Impact of Metabolic Syndrome and Diabetes on Prognosis and Outcomes With Early Percutaneous Coronary Intervention in the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) Trial

Associations Between Metabolic Syndrome and Long-Term Mortality in Patients who underwent Percutaneous Coronary Intervention: An Australian Cohort Analysis

Metabolic syndrome (MetS) provides significant risk for coronary disease, however long-term prognosis after percutaneous coronary intervention (PCI) has been understudied. We assessed the prevalence and outcomes of patients with MetS from an Australian PCI cohort. We retrospectively examined data from the Melbourne Interventional Group multicenter PCI registry using a modified definition for MetS including ≥3 of the following: hypertension, diabetes mellitus, dyslipidemia, and body mass index ≥30 kg/m2. Thirty-day outcomes and long-term mortality were compared with patients without MetS. Cox regression methods were used to assess the multivariable effect of MetS on long-term mortality. Of 41,146 patients, 12,228 (34%) had MetS. Patients with MetS experienced greater 30-day myocardial infarction (2.2% vs 1.8%, p = 0.013), whereas patients without MetS had a trend for greater 30-day mortality (3.0% vs 3.4%, p = 0.051) and greater in-hospital major bleeding (1.7% vs 2.4%, p <0.001). After a median follow-up of 5.62 years (Q1 2.03, Q3 8.89), patients with MetS experienced greater mortality (24% vs 19%, p <0.001). After adjustment, MetS was not an independent predictor of long-term mortality (hazard ratio 0.95 confidence interval 0.86 to 1.05, p = 0.35). In sensitivity analyses, MetS-Diabetic patients had the highest, and MetS-NonDiabetic obese patients had the lowest long-term mortality. One in 3 patients who underwent all-comer PCI presented with MetS and experienced greater long-term mortality compared with others. However, this association was lost after adjustment for baseline confounders, highlighting that MetS is a marker of risk after PCI. Our findings support the obesity paradox and confirm robust associations between diabetes mellitus and long-term mortality.

Coronary revascularization for heart failure with coronary artery disease: A systematic review and meta-analysis of randomized trials

AIMS

Coronary artery disease (CAD) is a common cause of heart failure (HF). Whether coronary revascularization improves outcomes in patients with HF receiving guideline-recommended pharmacological therapy (GRPT) remains uncertain; therefore, we conducted a systematic review and meta-analysis of relevant randomized controlled trials (RCTs).

METHODS AND RESULTS

We searched in public databases for RCTs published between 1 January 2001 and 22 November 2022, investigating the effects of coronary revascularization on morbidity and mortality in patients with chronic HF due to CAD. All-cause mortality was the primary outcome. We included five RCTs that enrolled, altogether, 2842 patients (most aged <65 years; 85% men; 67% with left ventricular ejection fraction ≤35%). Overall, compared to medical therapy alone, coronary revascularization was associated with a lower risk of all-cause mortality (hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.79-0.99; p = 0.0278) and cardiovascular mortality (HR 0.80, 95% CI 0.70-0.93; p = 0.0024) but not the composite of hospitalization for HF or all-cause mortality (HR 0.87, 95% CI 0.74-1.01; p = 0.0728). There were insufficient data to show whether the effects of coronary artery bypass graft surgery or percutaneous coronary intervention were similar or differed.

CONCLUSIONS

For patients with chronic HF and CAD enrolled in RCTs, the effect of coronary revascularization on all-cause mortality was statistically significant but neither substantial (HR 0.88) nor robust (upper 95% CI close to 1.0). RCTs were not blinded, which may bias reporting of the cause-specific reasons for hospitalization and mortality. Further trials are required to determine which patients with HF and CAD obtain a substantial benefit from coronary revascularization by either coronary artery bypass graft surgery or percutaneous coronary intervention.

Impact of Metabolic Syndrome and It's Components on Prognosis in Patients With Cardiovascular Diseases: A Meta-Analysis

Background: Patients with metabolic syndrome (MetS) have a higher risk of developing cardiovascular diseases (CVD). However, controversy exists about the impact of MetS on the prognosis of patients with CVD. Methods: Pubmed, Cochrane library, and EMBASE databases were searched. Cohort Studies and randomized controlled trials post hoc analyses that evaluated the impact of MetS on prognosis in patients (≥18 years) with CVD were included. Relative risk (RR), hazard rate (HR) and 95% confidence intervals (CIs) were calculated for each individual study by random-effect model. Subgroup analysis and meta-regression analysis was performed to explore the heterogeneity. Results: 55 studies with 16,2450 patients were included. Compared to patients without MetS, the MetS was associated with higher all-cause death [RR, 1.220, 95% CI (1.103 to 1.349), P, 0.000], CV death [RR, 1.360, 95% CI (1.152 to 1.606), P, 0.000], Myocardial Infarction [RR, 1.460, 95% CI (1.242 to 1.716), P, 0.000], stroke [RR, 1.435, 95% CI (1.131 to 1.820), P, 0.000]. Lower high-density lipoproteins (40/50) significantly increased the risk of all-cause death and CV death. Elevated fasting plasma glucose (FPG) (>100 mg/dl) was associated with an increased risk of all-cause death, while a higher body mass index (BMI>25 kg/m2) was related to a reduced risk of all-cause death. Conclusions: MetS increased the risk of cardiovascular-related adverse events among patients with CVD. For MetS components, there was an increased risk in people with low HDL-C and FPG>100 mg/dl. Positive measures should be implemented timely for patients with CVD after the diagnosis of MetS, strengthen the prevention and treatment of hyperglycemia and hyperlipidemia.

Risk stratification for mortality in cardiovascular disease survivors: A survival conditional inference tree analysis

BACKGROUND AND AIMS

Efficient analysis strategies for complex network with cardiovascular disease (CVD) risk stratification remain lacking. We sought to identify an optimized model to study CVD prognosis using survival conditional inference tree (SCTREE), a machine-learning method.

METHODS AND RESULTS

We identified 5379 new onset CVD from 2006 (baseline) to May, 2017 in the Kailuan I study including 101,510 participants (the training dataset). The second cohort composing 1,287 CVD survivors was used to validate the algorithm (the Kailuan II study, n = 57,511). All variables (e.g., age, sex, family history of CVD, metabolic risk factors, renal function indexes, heart rate, atrial fibrillation, and high sensitivity C-reactive protein) were measured at baseline and biennially during the follow-up period. Up to December 2017, we documented 1,104 deaths after CVD in the Kailuan I study and 170 deaths in the Kailuan II study. Older age, hyperglycemia and proteinuria were identified by the SCTREE as main predictors of post-CVD mortality. CVD survivors in the high risk group (presence of 2-3 of these top risk factors), had higher mortality risk in the training dataset (hazard ratio (HR): 5.41; 95% confidence Interval (CI): 4.49-6.52) and in the validation dataset (HR: 6.04; 95%CI: 3.59-10.2), than those in the lowest risk group (presence of 0-1 of these factors).

CONCLUSION

Older age, hyperglycemia and proteinuria were the main predictors of post-CVD mortality.

TRIAL REGISTRATION

ChiCTR-TNRC-11001489.

Metabolic Risk Factors and Left Ventricular Diastolic Function in Middle-Aged Chinese Living in the Tibetan Plateau

Background

Data regarding the metabolic risk factors clustering on the risk of left ventricular diastolic dysfunction (LVDD) are lacking among people living at high altitude and under hypoxic conditions. In this study, we explored the association between metabolic risk factor clustering and LVDD among the Tibetan population of China.

Methods and Results

We conducted a cross‐sectional survey in a representative sample of 1963 Tibetans in 2014 to 2016. Grading LVDD was based on recommendations for the evaluation of LV diastolic function by echocardiography (2009). The prevalence of LVDD among 1963 participants (mean age: 51.51 years, 41.11% male) was 34.39%. Odds ratios (95% CI) of LVDD for the 1, 2, and 3 to 5 risk factors clustering were 1.45 (0.96–2.17), 2.68 (1.8–3.98), and 2.9 (1.9–4.43), respectively (P for trend <0.001). The association between metabolic risk factors clustering and LVDD was much more pronounced in the middle‐aged group than in the elderly (P for interaction=0.0170). High altitude was one of the major independent risk factors for LVDD; however, habitation altitude had no significant effect on the association between metabolic risk factors and LVDD (P for interaction=0.1022). The multivariable dominance analysis indicated that abdominal obesity, hypertension, and elevated blood glucose were the significant contributors to LVDD.

Conclusions

There was a significant positive association between the metabolic risk factor clustering number and LVDD among a population living at high altitude, especially in middle‐aged adults. However, habitation altitude itself has no significant effect on the association between metabolic risk factors and LVDD.

Impacts of triglyceride-glucose index on prognosis of patients with type 2 diabetes mellitus and non-ST-segment elevation acute coronary syndrome: results from an observational cohort study in China

BACKGROUND

The relationship between triglyceride-glucose index (TyG index) and the prevalence and prognosis of cardiovascular disease has been confirmed by former studies. However, it remains uncertain whether TyG index has a prognostic impact in patients with type 2 diabetes mellitus (T2DM) and non-ST-segment elevation acute coronary syndrome (NSTE-ACS) undergoing percutaneous coronary intervention (PCI).

METHODS

The study retrospectively enrolled 798 patients (mean age: 60.9 ± 8.3 years; 68.3% men) with T2DM and NSTE-ACS who underwent PCI at Beijing Anzhen Hospital from January to December 2015. TyG index was calculated as previously reported: ln [fasting TGs (mg/dL) * FBG (mg/dL)/2]. The primary endpoint was a composite of adverse events as follows: all-cause death, non-fatal myocardial infarction (MI) and ischemia-driven revascularization.

RESULTS

TyG index was significantly higher in patients with a primary endpoint event compared with those without. Multivariate Cox proportional hazards analysis showed that 1-unit increase of TyG index was independently associated with higher risk of primary endpoint, independent of other risk factors [hazard ratio (HR) 3.208 per 1-unit increase, 95% confidence interval (CI) 2.400-4.289, P < 0.001]. The addition of TyG index to a baseline risk model had an incremental effect on the predictive value for adverse prognosis [AUC: baseline risk model, 0.800 vs. baseline risk model + TyG index, 0.856, P for comparison < 0.001; category-free net reclassification improvement (NRI) 0.346, P < 0.001; integrated discrimination improvement (IDI) 0.087, P < 0.001].

CONCLUSIONS

Increased TyG index is a significant predictor of adverse prognosis in patients with T2DM and NSTE-ACS undergoing PCI. Further studies need to be performed to determine whether interventions for TyG index have a positive impact on improving clinical prognosis.

Metabolic syndrome cluster does not provide incremental prognostic information in patients with stable cardiovascular disease: A post hoc analysis of the AIM-HIGH trial

BACKGROUND

Metabolic syndrome (MS) is a well-known risk factor for the development of cardiovascular (CV) disease; yet, controversy persists whether it adds incremental prognostic value in patients with established CV disease.

OBJECTIVES

This study was performed to determine if MS is associated with worse CV outcomes in patients with established CV disease treated intensively with statins.

METHODS

We performed a post hoc analysis of the Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides and Impact on Global Health Outcomes trial, in which patients with established CV disease and atherogenic dyslipidemia (n = 3414) were randomly assigned to receive extended release niacin or placebo during a mean 36-month follow-up, to assess whether the presence of MS or the number of MS components contributed to CV outcomes.

RESULTS

The composite primary end point of CV events occurred in 15.1% of patients without MS vs 13.8%, 16.9%, and 16.8% of patients with MS in the subsets with 3, 4, and 5 MS components, respectively (corresponding adjusted hazard ratios 0.9, 1.1, and 1.1 relative to patients without MS), P = .55. Comparing subgroups with 3 vs 4 or 5 MS components, there was no significant difference in either the composite primary end point or secondary end points. Patients with diabetes mellitus had higher event rates, with or without the presence of MS.

CONCLUSIONS

The presence of MS was not associated with worse CV outcomes in the AIM-HIGH population. The rate of CV events in statin-treated Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides and Impact on Global Health Outcomes patients with MS was not significantly influenced by the number of MS components.

Metabolic syndrome and its individual components with mortality among patients with coronary heart disease

BACKGROUND

The metabolic syndrome (MetS) and its metabolic risk factors appear to promote the development of atherosclerotic cardiovascular disease. The aim of this study was to examine the association of MetS and its individual components with all-cause and cardiovascular mortality among patients with coronary heart disease (CHD).

METHODS

We performed a prospective, hospital-based cohort among 3599 CHD patients in China. Cox proportional hazards regression models were used to estimate the association of MetS and its components at baseline with risk of mortality.

RESULTS

During a mean follow-up period of 4.9years, 308 deaths were identified, 200 of which were due to cardiovascular disease. Compared with patients without MetS, patients with MetS according to the AHA/NHLBI statement had a 1.26-fold higher risk (95% CI, 1.01-1.59) of all-cause mortality and a 1.41-fold higher risk (1.06-1.87) of cardiovascular mortality. Patients with increasing numbers of components of MetS had a gradually increased risk for all-cause and cardiovascular mortality (P<0.05). When each component of MetS was considered as a dichotomized variable separately, only low high-density lipoprotein cholesterol (HDL-C) and elevated fasting blood glucose (FBG) were associated with all-cause and cardiovascular mortality. After using restricted cubic splines, we found a U-shaped association of HDL-C, body mass index and blood pressure, a positive association of FBG, and no association of triglycerides with the risks of all-cause and cardiovascular mortality.

CONCLUSIONS

MetS is a risk factor for all-cause and cardiovascular mortality among CHD patients. It is very important to control metabolic components in a reasonable control range.

Impact of Modifiable Cardiovascular Risk Factors on Mortality After Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of 100 Studies

Modifiable cardiovascular risk factors such as obesity, hypertension, dyslipidemia, smoking, diabetes mellitus, and metabolic syndrome can easily give rise to coronary heart disease (CHD). However, due to the existence of the so-called "obesity paradox" and "smoking paradox," the impact of these modifiable cardiovascular risk factors on mortality after percutaneous coronary intervention (PCI) is still not clear. Therefore, in order to solve this issue, we aim to compare mortality between patients with low and high modifiable cardiovascular risk factors after PCI. Medline and EMBASE were searched for studies related to these modifiable cardiovascular risk factors. Reported outcome was all-cause mortality after PCI. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated, and the pooled analyses were performed with RevMan 5.3 software. A total of 100 studies consisting of 884,190 patients (330,068 and 514,122 with high and low cardiovascular risk factors respectively) have been included in this meta-analysis. Diabetes mellitus was associated with a significantly higher short and long-term mortality with RR 2.11; 95% CI: (1.91-2.33) and 1.85; 95% CI: (1.66-2.06), respectively, after PCI. A significantly higher long-term mortality in the hypertensive and metabolic syndrome patients with RR 1.45; 95% CI: (1.24-1.69) and RR 1.29; 95% CI: (1.11-1.51), respectively, has also been observed. However, an unexpectedly, significantly lower mortality risk was observed among the smokers and obese patients. Certain modifiable cardiovascular risk subgroups had a significantly higher impact on mortality after PCI. However, mortality among the obese patients and the smokers showed an unexpected paradox after coronary intervention.

Risk of major adverse cardiovascular events in patients with metabolic syndrome after revascularization: A meta-analysis of eighteen cohorts with 18,457 patients

OBJECTIVE

To provide a comprehensive evaluation of the association between metabolic syndrome (MetS) and major adverse cardiovascular events (MACE) and to clarify the effect of revascularization methods among them in patients with coronary artery disease (CAD) undergoing successful revascularization.

METHODS

PubMed and Embase databases were searched. Cohort studies evaluating the association between MetS and risk of MACE and providing the hazard ratio (HR) with 95% confidence interval (CI) or sufficient data to calculate HR and its 95%CI among patients after revascularization were included. The pooled estimates were performed by using a random-effects model despite heterogeneity. Subgroup and sensitivity analyses were also conducted adherence to guidelines.

RESULTS

Eighteen trials with 18457 patients were included. Overall, MetS was associated with significant increased risks of MACE (HR 1.47, 95%CI 1.26-1.72, I(2)=46.4%, PH=0.016, P<0.001) and all-cause mortality (HR 1.58, 95%CI 1.29-1.92, I(2)=45.6%, PH=0.075, P<0.001) in CAD patients received revascularization. The results remained stable and robust in our subgroup analysis. However, no significant increased risk of MACE or all-cause mortality was found in patients undergoing coronary artery bypass graft (CABG) or drug-eluting stent (DES) in the sensitivity analysis.

CONCLUSION

MetS was associated with increased risks of MACE and all-cause mortality in patients after revascularization, but not in patients receiving CABG or DES. Therefore, prevention and treatment of MetS are extremely necessary in patients undergoing revascularization. Moreover, CABG and DES should be recommended for CAD patients with MetS and future researches are still warranted.

The impact of metabolic syndrome and hypertension on medical costs of patients with acute myocardial infarction at hospital

OBJECTIVE

This study aimed to find out the impact of metabolic syndrome (MS) and hypertension on medical costs of patients with acute myocardial infarction (AMI) at hospital.

METHODS

Patients with AMI at Qilu Hospital of Shandong University during January 2011 to May 2013 were separated into four groups according to whether with MS or history of hypertension. Comparison of medical costs, complication rate and cost-effectiveness ratio were analyzed.

RESULTS

We found that total costs, each day costs, medical treatment costs, chemical examination costs and drug costs were significantly different in four groups. In variance analysis, MS led to high medical costs without significance. Hypertension was a significant factor influencing medical costs and lead to low medical costs. In multiple linear regression, we found that body mass index (BMI) and percutaneous coronary intervention (PCI) were important predictors of total costs and each day costs. With higher BMI and utilization rate of PCI, medical costs were increased. Trend of total costs in four groups is similar to that of the rate of PCI utilization.

CONCLUSIONS

Metabolic syndrome has no impact on medical costs because of discordance in MS components. Hypertension will lead to lower PCI utilization rate, which results in less medical costs and bad hospital outcomes.

Coronary artery disease and diabetes mellitus

Diabetes mellitus (DM) is a major risk factor for cardiovascular disease. Near-normal glycemic control does not reduce cardiovascular events. For many patients with 1- or 2-vessel coronary artery disease, there is little benefit from any revascularization procedure over optimal medical therapy. For multivessel coronary disease, randomized trials demonstrated the superiority of coronary artery bypass grafting over multivessel percutaneous coronary intervention in patients with treated DM. However, selection of the optimal myocardial revascularization strategy requires a multidisciplinary team approach ('heart team'). This review summarizes the current evidence regarding the effectiveness of various medical therapies and revascularization strategies in patients with DM.

Investigation route of the coronary patient in the public health system in Curitiba, São Paulo and in InCor--IMPACT study

Background:

The investigation of stable coronary artery disease (CAD) and its treatment depend on risk stratification for decision-making on the need for cardiac catheterization and revascularization.

Objective:

To analyze the procedures used in the diagnosis and invasive treatment of patients with CAD, at the Brazilian Unified Health System (SUS) in the cities of Curitiba, São Paulo and at InCor-FMUSP.

Methods:

Retrospective, descriptive, observational study of the diagnostic and therapeutic itineraries of the Brazilian public health care system patient, between groups submitted or not to prior noninvasive tests to invasive cardiac catheterization. Stress testing, stress echocardiography, perfusion scintigraphy, catheterization and percutaneous or surgical revascularization treatment procedures were quantified and the economic impact of the used strategies.

Results:

There are significant differences in the assessment of patients with suspected or known CAD in the metropolitan region in the three scenarios. Although functional testing procedures are most often used the direct costs of these procedures differ significantly (6.1% in Curitiba, 20% in São Paulo and 27% in InCor-FMUSP). Costs related to the procedures and invasive treatments represent 59.7% of the direct costs of SUS in São Paulo and 87.2% in Curitiba. In InCor-FMUSP, only 24.3% of patients with stable CAD submitted to CABG underwent a noninvasive test before the procedure.

Conclusion:

Although noninvasive functional tests are the ones most often requested for the assessment of patients with suspected or known CAD most of the costs are related to invasive procedures/treatments. In most revascularized patients, the documentation of ischemic burden was not performed by SUS.

Interventions for coronary artery disease (surgery vs angioplasty) in diabetic patients

Patients with diabetes develop more widespread and more severe atherosclerotic coronary artery disease than patients without diabetes. Medical management of this coronary disease is inferior to revascularization for more complex or more widespread disease. Revascularization by percutaneous intervention (PCI) for patients with diabetes is associated with high mortality and complication rates. Surgical revascularization by coronary artery bypass grafting, yields superior results to PCI for patients with diabetes and coronary artery disease. Patients with diabetes benefit from the same medical management of their coronary artery disease and secondary risk modification as patients without diabetes.

Diabetes-associated macrovascular complications: cell-based therapy a new tool?

Diabetes mellitus and its ongoing macrovascular complications represent one of the major health problems around the world. Rise in obesity and population ages correlate with the increased incidence of diabetes. This highlights the need for novel approaches to prevent and treat this pandemic. The discovery of a reservoir of stem/progenitors in bone marrow and in mesenchymal tissue has attracted interest of both biologists and clinicians. A number of preclinical and clinical trials were developed to explore their potential clinical impact, as target or vehicle, in different clinical settings, including diabetes complications. Currently, bone marrow, peripheral blood, mesenchymal, and adipose tissues have been used as stem/progenitor cell sources. However, evidences have been provided that both bone marrow and circulating progenitor cells are dysfunctional in diabetes. These observations along with the growing advantages in genetic manipulation have spurred researchers to exploit ex vivo manipulated cells to overcome these hurdles. In this article, we provide an overview of data relevant to stem-progenitors potential clinical application in revascularization and/or vascular repair. Moreover, the hurdles at using progenitor cells in diabetic patients will be also discussed.

Does metabolic syndrome predict significant angiographic coronary artery disease?

INTRODUCTION

Metabolic syndrome (MS) is an independent predictor of acute cardiovascular events. However, few studies have addressed the relationship between MS and stable angiographic coronary artery disease (CAD), which has a different pathophysiological mechanism. We aimed to study the independent predictors for significant CAD, and to analyze the impact of MS (by the AHA/NHLBI definition) on CAD.

METHODS

We prospectively included 300 patients, mean age 64±9 years, 59% male, admitted for elective coronary angiography (suspected ischemic heart disease), excluding patients with known cardiac disease. All patients underwent assessment of demographic, anthropometric, and laboratory data and risk factors, and subsequently underwent coronary angiography.

RESULTS

In the study population, 23.0% were diabetic, 40.5% had MS (and no diabetes) and 36.7% had neither diagnosis. Significant CAD was present in 51.3% of patients. CAD patients were older and more frequently male and diabetic, with increased triglycerides and glucose and lower HDL cholesterol. Abdominal obesity was also less prevalent. MS was not associated with the presence of CAD (OR 0.94, 95% CI 0.59-1.48, p=0.778). Of the MS components, the most important predictors of CAD were increased glucose and triglycerides. Abdominal obesity was associated with a lower risk of CAD. In a multivariate logistic regression model for CAD, independent predictors of CAD were age, male gender, glucose and triglycerides. Body mass index had a protective effect.

CONCLUSIONS

Although MS is associated with cardiovascular events, the same was not found for stable angiographically proven CAD. Age, gender, diabetes and triglycerides are the most influential factors for CAD, with abdominal obesity as a protective factor.

Impact of different exercise training modalities on the coronary collateral circulation and plaque composition in patients with significant coronary artery disease (EXCITE trial): study protocol for a randomized controlled trial

BACKGROUND

Exercise training (ET) in addition to optimal medical therapy (OMT) in patients with stable coronary artery disease (CAD) has been demonstrated to be superior to percutaneous coronary interventions (PCI) with respect to the composite endpoint of death, myocardial infarction, stroke, revascularization and hospitalization due to worsening of angina. One mechanism leading to this superiority discussed in the literature is the increase in coronary collateral blood flow due to ET. Until now, data demonstrating the positive effect of ET on the collateral blood flow and the functional capacity of the coronary collateral circulation are still lacking.

METHODS/DESIGN

The EXCITE trial is a three-armed randomized, prospective, single-center, open-label, controlled study enrolling 60 patients with stable CAD and at least one significant coronary stenosis (fractional flow reserve ≤0.75). The study is designed to compare the influence and efficacy of two different 4-week ET programs [high-intensity interval trainings (IT) versus moderate-intensity exercise training (MT) in addition to OMT] versus OMT only on collateral blood flow (CBF). The primary efficacy endpoint is the change of the CBF of the target vessel after 4 weeks as assessed by coronary catheterization with a pressure wire during interruption of the antegrade flow of the target vessel by balloon occlusion. Secondary endpoints include the change in plaque composition as assessed by intravascular ultrasound (IVUS) after 4 weeks, myocardial perfusion as analyzed in MRI after 4 weeks and 12 months, peak oxygen uptake (V02 peak), change in endothelial function and biomarkers after 4 weeks, 3, 6 and 12 months. The safety endpoint addresses major adverse cardiovascular events (death from cardiovascular cause, myocardial infarction, stroke, TIA, target vessel revascularization or hospitalization) after 12 months.

DISCUSSION

The trial investigates whether ET for 4 weeks increases the CBF in patients with significant CAD compared to a sedentary control group. It also examines the impact of two intensities of ET on the CBF as well as the histological plaque composition. The trial started recruitment in June 2009 and will complete recruitment until June 2012. First results are expected in December 2012 (4-week follow-up), final results (12-month long-term secondary endpoint) in December 2013.

TRIAL REGISTRATION

Clinical trial registration information-URL: http://www.clinicaltrials.gov.Unique identifier: NCT01209637.

Diabetes mellitus and the heart

Diabetes mellitus is a risk factor for the development of coronary artery disease and chronic heart failure. When carefully screened for, diabetes or prediabetic disorders, are present in the majority of patients with clinically manifest ischaemic heart disease, and confer a major adverse impact upon morbidity and mortality. Important therapeutic modifications are required in the management of coronary artery disease and chronic heart failure associated with diabetes, and vice versa. However, despite optimal management, aided by recent landmark trials solely recruiting patients with diabetes, outcomes for patients with diabetes and heart disease remain poor. This review outlines the epidemiology, pathogenesis and management of diabetic heart disease, along with highlighting the many gaps in the evidence-base and suggesting future research priorities.

Role of CABG in the management of obstructive coronary arterial disease in patients with diabetes mellitus

Multiple studies have shown that diabetes mellitus (DM) can affect the efficacy of revascularization therapies and subsequent clinical outcomes. Selection of the appropriate myocardial revascularization strategy is critically important in the setting of multivessel coronary disease. Optimal medical therapy is an appropriate first-line strategy in patients with DM and mild symptoms. When medical therapy does not adequately control symptoms, revascularization with either PCI or CABG may be used. In patients with treated DM, moderate to severe symptoms and complex multivessel coronary disease, coronary artery bypass graft surgery provides better survival, fewer recurrent infarctions and greater freedom from re-intervention. Decisions regarding revascularization in patients with DM must take into account multiple factors and as such require a multidisciplinary team approach ('heart team').