The Evolving Epidemiology of Atherosclerotic Cardiovascular Disease in People with Diabetes

Icosapent ethyl therapy for very high triglyceride levels: a 12-week, multi-center, placebo-controlled, randomized, double-blinded, phase III clinical trial in China

OBJECTIVES

Eicosapentaenoic acid in its ethyl ester form is the single active component of icosapent ethyl (IPE). This study was a phase III, multi-center trial assessing the safety and efficiency of IPE for treating very high triglyceride (TG) in a Chinese cohort.

METHODS

Patients having TG levels (5.6-22.6 mmol/L) were enrolled and randomly assigned to receive a treatment of oral intake of 4 g or 2 g/day of IPE, or placebo. Before and after 12 weeks of treatment, TG levels were assessed and the median was calculated to determine the change between the baseline and week 12. In addition to examining TG levels, the impact of such treatments on other lipid changes was also investigated. The official Drug Clinical Trial Information Management Platform has registered this study (CTR20170362).

RESULTS

Random assignments were performed on 373 patients (mean age 48.9 years; 75.1% male). IPE (4 g/day) lowered TG levels by an average of 28.4% from baseline and by an average of 19.9% after correction for placebo (95% CI: 29.8%-10.0%, P < 0.001). In addition, plasma concentration of non-high-density lipoprotein cholesterol (non-HDL-C), very low-density lipoprotein (VLDL) cholesterol, and VLDL-TG remarkedly reduced after IPE (4 g/day) treatment by a median of 14.6%, 27.9%, and 25.2%, respectively compared with participants in placebo group. Compared to the placebo, neither 4 nor 2 g of IPE daily elevated LDL-C levels with statistical significance. IPE was well tolerated by all the treatment groups.

CONCLUSIONS

IPE at 4 g/day dramatically lowered other atherogenic lipids without a noticeable increase in LDL-C, thereby decreasing TG levels in an exceptionally high-TG Chinese population.

Role of cerebral microbleeds in acute ischemic stroke and atrial fibrillation

Cerebral microbleeds (CMBs) are commonly detected in the brains of patients with acute ischemic stroke (AIS). With the development of neuroimaging, clinicians are paying more attention to the presence of CMBs. CMBs were found to significantly increase the risk of intracranial hemorrhagic transformation and hemorrhage in patients with AIS, especially in patients with concurrent atrial fibrillation (AF). Additionally, the presence of CMBs is thought to be a symbol of a high risk of recurrent ischemic stroke (IS). A few researchers have found that the presence of CMBs has no significant effect on the prognosis of patients with AIS. Therefore, the current views on the role of CMBs in the prognoses of patients with IS are controversial. The use of anticoagulants and other drugs has also become a dilemma due to the special influence of CMBs on the prognosis of these patients. Due to the large number of patients with AF and CMBs, many studies have been conducted on the effects of CMBs on these patients and subsequent pharmacological treatments. However, at present, there are no relevant guidelines to guide the secondary preventive treatment of patients with stroke, CMBs, and AF. In this paper, we summarized the role of CMBs in AIS combined with AF and relevant preventive measures against the recurrence of stroke and the occurrence of intracerebral hemorrhage to help clarify the specifics of drug therapies for this group of patients.

miR-100-5p in human umbilical cord mesenchymal stem cell-derived exosomes mediates eosinophilic inflammation to alleviate atherosclerosis via the FZD5/Wnt/β-catenin pathway

Exosomes derived from human umbilical cord mesenchymal stem cells (hUCMSC-Ex) play important roles in immune and inflammation diseases. However, the role of hUCMSC-Ex in atherosclerosis has not been elucidated. In this study, the isolated exosomes were identified by transmission electron microscopy and nanoparticle tracking analysis. Exosome marker protein levels were increased in the hUCMSC-Ex compared with those in hUCMSC suspension, indicating that exosomes were successfully isolated from hUCMSCs. Furthermore, eosinophils were treated with oxidized low-density lipoprotein (ox-LDL) to construct inflammation model and then incubated with hUCMSC-Ex derived from hUCMSCs which were transfected with miR-100-5p mimic or miR-100-5p inhibitor. We found that hUCMSC-Ex increased miR-100-5p expression, inhibited cell migration, promoted cell apoptosis, and reduced inflammatory cytokine levels in ox-LDL-treated eosinophils, and miR-100-5p overexpression in hUCMSCs enhanced these effects, while miR-100-5p inhibition reversed these effects. Moreover, frizzled 5 (FZD5) was a target gene of miR-100-5p. FZD5 overexpression reversed the inhibitory effects of hUCMSC-Ex-miR-100-5p on cell progression and inflammation in eosinophils. Additionally, hUCMSC-Ex-miR-100-5p decreased the expression of cyclin D1 and β-catenin proteins. Wnt/β-catenin pathway activator BML-284 effectively reversed the effects of hUCMSC-Ex-miR-100-5p on cell progression and inflammation in eosinophils. ApoE-/- mice were fed with high-fat diet to construct an atherosclerosis mice model, and hUCMSC-Ex was injected into mice. hUCMSC-Ex reduced atherosclerotic plaque area and inflammation response in atherosclerosis mice. This study demonstrates that hUCMSC-Ex-miR-100-5p inhibits cell progression and inflammatory response in eosinophils via the FZD5/Wnt/β-catenin pathway, thereby alleviating atherosclerosis progression.

Increased serum ferritin is associated with oxidized low-density lipoprotein in prediabetes patients: A pilot study

Aims

This pilot study aimed to determine if increased serum ferritin (SF) is associated with cardiovascular risk factors in patients with prediabetes.

Methods

Eighteen patients with prediabetes and 36 subjects without prediabetes (control), non-white Hispanic, non-indigenous origin, Mexican mestizo descent were included. Participants had no inflammation, or vascular complications. SF and metabolic markers were evaluated in both groups.

Results

SF and oxidized low-density lipoprotein (oxLDL) were increased in prediabetes subjects. Moreover, in prediabetes and control groups as a whole, natural logarithm (ln)-SF correlated with oxLDL and ln-oxLDL/LDL after adjustment for sex, ln-age, ln-fasting plasma glucose (FPG), ln-body mass index, ln-triglyceride (TG), total cholesterol (TC), and high-density lipoproteins. Finally, ln-SF was an independent contributor to ln-oxLDL/LDL ratio in control and prediabetes subjects (β = 0.2915) after the introduction of potential confounders such as FPG, TC, TG, and hypertension.

Conclusions

The results of this study indicate that hyperferritinemia is associated with oxLDL, considered one of the main cardiovascular risk factors, which allows us to suggest that an increase in SF could contribute to the progression of prediabetes, prior to the appearance of diabetes. Further research is required to establish a causal relationship of iron disruption metabolism in oxLDL generation under prediabetes conditions.

Cardiovascular diseases in people with diabetes mellitus in Spain according to the Primary Care Clinical Database (BDCAP) in 2017

INTRODUCTION AND OBJECTIVES

Atherosclerotic cardiovascular disease and heart failure are the leading cause of morbidity and mortality in patients with diabetes. The objective of this work is to know the prevalence of atherosclerotic cardiovascular diseases and heart failure in people diagnosed with diabetes in Spain during 2017 and compare them with those not diagnosed with diabetes according to age and sex.

METHODS

Data for diagnoses of diabetes mellitus (DM), acute myocardial infarction (AMI), stroke, peripheral artery disease (PAD) or heart failure (HF) for 2017 were obtained from the National Health System's Primary Care Clinical Database (BDCAP).

RESULTS

Comparing people with diabetes and people without diabetes over 35 years of age, the Odds Ratio (OR) for being diagnosed with acute myocardial infarction, stroke, peripheral artery disease or heart failure is about 2 in those over 64 years of age and more than 4 in patients under that age. This OR is superior in females versus males for all diagnoses apart from peripheral artery disease.

CONCLUSIONS

This study shows the high cardiovascular comorbidity of patients with diabetes in Spain, with a greater excess of risk in patients under 65 years of age, more pronounced in women. We should offer more intensive treatment for DM2 in women.

Prospects for the application of transcranial magnetic stimulation in diabetic neuropathy

Encouraging results have been reported for the use of transcranial magnetic stimulation-based nerve stimulation in studies of the mechanisms of neurological regulation, nerve injury repair, and nerve localization. However, to date, there are only a few reviews on the use of transcranial magnetic stimulation for diabetic neuropathy. Patients with diabetic neuropathy vary in disease progression and show neuropathy in the early stage of the disease with mild symptoms, making it difficult to screen and identify. In the later stage of the disease, irreversible neurological damage occurs, resulting in treatment difficulties. In this review, we summarize the current state of diabetic neuropathy research and the prospects for the application of transcranial magnetic stimulation in diabetic neuropathy. We review significant studies on the beneficial effects of transcranial magnetic stimulation in diabetic neuropathy treatment, based on the outcomes of its use to treat neurodegeneration, pain, blood flow change, autonomic nervous disorders, vascular endothelial injury, and depression. Collectively, the studies suggest that transcranial magnetic stimulation can produce excitatory/inhibitory stimulation of the cerebral cortex or local areas, promote the remodeling of the nervous system, and that it has good application prospects for the localization of the injury, neuroprotection, and the promotion of nerve regeneration. Therefore, transcranial magnetic stimulation is useful for the screening and early treatment of diabetic neuropathy. Transcranial magnetic stimulation can also alleviate pain symptoms by changing the cortical threshold and inhibiting the conduction of sensory information in the thalamo-spinal pathway, and therefore it has therapeutic potential for the treatment of pain and pain-related depressive symptoms in patients with diabetic neuropathy. Additionally, based on the effect of transcranial magnetic stimulation on local blood flow and its ability to change heart rate and urine protein content, transcranial magnetic stimulation has potential in the treatment of autonomic nerve dysfunction and vascular injury in diabetic neuropathy. Furthermore, oxidative stress and the inflammatory response are involved in the process of diabetic neuropathy, and transcranial magnetic stimulation can reduce oxidative damage. The pathological mechanisms of diabetic neuropathy should be further studied in combination with transcranial magnetic stimulation technology.

1-Deoxynojirimycin in Mulberry (Morus indica L.) Leaves Ameliorates Stable Angina Pectoris in Patients With Coronary Heart Disease by Improving Antioxidant and Anti-inflammatory Capacities

Objective: Stable angina pectoris (SAP) in patients with coronary heart disease (CHD) and blood stasis syndrome (BSS) is a potentially serious threat to public health. NF-κB signaling is associated with angina pectoris. 1-Deoxynojirimycin (DNJ), which is a unique polyhydroxy alkaloid, is the main active component in mulberry (Morus indica L.) leaves and may exhibit protective properties in the prevention of SAP in patients with CHD by affecting the NF-κB pathway.

Methods: DNJ was purified from mulberry leaves by using a pretreated cation exchange chromatography column. A total of 144 SAP patients were randomly and evenly divided into experimental (DNJ treatment) and control (conventional treatment) groups. Echocardiography and ascending aortic elasticity were evaluated. The changes in inflammatory, oxidative, and antioxidant factors, including C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), superoxide dismutase (SOD), and malondialdehyde (MDA), were measured before and after a 4-week treatment. Self-Rating Anxiety Scale (SAS) and Hamilton Depression Scale (HAMD) scores were compared between the two groups. The improvement in SAP score, associated symptoms, and BSS was also investigated. The levels of IkB kinase (IKK), nuclear factor-kappa B (NF-κB), and inhibitor of kappa B α (IkBα) were measured by Western blot.

Results: After the 4-week treatment, DNJ increased left ventricular ejection fraction and reduced left ventricular mass index, aortic distensibility, and atherosclerosis index (p < 0.05). DNJ intervention increased angina-free walking distance (p < 0.05). DNJ significantly reduced the levels of hs-CRP, IL-6, TNF-a, MDA, SAS, HAMD, AP, and BSS scores and increased SOD level (p < 0.05). The total effective rate was significantly increased (p < 0.05). The symptoms of angina attack frequency, nitroglycerin use, chest pain and tightness, shortness of breath, and emotional upset were also improved. DNJ reduced IKK and NF-κB levels and increased IkBα level (p < 0.05).

Conclusion: The DNJ in mulberry leaves improved the SAP of patients with CHD and BSS by increasing their antioxidant and anti-inflammatory capacities.

Emerging Biomarkers, Tools, and Treatments for Diabetic Polyneuropathy

Diabetic neuropathy, with its major clinical sequels, notably neuropathic pain, foot ulcers, and autonomic dysfunction, is associated with substantial morbidity, increased risk of mortality, and reduced quality of life. Despite its major clinical impact, diabetic neuropathy remains underdiagnosed and undertreated. Moreover, the evidence supporting a benefit for causal treatment is weak at least in patients with type 2 diabetes, and current pharmacotherapy is largely limited to symptomatic treatment options. Thus, a better understanding of the underlying pathophysiology is mandatory for translation into new diagnostic and treatment approaches. Improved knowledge about pathogenic pathways implicated in the development of diabetic neuropathy could lead to novel diagnostic techniques that have the potential of improving the early detection of neuropathy in diabetes and prediabetes to eventually embark on new treatment strategies. In this review, we first provide an overview on the current clinical aspects and illustrate the pathogenetic concepts of (pre)diabetic neuropathy. We then describe the biomarkers emerging from these concepts and novel diagnostic tools and appraise their utility in the early detection and prediction of predominantly distal sensorimotor polyneuropathy. Finally, we discuss the evidence for and limitations of the current and novel therapy options with particular emphasis on lifestyle modification and pathogenesis-derived treatment approaches. Altogether, recent years have brought forth a multitude of emerging biomarkers reflecting different pathogenic pathways such as oxidative stress and inflammation and diagnostic tools for an early detection and prediction of (pre)diabetic neuropathy. Ultimately, these insights should culminate in improving our therapeutic armamentarium against this common and debilitating or even life-threatening condition.

Cardiovascular disease in diabetes type 2: current concepts

Type 2 diabetes is a major and accelerating public health challenge. Between 1980 and 2014, a period of just 35 years, the number of adults with diabetes globally is estimated to have increased from 108 to 422 million, due not only to sharply rising obesity rates, but also to increasing population size, longer life expectancy, and rising prevalence of diabetes worldwide. Overall, worldwide age-standardized adult diabetes prevalence doubled from 4.3% to 9.0% in men and from 5.0% to 7.9% in women. The largest increases in diabetes type 2 have been demonstrated in low- and middle-income countries, whilst rises in high-income countries have been less marked, or even flat. Diabetes type 2 rates in low- and middle-income countries now in many instances surpass those in high-income countries, in response to changes in lifestyle. One factor of particular concern are the large relative increases in type 2 diabetes amongst young individuals observed in many countries, their higher overall risk factor burden, long exposure to hyperglycaemia and greater risk of complications over the life course. Type 2 diabetes is increasingly found to be a heterogeneous condition, where risk of cardiovascular disease that traditionally has been estimated at 2-4 times that of the nondiabetic population varies substantially with diabetes phenotype and accordingly diabetes does not confer the same increase in relative or absolute risk in all people. New research shows that excess risk varies substantially with type of outcome, age, glycaemic control, the presence of renal complications and other factors. Heart failure, previously less recognized that other cardiovascular conditions, is increasingly coming into focus, because of strong links with poor glycaemic control and obesity. The knowledge about risk of cardiovascular disease in diabetes is almost entirely derived from high-income countries, whereas there is comparatively very little data from low- and middle income countries, where the majority of persons with type 2 diabetes live, and where management in many cases is far from optimal. The reductions in cardiovascular disease incidence and mortality now observed in high-income countries are encouraging, because this reinforces the fact that improvement is possible and that a near-normal, or even normal life-expectancy can be achieved in subtypes of type 2 diabetes.

Cellular senescence links aging and diabetes in cardiovascular disease

Aging is a powerful independent risk factor for cardiovascular diseases such as atherosclerosis and heart failure. Concomitant diabetes mellitus strongly reinforces this effect of aging on cardiovascular disease. Cellular senescence is a fundamental mechanism of aging and appears to play a crucial role in the onset and prognosis of cardiovascular disease in the context of both aging and diabetes. Senescent cells are in a state of cell cycle arrest but remain metabolically active by secreting inflammatory factors. This senescence-associated secretory phenotype is a trigger of chronic inflammation, oxidative stress, and decreased nitric oxide bioavailability. A complex interplay between these three mechanisms results in age- and diabetes-associated cardiovascular damage. In this review, we summarize current knowledge on cellular senescence and its secretory phenotype, which might be the missing link between aging and diabetes contributing to cardiovascular disease.