Postchallenge plasma glucose excursions, carotid intima-media thickness, and risk factors for atherosclerosis in Chinese population with type 2 diabetes

Serum ErbB2 concentration positively correlated to the glycemic variations in newly diagnosed Type 2 diabetic patients

Evidences indicate that elevated levels of circulating ErbB2 are closely associated with increased incidence of diabetes. However, the relationship between ErbB2 concentration and glycemic variations (GV) in type 2 diabetic (T2D) patients remains elucidated. The aim of this study was to assess whether there is an association between serum ErbB2 concentration and GV in newly diagnosed T2D patients. This was a three-center, and observational study. Between April 2019 and July 2019, a total of 106 newly diagnosed T2D patients were recruited. All recruited subjects were admitted as inpatients and received anti-diabetes agents free during the study period. At baseline, fasting serum was collected for ErbB2 measurement and all recruited patients were subjected a prospective CGM for at least 3 days. The primary endpoint was the relationships between ErbB2 concentrations and GV in T2D patients. Data of a total of 95 subjects who met the inclusion criteria were analyzed at the endpoint. Subjects were divided into quartiles according to their serum ErbB2 concentrations. We observed that subjects with an elevated level of ErbB2 had a higher value of GV in terms of mean amplitude of glucose excursion (MAGE), standard deviation of mean glucose (SDMG), and the coefficient of variation (CV%) than those with lower levels (all P < 0.05). Multiple linear regression analyzes after adjusting for confounder factors indicate that serum ErbB2 levels were significantly positively correlated with the MAGE (β = 0.664, t = 7.218, P < 0.01), SD (β = 0.469, t = 5.125, P < 0.01) and CV% (β = 0.337, t = 4.442, P < 0.01), respectively. Our data indicated that diabetic patients with higher ErbB2 concentrations may have large GV, which is an independent risk factor for microvascular and macrovascular complications.

Carotid intima-media thickness in patients with hyperuricemia: a systematic review and meta-analysis

OBJECTIVE

Despite the high incidence and mortality of cardiovascular events in hyperuricemia patients, the role of serum uric acid in cardiovascular diseases is still controversial. The aim of this meta-analysis was to explore the difference of carotid intima-media thickness in hyperuricemia and control groups.

METHODS

We performed this meta-analysis by searching the PubMed, Cochrane Library, Embase and Web of Science databases up to July 2020. The 95% confidence intervals and standard mean differences were calculated to analyze the differences in carotid intima-media thickness in hyperuricemia groups and control groups. Sensitivity analysis, subgroup analysis and meta-regression were used to explore the sources of heterogeneity. Publication bias was evaluated by funnel plot and Begg's regression test. We used Stata 14.0 software to complete our analyses.

RESULTS

A total of 8 articles were included. The results showed that there was a significant increase in carotid intima-media thickness in the hyperuricemia groups compared with the control groups [SMD = 0.264, 95% CI (0.161-0.366), P < 0.001]. Subgroup analyses showed that age, sample size, blood pressure and body mass index were not the source of heterogeneity. Meta-regression enrolled the method of CIMT measurement, location, age, smoking and diabetes mellitus as categorical variables, but none of these factors was found to be significant in the model. The Begg's test value (P = 0.174) was greater than 0.05, indicating there was no publication bias.

CONCLUSION

The results showed that carotid intima-media thickness was increased in hyperuricemia patients compared with controls, which indicated that hyperuricemia patients may have a higher risk of cardiovascular diseases.

Effects of Dapagliflozin Adjunct to Insulin on Glycemic Variations in Patients with Newly Diagnosed Type 2 Diabetes: A Randomized, Controlled, Open-Labeled Trial

Background

This study is aimed at investigating whether dapagliflozin adjunct to insulin therapy further improves glycemic control compared to insulin therapy alone in patients with newly diagnosed type 2 diabetes (T2D).

Methods

This single-centre, randomized, controlled, open-labeled trial recruited newly diagnosed T2D patients. Subjects were randomized 1 : 1 to the dapagliflozin add-on to continuous subcutaneous insulin infusion (CSII) group (DAPA) or the CSII therapy group for 5 weeks. Standard meal tests were performed 3 times at days -3, 7, and 35 for glucose, C-peptide, and insulin level determination. Two-time continuous glucose monitoring (CGM) was performed at baseline and at the end of the study. The primary endpoint was the difference in the mean amplitude of glycemic excursions (MAGEs) between the groups.

Results

A total of 66 subjects completed the study, with 34 and 32 patients in the DAPA and CSII groups, respectively. Patients in the DAPA group exhibited significant decreases in MAGE levels at the endpoint. We also observed that patients in the DAPA group had a lower homoeostasis model assessment insulin resistance (HOMA-IR) and a higher homoeostasis model assessment B (HOMA-B) value at 1 week and 5 weeks compared to those with insulin therapy, respectively. In addition, our data showed that patients in the DAPA group showed a significantly lower insulin dose (0.07 U/kg) and weighed less than those in the CSII group.

Conclusion

Our data indicate that dapagliflozin adjunct to insulin is a safe and effective therapy for improving glycemic variations, insulin sensitivity, and weight loss in newly diagnosed T2D patients.

Impact of glucose variability on coronary plaque vulnerability in patients with dysglycemia: A whole coronary analysis with multislice computed tomography

BACKGROUND

Dysglycemia is associated with an increased risk of acute coronary syndrome caused by the disruption of vulnerable plaques. The relationship between glycemic variability (GV), which is a component of impaired glucose metabolism, and coronary plaque vulnerability has not been fully elucidated. This study investigated the impact of GV on whole coronary plaque vulnerability using multislice computed tomography (MSCT).

METHODS

We analyzed 88 patients with dysglycemia who underwent 24 h blood glucose monitoring and MSCT. The mean amplitude of glycemic excursion (MAGE) was calculated as an index of the GV. We defined a CT-derived vulnerable plaque as a plaque with a remodeling index > 1.10 and a mean CT density < 30 HU. We calculated the percentage of low-attenuation plaque (% LAP) as the ratio of the low-attenuation component (CT density < 30HU) volume to the total vessel volume.

RESULTS

Vulnerable plaques were detected in 27 patients (31%). Patients with vulnerable plaques had higher MAGE (110.0 ± 40.7 vs. 71.7 ± 21.7, p < 0.01) than patients without vulnerable plaques. A univariate logistic regression analysis showed that vulnerable plaques were associated with the MAGE [odds ratio (OR) 1.04, 95% confidence interval (CI), 1.02-1.07, p < 0.01]. In a multivariate model, the MAGE (OR 1.05, 95% CI 1.02-1.07) remained a significant predictor of vulnerable plaque presence. Patients with multivessel-vulnerable plaques had higher MAGE values than those with single-vessel involvement or no vulnerable plaques (132.3 ± 39.4 vs. 102.2 ± 39.7, vs. 71.7 ± 21.7, p < 0.01). The regression analysis showed a positive correlation between MAGE levels and the % LAP (r = 0.55, p < 0.01). In a multiple linear regression analysis, the MAGE was independently associated with the % LAP (β = 0.42, p < 0.01).

CONCLUSIONS

Increased GV is associated with the presence and extent of vulnerable plaques.

The Role of Glycemic Variability in Cardiovascular Disorders

Diabetes mellitus (DM) is one of the most common and costly disorders that affect humans around the world. Recently, clinicians and scientists have focused their studies on the effects of glycemic variability (GV), which is especially associated with cardiovascular diseases. In healthy subjects, glycemia is a very stable parameter, while in poorly controlled DM patients, it oscillates greatly throughout the day and between days. Clinically, GV could be measured by different parameters, but there are no guidelines on standardized assessment. Nonetheless, DM patients with high GV experience worse cardiovascular disease outcomes. In vitro and in vivo studies showed that high GV causes several detrimental effects, such as increased oxidative stress, inflammation, and apoptosis linked to endothelial dysfunction. However, the evidence that treating GV is beneficial is still scanty. Clinical trials aiming to improve the diagnostic and prognostic accuracy of GV measurements correlated with cardiovascular outcomes are needed. The present review aims to evaluate the clinical link between high GV and cardiovascular diseases, taking into account the underlined biological mechanisms. A clear view of this challenge may be useful to standardize the clinical evaluation and to better identify treatments and strategies to counteract this DM aspect.

Long-term glucose variability and incident cardiovascular diseases and all-cause mortality events in subjects with and without diabetes: Tehran Lipid and Glucose Study

AIM

To examine whether visit to visit variability (VVV) of fasting plasma glucose (FPG) is associated with incident cardiovascular diseases (CVD) and all-cause mortality in individuals with and without type 2 diabetes (T2D).

METHODS

A total of 4756 participants aged ≥30 years entered the study in 2002-2005 and underwent two subsequent examinations in 2005-2008 and 2008-2011. FPG variability measures included standard deviation (SD), coefficient of variation (CV), average real variability (ARV), and variability independent of mean (VIM). Multivariate Cox proportional hazard models were used to assess the risk of incident CVD and all-cause mortality for each unit increase in different FPG variability measures.

RESULTS

During a median follow-up of 18.14 years after baseline recruitment, 492 incident cardiovascular diseases and 338 all-cause mortality were recorded. Among individuals without T2D, the multivariate-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for incident CVD were 1.02 (1.01-1.04), 1.02 (1.01-1.04), 1.01 (1.00-1.02), and 1.01 (1.00-1.01) for SD, CV, ARV, and VIM, respectively (all P-values <0.05). Among individuals with T2D, the corresponding HRs and 95% CIs for all-cause mortality were 1.01 (1.00-1.02), 1.02 (1.01-1.03), 1.01 (1.00-1.02), and 1.01 (1.00-1.01), respectively (all P-values <0.05).

CONCLUSION

Long-term (VVV) of FPG is significantly associated with increased risk of CVD among participants without T2D, and all-cause mortality among participants with T2D.

Higher Non-fasting Serum Triglyceride Preceding the Carotid Stenosis Progression

The present study was conducted to investigate whether non-fasting serum triglyceride (TG) levels can be used to assess a risk for the progression of carotid artery stenosis. This was a single-center retrospective study. Consecutive 96 patients with ≥50% stenosis of at least unilateral cervical internal carotid artery and normal fasting serum low-density lipoprotein cholesterol (LDL-C) levels of ≤140 mg/dL were followed up for at least 1 year (mean, 3.1 years), and clinical variables were compared between patients with and without carotid stenosis progression (≥10% increases in the degree on ultrasonography). Carotid stenosis progression was shown in 21 patients, associated with less frequent treatment with calcium channel blockers (CCBs), higher non-fasting TG and glucose levels. In carotid artery-based analyses including <50% stenosis side, stenosis progression was shown in 23 of 121 arteries except for those with complete occlusion and less than 1-year follow-up period because of carotid artery stenting (CAS) or carotid endarterectomy (CEA). Stenosis progression was more frequently observed in symptomatic and/or radiation-induced lesions, and was also accompanied with less frequent treatment with CCBs, higher non-fasting TG and glucose levels in carotid artery-based analyses. The receiver operating characteristic (ROC) curve analyses revealed that a cutoff value of non-fasting TG to discriminate carotid stenosis progression was 169.5 mg/dL for carotid arteries with the baseline stenosis of <50%, and 154.5mg/dL for those of ≥50%. Non-fasting TG level was an independent risk factor of carotid stenosis progression, and more strict control of non-fasting TG may be necessary for higher degree of carotid artery stenosis.

Postload glucose spike but not fasting glucose determines prognosis after myocardial infarction in patients without known or newly diagnosed diabetes

BACKGROUND

The effect of postload glucose spikes (PGS), the difference between 2 hour post-load plasma glucose (2hPLPG) and fasting plasma glucose (FPG), on post-myocardial infarction (post-MI) prognosis in nondiabetic patients is unexplored.

METHODS

This is a retrospective cohort analysis of 847 nondiabetic post-MI survivors who underwent a predischarge oral glucose tolerance test (median PGS: 2.4 mmol/L). Patients were divided into the unmatched groups 1 and 2 (PGS ≤ and > 2.4 mmol/L) and the propensity score-matched groups 1M and 2M (355 pairs assembled from the overall cohort), and these groups were compared. Major adverse cardiac events (MACE: death and nonfatal reinfarction) were recorded during follow-up (median: 3.4 years). Event-free survival was compared by the Kaplan-Meier method. Multivariate Cox proportional hazards regression determined the predictors of MACE. C-statistics (change in area under the curve, δAUC), continuous net reclassification improvement (NRI^>0 ), and integrated discrimination improvement (IDI) were used to compare models.

RESULTS

The number of MACE was higher in groups 2 (27.3% vs 14.2%, P < .001) and 2M (24.5% vs 15.5%, P < .001). Event-free survival was worse in groups 2 (hazard ratio [HR] 2.01; 95% CI, 1.49-2.71; P < .001) and 2M (HR 1.63; 95% CI, 1.17-2.27; P = .004). PGS independently predicted MACE-free survival in the whole (HR 1.16; 95% CI, 1.06-1.26; P = .002) and matched cohort (HR 1.12; 95% CI, 1.02-1.24; P = .021). PGS, but not FPG or 2hPPG, improved the predictive performance of the base model (δAUC 0.013, P = .046), with greater improvement seen when PGS was added and compared to 2hPPG (δAUC 0.005, P = .034; NRI^>0 0.2107, P = .013; IDI 0.0042, P = .046).

CONCLUSION

PGS is a better predictor of post-MI prognosis than 2hPPG in nondiabetic patients.

Cardiovascular Risk Factors: It's Time to Focus on Variability!

Atherosclerotic heart disease remains a leading cause of morbidity and mortality worldwide. While extensive research supports cardiovascular risk factor reduction in the form of achieving evidence-based blood pressure, lipid, glucose, and body weight targets as a means to improve cardiovascular outcomes, residual risk remains. Emerging data have demonstrated that the intraindividual variability of these risk factor targets potentially contribute to this residual risk. It may therefore be time to define risk factor by not only its magnitude and duration as done traditionally, but perhaps also by the variability of that particular risk factor over time.

Repetitive Intermittent Hyperglycemia Drives the M1 Polarization and Inflammatory Responses in THP-1 Macrophages Through the Mechanism Involving the TLR4-IRF5 Pathway

Repetitive intermittent hyperglycemia (RIH) is an independent risk factor for complications associated with type-2 diabetes (T2D). Glucose fluctuations commonly occur in T2D patients with poor glycemic control or following intensive therapy. Reducing blood glucose as well as glucose fluctuations is critical to the control of T2D and its macro-/microvascular complications. The interferon regulatory factor (IRF)-5 located downstream of the nutrient sensor toll-like receptor (TLR)-4, is emerging as a key metabolic regulator. It remains unclear how glucose fluctuations may alter the IRF5/TLR4 expression and inflammatory responses in monocytes/macrophages. To investigate this, first, we determined IRF5 gene expression by real-time qRT-PCR in the white adipose tissue samples from 39 T2D and 48 nondiabetic individuals. Next, we cultured THP-1 macrophages in hypo- and hyperglycemic conditions and compared, at the protein and transcription levels, the expressions of IRF5, TLR4, and M1/M2 polarization profile and inflammatory markers against control (normoglycemia). Protein expression was assessed using flow cytometry, ELISA, Western blotting, and/or confocal microscopy. IRF5 silencing was achieved by small interfering RNA (siRNA) transfection. The data show that adipose IRF5 gene expression was higher in T2D than nondiabetic counterparts (p = 0.006), which correlated with glycated hemoglobin (HbA1c) (r = 0.47/p < 0.001), homeostatic model assessment of insulin resistance (HOMA-IR) (r = 0.23/p = 0.03), tumor necrosis factor (TNF)-α (r = 0.56/p < 0.0001), interleukin (IL)-1β (r = 0.40/p = 0.0009), and C-C motif chemokine receptor (CCR)-2 (r = 0.49/p < 0.001) expression. IRF5 expression in macrophages was induced/upregulated (p < 0.05) by hypoglycemia (3 mM/L), persistent hyperglycemia (15 mM/L–25 mM/L), and RIH/glucose fluctuations (3–15 mM/L) as compared to normoglycemia (5 mM/L). RIH/glucose fluctuations also induced M1 polarization and an inflammatory profile (CD11c, IL-1β, TNF-α, IL-6, and monocyte chemoattractant protein (MCP)-1) in macrophages. RIH/glucose fluctuations also drove the expression of matrix metalloproteinase (MMP)-9 (p < 0.001), which is a known marker for cardiovascular complication in T2D patients. Notably, all these changes were counteracted by IRF5 silencing in macrophages. In conclusion, RIH/glucose fluctuations promote the M1 polarization and inflammatory responses in macrophages via the mechanism involving TLR4-IRF5 pathway, which may have significance for metabolic inflammation.

Effects of Acute Cocoa Supplementation on Postprandial Apolipoproteins, Lipoprotein Subclasses, and Inflammatory Biomarkers in Adults with Type 2 Diabetes after a High-Fat Meal

Dyslipidemia and inflammation exacerbate postprandial metabolic stress in people with diabetes. Acute dietary supplementation with polyphenols shows promise in improving postprandial metabolic stress in type 2 diabetes (T2D). Cocoa is a rich source of dietary polyphenols with demonstrated cardioprotective effects in adults without diabetes. To date, the acute effects of cocoa on postprandial lipids and inflammation have received little attention in the presence of T2D. This report expands on our earlier observation that polyphenol-rich cocoa, given as a beverage with a fast-food-style, high-fat breakfast, increased postprandial high-density lipoprotein-cholesterol (HDL-C) in adults with T2D. We now test whether polyphenol-rich cocoa modulated postprandial apolipoproteins (Apo-A1, B), non-esterified fatty acids, nuclear magnetic resonance (NMR)-derived lipoprotein subclass profiles, and select biomarkers of inflammation following the same dietary challenge. We found that cocoa decreased NMR-derived concentrations of total very low-density lipoprotein and chylomicron particles and increased the concentration of total HDL particles over the 6-hour postprandial phase. Serum interleukin-18 was decreased by cocoa vs. placebo. Thus, polyphenol-rich cocoa may alleviate postprandial dyslipidemia and inflammation following a high-fat dietary challenge in adults with T2D. The study was registered at clinicaltrials.gov as NCT01886989.

Risk Factor Variability and Cardiovascular Outcome: JACC Review Topic of the Week

Until recently, intraindividual visit-to-visit variability of cardiovascular risk factors has been dismissed as random fluctuation. This simplistic concept was challenged by demonstrating that visit-to-visit blood pressure variability, independent of average blood pressure, was a powerful risk factor for stroke. Subsequently, variability of other cardiovascular risk factors such as cholesterol, glycemia, and body weight was documented to increase risk independent of their absolute values. Variability of these risk factors has been demonstrated to be a powerful predictor for all-cause and cardiovascular mortality, stroke, coronary artery disease, heart failure, end-stage renal disease, and dementia. With the notable exception of heart rate, cardiovascular risk factors must now be defined by 2 components: the magnitude and duration of sustained risk factor elevation and, equally important, the variability of the same risk factor over time.

Association of glycemic variability with left ventricular diastolic function in type 2 diabetes mellitus

Background

Type 2 diabetes mellitus (T2DM) is a major cause of heart failure (HF) with preserved ejection fraction (HFpEF), usually presenting as left ventricular (LV) diastolic dysfunction. Thus, LV diastolic function should be considered a crucial marker of a preclinical form of DM-related cardiac dysfunction. However, the impact of glycemic variability (GV) on LV diastolic function in such patients remains unclear.

Methods

We studied 100 asymptomatic T2DM patients with preserved LV ejection fraction (LVEF) without coronary artery disease (age: 60 ± 14 years, female: 45%). GV was evaluated as standard deviation of blood glucose level using continuous glucose monitoring system for at least 72 consecutive hours. LV diastolic function was defined as mitral inflow E and mitral e’ annular velocities (E/e’), and > 14 was determined as abnormal.

Results

E/e’ in patients with high GV (≥ 35.9 mg/dL) was significantly higher than that in patients with low GV (11.3 ± 3.9 vs. 9.8 ± 2.8, p = 0.03) despite similar age, gender-distribution, and hemoglobin A1c (HbA1c). Multivariate logistic regression analysis showed that GV ≥ 35.9 mg/dL (odds ratio: 3.67; 95% confidence interval: 1.02–13.22; p < 0.05) was an independently associated factor, as was age, of E/e’ > 14. In sequential logistic models for the associations of LV diastolic dysfunction, one model based on clinical variables including age, gender and hypertension was not improved by addition of HbA1c (p = 0.67) but was improved by addition of high GV (p = 0.04).

Conclusion

Since HFpEF is a syndrome caused by diverse agents, reducing GV may represent a potential new therapeutic strategy for the prevention of the development of HFpEF in T2DM patients.

The oral glucose tolerance test-derived incremental glucose peak is associated with greater arterial stiffness and maladaptive arterial remodeling: The Maastricht Study

Background

Daily glucose variability may contribute to vascular complication development irrespective of mean glucose values. The incremental glucose peak (IGP) during an oral glucose tolerance test (OGTT) can be used as a proxy of glucose variability. We investigated the association of IGP with arterial stiffness, arterial remodeling, and microvascular function, independent of HbA_1c and other confounders.

Methods

IGP was calculated as the peak minus baseline plasma glucose value during a seven-point OGTT in 2758 participants (age: 60 ± 8 years; 48% women) of The Maastricht Study, an observational population-based cohort. We assessed the cross-sectional associations between IGP and arterial stiffness (carotid-femoral pulse wave velocity [cf-PWV], carotid distensibility coefficient [carDC]), arterial remodeling (carotid intima-media thickness [cIMT]; mean [CWS_mean] and pulsatile [CWS_puls] circumferential wall stress), and microvascular function (retinal arteriolar average dilatation; heat-induced skin hyperemia) via multiple linear regression with adjustment for age, sex, HbA_1c, cardiovascular risk factors, lifestyle factors, and medication use.

Results

Higher IGP was independently associated with higher cf-PWV (regression coefficient [B]: 0.054 m/s [0.020; 0.089]) and with higher CWS_mean (B: 0.227 kPa [0.008; 0.446]). IGP was not independently associated with carDC (B: − 0.026 10⁻³/kPa [− 0.112; 0.060]), cIMT (B: − 2.745 µm [− 5.736; 0.245]), CWS_puls (B: 0.108 kPa [− 0.054; 0.270]), retinal arteriolar average dilatation (B: − 0.022% [− 0.087; 0.043]), or heat-induced skin hyperemia (B: − 1.380% [− 22.273; 19.513]).

Conclusions

IGP was independently associated with aortic stiffness and maladaptive carotid remodeling, but not with carotid stiffness, cIMT, and microvascular function measures. Future studies should investigate whether glucose variability is associated with cardiovascular disease.

Effects of long-term glycemic variability on incident cardiovascular disease and mortality in subjects without diabetes: A nationwide population-based study

Increased glycemic variability (GV) is an independent risk factor for cardiovascular complications in patients with diabetes. We evaluated the risk of future development of cardiovascular disease (CVD) and death according to GV in a general population without diabetes.We used the National Health Insurance Service, providing a population-based, nationwide database of Koreans. We included individuals without diabetes who underwent glucose measurement at least 3 times during 2002 to 2006. GV was calculated as standard deviation (SD) of fasting plasma glucose (FPG) levels. We observed development of CVD or all-cause death from 2007 to 2015, and also evaluated the mortality within 1 year after CVD.Among 3,211,319 people, we found 23,374 incident cases of myocardial infarction (MI), 27,705 cases of stroke, and 63,275 deaths during 8.3 years of follow-up. After multivariate adjustment, GV was found to be a significant predictor of MI, stroke and all-cause death for their highest quartile, with corresponding hazard ratios (HR) of 1.08 (95% confidence interval, CI 1.04-1.11), 1.09 (95% CI 1.06-1.13), and 1.12 (95% CI 1.10-1.15), respectively. The risk of death increased more in those who had both impaired fasting glucose and the highest quartile of GV (HR 1.24 [95% CI 1.21-1.28]). Moreover, early death rate after 1 year of CVD was higher in the highest quartile of GV compared to the lowest quartile (HR 1.21 [95% CI 1.03-1.41]).Long-term FPG variation was independently associated with CVD and mortality in a general population without diabetes.

Influence of blood glucose fluctuation, C-peptide level and conventional risk factors on carotid artery intima-media thickness in Chinese Han patients with type 2 diabetes mellitus

BACKGROUND

Some studies have suggested that blood glucose fluctuation and C-peptide level were considered as predictive factors for carotid artery intima-media thickness (CIMT). However, the relationships of these variables are unclear. This research was aimed to identify the potential effects of blood glucose fluctuation, C-peptide level and conventional risk factors on CIMT.

METHODS

A total of 280 type 2 diabetes mellitus (T2DM) patients were enrolled into this study. Population characteristics were obtained through medical history and clinical parameters. The patients were divided into two groups according to the critical value of CIMT (0.9). Research data were analyzed to identify risk factors of CIMT between the two groups.

RESULTS

The comparison results of basic information showed that differences in age and illness years between the two groups were statistically significant (p = 0.0002 and p = 0.0063). Logistic regression analysis results indicated that smoking, uric acid (UA) levels, 2 h C-peptide and standard deviation of blood glucose (SDBG) were the influence factors for CIMT thickening (p = 0.032, p = 0.047, p = 0.049 and p = 0.042, respectively). Blood glucose fluctuation could affect the risk of some complications. In largest amplitude of glycemic excursions (LAGE) > 4.4 group, the CIMT abnormal rate was 27.10%, which was significantly higher than 12.12% in the LAGE ≤ 4.4 group (p = 0.012). The CIMT abnormal rate of SDBG > 2.0 group was 27.81%, which was significantly higher than that of the SDBG ≤ 2.0 group (p = 0.018).

CONCLUSIONS

Blood glucose fluctuation is an independent risk factor associated with CIMT in T2DM patients, in addition to conventional risk factors, such as smoking, high UA level and 2 h C-peptide. Therefore, more attention should be given to the change of CIMT and the complications.

The impact of intraday glucose variability on coronary artery spasm in patients with dysglycemia

Impaired glucose metabolism is associated with an increased risk of cardiovascular complications, and coronary artery spasm is thought to underlie the development of coronary artery disease. Intraday glucose variability (GV) accelerates oxidative stress and inflammatory cytokine release, but its impact on coronary artery spasm remains unclear. This study investigated the relationship between intraday GV and coronary artery spasm. The study included 50 patients with dysglycemia and suspected coronary spastic angina. GV was analyzed by 24-h monitoring of the blood glucose concentration using a flash glucose monitoring system. The mean amplitude of glycemic excursion (MAGE) was calculated as an index of GV. Coronary artery spasm was assessed using the intracoronary acetylcholine provocation test. Coronary spasm was defined as acetylcholine-induced total or subtotal coronary occlusion. Changes in vessel diameter in response to acetylcholine were evaluated with quantitative coronary angiography. Coronary artery spasms were observed in 21 patients (42%). MAGE was significantly higher in patients with spasms compared to those without spasms (127.5 ± 33.5 vs. 91.4 ± 37.6, p < 0.01). Regression analysis showed a positive correlation between MAGE levels and coronary diameter changes induced by acetylcholine (r = 0.47, p < 0.01). In multiple regression analysis, MAGE was independently associated with acetylcholine-induced coronary diameter change (β = 0.47, p < 0.01). Intraday GV was associated with coronary artery spasm in patients with dysglycemia.

Effect of short-term treatment with sitagliptin or glibenclamide on daily glucose fluctuation in drug-naïve Japanese patients with type 2 diabetes mellitus

AIMS

To compare the effect of a dipeptidyl peptidase-4 inhibitor (DPP4-i) and a sulfonylurea (SU) on daily glucose fluctuation in drug-naïve Japanese patients with type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

A total of 53 drug-naïve Japanese patients with T2DM (HbA1c, 7.0%-9.0%; fasting plasma glucose, 6.1 mmol/L or higher) were randomly assigned to either sitagliptin 50 mg qd or glibenclamide 2.5 mg per day (given in divided doses) in a 1:1 ratio. A continuous glucose monitoring (CGM) device was used to obtain 24-hour glucose profiles for each patient at baseline and at Week 2. The primary study endpoint was change from baseline in mean amplitude of glucose excursion (MAGE) during a 24-hour period. A key secondary endpoint was change from baseline in the standard deviation (SD) of 24-hour glucose levels.

RESULTS

After 2 weeks of treatment, a numerically greater reduction in MAGE from baseline was observed in the sitagliptin group compared with the glibenclamide group, but the between-treatment difference was not statistically significant (LS mean difference [95% CI]: -0.48 mmol/L [-1.31, 0.34]; P = .245). However, a significantly greater reduction in the change from baseline in SD was observed in the sitagliptin group compared with the glibenclamide group (LS mean difference [95% CI]: -0.33 mmol/L [-0.62, -0.03]; P = .029).

CONCLUSIONS

This study suggests that the DPP4 inhibitor sitagliptin has a greater ability to reduce daily glucose fluctuation than the SU glibenclamide in drug-naïve Japanese patients with T2DM. ClinicalTrials.gov: NCT02318693.

Continuous glucose monitoring is more sensitive than HbA1c and fasting glucose in detecting dysglycaemia in a Spanish population without diabetes

AIMS

To investigate whether continuous glucose monitoring (CGM) reveals patterns of glycaemic behaviour, the detection of which might improve early diagnosis of dysglycaemia.

METHODS

A total 1521 complete days of valid CGM data were recorded under real-life conditions from a healthy sample of a Spanish community, as were matching FPG and HbA1_C data. No participant was pregnant, had a history of kidney or liver disease, or was taking drugs known to affect glycaemia.

RESULTS

CGM and fingerstick measurements showed a mean relative absolute difference of 6.9 ± 2.2%. All subjects were normoglycaemic according to FPG and HbA_1C except 21% who were prediabetic. The normoglycaemic subjects had a 24-hour mean blood glucose concentration (MBG) of 5.7 ± 0.4 mmol/L, spending a median of 97% of their time within the target range (3.9-7.8 mmol/L). 73% of them experienced episodes with blood glucose levels above the threshold for impaired glucose tolerance, and 5% levels above the threshold for diabetes. These normoglycaemic participants with episodes of high glycaemia had glycaemic variabilities similar to those of prediabetic subjects with episodes of similar intensity or combined duration.

CONCLUSIONS

CGM is a better indicator of possible early dysglycaemia than either FPG or HbA1c.

Admission glycemic variability correlates with in-hospital outcomes in diabetic patients with non-ST segment elevation acute coronary syndrome undergoing percutaneous coronary intervention

OBJECTIVE

The aim of this study is to evaluate the effects of admission glycemic variability (AGV) on in-hospital outcomes in diabetic patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) undergoing percutaneous coronary intervention (PCI).

METHODS

We studied 759 diabetic patients with NSTE-ACS undergoing PCI. AGV was accessed based on the mean amplitude of glycemic excursions (MAGEs) in the first 24 hours after admission. Primary outcome was a composite of in-hospital events, all-cause mortality, new-onset myocardial infarction, acute heart failure, and stroke. Secondary outcomes were each of these considered separately. Predictive effects of AGV on the in-hospital outcomes in patients were analyzed.

RESULTS

Patients with high MAGE levels had significantly higher incidence of total outcomes (9.9% vs. 4.8%, p=0.009) and all-cause mortality (2.3% vs. 0.4%, p=0.023) than those with low MAGE levels during hospitalization. Multivariable analysis revealed that AGV was significantly associated with incidence of in-hospital outcomes (Odds ratio=2.024, 95% CI 1.105-3.704, p=0.022) but hemoglobin A1c (HbA1c) was not. In the receiver-operating characteristic curve analysis for MAGE and HbA1c in predicting in-hospital outcomes, the area under the curve for MAGE (0.608, p=0.012) was superior to that for HbA1c (0.556, p=0.193).

CONCLUSION

High AGV levels may be closely correlated with increased in-hospital poor outcomes in diabetic patients with NSTE-ACS following PCI.

Burden of high blood pressure as a contributing factor to stroke in the Japanese community-based diabetic population

Diabetes mellitus is characterized by alterations in blood glucose (BG) metabolism, and glycated hemoglobin (HbA₁c) has been widely used as a marker of the BG concentration. Diabetes often coexists with high blood pressure (BP). High BP and hyperglycemia are well-known risk factors of stroke. We examined the extent to which the increased risk of stroke in diabetic individuals is attributable to BP and BG using prospectively collected data from the Japanese general population. During an average 8.3 ± 2.2 years of follow-up, out 1606 diabetic individuals aged ≥40 years who were free of cardiovascular disease, 119 participants (7.4%) developed stroke. In multivariable analysis, a significant difference in the risk of incident stroke was noted among the BP categories, including normotension (BP1), prehypertension (BP2), and hypertension (BP3; P for trend = 0.001). By contrast, no difference was noted among the BG categories, including HbA₁c levels <7.0% (HB1), 7.0–7.9% (HB2), and ≥8.0% (HB3; P for trend = 0.430). Compared with the category that included both BP1 and HB1, the population-attributable fraction (PAF) for stroke incidence was 52.0% from the BP2 and BP3 categories and 24.1% from the HB2 and HB3 categories, and the increased incidence from the HB2 and HB3 categories was mostly caused from coexistent BP2 and BP3 categories. In conclusion, in the Japanese community-based diabetic population, concomitant BP elevation largely contributes to the increased incidence of stroke and links BG elevation, as indicated by HbA₁c, to the increased risk of stroke.

Management of glycemic variation in diabetic patients receiving parenteral nutrition by continuous subcutaneous insulin infusion (CSII) therapy

To compare the continuous subcutaneous insulin infusion (CSII) or insulin glargine based multiple injections (MDI) therapy on glycemic variations in diabetic patients receiving PN outside of intensive care settings. This was a single-center, randomized, open-label trial. Patients with type 2 diabetes (T2D) who were receiving parenteral nutrition (PN) were recruited. After baseline data were collected, recruited patients were then randomized 1:1 to a CSII group or a MDI group. All patients were subjected to a 4-day retrospective Continuous Glucose Monitoring (CGM). The primary endpoint was the differences of the 24-hrs mean amplitude of glycemic excursion (MAGE) in patients receiving the PN therapy between the two groups. A total of 102 patients with T2D receiving PN were recruited. Patients in the CSII group had a significantly decreased mean glucose level (MBG), the standard deviation of MG (SDBG), MAGE, and the coefficient of variation (CV%) compared to those in MDI group (all P < 0.01). Furthermore, we found that the patients who received a bolus insulin dose required maintaining euglycemic control was gradually decreased during the PN period in both groups at the endpoint. The administration of insulin via CSII led to a significant decrease in glycemic variations in patients receiving PN.

Young onset type 2 diabetic patients might be more sensitive to metformin compared to late onset type 2 diabetic patients

It is unknown whether YOD (young onset diabetes) and LOD (late onset diabetes) require similar insulin doses for intensive insulin therapy with a metformin add-on to achieve glycemic control. We analyzed data from our two previously performed randomized, controlled open-label trials. Patients were randomized to receive either continuous subcutaneous insulin infusion (CSII) therapy or CSII combined with metformin therapy for 4 weeks. The studies concentrated on the differences in the insulin doses used for the two groups. We included 36 YOD (age < 40 yrs) and 152 LOD (age > 40 yrs) patients. YOD patients who received metformin combined with CSII therapy required significantly lower insulin doses to maintain euglycemic control compared to patients with LOD. A multivariate analysis, controlled for gender and the fasting blood concentration, was performed to determine the significance of the differences between groups, particularly with respect to the total and basal insulin doses. There was a trend toward improvement in β-cell function and insulin resistance in terms of ΔHOMA-B and ΔHOMA-IR in patients with YOD compared to those with LOD. Newly diagnosed T2D patients with YOD required significantly lower insulin doses, particularly basal insulin doses, to maintain glycemic control compared to the LOD patients.

A randomized controlled trial comparing the effects of dapagliflozin and DPP-4 inhibitors on glucose variability and metabolic parameters in patients with type 2 diabetes mellitus on insulin

BACKGROUND

Dipeptidyl peptidase-4 (DPP-4) inhibitors and sodium-glucose co-transporter 2 (SGLT2) inhibitors improve hyperglycemia, and the usefulness of co-administration of DPP-4 inhibitors and insulin therapy has been well established. However, it has been still uncertain whether combination therapy of SGLT2 inhibitors and insulin is superior to that of DPP-4 inhibitors and the latter. Therefore, we investigated the superiority of dapagliflozin on glucose fluctuation compared with DPP-4 inhibitors in patients with type 2 diabetes mellitus (T2DM) on insulin using a continuous glucose monitoring (CGM) system.

METHODS

In this prospective, randomized, open-label controlled trial, 36 patients with T2DM and treated with DPP-4 inhibitors and insulin therapy, were enrolled and allocated into two groups. The patients either switched their DPP-4 inhibitors to dapagliflozin 5 mg for 12 weeks, or continued their DPP-4 inhibitors for the same period. CGM analyses and metabolic markers were assessed before and after treatment periods.

RESULTS

In total, data from 29 patients were analyzed. There were no significant differences in the mean amplitude of glycemic excursions and other CGM profiles in either group after treatment. Within the dapagliflozin treatment group, significant reductions of body mass index and albuminuria, and increases of HbA1c, hemoglobin and hematocrit were observed, but improvement of albuminuria was not significant if compared with the DPP-4 continuation group.

CONCLUSIONS

Combination therapy of dapagliflozin and insulin was not superior in glucose fluctuation to DPP-4 inhibitors on insulin. However, dapagliflozin may in part provide favorable effects on metabolism in patients with T2DM treated with insulin therapy. Trial registration UMIN-CTR: UMIN000015033. Registered 2 September 2014.

Features of glycemic variations in drug naïve type 2 diabetic patients with different HbA1c values

To define the features of glycemic variations in drug naïve type 2 diabetic (T2D) patients with different HbA_1c values using continuous glucose monitoring (CGM), a total of 195 drug naïve T2D patients were admitted. The subjects were divided into the following groups: lower HbA_1c values (≤8%), moderate HbA_1c values (>8% and ≤10%), and higher HbA_1c values (>10%). The patients underwent oral glucose tolerance tests and were then subjected to 3-day CGM. The primary endpoint was the differences in the 24-hr mean amplitude of glycemic excursions (MAGE) in patients with different HbA_1c values. Patients with higher HbA_1c values had larger MAGEs than those in the moderate and lower groups (7.44 ± 3.00 vs. 6.30 ± 2.38, P < 0.05, 7.44 ± 3.00 vs. 5.20 ± 2.35, P < 0.01, respectively). The 24-hr mean glucose concentrations increased incrementally in the patients with lower, moderate and higher HbA_1c values. Moreover, the patients with higher HbA_1c values exhibited higher peak glucose concentrations and prolongation in the time to peak glucose. Patients with higher HbA_1c values had larger MAGE compared with those with lower and moderate HbA_1c values. Our data indicated patients with higher HbA_1c values should receive special therapy aimed at reducing the larger glycemic variations.

Association Between IL-18 and Carotid Intima-Media Thickness in Patients with Type II Diabetic Nephropathy

Background

We specifically designed this study to determine the relationship between levels of IL-8 and carotid intima-media thickness (cIMT) in patients with type 2 diabetes mellitus (T2DM).

Material/Methods

A total of 149 diabetic patients at different stages of diabetic nephropathy and 72 matched controls were recruited in this study. A wide range of parameters were measured: IL-18 (by ELISA), urinary albumin excretion rates (UAER), and carotid intima-media thickness (cIMT, by pulse wave velocity [PWV]). All the diabetic patients were treated by alprostadil.

Results

ELISA indicated that the level of IL-18 in the patient group was significantly higher compared with that in the control group. The level of IL-18 apparently increased in the higher cIMT group in T2DM patients. Serum IL-18 levels were positively correlated with cIMT in patients with T2DM, the level of IL-18 was negatively correlated with cIMT, and IL-18 levels were positively correlated to age. Moreover, IMT was positively correlated with hemoglobin A1C (HbA1C) and IL-18 levels were significantly associated with cIMT (all P<0.05).

Conclusions

IL-18 levels were positively correlated with atherosclerotic burden in patients with T2DM and it may be considered as a significant therapeutic target.

Comparison of in-hospital glycemic variability and admission blood glucose in predicting short-term outcomes in non-diabetes patients with ST elevation myocardial infarction underwent percutaneous coronary intervention

AIMS

Admission hyperglycemia is associated with increased mortality and major adverse cardiac events (MACE) in patients with or without diabetes mellitus after acute myocardial infarction (AMI). However, effects of glycemic variability (GV) on outcomes of non-diabetes patients with AMI still remains unclear. The aim of this study is to compare the prognostic value of in-hospital GV with admission blood glucose (ABG) for 3-month MACE in non-diabetes patients with ST elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention (PCI).

METHODS

We analyzed 256 non-diabetes patients with STEMI in study. The GV accessed by mean amplitude of glycemic excursions (MAGE) was calculated from blood glucose profiles of continuous glucose monitoring system (CGMS) during hospitalization. ABG was measured on admission. Main endpoints were 3-month MACE; secondary endpoints were GRACE scores and enzymatic infarct size. Predictive effects of MAGE and ABG on the MACE in patients were analyzed.

RESULTS

In all participants, MAGE level was associated with ABG level (r = 0.242, p < 0.001). Both elevated MAGE levels (p = 0.001) and elevated ABG (p = 0.046) were associated with incidences of short-term MACE. Patients with a higher MAGE level had a significantly higher cardiac mortality (5.8 vs. 0.6%, p = 0.017) and incidence of acute heart failure (12.8 vs. 2.4%, p = 0.001) during 3 months follow-up. In multivariable analysis, high MAGE level (HR 2.165, p = 0.023) was significantly associated with incidence of short-term MACE, but ABG (HR 1.632, p = 0.184) was not. The area under the receiver-operating characteristic curve for MAGE (0.690, p < 0.001) was superior to that for ABG (0.581, p = 0.076).

CONCLUSIONS

To compare with ABG, in-hospital GV may be a more important predictor of short-term MACE and mortality in non-diabetes patients with STEMI treated with PCI.

Influence of Dapagliflozin on Glycemic Variations in Patients with Newly Diagnosed Type 2 Diabetes Mellitus

Objectives. To observe changes in blood glycemic variations and oxidative stress level before and after dapagliflozin treatment in patients with newly diagnosed T2DM. Methods. This was a randomized, double-blind, placebo-controlled, phase 3 trial. A total of 28 patients with newly diagnosed T2DM with HbA1c levels of 7.5-10.5% were randomly selected to receive dapagliflozin or placebo treatment for 24 weeks. After baseline data were collected, we analyzed glycemic variations and plasma 8-iso PGF2α level at baseline and at the endpoint. Primary outcome was the changes of mean amplitude glycemic excursion (MAGE) within groups. Results. After 24-week dapagliflozin therapy, our data showed the significant improvement of MAGE with dapagliflozin therapy (P = 0.010). Compared with control group, patients in dapagliflozin group exhibited reduction in 24-hour MBG (P = 0.026) and lower mean plasma glucose concentrations, especially during periods from 2400 to 0200 and 1300 to 1800 (P < 0.05, resp.). In addition, plasma 8-iso PGF2α level was notably decreased in the treatment group compared to the control group (P = 0.034). Conclusions. In conclusion, this study shows the ability of dapagliflozin to improve glycemic variations and associate with reduction of oxidative stress in patients with T2DM, which may benefit the cardiovascular system.

Analysis of the add-on effect of α-glucosidase inhibitor, acarbose in insulin therapy: A pilot study

The aim of the present study was to evaluate the add-on effect of acarbose therapy in oxidative stress, and the lipid and inflammatory profiles of patients with type 2 diabetes mellitus (T2DM) treated with insulin. This was an open and unblended study. Patients (n=134) with T2DM (haemoglobin A_1c range, 9.0-12.0%) were recruited. After continuous subcutaneous insulin infusion for 7 days for initial rapid correction of hyperglycaemia, a premixed insulin titration period (duration, 4-6 days) subsequently followed. Patients were then randomized (1:1) into two groups as follows: An acarbose plus pre-mixed 30/70 insulin group or a pre-mixed 30/70 insulin only group; each group received treatment for 2 weeks. Plasma high-sensitivity C-reactive protein (Hs-CRP), 8-iso-prostaglandin F₂α (8-iso PGF_2α), tumor necrosis factor-α (TNF-α), interleukin (IL)-1β, and IL-6 levels were measured before and after therapy. Patients that received acarbose plus insulin demonstrated greater reduction in 8-iso PGF_2α, Hs-CRP, TNF-α, IL-1β and IL-6 levels when compared with the insulin only patients. Thus, acarbose add-on insulin therapy was identified to be associated with greater improvements in oxidative stress and inflammation in patients with T2DM when compared with those that received insulin only therapy.

Acute Cocoa Supplementation Increases Postprandial HDL Cholesterol and Insulin in Obese Adults with Type 2 Diabetes after Consumption of a High-Fat Breakfast

BACKGROUND

Dietary cocoa is an important source of flavonoids and is associated with favorable cardiovascular disease effects, such as improvements in vascular function and lipid profiles, in nondiabetic adults. Type 2 diabetes (T2D) is associated with adverse effects on postprandial serum glucose, lipids, inflammation, and vascular function.

OBJECTIVE

We examined the hypothesis that cocoa reduces metabolic stress in obese T2D adults after a high-fat fast-food-style meal.

METHODS

Adults with T2D [n = 18; age (mean ± SE): 56 ± 3 y; BMI (in kg/m(2)): 35.3 ± 2.0; 14 women; 4 men] were randomly assigned to receive cocoa beverage (960 mg total polyphenols; 480 mg flavanols) or flavanol-free placebo (110 mg total polyphenols; <0.1 mg flavanols) with a high-fat fast-food-style breakfast [766 kcal, 50 g fat (59% energy)] in a crossover trial. After an overnight fast (10-12 h), participants consumed the breakfast with cocoa or placebo, and blood sample collection [glucose, insulin, lipids, and high-sensitivity C-reactive protein (hsCRP)] and vascular measurements were conducted at 0.5, 1, 2, 4, and 6 h postprandially on each study day. Insulin resistance was evaluated by homeostasis model assessment.

RESULTS

Over the 6-h study, and specifically at 1 and 4 h, cocoa increased HDL cholesterol vs. placebo (overall Δ: 1.5 ± 0.8 mg/dL; P ≤ 0.01) but had no effect on total and LDL cholesterol, triglycerides, glucose, and hsCRP. Cocoa increased serum insulin concentrations overall (Δ: 5.2 ± 3.2 mU/L; P < 0.05) and specifically at 4 h but had no overall effects on insulin resistance (except at 4 h, P < 0.05), systolic or diastolic blood pressure, or small artery elasticity. However, large artery elasticity was overall lower after cocoa vs. placebo (Δ: -1.6 ± 0.7 mL/mm Hg; P < 0.05), with the difference significant only at 2 h.

CONCLUSION

Acute cocoa supplementation showed no clear overall benefit in T2D patients after a high-fat fast-food-style meal challenge. Although HDL cholesterol and insulin remained higher throughout the 6-h postprandial period, an overall decrease in large artery elasticity was found after cocoa consumption. This trial was registered at clinicaltrials.gov as NCT01886989.

Endothelial cell oxidative stress in diabetes: a key driver of cardiovascular complications?

Atherothrombotic disease is a well-recognized complication of diabetes and is a major contributor to the high morbidity and mortality associated with diabetes. Although there is substantial evidence linking diabetes with cardiovascular disease, the specific effect of hyper- (or hypo-) glycaemia is less well understood. The present review focuses on the impact that glycaemic dysregulation has on respiratory function and ROS (reactive oxygen species) generation in the endothelial cells that are critical in preventing several key steps in the atherothrombotic process. Endothelial cells are particularly susceptible to ROS-mediated dysfunction not only because of reduced cell viability and increased senescence, but also because one of the major endothelium-derived factors that help to protect against atherosclerosis, nitric oxide, is rapidly deactivated by superoxide radicals.

Continuous subcutaneous insulin infusion in patients with type 2 diabetes: a cohort study to establish the relationship between glucose control and plasma oxidized low density lipoprotein

BACKGROUND

Oxidative stress is a detrimental feature of diabetes implicated in the progression of the disease and its complications. The relationship between insulin therapy and oxidative stress is complex. This study tested the hypothesis that improved glucose control, rather than insulin dose, is central to reduced oxidative stress in patients with type 2 diabetes following continuous subcutaneous insulin infusion (CSII).

METHODS

In this 16-week, multicenter study, 54 CSII-naïve patients with type 2 diabetes (age 57 ± 10 years, HbA1c 69 ± 15 mmol/mol [8.5 ± 1.4%], diabetes duration 13 ± 6 years) treated with either oral antidiabetic agents (OAD) alone (n = 17), basal insulin ± OAD (n = 17), or multiple daily injections (MDI) ± OAD (n = 20) were the evaluable group. Diabetes medications except metformin were discontinued, and 16 weeks of CSII was initiated. Insulin dose was titrated to achieve optimal glycemic control. A plasma marker of oxidative stress relevant to cardiovascular disease (oxidized low density lipoprotein [ox-LDL]) was assessed at baseline and week 16.

RESULTS

CSII improved glycemic control (HbA1c -13 ± 2 mmol/mol [-1.2 ± 0.2%]; fasting glucose -36.6 ± 8.4 mg/dL; mean glucose excursion -23.2 ± 6.5 mg/dL, mean ± SE; all P < .001) and reduced ox-LDL (-10.5%; P < .05). The antioxidant effect was cohort-independent (P > .05), but was significantly more pronounced in patients on statins (P = .019). The effect of CSII was more closely correlated to improvements in glucose excursion (P = .013) than to insulin dose (P > .05) or reduction in HbA1c (P > .05).

CONCLUSIONS

CSII induces depression of plasma ox-LDL associated with change in glucose control, rather than with change in insulin dose. The effect is augmented in patients receiving statins.

Combined use of basal insulin analog and acarbose reduces postprandial glucose in patients with uncontrolled type 2 diabetes

Aims/Introduction

Early initiation of basal insulin therapy is recommended for normalizing fasting blood glucose in type 2 diabetes mellitus. However, basal insulin treatment might not adequately control postprandial glucose levels. The present study evaluated whether the combination of the α-glucosidase inhibitor, acarbose, and basal insulin improved blood glucose control under daily-life treatment conditions in a large sample of Korean patients.

Materials and Methods

The present study was a multicenter, prospective, observational study under daily-life treatment conditions. A total of 539 patients with type 2 diabetes who were treated with basal insulin and additional acarbose were enrolled and followed up for 20 weeks. Changes in hemoglobin A1c, fasting and postprandial blood glucose were evaluated at baseline and at the end of the observation period. The physician and patient satisfaction of the combination treatment and safety were assessed.

Results

Hemoglobin A1c decreased by 0.55 ± 1.05% from baseline (P < 0.0001). Fasting and postprandial blood glucose levels were reduced by 0.89 ± 3.79 and 2.59 ± 4.77 mmol/L (both P < 0.0001). The most frequently reported adverse drug reactions were flatulence (0.37%) and abnormal gastrointestinal sounds (0.37%), and all were mild in intensity and transient. In the satisfaction evaluation, 79.0% of physicians and 77.3% of patients were ‘very satisfied’ or ‘satisfied’ with the combined basal insulin and acarbose therapy.

Conclusions

Combination therapy of basal insulin and acarbose in patients with type 2 diabetes improved glucose control, and had no drug-specific safety concerns, suggesting that the treatment might benefit individuals who cannot control blood glucose with basal insulin alone.

Postdinner resistance exercise improves postprandial risk factors more effectively than predinner resistance exercise in patients with type 2 diabetes

Abnormally elevated postprandial glucose and triacylglycerol (TAG) concentrations are risk factors for cardiovascular disease in type 2 diabetes. The most effective time to exercise to lower postprandial glucose and TAG concentrations is unknown. Thus the aim of this study was to determine what time is more effective, either pre- or postdinner resistance exercise (RE), at improving postprandial risk factors in patients with type 2 diabetes. Thirteen obese patients with type 2 diabetes completed three trials in a random order in which they consumed a dinner meal with 1) no RE (NoRE), 2) predinner RE (RE → M), and 3) postdinner RE beginning 45 min after dinner (M → RE). Clinical outcome measures included postprandial glucose and TAG concentrations. In addition, postprandial acetaminophen (gastric emptying), endocrine responses, free fatty acids, and β-cell function (mathematical modeling) were measured to determine whether these factors were related to changes in glucose and TAG. The TAG incremental area under the curve (iAUC) was ∼92% lower (P ≤ 0.02) during M → RE compared with NoRE and RE → M, an effect due in part to lower very-low-density lipoprotein-1 TAG concentrations. The glucose iAUC was reduced (P = 0.02) by ∼18 and 30% during the RE → M and M → RE trials, respectively, compared with NoRE, with no difference between RE trials. RE → M and M → RE reduced the insulin iAUC by 35 and 48%, respectively, compared with NoRE (P < 0.01). The glucagon-like peptide-1 iAUC was ∼50% lower (P ≤ 0.02) during M → RE compared with NoRE and RE → M. Given that predinner RE only improves postprandial glucose concentrations, whereas postdinner RE improves both postprandial glucose and TAG concentrations, postdinner RE may lower the risk of cardiovascular disease more effectively.

Postdinner resistance exercise improves postprandial risk factors more effectively than predinner resistance exercise in patients with type 2 diabetes

Abnormally elevated postprandial glucose and triacylglycerol (TAG) concentrations are risk factors for cardiovascular disease in type 2 diabetes. The most effective time to exercise to lower postprandial glucose and TAG concentrations is unknown. Thus the aim of this study was to determine what time is more effective, either pre- or postdinner resistance exercise (RE), at improving postprandial risk factors in patients with type 2 diabetes. Thirteen obese patients with type 2 diabetes completed three trials in a random order in which they consumed a dinner meal with 1) no RE (NoRE), 2) predinner RE (RE → M), and 3) postdinner RE beginning 45 min after dinner (M → RE). Clinical outcome measures included postprandial glucose and TAG concentrations. In addition, postprandial acetaminophen (gastric emptying), endocrine responses, free fatty acids, and β-cell function (mathematical modeling) were measured to determine whether these factors were related to changes in glucose and TAG. The TAG incremental area under the curve (iAUC) was ∼92% lower (P ≤ 0.02) during M → RE compared with NoRE and RE → M, an effect due in part to lower very-low-density lipoprotein-1 TAG concentrations. The glucose iAUC was reduced (P = 0.02) by ∼18 and 30% during the RE → M and M → RE trials, respectively, compared with NoRE, with no difference between RE trials. RE → M and M → RE reduced the insulin iAUC by 35 and 48%, respectively, compared with NoRE (P < 0.01). The glucagon-like peptide-1 iAUC was ∼50% lower (P ≤ 0.02) during M → RE compared with NoRE and RE → M. Given that predinner RE only improves postprandial glucose concentrations, whereas postdinner RE improves both postprandial glucose and TAG concentrations, postdinner RE may lower the risk of cardiovascular disease more effectively.

Additive effects of postchallenge hyperglycemia and low-density lipoprotein particles on the risk of arterial stiffness in healthy adults

Background

To determine the effects of post-challenge hyperglycemia potentiate low-density lipoprotein cholesterol (LDL) particles on the risk of arterial stiffness in non-diabetic adults.

Methods

During 2009–2011, 592 adults without clinical diabetes (fasting glucose <7.0 mmol/L) or known coronary heart disease or stroke were recruited. All subjects underwent standard 75-g oral glucose tolerance test (OGTT) after overnight fasting. The glucose area under curve (GluAUC) after OGTT was defined as the postchallenge glucose load. Levels of LDL-C and small dense LDL-C (sdLDL-C) were measured. Arterial stiffness in terms of brachial–ankle pulse wave velocity (baPWV) was also measured.

Results

The baPWV in tertile distributions were significantly associated with all conventional cardiovascular risk factors, LDL-C, and sdLDL-C. Multivariate logistic regression analyses revealed that LDL-C (or sdLDL-C) combined with one of the seven glycemic indices (glucose levels at 0, 30, 60, 90, and 120 min; GluAUC; HbA1C) was associated with arterial stiffness after covariates being adjusted. Further interaction analyses showed only concurrent higher levels of both glycemic indices and atherogenic LDL-C or sdLDL-C have significant risk for arterial stiffness.

Conclusions

Additive effects of both postchallenge hyperglycemia and LDL subclass particles potentiate the risk of arterial stiffness. The adverse joint effects of hyperlipidemia and postchallenge hyperglycemia on subclinical cardiovascular function provide important information in primary prevention of cardiovascular disease in subjects without clinical diabetes.

Visit-to-visit variability of fasting plasma glucose as predictor of ischemic stroke: competing risk analysis in a national cohort of Taiwan Diabetes Study

BACKGROUND

Glycemic variation as an independent predictor of ischemic stroke in type 2 diabetic patients remains unclear. This study examined visit-to-visit variations in fasting plasma glucose (FPG), as represented by the coefficient of variation (CV), for predicting ischemic stroke independently, regardless of glycated hemoglobin (HbA1c) and other conventional risk factors in such patients.

METHODS

Type 2 diabetic patients enrolled in the National Diabetes Care Management Program, ≥30 years old and free of ischemic stroke (n = 28,354) in 2002 to 2004 were included, and related factors were analyzed with extended Cox proportional hazards regression models of competing risk data on stroke incidence.

RESULTS

After an average 7.5 years of follow-up, there were 2,250 incident cases of ischemic stroke, giving a crude incidence rate of 10.56/1,000 person-years (11.64 for men, 9.63 for women). After multivariate adjustment, hazard ratios for the second, third and fourth versus first FPG-CV quartile were 1.11 (0.98, 1.25), 1.22 (1.08, 1.38) and 1.27 (1.12, 1.43), respectively, without considering HbA1c, and 1.09 (0.96, 1.23), 1.16 (1.03, 1.31) and 1.17 (1.03, 1.32), respectively, after considering HbA1c.

CONCLUSIONS

Besides HbA1c, FPG-CV was a potent predictor of ischemic stroke in type 2 diabetic patients, suggesting that different therapeutic strategies now in use be rated for their potential to (1) minimize glucose fluctuations and (2) reduce HbA1c level in type 2 diabetic patients to prevent ischemic stroke.

Glycemic variability in nondiabetic morbidly obese persons: results of an observational study and review of the literature

Glycemic variability (GV) is correlated with oxidative stress which may lead to increased cardiovascular risk and poor clinical outcomes in people with prediabetes and diabetes. We sought to understand whether morbidly obese persons without diabetes by standard criteria have dysglycemia as measured by GV. We performed an observational study of GV metrics and carotid intima media thickness (CIMT) in 21 morbidly obese normoglycemic and 15 morbidly obese prediabetic applicants to The Biggest Loser television show. The results were compared to previously published studies in normoglycemic nonobese and obese individuals. Glucose was measured with a masked continuous glucose monitor (CGM) over 3 to 8 days and carotid intima media thickness (CIMT) was determined by ultrasound. CGM-derived GV metrics for GV were coefficient of variation (CV), standard deviation (SD), mean amplitude of glycemic excursions (MAGE), continuous overall net glycemic action-1 hour (CONGA1), and mean of daily differences (MODD). We found that morbidly obese subjects (n = 21) who were normoglycemic by standard criteria had higher GV (CV = 22%, SD = 24.2 mg/dl and MAGE = 48.6 mg/dl) than previous reports of normoglycemic, nonobese individuals (CV = 12-18%, SD = 11.5-15.0 mg/dl, and MAGE = 26.3-28.3 mg/dl). Morbidly obese prediabetic subjects (n = 15) had GV metrics indistinguishable from those morbidly obese subjects who were normoglycemic. CIMT was higher in both morbidly obese groups compared with historical age- and sex-matched controls. Normoglycemic and prediabetic morbidly obese individuals have higher GV compared with normal weight, nondiabetic individuals. We speculate that this may increase the risk for macrovascular disease through excessive oxidative stress.

Impact of glucose fluctuation and monocyte subsets on coronary plaque rupture

BACKGROUND AND AIMS

It remains unclear whether glycemic fluctuation can affect plaque rupture in acute myocardial infarction (AMI). Here we investigate the impact of glucose fluctuation on plaque rupture, as observed by optical coherence tomography (OCT), and monocyte subsets in patients with AMI.

METHODS AND RESULTS

We studied 37 consecutive patients with AMI. All patients underwent OCT examination, which revealed 24 patients with plaque rupture and 13 patients without plaque rupture at the culprit site. Peripheral blood sampling was performed on admission. Three monocyte subsets (CD14(+)CD16(-), CD14(bright)CD16(+), and CD14(dim)CD16(+)) were assessed by flow cytometry. Glycemic variability, expressed as the mean amplitude of glycemic excursion (MAGE), was determined by a continuous glucose monitoring system 7 days after the onset of AMI. MAGE was significantly higher in the rupture patients than in the non-rupture patients (P=0.036). Levels of CD14(bright)CD16(+) monocytes from the rupture patients were significantly higher than those from the non-rupture patients (P=0.042). Of interest, levels of CD14(bright)CD16(+) monocytes correlated positively and significantly with MAGE (r=0.39, P=0.02).

CONCLUSION

Dynamic glucose fluctuation may be associated with coronary plaque rupture, possibly through the preferential increase in CD14(bright)CD16(+) monocyte levels.

Lixisenatide as add-on therapy to basal insulin

Many patients with type 2 diabetes mellitus do not achieve target glycosylated hemoglobin A1c levels despite optimally titrated basal insulin and satisfactory fasting plasma glucose levels. Current evidence suggests that HbA1c levels are dictated by both basal glucose and postprandial glucose levels. This has led to a consensus that postprandial glucose excursions contribute to poor glycemic control in these patients. Lixisenatide is a once-daily, prandial glucagon-like peptide 1 (GLP-1) receptor agonist with a four-fold affinity for the GLP-1 receptor compared with native GLP-1. Importantly, lixisenatide causes a significant delay in gastric emptying time, an important determinant of the once-daily dosing regimen. An exendin-4 mimetic with six lysine residues removed at the C-terminal, lixisenatide has pronounced postprandial glucose-lowering effects, making it a novel incretin agent for use in combination with optimally titrated basal insulin. Lixisenatide exerts profound effects on postprandial glucose through established mechanisms of glucose-dependent insulin secretion and glucagon suppression in combination with delayed gastric emptying. This review discusses the likely place that lixisenatide will occupy in clinical practice, given its profound effects on postprandial glucose and potential to reduce glycemic variability.

Impact of admission glycemic variability, glucose, and glycosylated hemoglobin on major adverse cardiac events after acute myocardial infarction

OBJECTIVE

Dysglycemia is associated with poorer prognosis in patients with acute myocardial infarction (AMI). Whether admission glycemic variability (GV) has important value in prognosis of AMI patients is still unknown. The aim of the study is to investigate the prognostic value of admission GV, glucose, and glycosylated hemoglobin (HbA(1c)) in AMI patients.

RESEARCH DESIGN AND METHODS

We measured blood glucose, HbA(1c), and GV on admission in 222 consecutive patients with diagnosed AMI. GV, indicated as the mean amplitude of glycemic excursions (MAGE), was determined by a continuous glucose monitoring system. MAGE was categorized as ≥3.9 or <3.9 mmol/L, admission glucose as ≥8.61 or <8.61 mmol/L, and HbA(1c) as ≥6.5 or <6.5%. Participants were followed up prospectively for 12 months. The relationship of admission MAGE, glucose, and HbA(1c) to the major adverse cardiac event (MACE) of AMI patients was analyzed.

RESULTS

In 222 enrolled patients with AMI, the rate of MACE by MAGE category (<3.9 or ≥3.9 mmol/L) was 8.4 and 24.1%, respectively (P = 0.001), by admission glucose category (<8.61 or ≥8.61 mmol/L) was 10.1 and 21.6%, respectively (P = 0.020), and by HbA(1c) category (<6.5 vs. ≥6.5%) was 10.7 versus 18.7%, respectively (P = 0.091). In multivariate analysis, high MAGE level was significantly associated with incidence of MACE (hazard ratio 2.419 [95% CI 1.273-9.100]; P = 0.017) even after adjusting for Global Registry of Acute Coronary Events risk score, but admission glucose and HbA(1c) was not.

CONCLUSIONS

Elevated admission GV appears more important than admission glucose and prior long-term abnormal glycometabolic status in predicting 1-year MACE in patients with AMI.

Prognostic value of early in-hospital glycemic excursion in elderly patients with acute myocardial infarction

BACKGROUND

Acute phase hyperglycemia has been associated with increased mortality in patients with acute myocardial infarction (AMI). However, the predictive value of glycemic excursion for adverse outcome in elderly AMI patients is not clear. The aim of this study is to investigate the prognostic value of early in-hospital glycemic excursion and hemoglobin A1c (HbA1c) for one-year major adverse cardiac event (MACE) in elderly patients with AMI.

METHODS

We studied 186 elderly AMI patients, whose clinical data were collected and the Global Registry of Acute Coronary Events (GRACE) risk score were calculated on admission. The fluctuations of blood glucose in patients were measured by a continuous glucose monitoring system (CGMS) for 72 hours. Participants were grouped into tertiles of mean amplitude of glycemic excursions (MAGE) and grouped into HbA1c levels (as ≥6.5% or <6.5%). The MACE of patients, including new-onset myocardial infarction, acute heart failure and cardiac death, was documented during one year follow-up. The relationship of MAGE and HbA1c to the incidence of MACE in elderly AMI patients was analyzed.

RESULTS

In all participants, a higher MAGE level was associated with the higher GRACE score (r = 0.335, p < 0.001). The rate of MACE by MAGE tertiles (>3.94 mmol/L, 2.55-3.94 mmol/L or <2.55 mmol/L) was 30.2% vs. 14.8% vs. 8.1%, respectively (p = 0.004); by HbA1c category (≥6.5% vs. <6.5%) was 22.7% vs. 14.4%, respectively (p = 0.148). Elderly AMI patients with a higher MAGE level had a significantly higher cardiac mortality. In multivariable analysis, high MAGE level was significantly associated with incidence of MACE (HR 3.107, 95% CI 1.190-8.117, p = 0.021) even after adjusting for GRACE risk score, but HbA1c was not.

CONCLUSIONS

The early in-hospital intraday glycemic excursion may be an important predictor of mortality and MACE even stronger than HbA1c in elderly patients after AMI.

Glycemic variability in type 2 diabetes mellitus: oxidative stress and macrovascular complications

Diabetes mellitus is a world-wide health issue with potential for significant negative health outcomes, including microvascular and macrovascular complications. The relationship of hemoglobin HbA1c and other glycosylation end products (AGEs) to these complications, particularly microvascular disease, is well understood. More recent evidence suggests that glycemic variability may be associated with diabetes macrovascular complications. As HbA1c is better representative of average glucose levels and does not account as well for glycemic variability, hence new methods to assess and treat this variability is needed to reduce incidence of complications. In this chapter, the relationship of glycemic control to diabetes complications will be explored with focus on the mechanisms of tissue damage from this variability along with the oxidative stress. Additionally, treatment strategies to optimize HbA1c and glycemic variability with the goal of reducing risk of complications in persons with diabetes are reviewed.

Associations between blood glucose and carotid intima-media thickness disappear after adjustment for shared risk factors: the KORA F4 study

Objective

The association between blood glucose and carotid intima-media thickness (CIMT) is considered to be established knowledge. We aimed to assess whether associations between different measures of glycaemia and CIMT are actually independent of anthropometric variables and metabolic risk factors. Moreover, we checked published studies for the adjustment for shared risk factors of blood glucose and CIMT.

Methods

Fasting glucose, 2-hour glucose, HbA1c, and CIMT were measured in 31-81-years-old participants of the population-based Cooperative Health Research in the Region of Augsburg (KORA) F4 study in Southern Germany (n = 2,663). CIMT was assessed according to the Rotterdam protocol. Linear and logistic regression models with adjustment for age, sex, anthropometric measures, hypertension, and dyslipidaemia were fitted to assess the association between continuous measures of glycaemia, and categories of glucose regulation, respectively, with CIMT.

Results

We found a 0.10 mm increase (95%-confidence interval: 0.08–0.12) in CIMT in subjects with compared to subjects without diabetes in crude analysis. This increase was not significant in age-sex adjusted models (p = 0.17). Likewise, neither impaired fasting glucose (p = 0.22) nor impaired glucose tolerance (p = 0.93) were associated with CIMT after adjustment for age, sex, and waist circumference. In multivariable adjusted models, age, sex, hypertension, waist circumference, HDL and LDL cholesterol, but neither fasting glucose nor 2-hour glucose nor HbA1c were associated with elevated CIMT. Literature findings are inconclusive regarding an independent association of glucose levels and CIMT.

Conclusion

CIMT is highly dependent on traditional cardiovascular risk factors, but no relationships between blood glucose and CIMT were found after adjustment for age, sex, and anthropometric variables.

Gastric bypass and banding equally improve insulin sensitivity and β cell function

Bariatric surgery in obese patients is a highly effective method of preventing or resolving type 2 diabetes mellitus (T2DM); however, the remission rate is not the same among different surgical procedures. We compared the effects of 20% weight loss induced by laparoscopic adjustable gastric banding (LAGB) or Roux-en-Y gastric bypass (RYGB) surgery on the metabolic response to a mixed meal, insulin sensitivity, and β cell function in nondiabetic obese adults. The metabolic response to meal ingestion was markedly different after RYGB than after LAGB surgery, manifested by rapid delivery of ingested glucose into the systemic circulation, by an increase in the dynamic insulin secretion rate, and by large, early postprandial increases in plasma glucose, insulin, and glucagon-like peptide-1 concentrations in the RYGB group. However, the improvement in oral glucose tolerance, insulin sensitivity, and overall β cell function after weight loss were not different between surgical groups. Additionally, both surgical procedures resulted in a similar decrease in adipose tissue markers of inflammation. We conclude that marked weight loss itself is primarily responsible for the therapeutic effects of RYGB and LAGB on insulin sensitivity, β cell function, and oral glucose tolerance in nondiabetic obese adults.

Postprandial dyslipidaemia and diabetes: mechanistic and therapeutic aspects

PURPOSE OF REVIEW

There has been a resurgence of interest in the role of triglyceride-rich lipoproteins in the development of atherosclerosis and cardiovascular disease, and this is particularly relevant to diabetes mellitus and the postprandial state.

RECENT FINDINGS

Recent evidence suggests that insulin resistance in diabetes induces postprandial dyslipidemia by increasing the enterocytic production of chylomicrons and their remnant particles, but an impaired clearance capacity is also involved. Postprandial dyslipidaemia in diabetes induces oxidative stress, inflammation and endothelial dysfunction and this may be compounded by dysglycaemia. New guidelines for managing hypertriglyceridaemia in diabetes have been published, first-line therapies being improved glycaemic control, treatment of other secondary causes of dyslipidaemia and statin therapy, followed by judicious use of fibrates, n-3 fatty acids or niacin. A new role for incretin-based therapies in regulating dyslipidaemia has been identified.

SUMMARY

Postprandial dyslipidaemia is a pivotal mechanism whereby diabetes can induce and accelerate atherosclerosis. Regulating the plasma concentrations of triglyceride-rich lipoproteins may decrease the cardiovascular complications of diabetes. The mechanisms of action of incretin-based treatments on dyslipidaemia and endothelial dysfunction need further investigation. The efficacy of new therapies targeted at postprandial dysmetabolism in diabetes need to be confirmed, against best current levels of care, in clinical endpoint trials.

Age- and gender-specific prevalence of carotid atherosclerosis and its association with metabolic syndrome in Hangzhou, China

OBJECTIVE

Because of rapid alterations in lifestyle and the incidence of metabolic syndrome (MetS), the prevalence of carotid atherosclerosis (CA) and carotid plaque (CP) may increase in China. We aimed to evaluate the prevalence of CA and CP as well as its relation to MetS in an East Chinese population.

METHODS

The study included 6142 subjects who underwent general health screening including carotid ultrasonography in 2009. Diagnoses of MetS were made according to the revised Adult Treatment Panel III criteria.

RESULTS

The prevalence of CA and CP increased gradually with age. These conditions were more prevalent in men than in women (CA: 22.1%vs 12.0%, P < 0.001; CP: 12.6%vs 7.2%, P < 0.001). Multivariate logistic regression analysis showed that male gender, age, blood pressure, fasting blood glucose (FBG) and low-density lipoprotein cholesterol were risk factors for CA and CP, while high-density lipoprotein cholesterol was protective for CA. Age ≥ 50 years has the largest impact on CA and CP, followed by elevated blood pressure and elevated blood glucose. Individuals with MetS had a higher prevalence of CA (27.7%vs 20.0% in men, 24.0%vs 10.3% in women; P < 0.001 in both) and CP (16.6%vs 11.2% in men, P < 0.001; 11.8%vs 6.5% in women, P < 0.005) than those without MetS. The prevalence and odds ratios of CA and CP aggregated with an increasing number of MetS components, even in individuals exhibiting only one component.

CONCLUSIONS

These results indicate that CA and CP have become a major public health problem in China. MetS and its components were associated with an increased prevalence of CA and CP.