Effect of renal insufficiency and diabetes mellitus on in-hospital mortality after acute coronary syndromes treated with primary PCI. Results from the ALKK PCI Registry

The Use of Sodium-Glucose Cotransporter-2 Inhibitors in Coronary Revascularization: Where Are We Now? A Systematic Review

INTRODUCTION

Diabetes and coronary artery disease are two common conditions that often co-exist. In recent years, sodium-glucose cotransporter 2 inhibitors (SGLT2i) have been demonstrated to provide significant cardioprotective benefits, especially among patients with heart failure.

OBJECTIVE

In this systematic review, we look to identify the outcomes SGLT2i use in patients undergoing coronary revascularization.

METHODS

Pubmed and Embase were systematically searched for articles describing the outcomes of patients taking SGLT2i and undergoing coronary revascularization. 834 titles and abstracts were screened, 42 full texts were reviewed, and 18 studies were found to meet the inclusion criteria and were included in this review.

RESULTS

For patients undergoing coronary artery bypass grafting and percutaneous coronary intervention, the use of SGLT2i resulted in reductions in mortality, hospitalization for heart failure, and improved blood glucose; however, these benefits were not consistently reported in the literature. Reduced inflammatory markers and positive cardiac remodeling were identified among patients taking SGLT2i.

CONCLUSIONS

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have been demonstrated to provide benefits for patients with heart failure along with a host of positive modulatory effects on the cardiovascular system, including reductions in inflammatory properties, hypertension, and left ventricular volume load. Given the clear benefit provided by SGLT2i to patients with cardiovascular disease and a host of positive properties that are expected to be protective for patients with ischemic heart disease, future investigation into the relationship between SGLT2i and outcomes for patients undergoing revascularization is imperative.

Diabetes Mellitus with Mild or Moderate Kidney Dysfunction is Associated with Poor Prognosis in Patients with Coronary Artery Disease: A Large-Scale Cohort Study

AIM

Both kidney dysfunction and diabetes mellitus (DM) predict long-term poor prognosis in patients with coronary artery disease (CAD). We aimed to evaluate the clinical outcomes according to the combined status of DM and different stages of kidney dysfunction in CAD patients.

METHODS

From January 2013 to December 2013, 9293 eligible patients hospitalized for percutaneous coronary intervention (PCI) at Fuwai hospital were followed up for major adverse cardiovascular and cerebrovascular events (MACCEs), a composite of all-cause mortality, myocardial infarction and stroke. Baseline kidney function was considered as stage I: normal or high kidney function; stage II: mild dysfunction and stage III: moderate dysfunction according to estimated glomerular filtration rate (eGFR). Upon baseline kidney function, diabetic and non-diabetic patients were divided into six groups.

RESULTS

During a median follow-up of 2.4 years, 326 (3.5%) MACCEs occurred. Compared to patients in the stage I/non-DM group, patients in the stage II/DM and stage III/DM groups had significantly increased MACCE risk [adjusted hazard ratio (aHR), 1.53; 95% confidence interval (CI), 1.09-2.15; P = 0.014; aHR, 3.00; 95%CI, 1.74-5.18; P<0.002, respectively]. Additionally, there were J-shaped associations of eGFR with MACCE risk regardless of glycemic metabolism status after adjusted for confounders. Furthermore, moderate kidney dysfunction conferred an increased MACCE risk in diabetic patients with uncontrolled glycemia (aHR, 2.93; 95%CI, 1.48-5.78; P=0.002).

CONCLUSIONS

DM with mild or moderate kidney dysfunction is associated with poor prognosis in CAD patients. Categorical classification of patients with DM and kidney dysfunction could provide prognostic information for risk stratification of CAD patients.

Elevated postprandial triglyceride-rich lipoproteins in patients with diabetes and stable coronary artery disease correlated with early renal damage and systemic inflammation

BACKGROUND

Dyslipidaemia is key in the development of coronary heart disease (CHD) in patients with diabetes mellitus (DM). Accumulated evidence supports that diabetic nephropathy increases the mortality risk of patients with CHD, while the influence of diabetic dyslipidaemia on renal damage in patients with DM and CHD remains unknown. Moreover, recent data indicate that postprandial dyslipidaemia has predictive value in terms of CHD prognosis, especially in patients with DM. The study aimed to determine the relationship of triglyceride-rich lipoproteins (TRLs) after daily Chinese breakfast on systemic inflammation and early renal damage in Chinese patients with DM and SCAD.

METHODS

Patients with DM diagnosed with SCAD while in the Department of Cardiology of Shengjing Hospital from September 2016 to February 2017 were enrolled in this study. Fasting and 4-h postprandial blood lipids, fasting blood glucose, glycated haemoglobin, urinary albumin-to-creatinine ratio (UACR), serum interleukin-6 (IL-6) and tumour necrosis factor-α (TNF-α) concentrations, and other parameters were measured. Fasting and postprandial blood lipid profiles and inflammatory cytokines were analysed using a paired t-test. The association between variables was analysed using Pearson or Spearman bivariate analysis. P < 0.05 was considered to be statistically significant.

RESULTS

The study enrolled 44 patients in total. Compared with fasting state, postprandial total cholesterol high-density lipoprotein-cholesterol (HDL-C),low-density lipoprotein-cholesterol (LDL-C) and non-high-density lipoprotein-cholesterol (non-HDL-C) all showed no significant change. Postprandial serum triglyceride (TG) concentration increased significantly compared with that at fasting (1.40 ± 0.40 vs. 2.10 ± 0.94 mmol/L, P < 0.001), as did serum remnant lipoprotein-cholesterol (RLP-C) (0.54 ± 0.18 mmol/L vs. 0.64 ± 0.25 mmol/L). Pearson analysis revealed that serum TG and RLP-C positively correlated before and after breakfast. Moreover, during fasting, positive correlations were observed between TG and serum IL-6, TNF-α, and UACR. Positive correlations were observed between RLP-C and IL-6, UACR under fasting condition, while both TG and RLP-C were positively correlated with postprandial serum IL-6, TNF-α, and UACR concentrations. Finally, positive correlations were observed between UACR and IL-6 and TNF-α concentration under both fasting and postprandial conditions.

CONCLUSIONS

An increase in postprandial TRLs was observed in Chinese patients with DM and SCAD after daily breakfast, and this increase may be related to early renal injury via the induction of systemic inflammation.

Drug-Coated Balloon vs. Drug-Eluting Stents for De Novo Unprotected Left Main Stem Disease: The SPARTAN-LMS Study

The objective of this study is to compare the outcomes of patients treated with drug-coated balloons (DCBs) or second-generation drug-eluting stents (DESs) for de novo unprotected left main stem (LMS) disease. Previous studies comparing the treatment of LMS disease suggest that the mortality for DES PCI is not worse than CABG. There are limited data from studies investigating the treatment of de novo LMS disease with DCB angioplasty. We compared the all-cause and cardiac mortality of patients treated with paclitaxel DCB to those with second-generation DES for de novo LMS disease from July 2014 to November 2019. Data were analysed using Kaplan-Meier analyses and propensity-matched analyses. A total of 148 patients were treated with either a DCB or DES strategy. There was no significant difference in all-cause mortality in the DCB group (19.5%) compared to the DES group (15.9%) (HR 1.42 [0.61-3.32], p = 0.42). Regarding cardiac mortality, 2 (4.9%) were recorded for the DCB group and 7 (6.5%) for the DES group (HR 1.21 [0.31-4.67], p = 0.786); for target vessel myocardial infarction, there were 0 (0%) for the DCB group and 7 (6.5%) for the DES group; and for target lesion revascularisation, there were 3 (7.3%) in the DCB group and 9 (8.3%) in the DES group (HR: 0.89 [0.24-3.30]). p = 0.86. These remained not significant after propensity score matching. We found no difference in the mortality outcomes with DCB angioplasty compared to second-generation DES, with a median follow-up of 33 months. DCB can therefore be regarded as a safe option in the treatment of LMS disease in suitable patients.

Impact of Chronic Kidney Disease on Outcomes of Percutaneous Coronary Intervention in Patients With Diabetes Mellitus: A Systematic Review and Meta-Analysis

BACKGROUND

The impact of chronic kidney disease (CKD) on adverse cardiovascular outcomes after percutaneous coronary intervention in patients with diabetes mellitus (DM) is still unclear. This study aimed to systematically assess evidence on this topic.

METHODS

The PubMed, Embase, and CENTRAL databases were searched for studies comparing mortality, myocardial infarction (MI), or revascularization outcomes between patients with DM with and without CKD.

RESULTS

In 11 studies, the presence of CKD was associated with significantly increased risk of early all-cause mortality (risk ratio [RR], 3.45; 95% CI, 3.07-3.87; I2 = 0%; P < .001), late all-cause mortality (RR, 2.78; 95% CI, 1.92-4.02; I2 = 83%; P < .001), cardiac mortality (RR, 2.90; 95% CI, 1.99-4.22; I2 = 29%; P < .001), and MI (RR, 1.40; 95% CI, 1.06-1.85; I2 = 13%; P = .02) compared with no CKD. There was no difference in the risk of any revascularization between those with and without CKD. Analysis of adjusted hazard ratios (HRs) indicated significantly increased risk of mortality (HR, 2.64; 95% CI, 1.91-3.64; I2 = 0%; P < .001) in the CKD group but only a nonsignificant tendency of increased MI (HR, 1.59; 95% CI, 0.99-2.54; I2 = 0%; P = .05) and revascularization (HR, 1.24; 95% CI, 0.94-1.63; I2 = 2%; P = .12) in the CKD group.

CONCLUSION

The presence of CKD in patients with DM significantly increases the risk of mortality and MI. However, CKD had no impact on revascularization rates.

Divergence between serum creatine and cystatin C in estimating glomerular filtration rate of critically ill COVID-19 patients

Background

The clinical use of serum creatine (sCr) and cystatin C (CysC) in kidney function evaluation of critically ill patients has been in continuous discussion. The difference between estimated glomerular filtration rate calculated by sCr (eGFRcr) and CysC (eGFRcysc) of critically ill COVID-19 patients were investigated in this study.

Methods

This is a retrospective, single-center study of critically ill patients with COVID-19 admitted in intensive care unit (ICU) at Wuhan, China. Control cases were moderate COVID-19 patients matched in age and sex at a ratio of 1:1. The eGFRcr and eGFRcysc were compared. The association between eGFR and death were analyzed in critically ill cases. The potential factors influencing the divergence between eGFRcr and eGFRcysc were explored.

Results

A total of 76 critically ill COVID-19 patients were concluded. The mean age was 64.5 ± 9.3 years. The eGFRcr (85.45 (IQR 60.58–99.23) ml/min/1.73m²) were much higher than eGFRcysc (60.6 (IQR 34.75–79.06) ml/min/1.73m²) at ICU admission. About 50 % of them showed eGFRcysc < 60 ml/min/1.73 m² while 25% showed eGFRcr < 60 ml/min/1.73 m² (χ² = 10.133, p = 0.001). This divergence was not observed in moderate group. The potential factors influencing the divergence included serum interleukin-6 (IL-6), tumor necrosis factor (TNF-α) level as well as APACHEII, SOFA scores. Reduced eGFRcr (<60 mL/min/1.73 m²) was associated with death (HR = 1.939, 95%CI 1.078–3.489, p = 0.027).

Conclusions

The eGFRcr was generally higher than eGFRcysc in critically ill COVID-19 cases with severe inflammatory state. The divergence might be affected by inflammatory condition and illness severity. Reduced eGFRcr predicted in-hospital death. In these patients, we advocate for caution when using eGFRcysc.