Emerging Targets for Cardiovascular Disease Prevention in Diabetes

Influencing factors of stroke in patients with type 2 diabetes: A systematic review and meta-analysis

BACKGROUND

Stroke stands as a significant macrovascular complication among individuals with Type 2 diabetes mellitus (T2DM), often resulting in the primary cause of mortality and disability within this patient demographic. Presently, numerous studies have been conducted to investigate the underlying causes of stroke in individuals with T2DM, yet the findings exhibit inconsistencies.

OBJECTIVE

This paper aims to consolidate and summarize the available evidence concerning the influential factors contributing to stroke among patients diagnosed with T2DM.

METHODS

We conducted a comprehensive search across multiple databases, including Cochrane Library, PubMed, Web Of Science, Embase, China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), Wanfang and Weipu up to August 2023. Google Scholar was also searched to retrieve gray literature. We calculated odds ratios (OR) and 95% confidence intervals (CI) using Stata software.

RESULTS

Our analysis encompassed 43 observational studies, exploring factors across sociodemographic, biochemical, complications, and hypoglycemic agent categories. The findings identified several risk factors for stroke in patients with T2DM: age, gender, T2DM duration, hypertension, body-mass index (BMI), smoking, Glycated hemoglobin (HbA1c), estimated Glomerular Filtration Rate (eGFR), albuminuria, Triglycerides (TG), Low density lipoprotein cholesterol (LDL-C), Coronary heart disease (CHD), Atrial fibrillation (AF), diabetic retinopathy (DR), Peripheral vascular disease (PVD), and carotid plaque. Conversely, exercise, High density lipoprotein cholesterol (HDL-C), metformin (MET), pioglitazone, and metformin combination therapy emerged as protective factors.

CONCLUSION

This study underscores the multitude of influencing factors contributing to stroke in people with T2DM patients, among which the microvascular complications of T2DM play an most important role. Therefore, we emphasize the importance of screening for microvascular complications in patients with T2DM. However, due to limitations arising from the number of articles reviewed, there remain areas where clarity is lacking. Further research efforts are warranted to expand upon and reinforce our current findings.

Explore the value of carotid ultrasound radiomics nomogram in predicting ischemic stroke risk in patients with type 2 diabetes mellitus

Background and objective

Type 2 Diabetes Mellitus (T2DM) with insulin resistance (IR) is prone to damage the vascular endothelial, leading to the formation of vulnerable carotid plaques and increasing ischemic stroke (IS) risk. The purpose of this study is to develop a nomogram model based on carotid ultrasound radiomics for predicting IS risk in T2DM patients.

Methods

198 T2DM patients were enrolled and separated into study and control groups based on IS history. After manually delineating carotid plaque region of interest (ROI) from images, radiomics features were identified and selected using the least absolute shrinkage and selection operator (LASSO) regression to calculate the radiomics score (RS). A combinatorial logistic machine learning model and nomograms were created using RS and clinical features like the triglyceride-glucose index. The three models were assessed using area under curve (AUC) and decision curve analysis (DCA).

Results

Patients were divided into the training set and the testing set by the ratio of 0.7. 4 radiomics features were selected. RS and clinical variables were all statically significant in the training set and were used to create a combination model and a prediction nomogram. The combination model (radiomics + clinical nomogram) had the largest AUC in both the training set and the testing set (0.898 and 0.857), and DCA analysis showed that it had a higher overall net benefit compared to the other models.

Conclusions

This study created a carotid ultrasound radiomics machine-learning-based IS risk nomogram for T2DM patients with carotid plaques. Its diagnostic performance and clinical prediction capabilities enable accurate, convenient, and customized medical care.

Causal associations between type 1 diabetes mellitus and cardiovascular diseases: a Mendelian randomization study

BACKGROUND

The presence of type 1 diabetes mellitus (T1DM) has been demonstrated to pose an increased risk for developing cardiovascular diseases (CVDs). However, the causal relationships between T1DM and CVDs remain unclear due to the uncontrolled confounding factors and reverse causation bias of the observational studies.

METHODS

Summary statistics of T1DM and seven CVDs from the largest available genome-wide association studies (GWAS) of European ancestry and FinnGen biobank were extracted for the primary MR analysis, and the analysis was replicated using UK biobank (UKBB) for validation. Three complementary methods: inverse variance weighted (IVW), weighted median, and MR-Egger were used for the MR estimates. The potential pleiotropic effects were assessed by MR-Egger intercept and MR-PRESSO global test. Additionally, multivariable MR (MVMR) analysis was performed to examine whether T1DM has independent effects on CVDs with adjustment of potential confounding factors. Moreover, a two-step MR approach was used to assess the potential mediating effects of these factors on the causal effects between T1DM and CVDs.

RESULTS

Causal effects of T1DM on peripheral atherosclerosis (odds ratio [OR] = 1.06, 95% confidence interval [CI]: 1.02-1.10; p = 0.002)] and coronary atherosclerosis (OR = 1.03, 95% CI: 1.01-1.05; p = 0.001) were found. The results were less likely to be biased by the horizontal pleiotropic effects (both p values of MR-Egger intercept and MR-PRESSO Global test > 0.05). In the following MVMR analysis, we found the causal effects of T1DM on peripheral atherosclerosis and coronary atherosclerosis remain significant after adjusting for a series of potential confounding factors. Moreover, we found that hypertension partly mediated the causal effects of T1DM on peripheral atherosclerosis (proportion of mediation effect in total effect: 11.47%, 95% CI: 3.23-19.71%) and coronary atherosclerosis (16.84%, 95% CI: 5.35-28.33%). We didn't find significant causal relationships between T1DM and other CVDs, including heart failure (HF), coronary artery disease (CAD), atrial fibrillation (AF), myocardial infarction (MI) and stroke. For the reverse MR from CVD to T1DM, no significant causal relationships were identified.

CONCLUSION

This MR study provided evidence supporting the causal effect of T1DM on peripheral atherosclerosis and coronary atherosclerosis, with hypertension partly mediating this effect.

Predictive values of metabolic score for insulin resistance on risk of major adverse cardiovascular events and comparison with other insulin resistance indices among Chinese with and without diabetes mellitus: Results from the 4C cohort study

AIMS/INTRODUCTION

To investigate the relationship between the metabolic score for insulin resistance (METS-IR) index and major adverse cardiac events (MACEs) and to compare its ability to predict MACEs with other IR indices including homeostatic model assessment for IR (HOMA-IR) and triglyceride glucose (TyG) index-related parameters.

MATERIALS AND METHODS

We conducted a cohort study enrolling 7,291 participants aged ≥40 years. Binary logistic regression and restricted cubic splines were performed to determine the association between METS-IR and MACEs, and the receiver operating curve (ROC) was utilized to compare the predictive abilities of IR indices and to determine the optimal cut-off points.

RESULTS

There were 348 (4.8%) cases of MACEs during a median follow-up of 3.8 years. Compared with participants with a METS-IR in the lowest quartile, the multivariate-adjusted RRs and 95% CIs for participants with a METS-IR in the highest quartile were 1.47 (1.05-2.77) in all participants, 1.42 (1.18-2.54) for individuals without diabetes, and 1.75 (1.11-6.46) for individuals with diabetes. Significant interactions were found between the METS-IR and the risk of MACEs by sex in all participants and by age and sex in individuals without diabetes (all P values for interaction < 0.05). In the ROC analysis, the METS-IR had a higher AUC value than other indices for predicting MACEs in individuals with diabetes and had a comparable or higher AUC than other indices for individuals without diabetes.

CONCLUSIONS

The METS-IR can be an effective clinical indicator for identifying MACEs, as it had superior predictive power when compared with other IR indices in individuals with diabetes.

Monocyte and macrophage foam cells in diabetes-accelerated atherosclerosis

Diabetes results in an increased risk of atherosclerotic cardiovascular disease. This minireview will discuss whether monocyte and macrophage lipid loading contribute to this increased risk, as monocytes and macrophages are critically involved in the progression of atherosclerosis. Both uptake and efflux pathways have been described as being altered by diabetes or conditions associated with diabetes, which may contribute to the increased accumulation of lipids seen in macrophages in diabetes. More recently, monocytes have also been described as lipid-laden in response to elevated lipids, including triglyceride-rich lipoproteins, the class of lipids often elevated in the setting of diabetes.

Low-temperature plasma modification, structural characterization and anti-diabetic activity of an apricot pectic polysaccharide

To fully research the anti-diabetic activity of apricot polysaccharide, low temperature plasma (LTP) was used to modify apricot polysaccharide. The modified polysaccharide was isolated and purified using column chromatography. It was found that LTP modification can significantly improve the α-glucosidase glucosidase inhibition rate of apricot polysaccharides. The isolated fraction FAPP-2D with HG domain showed excellent anti-diabetic activity in insulin resistance model in L6 cell. We found that FAPP-2D increased the ADP/ATP ratio and inhibited PKA phosphorylation, activating the LKB1-AMPK pathway. Moreover, FAPP-2D activated AMPK-PGC1α pathway, which could stimulated mitochondrial production and regulate energy metabolism, promoting GLUT4 protein transport to achieve an anti-diabetic effect. The Fourier transform infrared spectroscopy and X-ray photoelectron spectroscopy data showed that the LTP modification could increase the CH bond content while decreasing the C-O-C/C-O bond content, indicating that LTP destroyed the C-O-C/C-O bond, which enhanced the anti-diabetes activity of the modified apricot pectin polysaccharide. Our findings could pave the way for the molecular exploitation of apricot polysaccharides and the application of low-temperature plasma.

Development and validation of risk prediction models for stroke and mortality among patients with type 2 diabetes in northern China

BACKGROUND

Stroke is one of the leading causes of disability and mortality in patients with type 2 diabetes mellitus (T2DM). Risk models have been developed for predicting stroke and stroke-associated mortality among patients with T2DM. Here, we evaluated risk factors of stroke for individualized prevention measures in patients with T2DM in northern China.

METHODS

In the community-based Tianjin Chronic Disease Cohort study, 58,042 patients were enrolled between January 2014 and December 2019. We used multiple imputation (MI) to impute missing variables and univariate and multivariate Cox's proportional hazard regression to screen risk factors of stroke. Furthermore, we established and validated first-ever prediction models for stroke (Model 1 and Model 2) and death from stroke (Model 3) and evaluated their performance.

RESULTS

In the derivation and validation groups, the area under the curves (AUCs) of Models 1-3 was better at 5 years than at 8 years. The Harrell's C-index for all models was above 0.7. All models had good calibration, discrimination, and clinical net benefit. Sensitivity analysis using the MI dataset indicated that all models had good and stable prediction performance.

CONCLUSION

In this study, we developed and validated first-ever risk prediction models for stroke and death from stroke in patients with T2DM, with good discrimination and calibration observed in all models. Based on lifestyle, demographic characteristics, and laboratory examination, these models could provide multidimensional management and individualized risk assessment. However, the models developed here may only be applicable to Han Chinese.

New Progress in Early Diagnosis of Atherosclerosis

Coronary atherosclerosis is a potentially chronic circulatory condition that endangers human health. The biological cause underpinning cardiovascular disease is coronary atherosclerosis, and acute cardiovascular events can develop due to thrombosis, platelet aggregation, and unstable atherosclerotic plaque rupture. Coronary atherosclerosis is progressive, and three specific changes appear, with fat spots and stripes, atherosclerosis and thin-walled fiber atherosclerosis, and then complex changes in arteries. The progression and severity of cardiovascular disease are correlated with various levels of calcium accumulation in the coronary artery. The therapy and diagnosis of coronary atherosclerosis benefit from the initial assessment of the size and degree of calcification. This article will discuss the new progress in the early diagnosis of coronary atherosclerosis in terms of three aspects: imaging, gene and protein markers, and trace elements. This study intends to present the latest methods for diagnosing patients with early atherosclerosis through a literature review.

ER-Stress and Senescence Coordinately Promote Endothelial Barrier Dysfunction in Diabetes-Induced Atherosclerosis

Diabetes mellitus is hallmarked by accelerated atherosclerosis, a major cause of mortality among patients with diabetes. Efficient therapies for diabetes-associated atherosclerosis are absent. Accelerated atherosclerosis in diabetic patients is associated with reduced endothelial thrombomodulin (TM) expression and impaired activated protein C (aPC) generation. Here, we directly compared the effects of high glucose and oxidized LDL, revealing that high glucose induced more pronounced responses in regard to maladaptive unfolded protein response (UPR), senescence, and vascular endothelial cell barrier disruption. Ex vivo, diabetic ApoE−/− mice displayed increased levels of senescence and UPR markers within atherosclerotic lesions compared with nondiabetic ApoE−/− mice. Activated protein C pretreatment maintained barrier permeability and prevented glucose-induced expression of senescence and UPR markers in vitro. These data suggest that high glucose-induced maladaptive UPR and associated senescence promote vascular endothelial cell dysfunction, which—however—can be reversed by aPC. Taken together, current data suggest that reversal of glucose-induced vascular endothelial cell dysfunction is feasible.

Hypercoagulability Impairs Plaque Stability in Diabetes-Induced Atherosclerosis

Diabetes mellitus, which is largely driven by nutritional and behavioral factors, is characterized by accelerated atherosclerosis with impaired plaque stability. Atherosclerosis and associated complications are the major cause of mortality in diabetic patients. Efficient therapeutic concepts for diabetes-associated atherosclerosis are lacking. Atherosclerosis among diabetic patients is associated with reduced endothelial thrombomodulin (TM) expression and impaired activated protein C (aPC) generation. Here, we demonstrate that atherosclerotic plaque stability is reduced in hyperglycemic mice expressing dysfunctional TM (TM^Pro/Pro mice), which have a pro-coagulant phenotype due to impaired thrombin inhibition and markedly reduced aPC generation. The vessel lumen and plaque size of atherosclerotic lesions in the truncus brachiocephalic were decreased in diabetic TM^Pro/Pro ApoE^-/- mice compared to diabetic ApoE^-/- mice. While lipid accumulation in lesions of diabetic TM^Pro/Pro ApoE^-/- mice was lower than that in diabetic ApoE^-/- mice, morphometric analyses revealed more prominent signs of instable plaques, such as a larger necrotic core area and decreased fibrous cap thickness in diabetic TM^Pro/Pro ApoE^-/- mice. Congruently, more macrophages and fewer smooth muscle cells were observed within lesions of diabetic TM^Pro/Pro ApoE^-/- mice. Thus, impaired TM function reduces plaque stability, a characteristic of hyperglycemia-associated plaques, thus suggesting the crucial role of impaired TM function in mediating diabetes-associated atherosclerosis.

Triglyceride lowering by omega-3 fatty acids: a mechanism mediated by N-acyl taurines

Interest in omega-3 fatty acids (colloquially known as fish oils) to lower residual cardiovascular risk in statin-treated patients has increased markedly in the wake of recent cardiovascular outcome trials. The triglyceride-lowering effects of omega-3 fatty acids are generally thought to occur by reduced hepatic VLDL production. In this issue of the JCI, Grevengoed et al. used mouse models and human plasma samples to reveal an additional mechanism whereby these polyunsaturated fatty acids can lower plasma triglycerides. Their findings indicate that omega-3 fatty acid-derived N-acyl taurines (NATs) greatly accumulate in bile and also in plasma following omega-3 supplementation. The authors further show that one of these NATs (C22:6 NAT) inhibited intestinal triglyceride hydrolysis and lipid absorption, which resulted in lower plasma triglycerides and protection against hepatic triacylglycerol accumulation in mice fed a high-fat diet. The findings open a potential avenue for triglyceride lowering by omega-3 fatty acids conjugated to taurine.

Long-term burden of higher body mass index from childhood on adult cardiometabolic biomarkers: A 30-year cohort study

BACKGROUND AND AIMS

Data are limited regarding the association between long-term burden of higher body mass index (BMI) from childhood and cardiometabolic biomarkers.

METHODS AND RESULTS

A total of 1553 individuals aged 6-15 years, who were examined 4 or more times for BMI since childhood and followed for 30 years were included in our analysis. Total area under the curve (AUCt) and incremental AUC (AUCi) were calculated as the long-term burden and trends of BMI. Cardiometabolic biomarkers including serum uric acid (SUA), fasting blood-glucose (FBG), and triglyceride to high-density lipoprotein cholesterol ratio (TG/HDL-C) were obtained from venous blood samples. The results showed a positive association of BMI AUCt and AUCi with cardiometabolic biomarkers. After adjusting for demographic variables, the AUCt and AUCi of BMI were significantly associated with a higher level of SUA (β = 3.71; 2.87), FBG (β = 0.09; 0.09), and TG/HDL-C (β = 0.14; 0.11). We performed further studies after dividing subjects into four groups according to AUCt and AUCi of BMI by quartiles. Compared with the lowest quartile group, the highest quartile group had significantly increased risk ratios of hyperuricemia (RR = 2.01; 1.74), type 2 diabetes mellitus (RR = 8.18; 3.96), and high-risk TG/HDL-C (RR = 4.05; 3.26).

CONCLUSION

Our study identifies all subjects' BMI growth curve from childhood and indicates that the long-term burden of higher BMI significantly increases the cardiometabolic risk, and the impact of excessive body weight on cardiometabolic health originates in early life. We emphasize the importance of weight control from childhood for cardiometabolic health.

Diabetes, Lipids, and CV Risk

PURPOSE OF REVIEW

Diabetes is often associated with diabetic dyslipidemia. Both hyperglycemia and disorders of lipid metabolism strongly contribute to development of atherosclerosis, the crucial factor of cardiovascular disease. The aim of the manuscript is to summarize possible treatment to reduce cardiovascular risk.

RECENT FINDINGS

Maximal cardiovascular risk reduction is maintained by targeting more pathologic disturbances together. While antihypertensive treatment has not changed much recently, novel PCSK9 inhibitors have significantly improved management of dyslipidemia. Similarly, modern antihyperglycemic agents (SGLT2 inhibitors and GLP-1 receptor agonists) show both significant metabolic effects and cardiovascular benefits. Diabetes treatment is no longer glucocentric. Apart from glucose management, there are effective pharmacologic tools for significant reduction of cardiovascular risk.