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Kamel AM, Ismail B, Abdel Hafiz G, Sabry N, Farid S. Effect of Metformin on Oxidative Stress and Left Ventricular Geometry in Nondiabetic Heart Failure Patients: A Randomized Controlled Trial. Metab Syndr Relat Disord 2024; 22:49-58. [PMID: 37816240 DOI: 10.1089/met.2023.0164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023] Open
Abstract
Introduction: There is an increasing interest in using metformin in cardiovascular diseases and its potential new roles. Only two randomized controlled trials investigated the effect of metformin in nondiabetic heart failure (HF) patients. However, none of these studies assess the role of metformin in reducing oxidative stress. We hypothesized that metformin might improve oxidative stress and left ventricular remodeling in nondiabetic HF patients with reduced ejection fraction (HFrEF). Methods and Methods: Seventy HFrEF patients (EF 37% ± 8%; median age 66 years) were randomized to metformin (n = 35) or standard of care (SOC) for HF (n = 35) for 6 months in addition to standard therapy. Outcomes included the difference in the change (Δ) in total antioxidant capacity (TAC) and malondialdehyde (MDA), both assessed colorimetrically and left ventricular mass index (LVMI) assessed through transthoracic echocardiography. Results: Compared with the SOC, metformin treatment increased TAC [Δ = 0.12 mmol/L, confidence intervals (95% CIs): 0.03-0.21; P = 0.007]. TAC increased significantly only in the metformin group (0.90 ± 0.08 mmol/L at baseline vs. 1.04 ± 0.99 mmol/L at 6 months, P < 0.05). Metformin therapy preserved LVMI (Δ = -23 g/m2, 95% CI: -42.91 to -4.92; P = 0.014) and reduced fasting plasma glucose (Δ = -6.16, 95% CI: -12.31 to -0.02, P = 0.047) compared with the SOC. Results did not change after adjusting for baseline values. Changes in MDA left ventricular ejection fraction (LVEF) and blood pressure were not significantly different between groups. Conclusion: Metformin treatment in HF patients with reduced LVEF improved TAC and prevented the increase in LVMI compared with the SOC. These effects of metformin warrant further research in HF patients without diabetes to explore the potential benefits of metformin. Trial Registration Number: This protocol was registered in ClinicalTrials.gov under the number NCT05177588.
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Affiliation(s)
- Ahmed M Kamel
- Clinical Pharmacy Department, Faculty of Pharmacy Cairo University, Cairo, Egypt
| | - Batool Ismail
- Ministry of Interior, Agouza Police Hospital, Cairo, Egypt
| | | | - Nirmeen Sabry
- Clinical Pharmacy Department, Faculty of Pharmacy Cairo University, Cairo, Egypt
| | - Samar Farid
- Clinical Pharmacy Department, Faculty of Pharmacy Cairo University, Cairo, Egypt
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Kelly T, Salter A, Pratt NL. The weighted cumulative exposure method and its application to pharmacoepidemiology: A narrative review. Pharmacoepidemiol Drug Saf 2024; 33:e5701. [PMID: 37749615 PMCID: PMC10952599 DOI: 10.1002/pds.5701] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 08/15/2023] [Accepted: 09/12/2023] [Indexed: 09/27/2023]
Abstract
PURPOSE The weighted cumulative exposure (WCE) method has been used in a number of fields including pharmacoepidemiology where it can account for intensity, duration and timing of exposures on the risk of an outcome. The method uses a data driven approach with flexible cubic B-splines to assign weights to past doses and select an aetiologically appropriate time window. Predictions of risk are possible for common exposure patterns encountered in real-world studies. The purpose of this study was to describe applications of the WCE method to pharmacoepidemiology and assess the strengths and limitations of the method. METHOD A literature search was undertaken to find studies applying the WCE method to the study of medicines. Articles published in PubMed using the search term 'weighted cumulative exposure' and articles citing Sylvestre et al. (2009) in Google Scholar or Scopus up to March 2023 were subsequently reviewed. Articles were selected based on title and review of abstracts. RESULTS Seventeen clinical applications using the data-driven WCE method with flexible cubic splines were identified in the review. These included 3 case-control studies and 14 cohort studies, of which 12 were analysed with Cox proportional hazards models and 2 with logistic regression. Thirteen studies used time windows of 1 year or longer. Of 11 studies which compared conventional models with the WCE method, 10 (91%) studies found a better fit with WCE models while one had an equivalent fit. The freely available 'WCE' software package has facilitated the applications of the WCE method with flexible cubic splines. CONCLUSIONS The WCE method allows additional insights into the effect of cumulative exposure on outcomes, including the timing and intensity (dose) of the exposure on the risk. The flexibility of the method is particularly well suited to studies with long-term exposures that vary over time or where the current risk of an event is affected by how far the exposure is in the past, which is difficult to model with conventional definitions of exposure. Interpretation of the results can be more complex than for conventional models and would be facilitated by a standardised reporting framework.
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Affiliation(s)
- Thu‐Lan Kelly
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health SciencesUniversity of South AustraliaAdelaideAustralia
| | - Amy Salter
- School of Public HealthThe University of AdelaideAdelaideAustralia
| | - Nicole L. Pratt
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health SciencesUniversity of South AustraliaAdelaideAustralia
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Sabbar R, Kadhim SAA, Fawzi HA, Flayih A, Mohammad B, Swadi A. Metformin effects on cardiac parameters in non-diabetic Iraqi patients with heart failure and mid-range ejection fraction - a comparative two-arm parallel clinical study. J Med Life 2023; 16:1400-1406. [PMID: 38107711 PMCID: PMC10719796 DOI: 10.25122/jml-2023-0253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 08/20/2023] [Indexed: 12/19/2023] Open
Abstract
Heart failure (HF) remains a difficult challenge to the healthcare system, necessitating promoting interventions and multidrug management. Metformin, typically used to manage diabetes, has emerged as a promising intervention in the treatment of HF. This study aimed to assess the effect of adding metformin to the standard treatment of HF on cardiac parameters. This clinical study comprised 60 newly diagnosed HF patients randomly assigned to two groups: Group C received standard HF treatment, while Group M received standard HF treatment in addition to daily metformin (500 mg). After 3 months of treatment, group M showed a significantly higher ejection fraction (EF) compared to Group C (6.1% and 3.2%, respectively; p-value=0.023) and a reduction in the left ventricular end-diastolic pressure (LVEDD) (0.28, and 0.21 mm respectively; p-value=0.029). No significant differences were observed in the interventricular septal thickness (IVST) or left ventricular end-systolic pressure (LVESD). For cardiac markers, N-Terminal pro-BNP (NT-proBNP) showed the highest reduction in Group M compared to Group C (719.9 pg/ml and 271.9 pg/ml respectively; p-value=0.009). No significant changes were reported for soluble ST2. Metformin demonstrated cardiac protective effects by increasing EF and reducing NT-proBNP. Given its affordability and accessibility, metformin offers a valuable addition to the current HF treatment options. This positive effect may be attributed to mechanisms that enhance the impact of conventional HF treatments or vice versa.
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Affiliation(s)
- Reeman Sabbar
- Department of Pharmacology, College of Medicine, University of Al-Qadisiyah, Al-Qadisiyah, Iraq
| | - Sinaa Abdul Amir Kadhim
- Department of Pharmacology, College of Medicine, University of Al-Qadisiyah, Al-Qadisiyah, Iraq
| | | | - Ali Flayih
- Department of Pharmacology, College of Medicine, University of Al-Qadisiyah, Al-Qadisiyah, Iraq
| | - Bassim Mohammad
- Department of Pharmacology, College of Medicine, University of Al-Qadisiyah, Al-Qadisiyah, Iraq
| | - Asma Swadi
- Department of Pharmacology, College of Medicine, University of Al-Qadisiyah, Al-Qadisiyah, Iraq
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Agay N, Dankner R, Murad H, Olmer L, Freedman LS. Reverse causation biases weighted cumulative exposure model estimates, but can be investigated in sensitivity analyses. J Clin Epidemiol 2023; 161:46-52. [PMID: 37437786 DOI: 10.1016/j.jclinepi.2023.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/30/2023] [Accepted: 07/02/2023] [Indexed: 07/14/2023]
Abstract
OBJECTIVES To examine the effects of reverse causation on estimates from the weighted cumulative exposure (WCE) model that is used in pharmacoepidemiology to explore drug-health outcome associations, and to identify sensitivity analyses for revealing such effects. STUDY DESIGN AND SETTING 314,099 patients with diabetes under Clalit Health Services, Israel, were followed over 2002-2012. The association between metformin and pancreatic cancer (PC) was explored using a WCE model within the framework of discrete-time Cox regression. We used computer simulations to explore the effects of reverse causation on estimates of a WCE model and to examine sensitivity analyses for revealing and adjusting for reverse causation. We then applied those sensitivity analyses to our data. RESULTS Simulation demonstrated bias in the weighted cumulative exposure model and showed that sensitivity analysis could reveal and adjust for these biases. In our data, a positive association was observed (hazard ratio (HR) = 3.24, 95% confidence interval (CI): 2.24-4.73) with metformin exposure in the previous 2 years. After applying sensitivity analysis, assuming reverse causation operated up to 4 years before cancer diagnosis, the association between metformin and PC was no longer apparent. CONCLUSION Reverse causation can cause substantial bias in the WCE model. When suspected, sensitivity analyses based on causal analysis are advocated.
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Affiliation(s)
- Nirit Agay
- Biostatistics and Biomathematics Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Rachel Dankner
- Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan 52621, Israel; Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Havi Murad
- Biostatistics and Biomathematics Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Liraz Olmer
- Biostatistics and Biomathematics Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Laurence S Freedman
- Biostatistics and Biomathematics Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan 52621, Israel.
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Kamel AM, Sabry N, Farid S. Effect of metformin on left ventricular mass and functional parameters in non-diabetic patients: a meta-analysis of randomized clinical trials. BMC Cardiovasc Disord 2022; 22:405. [PMID: 36088302 PMCID: PMC9464374 DOI: 10.1186/s12872-022-02845-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 09/01/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Left ventricular hypertrophy is a common finding in patients with ischemic heart disease and is associated with mortality in patients with cardiovascular disease (CVD). Metformin, an antidiabetic drug, has been shown to reduce oxidative stress and left ventricular mass index (LVMI) in animal hypertrophy models. We summarized evidence regarding the effect of metformin on LVMI and LVEF. METHODS Electronic databases were searched for randomized clinical trials (RCTs) that used metformin in non-diabetic patients with or without pre-existing CVD. The standardized mean change using change score standardization (SMCC) was calculated for each study. The random-effects model was used to pool the SMCC across studies. Meta-regression analysis was used to assess the association of heart failure (HF), metformin dose, and duration with the SMCC. RESULTS Data synthesis from nine RCTs (754 patients) showed that metformin use resulted in higher reduction in LVMI after 12 months (SMCC = -0.63, 95% CI - 1.23; - 0.04, p = 0.04) and an overall higher reduction in LVMI (SMCC = -0.5, 95% CI - 0.84; - 0.16, p < 0.01). These values equate to absolute values of 11.3 (95% CI 22.1-0.72) and 8.97 (95% CI 15.06-2.87) g/m2, respectively. The overall improvement in LVEF was also higher in metformin users after excluding one outlier (SMCC = 0.26, 95% CI 0.03-0.49, P = 0.03) which translates to a higher absolute improvement of 2.99% (95% CI 0.34; 5.63). Subgroup analysis revealed a favorable effect for metformin on LVEF in patients who received > 1000 mg/day (SMCC = 0.28, 95% CI 0.04; 0.52, P = 0.04), and patients with HF (SMCC = 0.23; 95% CI 0.1; 0.36; P = 0.004). These values translate to a higher increase of 2.64% and 3.21%, respectively. CONCLUSION Results suggest a favorable effect for metformin on LVMI and LVEF in patients with or without pre-existing CVD. Additional trials are needed to address the long-term effect of metformin. Registration The study was registered on the PROSPERO database with the registration number CRD42021239368 ( https://www.crd.york.ac.uk/prospero ).
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Affiliation(s)
- Ahmed M Kamel
- Clinical Pharmacy Department, Faculty of Pharmacy, Cairo University, Cairo, 11562, Egypt.
| | - Nirmeen Sabry
- Clinical Pharmacy Department, Faculty of Pharmacy, Cairo University, Cairo, 11562, Egypt
| | - Samar Farid
- Clinical Pharmacy Department, Faculty of Pharmacy, Cairo University, Cairo, 11562, Egypt
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Effects of Metformin in Heart Failure: From Pathophysiological Rationale to Clinical Evidence. Biomolecules 2021; 11:biom11121834. [PMID: 34944478 PMCID: PMC8698925 DOI: 10.3390/biom11121834] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/26/2021] [Accepted: 12/01/2021] [Indexed: 12/20/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) is a worldwide major health burden and heart failure (HF) is the most common cardiovascular (CV) complication in affected patients. Therefore, identifying the best pharmacological approach for glycemic control, which is also useful to prevent and ameliorate the prognosis of HF, represents a crucial issue. Currently, the choice is between the new drugs sodium/glucose co-transporter 2 inhibitors that have consistently shown in large CV outcome trials (CVOTs) to reduce the risk of HF-related outcomes in T2DM, and metformin, an old medicament that might end up relegated to the background while exerting interesting protective effects on multiple organs among which include heart failure. When compared with other antihyperglycemic medications, metformin has been demonstrated to be safe and to lower morbidity and mortality for HF, even if these results are difficult to interpret as they emerged mainly from observational studies. Meta-analyses of randomized controlled clinical trials have not produced positive results on the risk or clinical course of HF and sadly, large CV outcome trials are lacking. The point of force of metformin with respect to new diabetic drugs is the amount of data from experimental investigations that, for more than twenty years, still continues to provide mechanistic explanations of the several favorable actions in heart failure such as, the improvement of the myocardial energy metabolic status by modulation of glucose and lipid metabolism, the attenuation of oxidative stress and inflammation, and the inhibition of myocardial cell apoptosis, leading to reduced cardiac remodeling and preserved left ventricular function. In the hope that specific large-scale trials will be carried out to definitively establish the metformin benefit in terms of HF failure outcomes, we reviewed the literature in this field, summarizing the available evidence from experimental and clinical studies reporting on effects in heart metabolism, function, and structure, and the prominent pathophysiological mechanisms involved.
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Phillips J, Akemann C, Shields JN, Wu CC, Meyer DN, Baker BB, Pitts DK, Baker TR. Developmental phenotypic and transcriptomic effects of exposure to nanomolar levels of metformin in zebrafish. ENVIRONMENTAL TOXICOLOGY AND PHARMACOLOGY 2021; 87:103716. [PMID: 34311114 PMCID: PMC8446320 DOI: 10.1016/j.etap.2021.103716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 05/06/2023]
Abstract
Metformin is found in the majority of lakes and streams in the United States, leading to widespread environmental exposure. Results of the present study indicate that extended duration metformin exposure at critical developmental periods leads to decreased survival rates in zebrafish (danio rerio), an NIH approved human model. Significant abnormalities are seen with extended duration metformin exposure from 4 h post fertilization up to 5 days post fertilization, although short term metformin exposure for 24 h at 4-5 days post fertilization did not lead to any significant abnormalities. Both extended and short term duration did however have an impact on locomotor activity of zebrafish, and several genes involved in neurological and cardiovascular development were differentially expressed after exposure to metformin. The changes seen in behavior, gene expression and morphological abnormalities caused by metformin exposure should be examined further in future studies in order to assess their potential human health implications as metformin prescriptions continue to increase worldwide.
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Affiliation(s)
- Jessica Phillips
- Institute of Environmental Health Sciences, Wayne State University, 6135 Woodward Ave, Detroit, MI, 48202, USA; Department of Pharmacology, Wayne State University, 540 E Canfield, Detroit, MI, 28201, USA
| | - Camille Akemann
- Institute of Environmental Health Sciences, Wayne State University, 6135 Woodward Ave, Detroit, MI, 48202, USA; Department of Pharmacology, Wayne State University, 540 E Canfield, Detroit, MI, 28201, USA
| | - Jeremiah N Shields
- Institute of Environmental Health Sciences, Wayne State University, 6135 Woodward Ave, Detroit, MI, 48202, USA
| | - Chia-Chen Wu
- Institute of Environmental Health Sciences, Wayne State University, 6135 Woodward Ave, Detroit, MI, 48202, USA
| | - Danielle N Meyer
- Institute of Environmental Health Sciences, Wayne State University, 6135 Woodward Ave, Detroit, MI, 48202, USA; Department of Pharmacology, Wayne State University, 540 E Canfield, Detroit, MI, 28201, USA
| | - Bridget B Baker
- Institute of Environmental Health Sciences, Wayne State University, 6135 Woodward Ave, Detroit, MI, 48202, USA
| | - David K Pitts
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA
| | - Tracie R Baker
- Institute of Environmental Health Sciences, Wayne State University, 6135 Woodward Ave, Detroit, MI, 48202, USA; Department of Pharmacology, Wayne State University, 540 E Canfield, Detroit, MI, 28201, USA.
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Karwi QG, Ho KL, Pherwani S, Ketema EB, Sun QY, Lopaschuk GD. Concurrent diabetes and heart failure: interplay and novel therapeutic approaches. Cardiovasc Res 2021; 118:686-715. [PMID: 33783483 DOI: 10.1093/cvr/cvab120] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/29/2021] [Indexed: 12/12/2022] Open
Abstract
Diabetes mellitus increases the risk of developing heart failure, and the co-existence of both diseases worsens cardiovascular outcomes, hospitalization and the progression of heart failure. Despite current advancements on therapeutic strategies to manage hyperglycemia, the likelihood of developing diabetes-induced heart failure is still significant, especially with the accelerating global prevalence of diabetes and an ageing population. This raises the likelihood of other contributing mechanisms beyond hyperglycemia in predisposing diabetic patients to cardiovascular disease risk. There has been considerable interest in understanding the alterations in cardiac structure and function in the diabetic patients, collectively termed as "diabetic cardiomyopathy". However, the factors that contribute to the development of diabetic cardiomyopathies is not fully understood. This review summarizes the main characteristics of diabetic cardiomyopathies, and the basic mechanisms that contribute to its occurrence. This includes perturbations in insulin resistance, fuel preference, reactive oxygen species generation, inflammation, cell death pathways, neurohormonal mechanisms, advanced glycated end-products accumulation, lipotoxicity, glucotoxicity, and posttranslational modifications in the heart of the diabetic. This review also discusses the impact of antihyperglycemic therapies on the development of heart failure, as well as how current heart failure therapies influence glycemic control in diabetic patients. We also highlight the current knowledge gaps in understanding how diabetes induces heart failure.
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Affiliation(s)
- Qutuba G Karwi
- Cardiovascular Research Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Kim L Ho
- Cardiovascular Research Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Simran Pherwani
- Cardiovascular Research Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Ezra B Ketema
- Cardiovascular Research Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Qiu Yu Sun
- Cardiovascular Research Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Gary D Lopaschuk
- Cardiovascular Research Centre, University of Alberta, Edmonton, Alberta, Canada
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Rollot F, Casey R, Leray E, Debouverie M, Edan G, Wiertlewski S, Vukusic S, Laplaud DA. Cumulative effects of therapies on disability in relapsing multiple sclerosis. Mult Scler 2021; 27:1760-1770. [DOI: 10.1177/1352458520980366] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background: Long-term effectiveness of treatment remains a key question in multiple sclerosis (MS) and the cumulative effects of past treatment have not been investigated so far. Objective: Explore the relationship between treatment exposure and disability risk in patients with relapsing-remitting multiple sclerosis (RRMS). Methods: A total of 2285 adult patients from the French nationwide cohort were included. Outcomes were irreversible EDSS4, and conversion to secondary progression of multiple sclerosis (SPMS). Associations between treatments and risk of disability were assessed using a novel weighted cumulative exposure model, assuming a 3-year lag to account for reverse causality. This flexible approach accounts for past exposure in a multivariate Cox proportional hazards model by computing a weight function. Results: At baseline, mean ± standard deviation age of patients was 33.4 ± 8.9 years and 75.0% were women. A 15-year continuous treatment starting 20 years ago was associated with a decrease in risk of 26% for irreversible EDSS4, and 34% for SPMS compared to a 5-year treatment starting 10 years ago. The risk of disability decreased with increasing duration of exposure to disease-modifying treatment (DMT). Conclusion: Long-term use of treatments in RRMS has a stronger beneficial cumulative impact than only early uses and delays the occurrence of moderate disability and conversion to SPMS.
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Affiliation(s)
- Fabien Rollot
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; Service de Neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, Hospices Civils de Lyon, Bron, France; Observatoire Français de la Sclérose en Plaques, Centre de Recherche en Neurosciences de Lyon, INSERM 1028 et CNRS UMR 5292, Lyon, France; EUGENE DEVIC EDMUS Foundation, Bron, France
| | - Romain Casey
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; Service de Neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, Hospices Civils de Lyon, Bron, France; Observatoire Français de la Sclérose en Plaques, Centre de Recherche en Neurosciences de Lyon, INSERM 1028 et CNRS UMR 5292, Lyon, France; EUGENE DEVIC EDMUS Foundation, Bron, France
| | - Emmanuelle Leray
- Univ Rennes/EHESP, REPERES – EA 7449, Rennes, France; CIC-P 1414, CHU Rennes, Rennes, France
| | - Marc Debouverie
- Département de Neurologie, CHU Nancy, Nancy, France; EA 4360 APEMAC, Université Lorraine, Nancy, France
| | - Gilles Edan
- CIC-P 1414, CHU Rennes, Rennes, France; Département de Neurologie, CHU Rennes, Rennes, France
| | - Sandrine Wiertlewski
- Département de Neurologie, CHU Nantes, Nantes, France; CIC Inserm 1415, CHU Nantes, Nantes, France
| | - Sandra Vukusic
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; Service de Neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, Hospices Civils de Lyon, Bron, France; Observatoire Français de la Sclérose en Plaques, Centre de Recherche en Neurosciences de Lyon, INSERM 1028 et CNRS UMR 5292, Lyon, France; EUGENE DEVIC EDMUS Foundation, Bron, France
| | - David-Axel Laplaud
- Département de Neurologie, CHU Nantes, Nantes, France; CIC Inserm 1415, CHU Nantes, Nantes, France; Centre de Recherche en Transplantation et Immunologie, Inserm U1064, Nantes, France
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Mohan M, Al-Talabany S, McKinnie A, Mordi IR, Singh JSS, Gandy SJ, Baig F, Hussain MS, Bhalraam U, Khan F, Choy AM, Matthew S, Houston JG, Struthers AD, George J, Lang CC. A randomized controlled trial of metformin on left ventricular hypertrophy in patients with coronary artery disease without diabetes: the MET-REMODEL trial. Eur Heart J 2020; 40:3409-3417. [PMID: 30993313 PMCID: PMC6823615 DOI: 10.1093/eurheartj/ehz203] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/01/2019] [Accepted: 04/02/2019] [Indexed: 12/25/2022] Open
Abstract
Aim We tested the hypothesis that metformin may regress left ventricular hypertrophy (LVH) in patients who have coronary artery disease (CAD), with insulin resistance (IR) and/or pre-diabetes. Methods and results We randomly assigned 68 patients (mean age 65 ± 8 years) without diabetes who have CAD with IR and/or pre-diabetes to receive either metformin XL (2000 mg daily dose) or placebo for 12 months. Primary endpoint was change in left ventricular mass indexed to height1.7 (LVMI), assessed by magnetic resonance imaging. In the modified intention-to-treat analysis (n = 63), metformin treatment significantly reduced LVMI compared with placebo group (absolute mean difference −1.37 (95% confidence interval: −2.63 to −0.12, P = 0.033). Metformin also significantly reduced other secondary study endpoints such as: LVM (P = 0.032), body weight (P = 0.001), subcutaneous adipose tissue (P = 0.024), office systolic blood pressure (BP, P = 0.022) and concentration of thiobarbituric acid reactive substances, a biomarker for oxidative stress (P = 0.04). The glycated haemoglobin A1C concentration and fasting IR index did not differ between study groups at the end of the study. Conclusion Metformin treatment significantly reduced LVMI, LVM, office systolic BP, body weight, and oxidative stress. Although LVH is a good surrogate marker of cardiovascular (CV) outcome, conclusive evidence for the cardio-protective role of metformin is required from large CV outcomes trials. ![]()
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Affiliation(s)
- Mohapradeep Mohan
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, UK
| | - Shaween Al-Talabany
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, UK
| | - Angela McKinnie
- NHS Tayside Clinical Radiology, Ninewells Hospital & Medical School, Dundee, DD1 9SY, UK
| | - Ify R Mordi
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, UK
| | - Jagdeep S S Singh
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, UK
| | - Stephen J Gandy
- Department of Medical Physics, NHS Tayside, Ninewells Hospital & Medical School, Dundee, DD1 9SY, UK
| | - Fatima Baig
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, UK
| | - Muhammad S Hussain
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, UK
| | - U Bhalraam
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, UK
| | - Faisel Khan
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, UK
| | - Anna-Maria Choy
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, UK
| | - Shona Matthew
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, UK
| | - John Graeme Houston
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, UK
| | - Allan D Struthers
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, UK
| | - Jacob George
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, UK
| | - Chim C Lang
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, UK
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Ram E, Lavee J, Tenenbaum A, Klempfner R, Fisman EZ, Maor E, Ovdat T, Amunts S, Sternik L, Peled Y. Metformin therapy in patients with diabetes mellitus is associated with a reduced risk of vasculopathy and cardiovascular mortality after heart transplantation. Cardiovasc Diabetol 2019; 18:118. [PMID: 31526382 PMCID: PMC6747732 DOI: 10.1186/s12933-019-0925-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 09/06/2019] [Indexed: 12/26/2022] Open
Abstract
Background Cardiac allograft vasculopathy (CAV) is a major cause of morbidity and mortality following heart transplantation (HT). Reduced cardiovascular mortality and morbidity have been reported in non-HT patients treated with metformin. Given the high prevalence of type 2 diabetes mellitus (T2DM) in HT patients, we investigated the association between metformin therapy and cardiovascular outcomes after HT. Methods The study population comprised 103 DM patients who had undergone HT between 1994 and 2018 and were prospectively followed-up. We excluded from the study patients with type 1 diabetes mellitus. Fifty-five HT patients (53%) in the cohort were treated with metformin. Clinical data were recorded on prospectively designed forms. The primary outcomes included CAV, survival, and the combined end-point of CAV or cardiovascular mortality. Results Kaplan–Meier survival analysis showed that the CAV rate at 20 years of follow-up was lower in DM patients treated with metformin than in those who were not (30 vs. 65%; log-rank p = 0.044). Similarly, the combined risk of CAV or cardiovascular mortality was lower in the metformin-treated patients than in those not receiving metformin (32 vs. 68%; log rank p = 0.01). Consistently, multivariate analysis adjusted for age and comorbidities showed that metformin therapy was independently associated with a significant 90% reduction (95% confidence interval 0.02–0.46, p = 0.003) in the risk for the development of CAV, and a 91% reduction (95% confidence interval 0.02–0.42; p = 0.003) in the risk for CAV or cardiovascular mortality. Conclusions In diabetic HT patients, metformin therapy is independently associated with a significant reduction in the long-term risk for CAV and the combined end-point of CAV or cardiovascular mortality after HT.
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Affiliation(s)
- Eilon Ram
- Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jacob Lavee
- Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alexander Tenenbaum
- Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Robert Klempfner
- Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Enrique Z Fisman
- Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elad Maor
- Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Ovdat
- Israeli Association for Cardiovascular Trials, Ramat Gan, Israel
| | - Sergei Amunts
- Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Leonid Sternik
- Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Peled
- Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel. .,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Danieli C, Cohen S, Liu A, Pilote L, Guo L, Beauchamp ME, Marelli AJ, Abrahamowicz M. Flexible Modeling of the Association Between Cumulative Exposure to Low-Dose Ionizing Radiation From Cardiac Procedures and Risk of Cancer in Adults With Congenital Heart Disease. Am J Epidemiol 2019; 188:1552-1562. [PMID: 31107497 DOI: 10.1093/aje/kwz114] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 04/24/2019] [Accepted: 04/30/2019] [Indexed: 12/26/2022] Open
Abstract
Adults with congenital heart disease are increasingly being exposed to low-dose ionizing radiation (LDIR) from cardiac procedures. In a recent study, Cohen et al. (Circulation. 2018;137(13):1334-1345) reported an association between increased LDIR exposure and cancer incidence but did not explore temporal relationships. Yet, the impact of past exposures probably accumulates over years, and its strength may depend on the amount of time elapsed since exposure. Furthermore, LDIR procedures performed shortly before a cancer diagnosis may have been ordered because of early symptoms of cancer, raising concerns about reversal causality bias. To address these challenges, we combined flexible modeling of cumulative exposures with competing-risks methodology to estimate separate associations of time-varying LDIR exposure with cancer incidence and all-cause mortality. Among 24,833 patients from the Quebec Congenital Heart Disease Database, 602 had incident cancer and 500 died during a follow-up period of up to 15 years (1995-2010). Initial results suggested a strong association of cancer incidence with very recent LDIR exposures, likely reflecting reverse causality bias. When exposure was lagged by 2 years, an increased cumulative LDIR dose from the previous 2-6 years was associated with increased cancer incidence, with a stronger association for women. These results illustrate the importance of accurate modeling of temporal relationships between time-varying exposures and health outcomes.
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Affiliation(s)
- Coraline Danieli
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montréal, Quebec, Canada
- Center for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, Quebec, Canada
| | - Sarah Cohen
- Center for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, Quebec, Canada
- McGill Adult Unit for Congenital Heart Disease Excellence, McGill University Health Centre, Montréal, Quebec, Canada
| | - Aihua Liu
- Center for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, Quebec, Canada
- McGill Adult Unit for Congenital Heart Disease Excellence, McGill University Health Centre, Montréal, Quebec, Canada
| | - Louise Pilote
- Center for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, Quebec, Canada
- Department of Medicine, Faculty of Medicine, McGill University, Montréal, Quebec, Canada
| | - Liming Guo
- Center for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, Quebec, Canada
- McGill Adult Unit for Congenital Heart Disease Excellence, McGill University Health Centre, Montréal, Quebec, Canada
| | - Marie-Eve Beauchamp
- Center for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, Quebec, Canada
| | - Ariane J Marelli
- Center for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, Quebec, Canada
- McGill Adult Unit for Congenital Heart Disease Excellence, McGill University Health Centre, Montréal, Quebec, Canada
| | - Michal Abrahamowicz
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montréal, Quebec, Canada
- Center for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, Quebec, Canada
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Abstract
PURPOSE OF THE REVIEW To summarize current clinical data investigating the link between diabetes and heart failure pathophysiology, the association of glucose control with heart failure, and the impact of current antihyperglycemic drugs on heart failure. RECENT FINDINGS Although heart failure is one of the most prevalent outcomes occurring in real life and cardiovascular outcome trials, insufficient attention was given to this condition in diabetes research over the last decades. With both beneficial and detrimental findings for heart failure hospitalization in the health authority-mandated outcome trials for new antihyperglycemic agents, research on heart failure and its interplay with diabetes mellitus gained momentum. Diabetes mellitus and heart failure are both prevalent and intertwined conditions. While currently available heart failure therapies have a similar degree of effectiveness in patients with and without diabetes, the choice of glucose-lowering agents can substantially affect heart failure-related outcome.
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Affiliation(s)
- Markus Wallner
- 0000 0000 8988 2476grid.11598.34Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- 0000 0001 2248 3398grid.264727.2Cardiovascular Research Center, Lewis Katz School of Medicine, Temple University, Philadelphia, PA USA
- Center for Biomarker Research in Medicine, CBmed, Graz, Austria
| | - Deborah M. Eaton
- 0000 0001 2248 3398grid.264727.2Cardiovascular Research Center, Lewis Katz School of Medicine, Temple University, Philadelphia, PA USA
| | - Dirk von Lewinski
- 0000 0000 8988 2476grid.11598.34Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Harald Sourij
- Center for Biomarker Research in Medicine, CBmed, Graz, Austria
- 0000 0000 8988 2476grid.11598.34Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria
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