Mortality in diabetes compared with previous cardiovascular disease: a gender-specific meta-analysis

Quercetin Ameliorates Myocardial Injury in Diabetic Rats by Regulating Autophagy and Apoptosis through AMPK/mTOR Signaling Pathway

A high-glucose environment is involved in the progression of diabetes mellitus (DM). This study aims to explore the regulatory effects of quercetin (QUE) on autophagy and apoptosis after myocardial injury in rats with DM. The type 2 DM rat models were constructed using low-dose streptozotocin (STZ) treatment combined with a high-carbohydrate (HC) diet in vivo. Compared with the control group, the body weight was decreased, whereas blood pressure, blood glucose, and the LVW/BW ratio were increased in the diabetic group. The results showed that the myocardial fibers were disordered in the diabetic group. Moreover, we found that the myocardial collagen fibers, PAS-positive cells, and apoptosis were increased, whereas the mitochondrial structure was destroyed and autophagic vacuoles were significantly reduced in the diabetic group compared with the control group. The expression levels of autophagy-related proteins LC3 and Beclin1 were decreased, whereas the expression levels of P62, Caspae-3, and Bax/Bcl-2 were increased in the diabetic group in vitro and in vivo. Moreover, QUE treatment alleviated the cellular oxidative stress reaction under high-glucose environments. The results of immunoprecipitation (IP) showed that the autophagy protein Beclin1 was bound to Bcl-2, and the binding capacity increased in the HG group, whereas it decreased after QUE treatment, suggesting that QUE inhibited the binding capacity between Beclin1 and Bcl-2, thus leading to the preservation of Beclin1-induced autophagy. In addition, the blood pressure, blood glucose, and cardiac function of rats were improved following QUE treatment. In conclusion, QUE suppressed diabetic myocardial injury and ameliorated cardiac function by regulating myocardial autophagy and inhibition of apoptosis in diabetes through the AMPK/mTOR signaling pathway.

Review of the Protective Mechanism of Curcumin on Cardiovascular Disease

Cardiovascular diseases (CVDs) are the most common cause of death worldwide and has been the focus of research in the medical community. Curcumin is a polyphenolic compound extracted from the root of turmeric. Curcumin has been shown to have a variety of pharmacological properties over the past decades. Curcumin can significantly protect cardiomyocyte injury after ischemia and hypoxia, inhibit myocardial hypertrophy and fibrosis, improve ventricular remodeling, reduce drug-induced myocardial injury, improve diabetic cardiomyopathy(DCM), alleviate vascular endothelial dysfunction, inhibit foam cell formation, and reduce vascular smooth muscle cells(VSMCs) proliferation. Clinical studies have shown that curcumin has a protective effect on blood vessels. Toxicological studies have shown that curcumin is safe. But high doses of curcumin also have some side effects, such as liver damage and defects in embryonic heart development. This article reviews the mechanism of curcumin intervention on CVDs in recent years, in order to provide reference for the development of new drugs in the future.

Associations of eicosapentaenoic acid and docosahexaenoic acid intakes with cardiovascular and all-cause mortality in patients with diabetes: Result from National Health and Nutrition Examination Survey 1999-2008

Introduction

The evidence on eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) intake status and long-term mortality among people with diabetes is scarce. This study aimed to investigate the relationship between EPA and DHA intakes with all-cause and cause-specific mortality in adults with diabetes.

Methods

This study included 2,991 adults with diabetes from the National Health and Nutrition Examination Survey (NHANES) 1999-2008. Death outcomes were ascertained by linkage to the database records through 31 December 2015. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for mortality from all causes, cardiovascular disease (CVD), and coronary heart disease (CHD) in patients with diabetes.

Results

Among 2,991 patients with diabetes, the mean age was 61.9 years (55.2% males). During the mean follow-up duration of 9.4 years, a total of 1,091 deaths were documented, of which 273 were due to CVD, including 227 CHD deaths. EPA and DHA intakes were associated with lower mortality risks, especially that of CVD. After adjusting for demographic, major lifestyle factors, overall dietary intake patterns, and history of hypertension and dyslipidemia, the multivariable HRs (95% CIs) of mortality risk comparing Q4 to Q1 of EPA intake were 0.55 (0.33-0.92; P-trend = 0.019) for CHD, 0.55 (0.36-0.83; P-trend = 0.005) for CVD, and 0.91 (0.70-1.18; P-trend = 0.264) for all-cause. The respective HRs (95% CIs) comparing Q4 to Q1 of DHA were 0.60 (0.37-0.98; P-trend = 0.051) for CHD, 0.58 (0.38-0.89; P-trend = 0.014) for CVD, and 0.92 (0.72-1.18; P-trend = 0.481) for all-cause. In subgroup analysis, we found that the association trends of EPA and DHA intakes with death risk remained robust among patients with diabetes, especially among those who are old, female, those with higher BMI, and dyslipidemia patients with CVD and CHD.

Discussion

In the USA, higher EPA and DHA intakes were associated with a lower risk of CHD and CVD mortality in patients with diabetes. Our study supports the benefits of adequate EPA and DHA intakes in promoting the health of patients with diabetes.

Characteristics, Mortality, and Clinical Outcomes of Hospitalized Patients with COVID-19 and Diabetes: A Reference Single-Center Cohort Study from Poland

BACKGROUND

Diabetes is a risk factor for a severe course of COVID-19. We evaluated the characteristics and risk factors associated with undesirable outcomes in diabetic patients (DPs) hospitalized due to COVID-19.

MATERIALS AND METHODS

The data analysis of patients admitted between March 6, 2020, and May 31, 2021, to the University Hospital in Krakow (Poland), a reference center for COVID-19, was performed. The data were gathered from their medical records.

RESULTS

A total number of 5191 patients were included, of which 2348 (45.2%) were women. The patients were at the median age of 64 (IQR: 51-74) years, and 1364 (26.3%) were DPs. DPs, compared to nondiabetics, were older (median age: 70 years, IQR: 62-77 vs. 62, IQR: 47-72, and p < 0.001) and had a similar gender distribution. The DP group had a higher mortality rate (26.2% vs. 15.7%, p < 0.001) and longer hospital stays (median: 15 days, IQR: 10-24 vs. 13, IQR: 9-20, and p < 0.001). DPs were admitted to the ICU more frequently (15.7% vs. 11.0%, p < 0.001) and required mechanical ventilation more often (15.5% vs. 11.3%, p < 0.001). In a multivariate logistic regression, factors associated with a higher risk of death were age >65 years, glycaemia >10 mmol/L, CRP and D-dimer level, prehospital insulin and loop diuretic use, presence of heart failure, and chronic kidney disease. Factors contributing to lower mortality were in-hospital use of statin, thiazide diuretic, and calcium channel blocker.

CONCLUSION

In this large COVID-19 cohort, DPs constituted more than a quarter of hospitalized patients. The risk of death and other outcomes compared to nondiabetics was higher in this group. We identified a number of clinical, laboratory, and therapeutic variables associated with the risk of hospital death in DPs.

Combination Therapy of Alpha-Lipoic Acid, Gliclazide and Ramipril Protects Against Development of Diabetic Cardiomyopathy via Inhibition of TGF-β/Smad Pathway

Background: Diabetic cardiomyopathy (DCM) is a major long-term complication of diabetes mellitus, accounting for over 20% of annual mortality rate of diabetic patients globally. Although several existing anti-diabetic drugs have improved glycemic status in diabetic patients, prevalence of DCM is still high. This study investigates cardiac effect of alpha-lipoic acid (ALA) supplementation of anti-diabetic therapy in experimental DCM. Methods: Following 12 h of overnight fasting, 44 male Sprague Dawley rats were randomly assigned to two groups of healthy control (n = 7) and diabetic (n = 37) groups, and fasting blood glucose was measured. Type 2 diabetes mellitus (T2DM) was induced in diabetic group by intraperitoneal (i.p.) administration of nicotinamide (110 mg/kg) and streptozotocin (55 mg/kg). After confirmation of T2DM on day 3, diabetic rats received monotherapies with ALA (60 mg/kg; n = 7), gliclazide (15 mg/kg; n = 7), ramipril (10 mg/kg; n = 7) or combination of the three drugs (n = 7) for 6 weeks while untreated diabetic rats received distilled water and were used as diabetic control (n = 9). Rats were then sacrificed, and blood, pancreas and heart tissues were harvested for analyses using standard methods. Results: T2DM induction caused pancreatic islet destruction, hyperglycemia, weight loss, high relative heart weight, and development of DCM, which was characterized by myocardial degeneration and vacuolation, cardiac fibrosis, elevated cardiac damage markers (plasma and cardiac creatine kinase-myocardial band, brain natriuretic peptide and cardiac troponin I). Triple combination therapy of ALA, gliclazide and ramipril preserved islet structure, maintained body weight and blood glucose level, and prevented DCM development compared to diabetic control (p < 0.001). In addition, the combination therapy markedly reduced plasma levels of inflammatory markers (IL-1β, IL-6 and TNF-α), plasma and cardiac tissue malondialdehyde, triglycerides and total cholesterol while significantly increasing cardiac glutathione and superoxide dismutase activity and high-density lipoprotein-cholesterol compared to diabetic control (p < 0.001). Mechanistically, induction of T2DM upregulated cardiac expression of TGF-β1, phosphorylated Smad2 and Smad3 proteins, which were downregulated following triple combination therapy (p < 0.001). Conclusion: Triple combination therapy of ALA, gliclazide and ramipril prevented DCM development by inhibiting TGF-β1/Smad pathway. Our findings can be extrapolated to the human heart, which would provide effective additional pharmacological therapy against DCM in T2DM patients.

FTZ Ameliorates Diabetic Cardiomyopathy by Inhibiting Inflammation and Cardiac Fibrosis in the Streptozotocin-Induced Model

Background

The pathogenesis and clinical features of diabetic cardiomyopathy (DCM) have been well studied in the past decade; however, effective approaches to prevent and treat this disease are limited. Fufang Zhenzhu Tiaozhi (FTZ) formula, a traditional Chinese prescription, is habitually used to treat dyslipidemia and diabetes. Recently, several studies have reported the therapeutic effects of FTZ on cardiovascular diseases. However, the effects of FTZ on DCM have not yet been fully elucidated. This study investigated the effects of FTZ on DCM and determined the mechanisms underlying its efficacy.

Methods

Diabetes was induced in mice by intraperitoneal injection of streptozotocin; the mice were randomly divided into a control group (Con), diabetes group (DCM), and diabetes-treated with FTZ (DCM + FTZ). Myocardial structural alterations, fibrosis biomarkers, and inflammation were observed. Besides, the potential targets and their related signaling pathways were analyzed using network pharmacology and further verified by Western blot.

Results

Diabetic mice showed significant body weight loss, hyperglycemia, and excessive collagen content in the cardiac tissue, while serum and myocardial inflammatory factors significantly increased. Nerveless, treatment with FTZ for 1 month significantly improved body weight, attenuated hyperglycemia, and alleviated diabetes-associated myocardial structure and function abnormalities. Furthermore, the serum levels of interleukin 12 (IL-12) and chemokine (C–C motif) ligand 2 (CCL2) as well as the mRNA levels of cardiac IL-12, IL-6, and C–C motif chemokine receptor 2 (Ccr2) reduced after FTZ treatment. Additionally, a total of 67 active compounds and 76 potential targets related to DCM were analyzed. Pathway and functional enrichment analyses showed that FTZ mainly regulates inflammation-related pathways, including MAPK and PI3K-AKT signaling pathways. Further investigation revealed that the activities of STAT3, AKT, and ERK were augmented in diabetic hearts but decreased in FTZ-treated cardiac tissues.

Conclusion

Our results suggest that FTZ exhibits therapeutic properties against DCM by ameliorating hyperglycemia-induced inflammation and fibrosis via at least partial inhibition of AKT, ERK, and STAT3 signaling pathways.

Ten-year cardiovascular risk in diabetes patients without obstructive coronary artery disease: a retrospective Western Denmark cohort study

BACKGROUND

Diabetes patients without obstructive coronary artery disease as assessed by coronary angiography have a low risk of myocardial infarction, but their myocardial infarction risk may still be higher than the general population. We examined the 10-year risks of myocardial infarction, ischemic stroke, and death in diabetes patients without obstructive coronary artery disease according to coronary angiography, compared to risks in a matched general population cohort.

METHODS

We included all diabetes patients without obstructive coronary artery disease examined by coronary angiography from 2003 to 2016 in Western Denmark. Patients were matched by age and sex with a cohort from the Western Denmark general population without a previous myocardial infarction or coronary revascularization. Outcomes were myocardial infarction, ischemic stroke, and death. Ten-year cumulative incidences were computed. Adjusted hazard ratios (HR) then were computed using stratified Cox regression with the general population as reference.

RESULTS

We identified 5734 diabetes patients without obstructive coronary artery disease and 28,670 matched individuals from the general population. Median follow-up was 7 years. Diabetes patients without obstructive coronary artery disease had an almost similar 10-year risk of myocardial infarction (3.2% vs 2.9%, adjusted HR 0.93, 95% CI 0.72-1.20) compared to the general population, but had an increased risk of ischemic stroke (5.2% vs 2.2%, adjusted HR 1.87, 95% CI 1.47-2.38) and death (29.6% vs 17.8%, adjusted HR 1.24, 95% CI 1.13-1.36).

CONCLUSIONS

Patients with diabetes and no obstructive coronary artery disease have a 10-year risk of myocardial infarction that is similar to that found in the general population. However, they still remain at increased risk of ischemic stroke and death.

Curcumin alleviates oxidative stress and inhibits apoptosis in diabetic cardiomyopathy via Sirt1-Foxo1 and PI3K-Akt signalling pathways

Diabetes is a disorder of glucose metabolism, and over 90% are type 2 diabetes. Diabetic cardiomyopathy (DCM) is one of the type 2 diabetes complications, usually accompanied by changes in myocardial structure and function, together with cardiomyocyte apoptosis. Our study investigated the effect of curcumin on regulating oxidative stress (OS) and apoptosis in DCM. In vivo, diabetes was induced in an experimental rat model by streptozoticin (STZ) together with high‐glucose and high‐fat (HG/HF) diet feeding. In vitro, H9c2 cardiomyocytes were cultured with high‐glucose and saturated free fatty acid palmitate. Curcumin was orally or directly administered to rats or cells, respectively. Streptozoticin ‐induced diabetic rats showed metabolism abnormalities and elevated markers of OS (superoxide dismutase [SOD], malondialdehyde [MDA], gp91^phox, Cyt‐Cyto C), enhanced cell apoptosis (Bax/Bcl‐2, Cleaved caspase‐3, TUNEL‐positive cells), together with reduced Akt phosphorylation and increased Foxo1 acetylation. Curcumin attenuated the myocardial dysfunction, OS and apoptosis in the heart of diabetic rats. Curcumin treatment also enhanced phosphorylation of Akt and inhibited acetylation of Foxo1. These results strongly suggest that apoptosis was increased in the heart of diabetic rats, and curcumin played a role in diabetic cardiomyopathy treatment by modulating the Sirt1‐Foxo1 and PI3K‐Akt pathways.

Cardiovascular Disease in Women Across the Lifespan: The Importance of Sleep

Cardiovascular disease (CVD) and sleep disturbances are both common and associated with significant morbidity and mortality. Compared with men, women are more likely to report insufficient sleep. During the 2018 Research Conference on Sleep and the Health of Women sponsored by the National Heart, Lung, and Blood Institute, researchers in cardiology, integrative physiology and sleep medicine reviewed the current understanding of how sleep and sleep disturbances influence CVD in women across the lifespan. Women may be particularly vulnerable to the negative effects of sleep disturbances at important stages of their life, including during pregnancy and after menopause. The proposed pathways linking sleep disturbances and adverse cardiovascular outcomes in women are numerous and the complex interaction between them is not well understood. Future research focused on understanding the scope of sleep disorders in women, defining the underlying mechanisms, and testing interventions to improve sleep are critical for improving the cardiovascular health of all women.

The Dose-Response Associations of Sedentary Time with Chronic Diseases and the Risk for All-Cause Mortality Affected by Different Health Status: A Systematic Review and Meta-Analysis

PURPOSE

To determine the dose-response associations of sedentary behaviour with cardiovascular diseases (CVD), cancer, and all-cause mortality, and to examine whether the sedentary-associated all-cause mortality risk was affected by appearance of diabetes and hypertension, physical activity, and body mass index (BMI).

DESIGN

We carried out a systematic review and meta-analysis to search Medline, SportDiscus, and Web of Science for eligible studies.

SETTINGS

Prospective cohort studies that reported sedentary time and CVD, cancer, and mortality incidents.

MEASUREMENTS

Two authors independently extracted data based on predefined criteria. The effect estimates were evaluated by hazard ratios (HRs) with 95% confidences (CIs).

RESULTS

Twenty-four studies met the inclusion criteria. Sitting time showed dose-response associations with CVD, cancer, and all-cause mortality, with each 1-hour increment of sitting time daily accounting for HRs 1.04 (95% CIs 1.02-1.07), 1.01 (1.00-1.02), and 1.03 (1.02-1.03), respectively. The link between sitting time and CVD and all-cause mortality was non-linear (pnon-linear < 0.0001). The relationship between TV viewing and CVD and all-cause mortality was dose-dependent, with HRs 1.07 (1.06-1.09) and 1.04 (1.01-1.06) for per 1-hour increment of TV time every day, respectively. The regression was curved (pnon-linear < 0.0001). When the analysis was stratified by the percentage of diabetes and hypertension, BMI values, and physical activity levels, we found that higher BMI and a greater percentage of diabetes and hypertension further increased all-cause mortality risk in the most sedentary populations, whereas higher physical activity levels decreased it.

CONCLUSION

Sitting time and TV viewing significantly increased cardiovascular, cancer, and mortality risk; the associations were dose-dependent. More importantly, sedentary behaviour in combination with chronic diseases or high BMI increased all-cause mortality risk whereas physical activity was likely to alleviate the adverse associations.

Sirt6 deletion in hepatocytes increases insulin sensitivity of female mice by enhancing ERα expression

Sirtuin 6 (Sirt6), a NAD⁺ -dependent protein deacetylase, is involved in hepatic glucose metabolism and insulin sensitivity, which impact metabolic homeostasis. In this paper, we discover that Sirt6 affects the insulin sensitivity of mice in a gender-dependent manner; few studies have been conducted on this issue. Based on reports revealing the influences of sex hormones on insulin signaling, this investigation explores the mechanism by which Sirt6 regulates the estrogen pathway and disrupts insulin signal transduction. Hepatocyte-specific Sirt6 knockout (Sirt6HKO) mice were generated to investigate the function of Sirt6 in hepatocytes. Mice were castrated or spayed to eliminate sex hormones. Insulin sensitivity was assessed via an insulin tolerance test (ITT) in vivo. The interaction of Sirt6 with the estrogen pathway and their impacts on insulin signal transduction were revealed by immunoblot and immunoprecipitation. Sirt6 deletion in hepatocytes significantly enhanced insulin sensitivity and signal transduction in female mice but not in male or spayed female mice as demonstrated by ITT and the phosphorylation level of Akt in the liver. We also identified upregulation of p300, ERα, and interaction of ERα with p85 in the liver of female Sirt6HKO mice. Additionally, Sirt6 was found to inhibit ERα protein stability in a p300-dependent manner without interacting directly with ERα. Our findings show that hepatic Sirt6 downregulates the ERα protein level in a p300-dependent manner and thus disturbs estrogen-induced improvement in insulin sensitivity in the liver, which may partially explain the gender difference in insulin sensitivity.

Curcumin protects against diabetic cardiomyopathy by promoting autophagy and alleviating apoptosis

The effects of curcumin on regulating cardiac apoptosis and autophagy were analyzed in diabetic models both in vivo and in vitro. In vivo, experimental diabetes was induced in mice by low-dose STZ injection combined with a high-fat diet. In vitro, cultured H9c2 cardiomyoblasts were exposed to high d-glucose concentrations combined with palmitate. Our results showed that apoptosis was increased and autophagy was suppressed in the hearts of diabetic mice, which was ameliorated by curcumin treatment, ultimately improving cardiac function. Moreover, the inhibition of autophagy exacerbated apoptotic death in cardiac cells under diabetic condition. Curcumin activated AMPK and JNK1, which phosphorylated Bcl-2 and Bim and subsequently disrupted their interactions with Beclin1, thereby promoting autophagy and alleviating apoptosis respectively. In addition, AMPK-mediated inhibition of mTORC1 pathway likely played a role in regulating autophagy by curcumin under diabetic condition. Our study suggests that curcumin protects against diabetic cardiomyopathy by modulating the crosstalk between autophagic and apoptotic machinery. Modulation of autophagy may be an effective strategy for the treatment of cardiovascular diseases associated with diabetes.

Dyslipidaemia in type 2 diabetes mellitus: bad for the heart

PURPOSE OF REVIEW

Type 2 diabetes mellitus (T2DM) is associated with increased coronary heart disease (CHD) morbidity and mortality. These patients are also more prone to heart failure, arrhythmias and sudden cardiac death. Furthermore, coronary interventions performed in such high-risk patients have worse outcomes. In this narrative review, we discuss the role of diabetic dyslipidaemia on the risk of CHD in patients with T2DM. The effects of hypolipidaemic, antihypertensive and antidiabetic drugs on lipid and glucose metabolism in T2DM are also considered.

RECENT FINDINGS

Among CHD risk factors, diabetic dyslipidaemia characterized by moderately elevated low-density lipoprotein (LDL) cholesterol, increased triglycerides and small, dense LDL particles as well as decreased high-density lipoprotein cholesterol levels may contribute to the increased CHD risk associated with T2DM. Hypolipidaemic, antihypertensive and antidiabetic drugs can affect lipid and glucose parameters thus potentially influencing CHD risk. Such drugs may improve not only the quantity, but also the quality of LDL as well as postprandial lipaemia.

SUMMARY

Current data highlight the importance of treating diabetic dyslipidaemia in order to minimize CHD risk. Both fasting and postprandial lipids are influenced by drugs in patients with T2DM; physicians should take this into consideration in clinical decision making.

Matched or nonmatched interventions based on the transtheoretical model to promote physical activity. A meta-analysis of randomized controlled trials

PURPOSE

The aim of this study was to examine whether the efficacy of transtheoretical model (TTM)-based interventions on physical activity (PA) varied according to the following criteria: (1) interventions targeted the actual stages of change (SOCs) or did not; (2) participants were selected according to their SOC or were not; and (3) its theoretical constructs (decisional balance, temptation, self-efficacy, processes of change).

METHODS

Thirty-three randomized controlled trials assessing TTM-based interventions promoting PA in adults were systematically identified.

RESULTS

The between-group heterogeneity statistic (Qb) did not reveal any differential efficacy either in interventions targeting the actual SOC compared with those that did not (Qb = 1.48, p = 0.22) or in interventions selecting participants according to their SOC compared with those that did not (Qb = 0.01, p = 0.91). TTM-based interventions enhanced PA behavior whether they targeted the actual SOC (Cohen's d = 0.36; 95% confidence interval (CI): 0.22-0.49) or not (d = 0.23; 95%CI: 0.09-0.38) and whether they selected their participants according to their SOC (d = 0.33; 95%CI: 0.13-0.53) or not (d = 0.32; 95%CI: 0.19-0.44). The moderators of the efficacy of TTM-based interventions were the number of theoretical constructs used to tailor the intervention (Qb = 8.82, p = 0.003), the use of self-efficacy (Qb = 6.09, p = 0.01), and the processes of change (Qb = 3.51, p = 0.06).

CONCLUSION

TTM-based interventions significantly improved PA behavior, and their efficacy was not moderated by SOC but by the TTM theoretical constructs.

Attainment of recommended therapeutic targets of modifiable cardiovascular risk factors among individuals with type 2 diabetes mellitus screened at a diabetes clinic in Sri Lanka

INTRODUCTION

Implementation of effective measures to control rising burden of cardiovascular diseases among patients with type 2 diabetes mellitus (T2DM) requires information on the adequacy of control and identification of specific groups with suboptimal control of blood glucose, lipids and blood pressure.

METHODS

A cross-sectional study of patients with T2DM referred from primary care to a diabetes center was carried out to estimate the proportion of patients achieving the recommended therapeutic targets of four major modifiable cardiovascular risk factors: glycosylated hemoglobin (HbA1c <7%), low-density lipoprotein cholesterol <100 mg/dL, systolic blood pressure (SBP) <130 mmHg and diastolic blood pressure (DBP) <80 mmHg and their associations with age, gender, duration of diabetes and body mass index were studied.

RESULTS

Mean (SD) age and the duration of the sample of 2422 (65% males) were 52 (11) and 9 (3), respectively. Percentages with optimal HbA1c, low-density lipoprotein cholesterol, SBP and DBP were 25.2%, 24.3%, 32% and 56.7%, respectively. Only 2% had achieved optimal control of all four risk factors. Significantly higher percentages of males were having optimal HbA1C, SBP and DBP, and regression analysis revealed that male gender was significantly associated with optimal control of SBP.

CONCLUSION

Control of cardiovascular risk diseases factors among patients with T2DM managed in the primary care settings needs further improvements in target achievement in all four modifiable risk factors.

All-cause mortality in adults with and without type 2 diabetes: findings from the national health monitoring in Germany

OBJECTIVE

To estimate age-specific and sex-specific all-cause mortality among adults with and without type 2 diabetes (T2D) in Germany.

RESEARCH DESIGN AND METHODS

The German National Health Interview and Examination Survey 1998 (GNHIES98) included a mortality follow-up (median follow-up time 12.0 years) of its nationwide sample representative of the population aged 18-79 years. After exclusion of participants with type 1 diabetes, age- and sex-stratified mortality rates (MR) were calculated for 330 GNHIES98 participants with diagnosed T2D (self-reported diagnosis or antidiabetic medication), 245 with undiagnosed T2D (no diagnosed T2D, glycated hemoglobin A1c ≥6.5% (≥48 mmol/mol)), and 5975 without T2D. Mortality rate ratios (MRR) comparing MR of persons with and without T2D were estimated. Age-/sex-standardized MR and MRR were calculated including persons aged 45 years or older. MRR were used to estimate the number of years of life lost (YLL) due to diagnosed diabetes in 2010.

RESULTS

Over 75 994 person-years, 73 persons with undiagnosed T2D, 103 with diagnosed T2D, and 425 persons without T2D died. MRR were significantly higher in younger age groups, except for analyses limited to women or diagnosed T2D. Age- and sex-standardized MRR (95% CI) among persons aged 45 years or older were 1.96 (1.41 to 2.71) for undiagnosed, 1.68 (1.26 to 2.23) for diagnosed, and 1.82 (1.45 to 2.28) for total (undiagnosed or diagnosed) T2D. Sex-stratified analysis revealed similar age-standardized MRR for undiagnosed (1.56 (0.79 to 3.06)) and diagnosed T2D (1.56 (1.03 to 2.37)) among women, and a higher age-standardized MRR for undiagnosed (2.06 (1.43 to 2.97)) than diagnosed T2D (1.70 (1.10 to 2.63)) among men. YLL due to diagnosed diabetes in Germany in 2010 were 164 600 (35 000 to 279 300) among women and 169 900 (28 300 to 328 300) among men.

CONCLUSIONS

In Germany, age- and sex-standardized all-cause mortality is almost twice as high for adults with T2D as for adults without T2D. The T2D-associated excess risk of mortality appears to be most pronounced in younger adults and among men unaware of their T2D.

Individualizing treatment targets for elderly patients with type 2 diabetes: factors influencing clinical decision making in the 24-week, randomized INTERVAL study

We tested the feasibility of setting individualized glycemic goals and factors influencing targets set in a clinical trial in elderly patients with type 2 diabetes.

A 24-week, randomized, double-blind, placebo-controlled study was conducted in 45 outpatient centers in seven European countries. 278 drug-naïve or inadequately controlled (mean HbA1c 7.9%) patients with type 2 diabetes aged ≥70 years with HbA1c levels ≥7.0% and ≤10.0% were enrolled. Investigator-defined individualized HbA1c targets and the impact of baseline characteristics on individualized treatment targets was evaluated.

The average individualized HbA1c target was set at 7.0%. HbA1c at baseline predicted a target setting such that higher the HbA1c, more aggressive was the target (P<0.001). Men were more likely to be set aggressive targets than women (P=0.026). Frailty status of patients showed a trend towards significance (P=0.068), whereas diabetes duration, age, or polypharmacy did not. There was heterogeneity between countries regarding how baseline factors were viewed.

Despite training and guidance to individualize HbA1c goals, targets were still set in line with conventional values. A strong influence of country-specific guidelines on target setting was observed; confirming the importance of further education to implement new international guidelines in older adults.

Are women with type 2 diabetes mellitus more susceptible to cardiovascular complications following coronary angioplasty?: a meta-analysis

Background

Scientific reports have shown Type 2 Diabetes Mellitus (T2DM) to be independently associated with adverse outcomes following Percutaneous Coronary Intervention (PCI). However, gender difference has also often been a controversial issue following PCI. Till date, very few meta-analyses have systematically compared the adverse cardiovascular outcomes in male versus female patients with T2DM following PCI. Therefore, we aimed to carry out this analysis in order to find out an answer to this interesting question.

Methods

Electronic databases were searched for English language publications reporting adverse cardiovascular outcomes in male versus female patients with diabetes mellitus respectively following coronary angioplasty. The RevMan 5.3 software was used to analyze selected adverse cardiovascular events whereby Odds Ratios (OR) and 95% Confidence Intervals (CI) were the statistical parameters.

Results

A total number of 19,304 patients with T2DM (12,986 male patients versus 6318 female patients) were included in this analysis. At baseline, female patients were older (68.7 versus 62.9 years), with a higher percentage of hypertension (75.6% versus 66.5%) and dyslipidemia (53.3% versus 50.0%) whereas majority of the male patients were smokers (46.3% versus 14.9%). Results of this analysis showed short and long-term mortality to be significantly higher in female patients with T2DM (OR: 1.71, 95% CI: 1.46–2.00; P = 0.00001), and (OR: 1.20, 95% CI: 1.07–1.35; P = 0.002) respectively. In addition, women were also more at risk for short and long-term major adverse cardiac events (MACEs) with OR: 1.49, 95% CI: 1.07–2.07; P = 0.02 and OR: 1.15, 95% CI: 1.04–1.28; P = 0.009 respectively. Subgroup analysis showed this significant result to have mainly been observed in patients with acute myocardial infarction compared to those with stable coronary artery disease.

Conclusions

Following PCI, women with T2DM were indeed more susceptible to short and long-term cardiovascular complications compared to male patients with the same chronic disease. Even though this result was more applicable to patients with acute myocardial infarction, the fact that women were older with higher co-morbidities at baseline compared to men, should also not be ignored.

Structure, process, and outcomes of care in a telemonitoring program for patients with type 2 diabetes

Background

Using Donabedian’s structure-process-outcomes (SPO) framework, this descriptive, exploratory study examined the structure of a telemonitoring program in a population of patients with type 2 diabetes (T2D), the process of nurse–patient telephonic interactions, and patients’ clinical outcomes.

Methods

Secondary data analysis was conducted using data from 581 patients who participated in a home telemonitoring program for 12 months. Three point-biserial and six Pearson correlations were estimated to determine how patient demographics related to clinical characteristics. Mixed model regressions were conducted predicting hemoglobin A_1c (HbA_1c), systolic blood pressure (SBP), and diastolic blood pressure (DBP) levels at 6, 9, and 12 months based on the frequency of contact in the earlier 3 months. Analysis of variances were conducted to assess if the frequency of contact was significantly different by change in HbA_1c levels from 3 to 6, 6 to 9, and 9 to 12 months.

Results

Significant negative correlations were found between age and HbA_1c (r=−0.10, P=0.015) and DBP (r=−0.16, P<0.001), a significant positive correlation was found between age and SBP (r=0.15, P=0.001). A significant correlation was found between sex and DBP (r_pb=−0.11, P=0.015); female participants had lower DBP levels than males. Frequency of contact was not related to the change in clinical outcomes. However, the frequency of contact for the time period 3 to 6 months was associated with change in HbA_1c for the 6- to 9- month period and frequency of contact during the 6- to 9- month period was associated with change in HbA_1c from 9 to 12 months.

Conclusion

Examination of the SPO measures in the telemonitoring environment assisted in understanding the effectiveness of this type of unique intervention and the need for further in-depth exploration of self-management techniques among individuals with T2D.

The impact of gender on the long-term morbidity and mortality of patients with type 2 diabetes receiving structured personal care: a 13 year follow-up study

AIMS/HYPOTHESIS

The aim of this study was to assess gender differences in mortality and morbidity during 13 follow-up years after 6 years of structured personal care in patients with type 2 diabetes mellitus.

METHODS

In the Diabetes Care in General Practice (DCGP) multicentre, cluster-randomised, controlled trial (ClinicalTrials.gov registration no. NCT01074762), 1,381 patients newly diagnosed with type 2 diabetes were randomised to receive 6 years of either structured personal care or routine care. The intervention included regular follow-up, individualised goal setting and continuing medical education of general practitioners participating in the intervention. Patients were re-examined at the end of intervention. This observational analysis followed 970 patients for 13 years thereafter using national registries. Outcomes were all-cause mortality, incidence of diabetes-related death, any diabetes-related endpoint, myocardial infarction, stroke, peripheral vascular disease and microvascular disease.

RESULTS

In women, but not men, a lower HR for structured personal care vs routine care emerged for any diabetes-related endpoint (0.65, p = 0.004, adjusted; 73.4 vs 107.7 events per 1,000 patient-years), diabetes-related death (0.70, p = 0.031; 34.6 vs 45.7), all-cause mortality (0.74, p = 0.028; 55.5 vs 68.5) and stroke (0.59, p = 0.038; 15.6 vs 28.9). This effect was different between men and women for diabetes-related death (interaction p = 0.015) and all-cause mortality (interaction p = 0.005).

CONCLUSIONS/INTERPRETATION

Compared with routine care, structured personal diabetes care reduced all-cause mortality and diabetes-related death in women but not in men. This gender difference was also observed for any diabetes-related outcome and stroke but was not statistically significant after extensive multivariate adjustment. These observational results from a post hoc analysis of a randomised controlled trial cannot be explained by intermediate outcomes like HbA1c alone, but involves complex social and cultural issues of gender. There is a need to rethink treatment schemes for both men and women to gain benefit from intensified treatment efforts.

Cardiovascular risk associated with the use of glitazones, metformin and sufonylureas: meta-analysis of published observational studies

BACKGROUND

The results of observational studies evaluating and comparing the cardiovascular safety of glitazones, metformin and sufonylureas are inconsistent.To conduct and evaluate heterogeneity in a meta-analysis of observational studies on the risk of acute myocardial infarction (AMI) or stroke in patients with type 2 diabetes using non-insulin blood glucose-lowering drugs (NIBGLD).

METHODS

We systematically identified and reviewed studies evaluating NIBGLD in patients with type 2 diabetes indexed in Medline, Embase, or the Cochrane Library that met prespecified criteria. The quality of included studies was assessed with the RTI item bank. Results were combined using fixed- and random-effects models, and the Higgins I(2) statistic was used to evaluate heterogeneity. Sensitivity analyses by study quality were conducted.

RESULTS

The summary relative risk (sRR) (95% CI) of AMI for rosiglitazone versus pioglitazone was 1.13 (1.04-1.24) [I(2) = 55%]. In the sensitivity analysis, heterogeneity was reduced [I(2) = 16%]. The sRR (95% CI) of stroke for rosiglitazone versus pioglitazone was 1.18 (1.02-1.36) [I(2)  = 42%]. There was strong evidence of heterogeneity related to study quality in the comparisons of rosiglitazone versus metformin and rosiglitazone versus sulfonylureas (I (2) ≥ 70%). The sRR (95% CI) of AMI for sulfonylurea versus metformin was 1.24 (1.14-1.34) [I(2) = 41%] and for pioglitazone versus metformin was 1.02 (0.75-1.38) [I(2) = 17%]. Sensitivity analyses decreased heterogeneity in most comparisons.

CONCLUSION/INTERPRETATION

Sulfonylureas increased the risk of AMI by 24% compared with metformin; an imprecise point estimate indicated no difference in risk of AMI when comparing pioglitazone with metformin. The presence of heterogeneity precluded any conclusions on the other comparisons. The quality assessment was valuable in identifying methodological problems in the individual studies and for analysing potential sources of heterogeneity.

Higher levels of serum lycopene are associated with reduced mortality in individuals with metabolic syndrome

Metabolic syndrome increases the risk of mortality. Increased oxidative stress and inflammation may play an important role in the high mortality of individuals with metabolic syndrome. Previous studies have suggested that lycopene intake might be related to the reduced oxidative stress and decreased inflammation. Using data from the National Health and Nutrition Examination Survey, we examined the hypothesis that lycopene is associated with mortality among individuals with metabolic syndrome. A total of 2499 participants 20 years and older with metabolic syndrome were divided into 3 groups based on their serum concentration of lycopene using the tertile rank method. The National Health and Nutrition Examination Survey from years 2001 to 2006 was linked to the mortality file for mortality follow-up data through December 31, 2011, to determine the mortality rate and hazard ratios (HR) for the 3 serum lycopene concentration groups. The mean survival time was significantly higher in the group with the highest serum lycopene concentration (120.6 months; 95% confidence interval [CI], 118.8-122.3) and the medium group (116.3 months; 95% CI, 115.2-117.4), compared with the group with lowest serum lycopene concentration (107.4 months; 95% CI, 106.5-108.3). After adjusting for possible confounding factors, participants in the highest (HR, 0.61; P = .0113) and in the second highest (HR, 0.67; P = .0497) serum lycopene concentration groups showed significantly lower HRs of mortality when compared with participants in the lower serum lycopene concentration. The data suggest that higher serum lycopene concentration has a significant association with the reduced risk of mortality among individuals with metabolic syndrome.

Non-proteinuric pathways in loss of renal function in patients with type 2 diabetes

Largely on the basis of data from patients with type 1 diabetes, the natural history of diabetic renal disease has been classified as a sequence of three stages: normoalbuminuria, microalbuminuria, and macroalbuminuria. Progressive decline of glomerular filtration rate (GFR) was thought to parallel the onset of macroalbuminuria (overt nephropathy), whereas glomerular hyperfiltration was deemed a hallmark of early disease. However, researchers have since shown that albuminuria is a continuum and that GFR can start to decline before progression to overt nephropathy. In addition to proteinuria, other risk factors might contribute to GFR deterioration including female sex, obesity, dyslipidaemia (in particular hypertriglyceridaemia), hypertension, and glomerular hyperfiltration, at least in a subgroup of patients. This phenomenon could explain why patients with type 2 diabetes can have renal insufficiency even before the onset of overt nephropathy, and might also suggest why the heterogeneous phenotype of type 2 diabetic renal disease does not necessarily associate with typical histological lesions of diabetic renal disease, unlike in type 1 diabetic renal disease. Patients with renal insufficiency but without albuminuria are usually excluded from randomised clinical trials in overt nephropathy, thus optimum treatment for this group of patients is unknown. The wide inter-patient variability of the disease probably needs individually tailored intervention.

Need and disparities in primary care management of patients with diabetes

BACKGROUND

An aging population means that chronic illnesses, such as diabetes, are becoming more prevalent and demands for care are rising. Members of primary care teams should organize and coordinate patient care with a view to improving quality of care and impartial adherence to evidence-based practices for all patients. The aims of the present study were: to ascertain the prevalence of diabetes in an Italian population, stratified by age, gender and citizenship; and to identify the rate of compliance with recommended guidelines for monitoring diabetes, to see whether disparities exist in the quality of diabetes patient management.

METHODS

A population-based analysis was performed on a dataset obtained by processing public health administration databases. The presence of diabetes and compliance with standards of care were estimated using appropriate algorithms. A multilevel logistic regression analysis was applied to assess factors affecting compliance with standards of care.

RESULTS

1,948,622 Italians aged 16+ were included in the study. In this population, 105,987 subjects were identified as having diabetes on January 1st, 2009. The prevalence of diabetes was 5.43% (95% CI 5.33-5.54) overall, 5.87% (95% CI 5.82-5.92) among males, and 5.05% (95% CI 5.00-5.09) among females. HbA1c levels had been tested in 60.50% of our diabetic subjects, LDL cholesterol levels in 57.50%, and creatinine levels in 63.27%, but only 44.19% of the diabetic individuals had undergone a comprehensive assessment during one year of care. Statistical differences in diabetes care management emerged relating to gender, age, diagnostic latency period, comorbidity and citizenship.

CONCLUSIONS

Process management indicators need to be used not only for the overall assessment of health care processes, but also to monitor disparities in the provision of health care.

Causes of death and associated risk factors among climacteric women from Southern Brazil: a population based-study

BACKGROUND

Aging and menopause are particular cardiovascular risk factors for women, due to estrogen deprivation at the time of menopause. Studies show that diabetes mellitus (DM), smoking, hypertension, high body mass index (BMI), and serum lipids are associated with increased risk of cardiovascular disease (CVD), the main cause of female mortality in Brazil. The aim of this study was to assess the mortality rate, causes of death and associated risk factors in a cohort of women from Brazil.

METHODS

A longitudinal population-based study of menopausal status is currently underway in a city in South Brazil. In 2010, a third follow-up of this population was performed to assess cardiovascular risk and mortality rate between 1995 and 2011. For this analysis, 358 participants were studied. At baseline, participants had completed a standardized questionnaire including demographic, lifestyle, medical and reproductive characteristics. In addition to the contacts with relatives, mortality data were obtained through review of medical records in all city hospitals and the Center for Health Information (NIS/RS-SES). Multivariate-adjusted hazard risk (HR) and 95% confidence intervals (CI95%) were estimated using Cox proportional hazards regression. Survival curves were estimated using the Kaplan-Meier curve.

RESULTS

There were 17 (4.7%) deaths from all causes during the study period. Seven (41.2%) deaths were caused by CVD, including four cases of stroke and three cases of myocardial infarction. Six (35.3%) deaths were due to cancer, and four (23.5%) were due to other reasons. In the age and smoking-adjusted multivariate models, diabetes (HR 6.645, 95% CI: 1.938-22.79, p=0.003), alcohol intake (HR 1.228, 95% CI: 1.014-1.487, p=0.035) and postmenopausal status (HR=6.216, 95% CI: 0.963-40.143, p=0.055) were associated with all-cause mortality. A significant association was found between abdominal obesity (WHR≥0.85) and mortality even after the adjustment for BMI (HR=9.229, 95% IC: 2.083-41.504, p=0.003).

CONCLUSION

CVD was an important cause of mortality in this cohort and DM and/or central adiposity were associated with all-cause mortality. Lifestyle and dietary factors seem to be related to risk of mortality in middle-aged women.

Effects of prescribed antithrombotics and other cardiovascular pharmacotherapies on all-cause mortality in patients with diabetes and atrial fibrillation - a cohort study from Sweden using propensity score analyses

AIMS

To study mortality rates among patients with diabetes and concomitant atrial fibrillation (AF), prescribed different cardiovascular drugs in primary health care.

METHODS

Study population consisted of men (n = 1319) and women (n = 1094) aged ≥45 years from a database including 75 primary care centres in Sweden. Cox regression analysis, with hazard ratios (HRs), 95% confidence interval (95% CIs) and mortality (years to death) as outcome, and Laplace regression, with difference in time to first 10% mortality (with 95% CI), were performed. Independent variables were prescribed cardiovascular drugs. Regression models were adjusted for a propensity score calculated separately for each prescribed drug class (comprising age, cardiovascular co-morbidities, education, marital status and pharmacotherapy).

RESULTS

Overall mortality was lower in the whole sample for anticoagulants vs no treatment (HR 0.45; 95% CI 0.26-0.77); and among patients < 80 years for anticoagulants vs. antiplatelets (HR 0.44; 95% CI 0.25-0.78); while among individuals aged ≥80 years, antiplatelets (HR 0.47; 95% CI 0.26-0.87) and anticoagulants (HR 0.49; 95% CI 0.24-1.00) vs. no treatment were equally effective. Statins were associated with lower mortality among those <80 years (HR 0.45; 95% CI 0.29-0.71). Laplace regression models in the whole sample, with years to first 10% of total mortality as outcome, were significant for: among patients < 80 years anticoagulants vs. no treatment 2.70 years (95% CI 0.04-5.37), anticoagulants vs. antiplatelets 2.31 years (95% CI 0.84-3.79), and those ≥80 antiplatelets vs. no treatment 1.78 years (95% CI 1.04-2.52).

CONCLUSIONS

Our findings suggest that antiplatelets could exert a beneficial effect among those above 80 years.

Sex differences in type 2 diabetes: focus on disease course and outcomes

BACKGROUND

Women with type 2 diabetes (T2D) are less likely to reach the goals for hemoglobin A1c compared with men, and have higher all-cause mortality. The risk of cardiovascular disease is elevated among both men and women with T2D, however, the risk has declined among men over recent years while it remains stationary in women. Reasons for these sex differences remain unclear, and guidelines for diabetes treatment do not differentiate between sexes. Possible causes for varying outcome include differences in physiology, treatment response, and psychological factors. This review briefly outlines sex differences in hormonal pathophysiology, and thereafter summarizes the literature to date on sex differences in disease course and outcome.

METHODS

Systematic searches were performed on PubMed using "sex", "gender", and various glucose-lowering therapies as keywords. Earlier reviews are summarized and results from individual studies are reported. Reference lists from studies were used to augment the search.

RESULTS

There is an increased risk of missing the diagnosis of T2D when screening women with only fasting plasma glucose instead of with an oral glucose tolerance test. The impact of various risk factors for complications may differ by sex. Efficacy and side effects of some glucose-lowering drugs differ between men and women. Men with T2D appear to suffer more microvascular complications, while women have higher morbidity and mortality in cardiovascular disease and also fare worse psychologically.

CONCLUSION

Few studies to date have focused on sex differences in T2D. Several questions demand further study, such as whether risk factors and treatment guidelines should be sex-specific. There is a need for clinical trials designed specifically to evaluate sex differences in efficacy and outcome of the available treatments.

Impaired endothelial function in female adolescents with type 1 diabetes measured by peripheral artery tonometry

BACKGROUND

The reactive hyperemia peripheral artery tonometry (RH-PAT) is a newly developed method for non-invasive endothelial function assessment.

OBJECTIVE

The goal of this study is to determine whether a significant difference in RH-PAT score is present between adolescents with type 1 diabetes (T1D) in comparison with controls.

SUBJECTS AND METHODS

Thirty-four adolescents with T1D and 25 control subjects (age 12-20 years) underwent RH-PAT endothelial function testing after an overnight fast. Height, weight, body mass index (BMI), blood pressure (BP), fasting lipid profile, Tanner stage, and glucose level were determined in each child.

RESULTS

Adolescents with T1D had significantly lower RH-PAT scores compared to healthy controls, and this difference remained significant when overweight cases were not considered (p < 0.05). This difference was also observed in the female subgroup (p = 0.005). The interindividual variability in RH-PAT observations in T1D cases was not explained by BMI standard deviation score (SDS), BP SDS, age, duration of T1D, hemoglobin A1c, triglycerides, and pubertal stage, respectively.

CONCLUSIONS

The RH-PAT technique is used as a non-invasive test to assess for early vascular changes in high-risk patient groups. Endothelial dysfunction, measured by RH-PAT, was present in diabetic adolescent, especially in the female subgroup. Although additional longitudinal studies are required, early detection of this reversible process may have therapeutic and prognostic implications.

Sex-specific outcomes of diabetic patients with acute myocardial infarction who have undergone percutaneous coronary intervention: a register linkage study

Background

The presence of diabetes mellitus poses a challenge in the treatment of patients with acute myocardial infarction (AMI). We aimed to evaluate the sex-specific outcomes of diabetic and non-diabetic patients with AMI who have undergone percutaneous coronary intervention (PCI).

Methods

Data of the Estonian Myocardial Infarction Registry for years 2006–2009 were linked with the Health Insurance Fund database and the Population Registry. Hazard ratios (HRs) with the 95% confidence intervals (CIs) for the primary composite outcome (non-fatal AMI, revascularization, or death whichever occurred first) and for the secondary outcome (all cause mortality) were calculated comparing diabetic with non-diabetic patients by sex.

Results

In the final study population (n = 1652), 14.6% of the men and 24.0% of the women had diabetes. Overall, the diabetics had higher rates of cardiovascular risk factors, co-morbidities, and 3–4 vessel disease among both men and women (p < 0.01). Among women, the diabetic patients were younger, they presented later and less often with typical symptoms of chest pain than the non-diabetics (p < 0.01). Women with diabetes received aspirin and reperfusion for ST-segment elevation AMI less often than those without diabetes (p < 0.01). During a follow-up of over two years, in multivariate analysis, diabetes was associated with worse outcomes only in women: the adjusted HR for the primary outcome 1.44 (95% CI 1.05 − 1.96) and for the secondary outcome 1.83 (95% CI 1.17 − 2.89). These results were largely driven by a high (12.0%) mortality during hospitalization of diabetic women.

Conclusions

Diabetic women with AMI who have undergone PCI are a high-risk group warranting special attention in treatment strategies, especially during hospitalization. There is a need to improve the expertise to detect AMI earlier, decrease disparities in management, and find targeted PCI strategies with adjunctive antithrombotic regimes in women with diabetes.