Microvascular Disease and Risk of Cardiovascular Events and Death From Intensive Treatment in Type 2 Diabetes: The ACCORDION Study

Microvascular burden and long-term risk of stroke and dementia in type 2 diabetes mellitus

OBJECTIVE

To examine the associations between microvascular disease (MVD) and risk of stroke, dementia, and their major subtypes among individuals with type 2 diabetes mellitus (T2DM).

METHODS

We included 26,173 participants with T2DM from the UK Biobank who had no known stroke or dementia at baseline. MVD burden was reflected by the presence of retinopathy, peripheral neuropathy, and chronic kidney disease. Cox regression models were used to estimate hazard ratios (HRs) and 95 % confidential intervals (CIs) of stroke and dementia associated with overall MVD burden and individual MVD.

RESULTS

During a median follow-up of 11.5 years, 1103 incident stroke (964 ischemic and 269 hemorrhagic stroke) and 813 incident dementia (312 Alzheimer's disease and 304 vascular dementia) cases were identified. The risk of stroke, dementia, and their major subtypes all increased with an increasing number of MVD (all P-trend <0.001). The adjusted HRs (95 % CIs) comparing three with no MVD were 5.03 (3.16, 8.02) for all stroke, 4.57 (2.75, 7.59) for ischemic stroke, and 6.60 (2.65, 16.43) for hemorrhagic stroke. The corresponding estimates were 4.28 (2.33, 7.86) for all-cause dementia, 6.96 (3.02, 16.01) for Alzheimer's disease, and 3.81 (1.40, 10.42) for vascular dementia. Among the three MVD, chronic kidney disease showed the strongest associations with both stroke subtypes, while peripheral neuropathy was most strongly associated with both dementia subtypes.

CONCLUSIONS

Risk of stroke, dementia, and their major subtypes increased with an increasing number of MVD. The associations of individual MVD with stroke and dementia varied substantially by types of MVD.

Impact of the PATH Statement on Analysis and Reporting of Heterogeneity of Treatment Effect in Clinical Trials: A Scoping Review

Background

The Predictive Approaches to Treatment Effect Heterogeneity (PATH) Statement provides guidance for using predictive modeling to identify differences (i.e., heterogeneity) in treatment effects (benefits and harms) among participants in randomized clinical trials (RCTs). It distinguished risk modeling, which uses a multivariable model to predict risk of trial outcome(s) and then examines treatment effects within strata of predicted risk, from effect modeling, which predicts trial outcomes using models that include treatment, individual participant characteristics and interactions of treatment with selected characteristics.

Purpose

To describe studies of heterogeneous treatment effects (HTE) that use predictive modeling in RCT data and cite the PATH Statement.

Data Sources

The Cited By functions in PubMed, Google Scholar, Web of Science and SCOPUS databases (Jan 7, 2020 - June 5, 2023).

Study Selection

42 reports presenting 45 predictive models.

Data Extraction

Double review with adjudication to identify risk and effect modeling and examine consistency with Statement consensus statements. Credibility of HTE findings was assessed using criteria adapted from the Instrument to assess Credibility of Effect Modification Analyses (ICEMAN). Clinical importance of credible HTE findings was also assessed.

Data Synthesis

The numbers of reports, especially risk modeling reports, increased year-on-year. Consistency with consensus statements was high, except for two: only 15 of 32 studies with positive overall findings included a risk model; and most effect models explored many candidate covariates with little prior evidence for effect modification. Risk modeling was more likely than effect modeling to identify both credible HTE (14/19 vs 5/26) and clinically important HTE (10/19 vs 4/26).

Limitations

Risk of reviewer bias: reviewers assessing credibility and clinical importance were not blinded to adherence to PATH recommendations.

Conclusions

The PATH Statement appears to be influencing research practice. Risk modeling often uncovered clinically important HTE; effect modeling was more often exploratory.

Intensive Glycemic Therapy in Type 2 Diabetes Patients With Cardiac Autonomic Dysfunction: The ACCORD Trial

OBJECTIVE

To assess whether the presence of cardiac autonomic dysfunction denoted by low heart rate variability (HRV) modifies the effect of intensive glycemic therapy on outcomes in patients with type 2 diabetes.

PATIENTS AND METHODS

This study included 7946 participants in the ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial from January 2001 through June 2009. Heart rate variability measures included standard deviation of all normal-to-normal intervals (SDNN) and root mean square of successive differences between normal-to-normal intervals (rMSSD). Abnormal values were defined based on less than the 10th percentile for SDNN and rMSSD.

RESULTS

Compared with standard therapy, intensive therapy was associated with improved primary outcome (composite of cardiovascular events) in the low-HRV group (SDNN: HR, 0.57; 95% CI, 0.39 to 0.84; rMSSD: HR, 0.57; 95% CI, 0.38 to 0.84), but not in the normal-HRV group (SDNN: HR, 0.90; 95% CI, 0.77 to 1.05; rMSSD: HR, 0.90; 95% CI, 0.77 to 1.05). A similar pattern was found for coronary heart disease. Conversely, intensive therapy had a neutral effect on all cause death in the low-HRV group (SDNN: HR, 0.88; 95% CI, 0.54 to 1.41; rMSSD: HR, 0.71; 95% CI, 0.43 to 1.17;), but increase risk of all-cause death in the normal-HRV group (SDNN: HR, 1.21; 95% CI, 1.00 to 1.46; rMSSD: HR, 1.25; 95% CI, 1.03 to 1.51). Intensive therapy induced a greater risk of hypoglycemia in the normal-HRV group than that in the low-HRV group.

CONCLUSION

Cardiac autonomic dysfunction expressed as low HRV identified subpopulations in ACCORD with more benefits and less harms from intensive therapy.

Glucose variability: a new risk factor for cardiovascular disease

AIMS AND DATA SYNTHESIS

Glucose variability (GV) is increasingly considered an additional index of glycemic control. Growing evidence indicates that GV is associated with diabetic vascular complications, thus being a relevant point to address in diabetes management. GV can be measured using various parameters, but to date, a gold standard has not been identified. This underscores the need for further studies in this field also to identify the optimal treatment.

CONCLUSIONS

We reviewed the definition of GV, the pathogenetic mechanisms of atherosclerosis, and its relationship with diabetic complications.

Glycaemic control in people with diabetes following acute myocardial infarction

Diabetes is a highly prevalent disease associated with considerable cardiovascular end organ damage and mortality. Despite significant changes to the management of acute myocardial infarction over the last two decades, people with diabetes remain at risk of complications and mortality following a myocardial infarct for a multitude of reasons, including increased coronary atherosclerosis, associated coronary microvascular dysfunction, and diabetic cardiomyopathy. Dysglycaemia causes significant endothelial dysfunction and upregulation of inflammation within the vasculature and epigenetic changes mean that these deleterious effects may persist despite subsequent efforts to tighten glycaemic control. Whilst clinical guidelines advocate for the avoidance of both hyper- and hypoglcyaemia in the peri-infarct period, the evidence base is lacking, and currently there is no consensus on the benefits of glycaemic control beyond this period. Glycaemic variability contributes to the glycaemic milieu and may have prognostic importance following myocardial infarct. The use of continuous glucose monitoring means that glucose trends and parameters can now be captured and interrogated, and its use, along with newer medicines, may provide novel opportunities for intervention after myocardial infarction in people with diabetes.

Diabetic peripheral neuropathy is associated with diabetic kidney disease and cardiovascular disease – The Silesia Diabetes-Heart Project

Microvascular complications of diabetes seem to be clustered and put patients at higher risk of developing cardiovascular disease (CVD). This was a questionnaire-based study designed to screen for the presence of diabetic peripheral neuropathy (DPN), defined as the score in the Michigan Neuropathy Screening Instrument (MNSI) above 2, and to evaluate its association with other complication of diabetes, including CVD. There were 184 patients included into the study. The prevalence of DPN in the study group was 37.5%. The regression model analysis revealed that the presence of DPN was significantly associated with the presence of diabetic kidney disease (DKD) (P = 0.0034;) and patient's age (P < 0.0001). Thirty-four patients (49.3%) with MNSI score >2 were diagnosed with CVD in comparison to 24 (20.1%) subjects with MNSI score ≤ 2 (P = 0.00006). In case of having one diabetes complication diagnosed, it is important to screen for others, including macrovascular ones.

The association between distal symmetric polyneuropathy in diabetes with all-cause mortality - a meta-analysis

BACKGROUND

Distal symmetric polyneuropathy (DSPN) is a common microvascular complication of both type 1 and 2 diabetes with substantial morbidity burden and reduced quality of life. Its association with mortality is equivocal.

PURPOSE

To describe the association between DSPN and all-cause mortality in people with diabetes and further stratify by the type of diabetes based on a meta-analysis of published observational studies.

DATA SOURCES

We searched Medline from inception to May 2021.

STUDY SELECTION

Original data were collected from case-control and cohort studies that reported on diabetes and DSPN status at baseline and all-cause mortality during follow-up.

DATA EXTRACTION

was completed by diabetes specialists with clinical experience in neuropathy assessment.

DATA SYNTHESIS

Data was synthesized using random-effects meta-analysis. The difference between type 1 and 2 diabetes was investigated using meta-regression.

RESULTS

A total of 31 cohorts (n=155,934 participants, median 27.4% with DSPN at baseline, all-cause mortality 12.3%) were included. Diabetes patients with DSPN had an almost twofold mortality (HR: 1.96, 95%CI: 1.68-2.27, I2 = 91.7%), I^{2 =} 91.7%) compared to those without DSPN that was partly explained by baseline risk factors (adjusted HR: 1.60, 95%CI: 1.37-1.87, I^{2 =} 78.86%). The association was stronger in type 1 compared to type 2 diabetes (HR: 2.22, 95%CI: 1.43-3.45). Findings were robust in sensitivity analyses without significant publication bias.

LIMITATIONS

Not all papers reported multiple adjusted estimates. The definition of DSPN was heterogeneous.

CONCLUSIONS

DSPN is associated with an almost twofold risk of death. If this association is causal, targeted therapy for DSPN could improve life expectancy of diabetic patients.

Efficacy and safety of intensive versus conventional glucose targets in people with type 2 diabetes: a systematic review and meta-analysis

OBJECTIVE

The aim of study is to re-evaluate the risk-benefits of intensive glycemic control in the context of multi-factorial intervention in adults with T2D.

METHODS

We searched Ovid MEDLINE, Embase, Cochrane, and CINHAL for randomized control trials comparing standard glucose targets to intensive glucose targets with pre-specified HbA_1clevels. Subgroup analysis was also performed to account for the inclusion of glucose only versus multi-factorial intervention trials. Results are reported as risk ratio (RR) and 95% confidence interval (CI).

RESULTS

Fifty-seven publications including 19 trials were included. Compared to conventional glycemic control, intensive glycemic control decreased the risk of non-fatal myocardial infarction (0.8, 0.7-0.91), macroalbuminuria (0.72, 0.5--0.87), microalbuminuria (0.67, 0.52-0.85), major amputation (0.6, 0.38-0.96), retinopathy (0.75 ,0.63-0.9), and nephropathy (0.78, 0.63-0.97). The risk of hypoglycemia increased with intensive glycemic control than conventional treatment (2.04, 1.34-3.1). No reduction in all-cause or cardiovascular mortality was observed. However, in the context of multifactorial intervention, intensive glucose control was associated with a significant reduction in all-cause mortality (0.74, 0.57-0.95).

CONCLUSION

Targeting HbA_1c levels should be individualized based on the clinical status, balancing risks and benefits and potential risk for developing these complications among people with T2D.

The 2-Year Leakage Index and Quantitative Microaneurysm Results of the RECOVERY Study: Quantitative Ultra-Widefield Findings in Proliferative Diabetic Retinopathy Treated with Intravitreal Aflibercept

Eyes with proliferative diabetic retinopathy (PDR) have been shown to improve in the leakage index and microaneurysm (MA) count after intravitreal aflibercept (IAI) treatment. The authors investigated these changes via automatic segmentation on ultra-widefield fluorescein angiography (UWFA). Forty subjects with PDR were randomized to receive either 2 mg IAI every 4 weeks (Arm 1) or every 12 weeks (Arm 2) through Year 1. After Year 1, Arm 1 switched to quarterly IAI and Arm 2 to monthly IAI through Year 2. By Year 2, the Arm 1 leakage index decreased by 43% from Baseline (p = 0.03) but increased by 59% from Year 1 (p = 0.04). Arm 2 decreased by 61% from Baseline (p = 0.008) and by 31% from Year 1 (p = 0.12). Both cohorts exhibited a significant decline in MAs from Baseline to Year 2 (871 to 410; p < 0.001; 776 to 207; p < 0.001, respectively). Subjects with an improved leakage and MA count showed a more significant improvement in the Diabetic Retinopathy Severity Scale (DRSS) score. Moreover, central subfield thickness (CST) was positively associated with changes in the leakage index. In conclusion, the leakage index and MA counts significantly improved from Baseline following IAI treatment, and monthly injections provided a more rapid and sustained reduction in these parameters compared with quarterly injections.