therapy were more likely to be persistent.

Conclusions: Our results show that treatment of T2D in Italy is consistent with clinical guidelines. Even if newer ADs were utilized during disease progression, they seem not to be preferred in patients with a higher comorbidity score, although these patients could benefit from this kind of treatment. Our study highlights patients’ characteristics that might help identify those who would benefit from counselling from their health-care practitioner on better AD usage.

The prevalence and risk factors associated with dyslipidemia in type 2 diabetic patients in the autonomous Region of Cantabria

BACKGROUND AND OBJECTIVE

Dyslipidemia is one of the main risk factors in cardiovascular disease in patients with diabetes mellitus type 2 (DM2). The aim of this study is to evaluate the prevalence and risk factors associated with dyslipidemia in the population with diabetes mellitus type 2 in the region of Cantabria.

MATERIAL AND METHODS

This is a transversal study carried out at Cantabrian primary health care centres (n=680). A representative, random sample of the population with DM2, ranging from 18-85, was selected using a multistage procedure. The medical records were obtained, and by means of interviews the data of the risk factors to be studied was secured. The correlation with dyslipidemia was analysed by means of logistic regression.

RESULTS

There were 52.1% of males, the average age was 69.8, the evolution of diabetes was 9.99 years, 84.3% had arterial hypertension, 76.6% were overweight or obese and the average HbA1c was 6.96%. The prevalence of dyslipidemia was 85.3%, and in the bivariate analysis this is associated with a history of peripheral artery disease, controlled diabetes, antihypertensive treatment, glomerular filtration, HbA1c>7%, body fat estimated as being either overweight or obese, a history of cardiovascular disease, age and HbA1c. In the multivariate analysis the independent factors were being female and a history of cardiovascular disease.

CONCLUSION

The prevalence of dyslipidemia in our study was 85.3%, and is consistent with figures found in previous published studies. The independent associated risk factors were being female and a past medical history of cardiovascular disease.

[Trends in the level of control of patients with type 2 diabetes from 2010 to 2015]

INTRODUCTION

Aim: To examine the trend in the level of control of glycated haemoglobin (HbA1c), blood pressure (BP), and LDL-cholesterol (LDL) in patients with type 2 diabetes mellitus between 2010 and 2015.

METHODS

Setting: 3 cut-offs in the years 2010, 2013, and 2015. Southeast area of Madrid.

DESIGN

Descriptive and cross-sectional epidemiological study.

PARTICIPANTS

Patients diagnosed and registered with type 2 diabetes. N=41,096 (2010), n=49,658 (2013), n=6,674 (2015) MAIN MEASUREMENTS: Measurement or not in the last year of HbA1c, BP, and LDL. Control of HbA1c (<7% individual targeting), BP (<140/90mmHg), and LDL (<100mg/dL, if cardiovascular disease <70mg/dL). Data were collected from electronic records of clinical history. The Chi-square test was used.

RESULTS

The percentages of patients with each parameter measured in 2010, 2013 and 2015 were: HbA1c: 36.4%, 37.0%, 62.0% (P<.001); BP: 33.2%, 43.3%, 65.0% (P<.001); LDL: 32.9%, 33.2%, 43.5% (P<.001). The percentages of patients with each parameter measured and controlled in 2010, 2013, and 2015 were: HbA1c: 59.6%, 59.1%, 79.6% (P<.001); BP: 74.9%, 67.4%, 79.2% (P<.001); LDL: 41.8%, 58.3%, 58.8% (P<.001) CONCLUSION: In the 2010-2015 period, a sustained but insufficient trend of better control of HbA1c, BP and LDL was observed in patients with diabetes. The frequency of the measurements of these parameters improved more than the control of them. It seems that efforts to improve care for the patient with diabetes pay off, but they still have to be maintained.

Barometer of type 2 diabetes in primary care. Metabolic control, styles of life and morbidity profile

OBJECTIVE

Knowing the profile of cardiovascular morbidity, degree of control and lifestyles in type 2 diabetes.

METHOD

Randomized multicenter cross-sectional study conducted in 2015 in primary care with 129 diabetics. It included sociodemographic variables, microvascular and macrovascular complications, organic damage, comorbidity and lifestyles of smoking, exercise and adherence to Mediterranean diet. Metabolic control was assessed with the latest annual glycosylated haemoglobin.

RESULTS

57% were men and 43% women. Metabolic control was acceptable (HbAc1%, 7.15%) without differences by town. 74.4% had cardiovascular comorbidity and the 99.2% risk factors. 23% were smokers and 41% sedentary with a 56% adherence to Mediterranean diet.

CONCLUSIONS

The cardiometabolic profile of diabetes includes retinopathy, peripheral arterial disease, comorbidity of hypertension and cardiovascular risk factors. Individual or group health education in self-care and healthy lifestyles can improve metabolic control.