Mortality and morbidity during a five-year follow-up of diabetics with myocardial infarction

Cardiometabolic Risk Factors Associated With Type 2 Diabetes Mellitus: A Mechanistic Insight

A complex metabolic condition referred to as Type 2 diabetes mellitus (T2DM) is characterized by insulin resistance (IR) and decreased insulin production. Obesity, dyslipidemia, hypertension, and chronic inflammation are just a few of the cardiometabolic illnesses that people with T2DM are more likely to acquire and results in cardiovascular issues. It is essential to comprehend the mechanistic insights into these risk variables in order to prevent and manage cardiovascular problems in T2DM effectively. Impaired glycemic control leads to upregulation of De novo lipogenesis (DNL), promote hepatic triglyceride (TG) synthesis, worsening dyslipidemia that is accompanied by low levels of high density lipoprotein cholesterol (HDL-C) and high amounts of small, dense low-density lipoprotein cholesterol (LDL-C) further developing atherosclerosis. By causing endothelial dysfunction, oxidative stress, and chronic inflammation, chronic hyperglycemia worsens already existing cardiometabolic risk factors. Vasoconstriction, inflammation, and platelet aggregation are caused by endothelial dysfunction, which is characterized by decreased nitric oxide production, increased release of vasoconstrictors, proinflammatory cytokines, and adhesion molecules. The loop of IR and endothelial dysfunction is sustained by chronic inflammation fueled by inflammatory mediators produced in adipose tissue. Infiltrating inflammatory cells exacerbate inflammation and the development of plaque in the artery wall. In addition, the combination of chronic inflammation, dyslipidemia, and IR contributes to the emergence of hypertension, a prevalent comorbidity in T2DM. The ability to target therapies and management techniques is made possible by improvements in our knowledge of these mechanistic insights. Aim of present review is to enhance our current understanding of the mechanistic insights into the cardiometabolic risk factors related to T2DM provides important details into the interaction of pathophysiological processes resulting in cardiovascular problems. Understanding these pathways will enable us to create efficient plans for the prevention, detection, and treatment of cardiovascular problems in T2DM patients, ultimately leading to better overall health outcomes.

Machine learning-based models to predict one-year mortality among Chinese older patients with coronary artery disease combined with impaired glucose tolerance or diabetes mellitus

PURPOSE

An accurate prediction of survival prognosis is beneficial to guide clinical decision-making. This prospective study aimed to develop a model to predict one-year mortality among older patients with coronary artery disease (CAD) combined with impaired glucose tolerance (IGT) or diabetes mellitus (DM) using machine learning techniques.

METHODS

A total of 451 patients with CAD combined with IGT and DM were finally enrolled, and those patients randomly split 70:30 into training cohort (n = 308) and validation cohort (n = 143).

RESULTS

The one-year mortality was 26.83%. The least absolute shrinkage and selection operator (LASSO) method and ten-fold cross-validation identified that seven characteristics were significantly associated with one-year mortality with creatine, N-terminal pro-B-type natriuretic peptide (NT-proBNP), and chronic heart failure being risk factors and hemoglobin, high density lipoprotein cholesterol, albumin, and statins being protective factors. The gradient boosting machine model outperformed other models in terms of Brier score (0.114) and area under the curve (0.836). The gradient boosting machine model also showed favorable calibration and clinical usefulness based on calibration curve and clinical decision curve. The Shapley Additive exPlanations (SHAP) found that the top three features associated with one-year mortality were NT-proBNP, albumin, and statins. The web-based application could be available at https://starxueshu-online-application1-year-mortality-main-49cye8.streamlitapp.com/ .

CONCLUSIONS

This study proposes an accurate model to stratify patients with a high risk of one-year mortality. The gradient boosting machine model demonstrates promising prediction performance. Some interventions to affect NT-proBNP and albumin levels, and statins, are beneficial to improve survival outcome among patients with CAD combined with IGT or DM.

Syringic Acid Ameliorates Cardiac, Hepatic, Renal and Neuronal Damage Induced by Chronic Hyperglycaemia in Wistar Rats: A Behavioural, Biochemical and Histological Analysis

This study investigated the effects of syringic acid (SA) on renal, cardiac, hepatic, and neuronal diabetic complications in streptozotocin-induced neonatal (nSTZ) diabetic rats. STZ (110 mg/kg i.p) was injected into Wistar rat neonates as a split dose (second and third postnatal day). Diabetes mellitus was diagnosed in adults by measuring fasting blood glucose levels, urine volume, and food and water intake. The treatment of SA (25 mg/kg, 50 mg/kg p.o) was given from the 8th to 18th postnatal week. To assess the development of diabetic complications and the effect of therapy, biochemical indicators in serum and behavioural parameters were recorded at specific intervals during the study period. SA (25 mg/kg, 50 mg/kg p.o) treatment reduced hyperglycaemia, polydipsia, polyphagia, polyuria, relative organ weight, cardiac hypertrophic indices, inflammatory markers, cell injury markers, glycated haemoglobin, histopathological score, and oxidative stress, and increased Na/K ATPase activity. These findings suggest that SA might significantly alleviate diabetic complications and/or renal, neuronal, cardiac, and hepatic damage in nSTZ diabetic rats.

Demographics and Characteristics of Patients Admitted With Acute Coronary Syndrome to the Coronary Care Unit at King Abdulaziz University

Background Over the previous decade, the incidence of cardiovascular diseases (CVDs) has risen in the Middle East and will increase mortality to 23 million individuals in Saudi Arabia by 2030, according to the Saudi Ministry of Health. CVDs, including acute coronary syndrome (ACS), are the most common cause of mortality globally. This study aimed to analyze the demographic and clinical characteristics of patients with ACS admitted to the coronary care unit (CCU) in a tertiary hospital in Jeddah, Saudi Arabia. To the best of our knowledge, a lack of research in this region has been undertaken. Methods This retrospective records review study was conducted in a tertiary center in Jeddah, Saudi Arabia. All patients admitted to our CCU in 2017 with a final diagnosis of ACS were retrospectively enrolled. Demographic details, coronary risk factors, investigation and procedures, management, and clinical outcomes are all part of the data. Results Of the 615 patients included in the study, 491 (79.84%) were males, 226 (36.75%) were 55-64 years old, and 161 (26.18%) were 45-54 years old. Males had a higher rate of ST-segment elevation myocardial infarction (STEMI) (214, 43.58%), while females had a higher rate of non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina (UA) (45.96% and 37.90%, respectively). Diabetes (62.60%), dyslipidemia (62.44%), and hypertension (61.46%) were the most prevalent risk factors. Angiography and percutaneous coronary intervention (PCI) were performed in 77.72% and 61.95% of patients, respectively. Coronary artery bypass graft was only performed in 4.39% of patients. PCI was performed more frequently in patients with STEMI than in those with NSTEMI/UA (P < 0.001). A large majority of patients (99.5%) recovered and were discharged. Of the 161 (26.18%) patients who attended a follow-up visit, only 45 (33.08%) met the therapeutic objective of 1.8 mmol/L (70 mg/dl) of low-density lipoprotein cholesterol. There were 100 (16.26%) patients readmitted to the CCU, and most of these were readmitted within a year after initial admission. Readmissions were more common in females and patients diagnosed with NSTEMI/UA during initial admission (15.47% and 19.35%, respectively). Conclusion This study revealed that our most common demographics were males between 45 and 64 years, which is a decade younger than the global average. STEMI was the most common presentation. The most common modifiable cardiovascular risk factors were hypertension, diabetes, and dyslipidemia. The most common adverse event was reinfarction, which was closely linked to hypertension and diabetes. In this study, the recovery rate was higher than in studies from other countries; however, the majority of patients did not achieve the goal of cholesterol levels at follow-up. Our population's younger age at presentation necessitates greater attention and more stringent preventive strategies, such as lifestyle changes and evidence-based treatments for CVD risk factors, to reduce the incidence and burden of ACS on CCUs.

Carnitine Palmitoyltransferase System: A New Target for Anti-Inflammatory and Anticancer Therapy?

Lipid metabolism involves multiple biological processes. As one of the most important lipid metabolic pathways, fatty acid oxidation (FAO) and its key rate-limiting enzyme, the carnitine palmitoyltransferase (CPT) system, regulate host immune responses and thus are of great clinical significance. The effect of the CPT system on different tissues or organs is complex: the deficiency or over-activation of CPT disrupts the immune homeostasis by causing energy metabolism disorder and inflammatory oxidative damage and therefore contributes to the development of various acute and chronic inflammatory disorders and cancer. Accordingly, agonists or antagonists targeting the CPT system may become novel approaches for the treatment of diseases. In this review, we first briefly describe the structure, distribution, and physiological action of the CPT system. We then summarize the pathophysiological role of the CPT system in chronic obstructive pulmonary disease, bronchial asthma, acute lung injury, chronic granulomatous disease, nonalcoholic fatty liver disease, hepatic ischemia–reperfusion injury, kidney fibrosis, acute kidney injury, cardiovascular disorders, and cancer. We are also concerned with the current knowledge in either preclinical or clinical studies of various CPT activators/inhibitors for the management of diseases. These compounds range from traditional Chinese medicines to novel nanodevices. Although great efforts have been made in studying the different kinds of CPT agonists/antagonists, only a few pharmaceuticals have been applied for clinical uses. Nevertheless, research on CPT activation or inhibition highlights the pharmacological modulation of CPT-dependent FAO, especially on different CPT isoforms, as a promising anti-inflammatory/antitumor therapeutic strategy for numerous disorders.

Diabetic Aldehyde Dehydrogenase 2 Mutant (ALDH2*2) Mice Are More Susceptible to Cardiac Ischemic-Reperfusion Injury Due to 4-Hydroxy-2-Nonenal Induced Coronary Endothelial Cell Damage

Background

Aldehyde dehydrogenase‐2 (ALDH2), a mitochondrial enzyme, detoxifies reactive aldehydes such as 4‐hydroxy‐2‐nonenal (4HNE). A highly prevalent E487K mutation in ALDH2 (ALDH2*2) in East Asian people with intrinsic low ALDH2 activity is implicated in diabetic complications. 4HNE‐induced cardiomyocyte dysfunction was studied in diabetic cardiac damage; however, coronary endothelial cell (CEC) injury in myocardial ischemia‐reperfusion injury (IRI) in diabetic mice has not been studied. Therefore, we hypothesize that the lack of ALDH2 activity exacerbates 4HNE‐induced CEC dysfunction which leads to cardiac damage in ALDH2*2 mutant diabetic mice subjected to myocardial IRI.

Methods and Results

Three weeks after diabetes mellitus (DM) induction, hearts were subjected to IRI either in vivo via left anterior descending artery occlusion and release or ex vivo IRI by using the Langendorff system. The cardiac performance was assessed by conscious echocardiography in mice or by inserting a balloon catheter in the left ventricle in the ex vivo model. Just 3 weeks of DM led to an increase in cardiac 4HNE protein adducts and, cardiac dysfunction, and a decrease in the number of CECs along with reduced myocardial ALDH2 activity in ALDH2*2 mutant diabetic mice compared with their wild‐type counterparts. Systemic pretreatment with Alda‐1 (10 mg/kg per day), an activator of both ALDH2 and ALDH2*2, led to a reduction in myocardial infarct size and dysfunction, and coronary perfusion pressure upon cardiac IRI by increasing CEC population and coronary arteriole opening.

Conclusions

Low ALDH2 activity exacerbates 4HNE‐mediated CEC injury and thereby cardiac dysfunction in diabetic mouse hearts subjected to IRI, which can be reversed by ALDH2 activation.

Empagliflozin and Liraglutide Differentially Modulate Cardiac Metabolism in Diabetic Cardiomyopathy in Rats

Glucagon-like peptide 1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT2is) are antihyperglycemic agents with cardioprotective properties against diabetic cardiomyopathy (DCM). However, the distinctive mechanisms underlying GLP-1RAs and SGLT2is in DCM are not fully elucidated. The purpose of this study was to investigate the impacts of GLP1RAs and/or SGLT2is on myocardial energy metabolism, cardiac function, and apoptosis signaling in DCM. Biochemistry and echocardiograms were studied before and after treatment with empagliflozin (10 mg/kg/day, oral gavage), and/or liraglutide (200 μg/kg every 12 h, subcutaneously) for 4 weeks in male Wistar rats with streptozotocin (65 mg/kg intraperitoneally)-induced diabetes. Cardiac fibrosis, apoptosis, and protein expression of metabolic and inflammatory signaling molecules were evaluated by histopathology and Western blotting in ventricular cardiomyocytes of different groups. Empagliflozin and liraglutide normalized myocardial dysfunction in diabetic rats. Upregulation of phosphorylated-acetyl coenzyme A carboxylase, carnitine palmitoyltransferase 1β, cluster of differentiation 36, and peroxisome proliferator-activated receptor-gamma coactivator, and downregulation of glucose transporter 4, the ratio of phosphorylated adenosine monophosphate-activated protein kinase α2 to adenosine monophosphate-activated protein kinase α2, and the ratio of phosphorylated protein kinase B to protein kinase B in diabetic cardiomyocytes were restored by treatment with empagliflozin or liraglutide. Nucleotide-binding oligomerization domain, leucine-rich repeat and pyrin domain-containing 3, interleukin-1β, tumor necrosis factor-α, and cleaved caspase-1 were significantly downregulated in empagliflozin-treated and liraglutide-treated diabetic rats. Both empagliflozin-treated and liraglutide-treated diabetic rats exhibited attenuated myocardial fibrosis and apoptosis. Empagliflozin modulated fatty acid and glucose metabolism, while liraglutide regulated inflammation and apoptosis in DCM. The better effects of combined treatment with GLP-1RAs and SGLT2is may lead to a potential strategy targeting DCM.

[Clinical characteristics and quality assessment of the treatment of patients with chronic heart failure with diabetes mellitus]

AIM

A study of the clinical and instrumental characteristics and quality of treatment of patients with chronic heart failure (CHF) with diabetes mellitus.

MATERIALS AND METHODS

The study was conducted by using the CHF register method, which is a computer program with remote access, which allows on-line data collection on patients who have been examined and treated in primary care and in hospitals. The study included 8272 patients with CHF IIIV FC (functional class) (New York Heart Association NYHA); among them 62% of patients were treated in hospital.

RESULTS

The study showed that the frequency of diabetes was 21%. The main causes of CHF in diabetic patients are coronary artery disease, myocardial infarction (in anamnesis) and hypertension. These patients are more often diagnosed with III and IV CHF FC according to (NYHA) and retained LV (left ventricular) ejection fraction. The reduced ejection fraction was observed in 6.8% of cases, and the frequency of the intermediate LV was significantly higher than among patients with CHF and with diabetes and accounted for 18.9%. At patients with CHF with diabetes in comparison with patients with CHF without diabetes, atherosclerosis of the peripheral arteries, stroke (in anamnesis) and chronic kidney disease of stage III and IV were significantly more common.

CONCLUSION

Under the treatment, patients with CHF with diabetes have higher levels of SBP (systolic blood pressure), lipids and glucose in the blood plasma, indicating a lack of quality of treatment and, accordingly, the doctors are not optimally performing the clinical guidelines on treating this category of patients.

Association of Glucose Concentrations at Hospital Discharge With Readmissions and Mortality: A Nationwide Cohort Study

CONTEXT

Low blood glucose concentrations during the discharge day may affect 30-day readmission and posthospital discharge mortality rates.

OBJECTIVE

To investigate whether patients with diabetes and low glucose values during the last day of hospitalization are at increased risk of readmission or mortality.

DESIGN AND OUTCOMES

Minimum point of care glucose values were collected during the last 24 hours of hospitalization. We used adjusted rates of 30-day readmission rate, 30-, 90-, and 180-day mortality rates, and combined 30-day readmission/mortality rate to identify minimum glucose thresholds above which patients can be safely discharged.

PATIENTS AND SETTING

Nationwide cohort study including 843,978 admissions of patients with diabetes at the Veteran Affairs hospitals 14 years.

RESULTS

The rate ratios (RRs) increased progressively for all five outcomes as the minimum glucose concentrations progressively decreased below the 90 to 99 mg/dL category, compared with the 100 to 109 mg/dL category: 30-day readmission RR, 1.01 to 1.45; 30-day readmission/mortality RR, 1.01 to 1.71; 30-day mortality RR, 0.99 to 5.82; 90-day mortality RR, 1.01 to 2.40; 180-day mortality RR, 1.03 to 1.91. Patients with diabetes experienced greater 30-day readmission rates, 30-, 90- and 180-day postdischarge mortality rates, and higher combined 30-day readmission/mortality rates, with glucose levels <92.9 mg/dL, <45.2 mg/dL, 65.8 mg/dL, 67.3 mg/dL, and <87.2 mg/dL, respectively.

CONCLUSION

Patients with diabetes who had hypoglycemia or near-normal glucose values during the last day of hospitalization had higher rates of 30-day readmission and postdischarge mortality.

Metabolic syndrome increases operative mortality in patients with impaired left ventricular systolic function who undergo coronary artery bypass grafting: a retrospective observational study

Background

Metabolic syndrome (MetS) is a prevalent risk factor for coronary artery disease progression. Past studies have shown that MetS and its components tends to increase mortality after coronary artery bypass grafting (CABG), but data on the impact of MetS on postoperative outcome in patients with a left ventricular (LV) ejection fraction (EF) < 50% are still lacking.

Methods

Out of 2300 patients who underwent CABG between 2008 and 2018 in our center, 190 patients were identified as having impaired LV systolic function (EF < 50%). The patients were divided into two groups: those with MetS (n = 87, 45.8%) and those without MetS (n = 103, 54.2%). The influence of MetS on postoperative mortality and major complications was investigated.

Results

Postoperative mortality occurred in 12.6% of patients with MetS and in 3.9% of patients without MetS (p < 0.05). Multivariate analysis showed that patients with MetS had a significantly greater risk of mortality compared with patients without MetS (relative risk 7.23, p < 0.05). After adjustment for other risk factors, the risk of mortality was increased 6.47-fold [95% confidence interval (CI):1.25–33.6; p < 0.05] in patients with MetS and diabetes and 5.4-fold (95% CI: 1.12–29.7; p < 0.05) in patients with MetS and without diabetes, whereas it was not significantly increased in patients with diabetes and without MetS.

Conclusions

MetS is an important predictor of increased mortality in patients with LVEF<50% who undergo CABG. The components of MetS have synergistic effect in postoperative mortality. Multifactorial intervention in MetS is required to improve surgical efficacy in these patients.

Subclinical Diastolic Dysfunction and Its Correlation with Laboratory Parameters in Type 2 Diabetes Mellitus in India: A Case Control Study

Background: This study was conducted to evaluate left ventricular dysfunction in diabetics and to find correlation with glycemic control and biochemical parameters compared to non-diabetic population. Methods: Thirty type 2 diabetics and thirty nondiabetic controls were recruited. Age, sex, body mass index of the controls were matched. Results: Mean duration of diabetes mellitus in study population was 10.97± 4.01years. Among study population both cases and controls had ejection fraction >55%( no systolic dysfunction). Among cases(n=16) 53.3% were having mean E/A ratio <1 and(n=14) 46.67% were had mean E/A ratio >1. In controls all of them had mean E/A ratio above 1. This difference of mean E/A ratio among cases and controls was statistically significant (p<0.001). Among patients with diabetes, 9.09% cases with a HbA1cbetween 6-7%, 33.33% between 7.1-8%, respectively 100% of cases with HbA1c>8.1% had diastolic dysfunction the differences between groups being statistically significant (p<0.001). Low density lipoprotein( LDL) was weakly and negative correlated with E/A ratio (r = - 0.38) while fasting blood sugar (r = -0.53) respectively Hemoglobin A1c (r = -0.66) were moderately and negatively correlated. All these correlations were statistically significant. Conclusion: Subclinical diastolic dysfunction is prevalent among diabetic population. Diastolic dysfunction in patients with diabetes was correlated with FBS, HbA1C and LDL.

A systematic review and meta-regression of temporal trends in the excess mortality associated with diabetes mellitus after myocardial infarction

BACKGROUND/OBJECTIVES

It is not well known whether the gap in outcomes after myocardial infarction (MI) between patients with and without diabetes mellitus (DM) has changed over time. We performed a systematic review and metaregression of temporal trends in the excess mortality associated with DM after MI.

METHODS

We searched the PubMed database for studies reporting mortality data according to diabetic status in patients hospitalized for MI or acute coronary syndromes (ACS). We included 139 studies/cohorts for analysis (432,066 diabetic patients and 1,182,108 nondiabetic patients).

RESULTS

When compared to their non-diabetic counterparts, patients with DM had an odds ratio (OR) [95% CI] of 1.66 [1.59-1.74] (P<0.0001) for early mortality, and of 1.86 [1.75-1.97] (P<0.0001) for 6-12months mortality. When all data from the 116 studies reporting early mortality were pooled, there was no significant relationship between calendar year and Log (OR). Likewise, when considering the 61 studies reporting 6-12months mortality, there was no significant relationship between calendar year and Log (OR). Similar to the overall pooled analysis, no significant relationship between inclusion year and Log (OR) for mortality in diabetic patients was observed in sensitivity analyses performed in studies with ST-elevation MI as inclusion criteria, in randomized trials, in studies including >2000 patients, and in studies with DM prevalence >20%.

CONCLUSIONS

We found no evidence for temporal changes in the incremental mortality risk associated with DM in the setting of MI. The improvements in management of MI patients during the last decades have not been associated with a reduction of the gap between diabetic and non-diabetic patients.

Treating Diabetes Mellitus: Pharmacophore Based Designing of Potential Drugs from Gymnema sylvestre against Insulin Receptor Protein

Diabetes mellitus (DM) is one of the most prevalent metabolic disorders which can affect the quality of life severely. Injectable insulin is currently being used to treat DM which is mainly associated with patient inconvenience. Small molecules that can act as insulin receptor (IR) agonist would be better alternatives to insulin injection. Herein, ten bioactive small compounds derived from Gymnema sylvestre (G. sylvestre) were chosen to determine their IR binding affinity and ADMET properties using a combined approach of molecular docking study and computational pharmacokinetic elucidation. Designing structural analogues were also performed for the compounds associated with toxicity and less IR affinity. Among the ten parent compounds, six were found to have significant pharmacokinetic properties with considerable binding affinity towards IR while four compounds were associated with toxicity and less IR affinity. Among the forty structural analogues, four compounds demonstrated considerably increased binding affinity towards IR and less toxicity compared with parent compounds. Finally, molecular interaction analysis revealed that six parent compounds and four analogues interact with the active site amino acids of IR. So this study would be a way to identify new therapeutics and alternatives to insulin for diabetic patients.

Use of imaging and clinical data to screen for cardiovascular disease in asymptomatic diabetics

Background

There is increasing evidence to suggest that not all individuals with type 2 diabetes mellitus (T2DM) have equal risk for developing cardiovascular disease. We sought to compare the yield of testing for pre-clinical atherosclerosis with various approaches.

Methods

98 asymptomatic individuals with T2DM without known coronary artery disease (CAD) were enrolled in a prospective study and underwent carotid ultrasound, exercise treadmill testing (ETT), coronary artery calcium (CAC) scoring, and coronary computed tomography angiography (CTA).

Results

Of 98 subjects (average age 55 ± 6, 64 % female), 43 (44 %) had coronary plaque detectable on CTA, and 38 (39 %) had CAC score >0. By CTA, 16 (16 %) had coronary stenosis ≥50 %, including three subjects with CAC = 0. Subjects with coronary plaque had greater prevalence of carotid plaque (58 % vs. 38 %, p = 0.01) and greater carotid intima media thickness (0.80 ± 0.20 mm vs. 0.70 ± 0.11 mm, p = 0.02). Notably, 18 of 55 subjects (33 %) with normal CTA had carotid plaque. Eight subjects had a positive ETT, of whom five had ≥ 50 % coronary stenosis, two had <50 % stenosis, and one had no CAD. Among these tests, CAC scoring had the highest sensitivity and specificity for prediction of CAD.

Conclusion

Among asymptomatic subjects with T2DM, a majority (56 %) had no CAD by CTA. When compared to CTA, CAC was the most accurate screening modality for detection of CAD, while ETT and carotid ultrasound were less sensitive and specific. However, 33 % of subjects with normal coronary CTA had carotid plaque, suggesting that screening for carotid plaque might better characterize stroke risk in such patients.

The mitochondria in diabetic heart failure: from pathogenesis to therapeutic promise

SIGNIFICANCE

Diabetes is an important risk factor for the development of heart failure (HF). Given the increasing prevalence of diabetes in the population, strategies are needed to reduce the burden of HF in these patients.

RECENT ADVANCES

Diabetes is associated with several pathologic findings in the heart including dysregulated metabolism, lipid accumulation, oxidative stress, and inflammation. Emerging evidence suggests that mitochondrial dysfunction may be a central mediator of these pathologic responses. The development of therapeutic approaches targeting mitochondrial biology holds promise for the management of HF in diabetic patients.

CRITICAL ISSUES

Despite significant data implicating mitochondrial pathology in diabetic cardiomyopathy, the optimal pharmacologic approach to improve mitochondrial function remains undefined.

FUTURE DIRECTIONS

Detailed mechanistic studies coupled with more robust clinical phenotyping will be necessary to develop novel approaches to improve cardiac function in diabetes. Moreover, understanding the interplay between diabetes and other cardiac stressors (hypertension, ischemia, and valvular disease) will be of the utmost importance for clinical translation of scientific discoveries made in this field.

Effects of metabolic syndrome with or without obesity on outcomes after coronary artery bypass graft. A cohort and 5-year study

BACKGROUND

Metabolic syndrome (MetS) and obesity are risk factors for cardiovascular disease, however, it remains unclear about effects of MetS with or without obesity on perioperative and long-term morbidity and mortality after coronary artery bypass graft (CABG).

METHODS

An observational cohort study was performed on 4,916 consecutive patients receiving isolated primary CABG in Fuwai hospital. Of all patients, 1238 patients met the inclusion criteria and were divided into three groups: control, MetS with obesity and MetS without obesity (n = 868, 76 and 294 respectively). The patient's 5-year survival and major adverse cerebral and cardiovascular events (MACCE) were studied.

RESULTS

Among all three groups, there were no significant differences in in-hospital postoperative complications, epinephrine use, stroke, ICU stay, ventilation time, atrial fibrillation, renal failure, coma, myocardial infarction, repeated revascularization, and long-term stroke. The patients in MetS without obesity group were not associated with increased perioperative or long-term morbidities and mortality. In contrast, the patients in MetS with obesity group were associated with significant increased perioperative complications including MACCE (30.26% vs. 20.75%, 16.7%, p = 0.0074) and mortality (11.84% vs. 3.74%, 3.11%, p = 0.0007) respectively. Patients in MetS with obesity group was associated with significantly increased long-term of MACCE (adjusted OR:2.040; 95%CI:1.196-3.481; P＜0.05) and 5-years of mortality (adjusted HR:4.659; 95%CI:1.966-11.042; P＜0.05).

CONCLUSIONS

Patients with metabolic syndrome and obesity are associated with significant increased perioperative and long-term complications and mortality, while metabolic syndrome without obesity do not worsen outcomes after CABG.

Atypical presentation of acute and chronic coronary artery disease in diabetics

In patients with diabetes mellitus, cardiovascular disease is the principal cause of mortality and chest pain is the most frequent symptom in patients with stable and acute coronary artery disease. However, there is little knowledge concerning the pervasiveness of uncommon presentations in diabetics. The symptomatology of acute coronary syndrome, which comprises both pain and non-pain symptoms, may be affected by traditional risk factors such as age, gender, smoking, hypertension, diabetes, and dyslipidemia. Such atypical symptoms may range from silent myocardial ischemia to a wide spectrum of non-chest pain symptoms. Worldwide, few studies have highlighted this under-investigated subject, and this aspect of ischemic heart disease has also been under-evaluated in the major clinical trials. The results of these studies are highly diverse which makes definitive conclusions regarding the spectrum of atypical presentation of acute and even stable chronic coronay artery disease difficult to confirm. This may have a significant impact on the morbidity and mortality of coronary artery disease in diabetics. In this up-to-date review we will try to analyze the most recent studies on the atypical presentations in both acute and chronic ischemic heart disease which may give some emphasis to this under-investigated topic.

Cardiac metabolism, inflammation, and peroxisome proliferator-activated receptors modulated by 1,25-dihydroxyvitamin D3 in diabetic rats

BACKGROUND

High free fatty acid with reduced glucose utilization in diabetes mellitus (DM) impairs cardiac function. Peroxisome proliferator-activated receptors (PPARs) modulate myocardial lipid and glucose homeostasis. The active 1,25-dihydroxyvitamin D3 (1,25(OH)2D3) regulates oxidative stress and inflammation, which may play a key role in the modulation of PPARs. The aim of this study was to investigate whether 1,25(OH)2D3 can modulate the cardiac PPARs and fatty acid metabolism.

METHODS

Electrocardiogram, echocardiogram, and Western blot analysis were used to evaluate cardiac fatty acid metabolism, inflammation, and PPAR isoform expression in Wistar-Kyoto (WKY) rats, DM rats, and DM rats treated with 1,25(OH)2D3.

RESULTS

Compared to healthy rats, DM and 1,25(OH)2D3-treated DM rats had lower body weight. DM rats had larger left ventricular end-diastolic diameter, and longer QT interval than healthy or 1,25(OH)2D3-treated DM rats. Moreover, compared to healthy or 1,25(OH)2D3-treated DM rats, DM rats had fewer cardiac PPAR-α and PPAR-δ protein expressions, but had increased cardiac PPAR-γ protein levels, tumor necrosis factor-α, interleukin-6, 5' adenosine monophosphate-activated protein kinaseα2, phosphorylated acetyl CoA carboxylase, carnitine palmitoyltransferase 1, PPAR-γ coactivator 1-α, cluster of differentiation 36, and diacylglycerol acyltransferase 2 protein expressions.

CONCLUSIONS

1,25(OH)2D3 significantly changed the cardiac function and fatty acid regulations in DM hearts, which may be caused by its regulations on cardiac PPARs and proinflammatory cytokines.

Merit of ginseng in the treatment of heart failure in type 1-like diabetic rats

The present study investigated the merit of ginseng in the improvement of heart failure in diabetic rats and the role of peroxisome proliferator-activated receptors δ (PPAR δ ). We used streptozotocin-induced diabetic rat (STZ-rat) to screen the effects of ginseng on cardiac performance and PPAR δ expression. Changes of body weight, water intake, and food intake were compared in three groups of age-matched rats; the normal control (Wistar rats) received vehicle, STZ-rats received vehicle and ginseng-treated STZ-rats. We also determined cardiac performances in addition to blood glucose level in these animals. The protein levels of PPAR δ in hearts were identified using Western blotting analysis. In STZ-rats, cardiac performances were decreased but the food intake, water intake, and blood glucose were higher than the vehicle-treated control. After a 7-day treatment of ginseng in STZ-rats, cardiac output was markedly enhanced without changes in diabetic parameters. This treatment with ginseng also increased the PPAR δ expression in hearts of STZ-rats. The related signal of cardiac contractility, troponin I phosphorylation, was also raised. Ginseng-induced increasing of cardiac output was reversed by the cotreatment with PPAR δ antagonist GSK0660. Thus, we suggest that ginseng could improve heart failure through the increased PPAR δ expression in STZ-rats.

Diabetes is associated with posttranslational modifications in plasminogen resulting in reduced plasmin generation and enzyme-specific activity

Diabetes is associated with hypofibrinolysis by mechanisms that are only partially understood. We investigated the effects of in vivo plasminogen glycation on fibrinolysis, plasmin generation, protein proteolytic activity, and plasminogen-fibrin interactions. Plasma was collected from healthy controls and individuals with type 1 diabetes before and after improving glycemia. Plasma-purified plasmin(ogen) functional activity was evaluated by chromogenic, turbidimetric, and plasmin conversion assays, with surface plasmon resonance employed for fibrin-plasminogen interactions. Plasminogen posttranslational modifications were quantified by mass spectrometry and glycation sites located by peptide mapping. Diabetes was associated with impaired plasma fibrin network lysis, which partly normalized upon improving glycaemia. Purified plasmin(ogen) from diabetic subjects had impaired fibrinolytic activity compared with controls (723 ± 16 and 317 ± 4 s, respectively; P < .01), mainly related to decreased fibrin-dependent plasmin generation and reduced protease activity (Kcat/KM 2.57 ± 1.02 × 10⁻³ and 5.67 ± 0.98 × 10⁻³ M⁻¹s⁻¹, respectively; P < .05). Nε-fructosyl-lysine residue on plasminogen was increased in diabetes compared with controls (6.26 ± 3.43 and 1.82 ± 0.95%mol, respectively; P < .01) with preferential glycation of lysines 107 and 557, sites involved in fibrin binding and plasmin(ogen) cleavage, respectively. Glycation of plasminogen in diabetes directly affects fibrinolysis by decreasing plasmin generation and reducing protein-specific activity, changes that are reversible with modest improvement in glycemic control.

Increase of myocardial performance by Rhodiola-ethanol extract in diabetic rats

ETHNOPHARMACOLOGICAL RELEVANCE

Rhodiola rosea (also known as golden root or roseroot) is a perennial plant of the Crassulaceae family that grows in the Arctic and in the mountainous regions of Europe, Asia, and North America. The rhizome and roots of this plant have been long used as traditional medicine in Eastern Europe and Asia for enhancing physical and mental performance.

AIM OF THE STUDY

The present study is designed to investigate the cardiac action of Rhodiola-ethanol extract in streptozotocin-induced diabetic rats (STZ-diabetic rats) with heart failure.

MATERIALS AND METHODS

Diabetes was induced in Wistar rats by injection of streptozotocin. We measured the changes of body weight, water intake, and food intake in three groups of age-matched rats; the normal control received vehicle, STZ-diabetic rat received Rhodiola-ethanol extract or vehicle. Cardiac output, heart rate, blood pressure, and hemodynamic dP/dt in addition to plasma insulin and glucose level were also determined. The mRNA and protein levels of PPARδ were measured using real-time PCR and Western blotting, respectively.

RESULTS

Food intake, water intake and blood glucose were raised in STZ-diabetic rats showing lower body weight and plasma insulin, as compared with the control. Also, cardiac output, heart rate, blood pressure and hemodynamic dP/dt were markedly reduced in STZ-diabetic rats indicating the heart failure physiologically. After a 21-day treatment with Rhodiola-ethanol extract, cardiac output was raised in STZ-rats while the diabetic parameters were not modified. The PPARδ expression of both mRNA and protein was markedly elevated in the heart of STZ-rats receiving treatment with Rhodiola-ethanol extract. Also, the increased phosphorylation level of cardiac troponin-I was restored by this treatment with Rhodiola-ethanol extract. Otherwise, increase of cardiac output by Rhodiola-ethanol extract was blocked by antagonist of PPARδ in STZ-diabetic rats.

CONCLUSIONS

Our results suggest that ethanol extract of Rhodiola has an ability to increase the cardiac output in STZ-diabetic rats showing heart failure. Also, increase of PPAR-δ is responsible for this action of Rodiola-ethanol extract.

Cardioprotective effects of gallic acid in diabetes-induced myocardial dysfunction in rats

BACKGROUND

Normalization of hyperglycemia, hyperlipidemia, and oxidative stress is an important objective in preventing diabetes-induced cardiac dysfunction.

OBJECTIVE

This study was undertaken to examine the effects of gallic acid in myocardial dysfunctions associated with type-1 diabetes.

MATERIALS AND METHODS

Diabetes was induced by single intravenous injection of streptozotocin (STZ, 50 mg/kg i.v.). Gallic acid was administered daily at three different doses (100, 50, and 25 mg/kg p.o.) for 8 weeks at the end of which blood samples were collected and analyzed for various biochemical parameters.

RESULTS

Injection of STZ produced significant loss of body weight (BW), polyphagia, polydypsia, hyperglycemia, hypoinsulinemia, hyperlipidemia, hypertension, bradycardia, and myocardial functional alterations. Treatment with gallic acid significantly lowered fasting glucose, the AUC(glucose) level in a dose-dependent manner; however, the insulin level was not increased significantly at same the dose and prevented loss of BW, polyphagia, and polydypsia in diabetic rats. It also prevented STZ-induced hyperlipidemia, hypertension, bradycardia, structural alterations in cardiac tissue such as increase in force of contraction, left ventricular weight to body weight ratio, collagen content, protein content, serum lactate dehydrogenase, and creatinine kinase levels in a dose-dependent manner. Further, treatment also produced reduction in lipid peroxidation and increase in antioxidant parameters in heart of diabetic rats.

CONCLUSION

The results of this study suggest that gallic acid to be beneficial for the treatment of myocardial damage associated with type-1 diabetes.

Characterization of the mechanisms of the increase in PPARδ expression induced by digoxin in the heart using the H9c2 cell line

BACKGROUND AND PURPOSE

Digoxin has been used as an inotropic agent in heart failure for a long time. Troponin I (TnI) phosphorylation is related to cardiac contractility, and the genes are regulated by peroxisome proliferator-activated receptors (PPARs). Our previous studies indicated that cardiac abnormality related to the depressed expression of PPARδ in the hearts of STZ rats is reversed by digoxin. However, the cellular mechanisms for this effect of digoxin have not been elucidated. The aim of the present study was to investigate possible mechanisms for this effect of digoxin using the H9c2 cell line cultured in high glucose (HG) conditions.

METHODS

The effects of digoxin on PPARδ expression, intracellular calcium and TnI phosphorylation were investigated in cultured H9c2 cells, maintained in a HG medium, by using Western blot analysis.

RESULTS

Digoxin increased PPARδ expression in H9c2 cells subjected to HG conditions, and increase the intracellular calcium concentration. This effect of digoxin was blocked by BAPTA-AM at concentrations sufficient to chelate calcium ions. In addition, the calcineurin inhibitor cyclosporine A and KN93, an inhibitor of calcium/calmodulin-dependent protein kinase, inhibited this action. Digoxin also increased TnI phosphorylation and this was inhibited when PPARδ was silenced by the addition of RNAi to the cells. Similar changes were observed on the contraction of H9c2 cells.

CONCLUSION

The results suggest that digoxin appears, through calcium-triggered signals, to reverse the reduced expression of PPARδ in H9c2 cells caused by HG treatment.

Molecular role of GATA binding protein 4 (GATA-4) in hyperglycemia-induced reduction of cardiac contractility

Background

Diabetic cardiomyopathy, a diabetes-specific complication, refers to a disorder that eventually leads to left ventricular hypertrophy in addition to diastolic and systolic dysfunction. In recent studies, hyperglycemia-induced reactive oxygen species (ROS) in cardiomyocytes have been linked to diabetic cardiomyopathy. GATA binding protein 4 (GATA-4) regulates the expression of many cardio-structural genes including cardiac troponin-I (cTnI).

Methods

Streptozotocin-induced diabetic rats and H9c2 embryonic rat cardiomyocytes treated with a high concentration of glucose (a D-glucose concentration of 30 mM was used and cells were cultured for 24 hr) were used to examine the effect of hyperglycemia on GATA-4 accumulation in the nucleus. cTnI expression was found to be linked to cardiac tonic dysfunction, and we evaluated the expression levels of cTnI and GATA-4 by Western blot analysis.

Results

Cardiac output was lowered in STZ-induced diabetic rats. In addition, higher expressions of cardiac troponin I (cTnI) and phosphorylated GATA-4 were identified in these rats by Western blotting. The changes were reversed by treatment with insulin or phlorizin after correction of the blood sugar level. In H9c2 cells, ROS production owing to the high glucose concentration increased the expression of cTnI and GATA-4 phosphorylation. However, hyperglycemia failed to increase the expression of cTnI when GATA-4 was silenced by small interfering RNA (siRNA) in H9c2 cells. Otherwise, activation of ERK is known to be a signal for phosphorylation of serine105 in GATA-4 to increase the DNA binding ability of this transcription factor. Moreover, GSK3β could directly interact with GATA-4 to cause GATA-4 to be exported from the nucleus. GATA-4 nuclear translocation and GSK3β ser9 phosphorylation were both elevated by a high glucose concentration in H9c2 cells. These changes were reversed by tiron (ROS scavenger), PD98059 (MEK/ERK inhibitor), or siRNA of GATA-4. Cell contractility measurement also indicated that the high glucose concentration decreased the contractility of H9c2 cells, and this was reduced by siRNA of GATA-4.

Conclusions

Hyperglycemia can cause systolic dysfunction and a higher expression of cTnI in cardiomyocytes through ROS, enhancing MEK/ERK-induced GATA-4 phosphorylation and accumulation in the cell nucleus.

Adiponectin and sE-selectin Concentrations in Relation to Inflammation in Obese Type 2 Diabetic Patients With Coronary Heart Disease

Adipose tissue can release proinflammatory mediators, namely C-reactive protein (CRP), interleukin 1β (IL-1β), and monocyte chemotactic protein 1 (MCP-1), contributing to vascular injury and insulin resistance (IR). Other mediators namely, adiponectin and nitric oxide (NO) are protective. We enrolled type 2 diabetes mellitus (T2DM) obese male patients without coronary heart disease ([CHD] group II, n = 25) and T2DM obese patients with CHD (group III, n = 25). They were compared with 20 age- and body mass index (BMI)-matched nondiabetic control males (group I). Fasting blood glucose (FBG), glycated hemoglobin (HbA1c%), lipids, insulin, malondialdehyde ([MDA]; lipid peroxidation product), NO, high-sensitivity CRP (hsCRP), IL-1β, MCP-1, adiponectin as well as sE-selectin concentration were significantly different in patients with T2DM and CHD compared with patients without CHD and nondiabetic controls ( P = .01). There was a significant negative correlation between adiponectin and E-selectin ( P = .0001). Adipose tissue in T2DM obese patients may contribute to the pathogenesis of CHD.

Diabetic cardiomyopathy: from the pathophysiology of the cardiac myocytes to current diagnosis and management strategies

Diabetic cardiomyopathy (DCM), although a distinct clinical entity, is also a part of the diabetic atherosclerosis process. It may be independent of the coexistence of ischemic heart disease, hypertension, or other macrovascular complications. Its pathological substrate is characterized by the presence of myocardial damage, reactive hypertrophy, and intermediary fibrosis, structural and functional changes of the small coronary vessels, disturbance of the management of the metabolic cardiovascular load, and cardiac autonomic neuropathy. These alterations make the diabetic heart susceptible to ischemia and less able to recover from an ischemic attack. Arterial hypertension frequently coexists with and exacerbates cardiac functioning, leading to the premature appearance of heart failure. Classical and newer echocardiographic methods are available for early diagnosis. Currently, there is no specific treatment for DCM; targeting its pathophysiological substrate by effective risk management protects the myocardium from further damage and has a recognized primary role in its prevention. Its pathophysiological substrate is also the objective for the new therapies and alternative remedies.

Early and late outcome after coronary artery bypass surgery in diabetic patients

OBJECTIVE

To determine the impact of diabetes on outcome after coronary artery bypass surgery.

DESIGN

We matched 866 diabetic patients with non-diabetic controls in regards to gender, age, left ventricular ejection fraction, body mass index, presence of unstable angina and history of myocardial infarction, and day of surgery. The 30-d mortality and morbidity were evaluated with univariate analysis and survival and freedom from cardiac death were assessed with the Kaplan-Meier method.

RESULTS

Follow-up time was 69+/-37 months. The 30-d mortality was 2.0% in the diabetic group and 1.0% in the non-diabetic group (p=0.15). Postoperative morbidity did not differ between groups. Cumulative 5- and 10-year survival rates were 89 and 71% in diabetics and 94 and 84% in non-diabetics (p=0.001). During follow-up, there was no difference between groups in regards to repeat revascularization.

CONCLUSIONS

The 30-d mortality was equally low in diabetic and non-diabetic patients with severe coronary artery disease. However, long-term survival was significantly lower in the diabetic group than in the non-diabetic group.

Mixed dyslipidemia, metabolic syndrome, diabetes mellitus, and cardiovascular disease: clinical implications

Metabolic syndrome and type 2 diabetes mellitus are individually associated with increased cardiovascular risk; furthermore, the combination of metabolic syndrome with diabetes accentuates this risk. An atherogenic dyslipidemia characterized by elevated triglycerides, low high-density lipoprotein cholesterol, or both conditions is a key modifiable risk factor associated with both conditions. As the development of this atherogenic mixed dyslipidemia precedes the onset of overt glycemia and the clinical diagnosis of diabetes, early effective intervention is recommended to reduce the risk of premature cardiovascular disease morbidity and mortality.

A description of the characteristics of patients with non-ST elevation acute coronary syndromes admitted to different settings in the 1990s

BACKGROUND

Little is known about the characteristics of patients who were admitted to the coronary care unit (CCU) in the 1990s with non-ST elevation acute coronary syndromes (ACS) compared with those admitted to medical and cardiology wards in hospitals in the United Kingdom (UK).

AIM

To understand if there were systematic differences in the characteristics of patients who were admitted to UK critical care units (CCU), intermediate care environments (cardiology wards) or generalist wards (acute medical ward) in an observational study carried out in the 1990s.

METHODS

This paper is based on a secondary analysis of PRAIS (UK), a prospective, observational, multi-centred study which recruited 1038 patients with non-ST elevation ACS. This analysis compares the characteristics of 860 of these patients dependent on whether they were cared for in a coronary care unit, acute medical ward or cardiology ward.

RESULTS

The results showed that patients admitted to CCU were more likely to be younger, male, have a history of diabetes or have ST depression on their ECG. There was very little difference in other risk factors or prior concomitant therapy. Interestingly there were no systematic differences in treatments or outcomes other than would be expected by chance, although there were trends to higher rates of MI and heart failure in the CCU group.

CONCLUSION

Our analysis shows that the main drivers of admission to CCU in the 1990s were ST depression and MI-both indicators of high risk, but older age and female gender seemed to decrease the likelihood of admission to CCU. Criteria for admission to specific specialist and non-specialist care environments should be standardised and the use of risk scores could be an important way forward.

The influence of a history of diabetes on treatment and outcome in acute myocardial infarction, during two time periods and in two different countries

AIMS

The aim of this study was to investigate the influence of diabetes on treatment and outcome in acute myocardial infarction (AMI), during two time periods, in two countries, and to assess whether this influence has changed over the past decades.

METHODS

Patients, aged 30 to 74, with a diagnosis of AMI in two urban areas--Göteborg, Sweden and Minneapolis-St. Paul, Minnesota, USA--hospitalized during 1990-1991 and 1995-1996 were included. The primary endpoint was 7-year all-cause mortality.

RESULTS

The study included 3824 patients, 734 (19%) had diabetes. Age-adjusted in-hospital mortality of diabetic patients was nearly twofold higher compared with non-diabetic patients (9.8% vs. 5.0%, p<0.05). Between 1990-1991 and 1995-1996 in-hospital mortality declined for both diabetic (11.9% vs. 7.6%, p=0.07) and non-diabetic (6.3% vs. 3.6%, p=0.002) patients. A history of diabetes was associated with nearly twofold higher long-term mortality rate (48.5% vs. 26%, p<0.05). Seven-year mortality was reduced between 1990-1991 and 1995-1996 in both diabetic (51.6% vs. 45.2%, p=0.13) and non-diabetic patients (29.3% vs. 22.1%, p<0.0001) (The results did not reach statistical significance for diabetic patients, due to smaller sample size.) During their hospital stay, diabetic patients received significantly less aspirin, beta-blockers and thrombolysis. After adjustment, a history of diabetes remained significantly associated with 7-year mortality following AMI, doubling the hazard of death (hazard ratio (HR)=2.11; 95% confidence interval (CI): 1.80-2.46).

CONCLUSION

A history of diabetes is associated with nearly twofold higher long-term mortality rate and is independently associated with 7-year mortality following AMI. Short- and long-term mortality decreased from 1990 to 1995 in both non-diabetic and diabetic patients. Underutilization of evidence-based treatments contributes to the remaining increased mortality in diabetic patients with acute coronary disease.

Prevalence of diabetes and other cardiovascular risk factors in an Iranian population with acute coronary syndrome

Background

Coronary artery disease is the leading cause of death in industrialized countries and most patients with diabetes die from complications of atherosclerosis. The objective of this study was to determine the presence of diabetes mellitus and other conventional coronary heart disease risk factors (cigarette smoking, hypertension and hyperlipidemia) in patients with acute coronary events in an Iranian population.

Methods

The study included 514 patients with unstable angina or myocardial infarction (MI) out of 720 patients admitted to CCU ward of a general hospital from March 2003 to March 2005. History of diabetes, hypertension and cigarette smoking, demographic indices, coronary heart disease and diabetes mellitus treatment, myocardial enzymes, serum triglycerides (TG) and cholesterol and fasting and non fasting blood glucose levels and HbA1C of diabetics were recorded of admission sheets. The data were structured to appropriate one way ANOVA, T tests, and chi square test with SPSS 13 product for windows.

Results

Out of all patients 35.8% were female, 30% were diabetics (Duration 13.4 ± 8.7 years), 42% were smoker and 91% were hypertensive. Twenty four percent had MI and 76% had unstable angina. MI was significantly higher in diabetic patients (36.4% vs. 19.2%, P < 0.001). Location and extension of MI and myocardial enzymes did not differ between diabetics and non-diabetic patients. Diabetic patients were older than non diabetics (65 ± 11.6 vs. 59.7 ± 12.5 years, p < 0.05). Five (66.7%) out of 9 patients with fatal MI were diabetics (Odds Ratio = 2.98). Age, duration of diabetes and HbA1c levels, did not differ between diabetic patients with or without MI. Hypertension and current smoking was significantly higher in patients with MI compared to patients with unstable angina (p < 0.05). Serum TG, HDL-C, LDL-C and total cholesterol level did not differ between patients with MI and unstable angina. Diabetic patients compare to non diabetic patients were more hypertensive (96% vs. 88.7%, p < 0.005) and had higher serum triglyceride (TG over 200 mg/dl, 35.1% vs. 26.4, p <0.05). Diabetes was more frequent among women than men (36.4% vs. 26.4%, p < 0.05). Women were older than men (65 ± 11.6 vs. 59.2 ± 13 years, p < 0.005) and had higher total serum cholesterol (200 ± 41.8 vs. 192 ± 42.5 mg/dl, p < 0.05) and HDL-C levels (49.7 ± 22 vs. 40 ± 13 mg/dl, p < 0.005). Ninety seven percent of all patients had at least one of cardiovascular risk factors (hypertension, smoking, diabetes, high cholesterol and low HDL-cholesterol levels).

Conclusion

In this study 19 out of 20 patients with acute coronary event have at least one of conventional cardiac risk factors. Diabetes and hypertension are leading risk factors, which may directly or indirectly interfere and predict more serious complications of coronary heart disease.

Diabetes and dyslipidaemia

The risk of developing cardiovascular disease (CVD) is higher and the prognosis poorer for diabetic than for non-diabetic individuals. Diabetic dyslipidaemia is characterized by hypertriglyceridaemia, low levels of high-density lipoprotein cholesterol (HDL-C) and the presence of small, dense low-density lipoprotein (LDL) particles. Increased physical activity and weight loss are the first steps in managing diabetic dyslipidaemia. A secondary goal is to achieve non-HDL-C targets with cholesterol-lowering therapy. Improved glycaemic control, the first priority in managing hypertriglyceridaemia, can also aid in lowering levels of LDL-C. Lipid-lowering therapy should be initiated if lifestyle changes and glycaemic control fail to reduce LDL-C levels to <100 mg/dl (5.5 mmol/l), regardless of the status of CVD, coronary heart disease or peripheral vascular disease, and to reduce triglyceride levels of > or =150 mg/dl (8.3 mmol/l). Many diabetic patients may need oral hypoglycaemic agents or insulin to achieve adequate glycaemic control. Intensive insulin therapy can provide tight glycaemic control and reduce elevated triglyceride levels.

Statement of the problem

The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) study poses 2 questions. Of the options in treating the hyperglycemia of type 2 diabetes mellitus, which, if either, would be best for decreasing the likelihood of death or a serious cardiovascular disease event such as a heart attack: correcting the relative insulin deficiency or reducing insulin resistance? Do individuals with diabetes whose coronary disease can be managed medically have a better outcome with initial medical or interventional (percutaneous intervention or coronary artery bypass grafting) treatment? This article outlines the reasons for asking these questions.

Comparison of rosuvastatin and atorvastatin for lipid lowering in patients with type 2 diabetes mellitus: results from the URANUS study

OBJECTIVE

The Use of Rosuvastatin versus Atorvastatin iN type 2 diabetes mellitUS (URANUS) study compared rosuvastatin with atorvastatin for the reduction of low-density lipoprotein cholesterol (LDL-C) in patients with type 2 diabetes.

METHODS

After a 6-week dietary run-in, patients aged > or = 18 years with type 2 diabetes and LDL-C > or = 3.3 mmol/L were randomised to double-blind treatment with rosuvastatin 10 mg (n = 232) or atorvastatin 10 mg (n = 233) for 4 weeks. Doses were then titrated up to a maximum of rosuvastatin 40 mg or atorvastatin 80 mg over 12 weeks to achieve the 1998 European LDL-C goal (<3.0 mmol/L).

RESULTS

Rosuvastatin reduced LDL-C levels significantly more than atorvastatin during the fixed-dose and titration periods (p < 0.0001). Significantly more patients reached the 1998 LDL-C goal with rosuvastatin 10 mg compared with atorvastatin 10 mg at 4 weeks (81% vs 65%, p < 0.001). At 16 weeks, significantly more patients achieved their LDL-C goal with rosuvastatin compared with atorvastatin (94% vs 88%, p < 0.05) and more patients receiving rosuvastatin remained at their starting dose with reduced requirement for dose titration. At 4 weeks, 65% of rosuvastatin patients had reached their 2003 European LDL-C goal (< 2.5 mmol/L), compared with 33% of atorvastatin patients (p < 0.0001). Both treatments were similarly well tolerated with no unexpected safety concerns.

CONCLUSION

At the start dose and following dose titration, rosuvastatin was significantly more effective than atorvastatin at reducing LDL-C and achieving European LDL-C goals in patients with type 2 diabetes.

Diabetic patients with acute coronary syndromes in the UK: high risk and under treated. Results from the prospective registry of acute ischaemic syndromes in the UK (PRAIS-UK)

OBJECTIVES

Short-term randomised trials suggest that patients with diabetes mellitus (DM), admitted with acute coronary syndromes (ACS) are at increased risk of subsequent adverse events. We tested whether this hypothesis was true for an unselected population of ACS patients with and without DM admitted with non-ST elevation MI or unstable angina, in a non-trial setting over a longer term of follow-up.

METHODS

Prospective, centrally, coordinated multicenter registry involving 56 centers throughout the UK (half having angiographic facilities). Consecutive patients admitted with ACS without ST elevation on the presenting ECG were followed up to 6 months. A sub-group of patients were flagged with the UK Office for National Statistics and followed-up for death over 4 years.

RESULTS

Data were collected on 1046 ACS patients of whom 170 (16%) had a prior diagnosis of DM. DM patients had higher baseline co-morbidities and unadjusted mortality rates at 6 months (11.8% vs. 6.4%, p=0.01). After correcting for clinical variables such as age, gender, smoking status and chest pain/ischaemic ECG changes on admission, prior history of any of myocardial infarction, heart failure, hypertension, hypercholesterolemia (on treatment), stroke or coronary revascularisation (PTCA or CABG), mortality rates for DM patients were no longer significantly raised (hazard ratio 1.35, 95% CI: 0.79-2.30; p=0.27 at 6 months and 1.15, 95% CI 0.72-1.83 at 4 years). 30% of diabetics were dead after 4 years of follow-up. Patients with DM were more likely to have been revascularised at 6 months and were more likely to receive ACE inhibitors. Based on the rate of recruitment and the population covered in the study, about 21,000 patients with DM will be admitted with non-ST elevation ACS each year in the UK.

CONCLUSIONS

DM is common amongst patients admitted with ACS without ST elevation and is associated with significant morbidity and mortality: approximately 1 in 8 will not survive up to 6 months and 1 in 3 to 4 years. DM patients should be managed aggressively to reduce their risk of future complications.

Associations of mortality and diabetes complications in patients with type 1 and type 2 diabetes: early treatment diabetic retinopathy study report no. 27

OBJECTIVE

Diabetes is a leading cause of morbidity and mortality. The purpose of this study is to assess the associations between diabetes complications and mortality in the Early Treatment Diabetic Retinopathy Study (ETDRS).

RESEARCH DESIGN AND METHODS

We examined demographic, clinical, and laboratory characteristics of the 3,711 subjects enrolled in the ETDRS, a randomized controlled clinical trial designed to evaluate the role of laser photocoagulation and aspirin therapy for diabetic retinopathy. The outcome assessed was all-cause mortality. Multivariable Cox proportional hazards regression was used to assess associations between diabetes complications and mortality for type 1 and type 2 diabetes separately.

RESULTS

The 5-year estimates of all-cause mortality were 5.5 and 18.9% for patients with type 1 and type 2 diabetes, respectively. In patients with type 1 diabetes, amputation (hazard ratio [HR] 5.08 [95% CI 2.06-12.54]) and poor visual acuity (1.74 [1.10-2.75]) remained significantly associated with mortality, after adjusting for other diabetes complications and baseline characteristics. In patients with type 2 diabetes, macrovascular disease and worsening levels of nephropathy, neuropathy, retinopathy, and visual acuity are associated with progressively increasing risks of mortality, after controlling for other baseline risk factors.

CONCLUSIONS

Amputation is the strongest predictor for mortality in patients with type 1 diabetes. All complications independently predict mortality in patients with type 2 diabetes. There is an increased risk for mortality as the degree of each complication worsens. Additional studies are needed to investigate the effectiveness of tertiary prevention to decrease mortality in these patients.

Coronary atherosclerosis in diabetic subjects: clinical significance, anatomic characteristics, and identification with in vivo imaging

Diabetes mellitus is an endocrine disorder that promotes the development and progression of atherosclerotic coronary disease. As a consequence, cardiovascular disease is the most important cause of morbidity and mortality in diabetics. Early identification and treatment of asymptomatic stages provides the opportunity to prevent cardiovascular end organ complications. Modem clinical imaging modalities allow the assessment of early atherosclerotic changes in coronary arteries; however, prospective evidence that atherosclerosis imaging impacts on clinical outcome is not yet available and future studies are necessary.

Increased hospital expenditures in diabetic patients hospitalized for cardiovascular diseases

OBJECTIVES

To measure the impact of diabetes on hospital resource use and expenditures in patients hospitalized for cardiovascular diseases (CVD).

RESEARCH DESIGN AND METHODS

We conducted an observational study of 4865 hospitalizations for CVD over 2 years (January 1998 to December 1999). Information with respect of the presence of diabetes mellitus, length of stay, readmissions, mortality, and costs were obtained through retrospective chart review.

RESULTS

Diabetic patients accounted for 35.1% of hospital admissions (1706 admissions), 40.8% of hospital stays (23,309 days), and 39% of direct medical cost (5,735,884 euros). On average, diabetic patients had longer hospital stay (13.6+/-13.2 vs. 10.7+/-11.2 days; P<.001) and direct in-patient cost (3438+/-4308 vs. 2513+/-3384 euros; P<.001) and experienced more readmissions (relative risk: 1.67; 95% CI: 1.45-1.91) compared with nondiabetic patients. However, despite the hospital mortality rate being higher in nondiabetic patients (6.3% vs. 5.8%), these results were not statistically significant (relative risk: 1.09; 95% CI: 0.86-1.40).

CONCLUSIONS

Diabetic patients hospitalized for CVD have longer hospital stay, greater risk of short-term readmission, and are more costly than nondiabetic patients. However, in-hospital mortality risk in patients hospitalized by CVD is no greater in diabetic than in nondiabetics.

Clinical profile of young patients with acute myocardial infarction in Saudi Arabia

OBJECTIVE

To define the risk factors and clinical presentations of young patients (<or=45 years) who present to King Fahd Hospital of the University (KFHU) with an acute myocardial infarction (MI).

METHODS AND RESULTS

A retrospective study was conducted over a 3-year period from January 1999 to December 2001. Sixty-five consecutive cases of acute MI in young patients were admitted to KFHU and were reviewed. The mean age was 40 years (range 29-45), 96.9% were males, 66.2% were from the Indian subcontinent, 23.1% were Saudi nationals and 10.8% were of other nationality. The major risk factor was tobacco use (76.9%), followed by low HDL (52.8%), high LDL (33.8%), diabetes (30.8%), hypertension (18.5%), family history of IHD (15.4%) and hypertriglyceridemia (7.7%). The most common anatomical location of the MI was the anterior wall and 92.3% of the cases were MIs with ST segment elevation. The hospital course was complicated by the development of CHF (4.6%), cardiogenic shock (4.6%), angina post-MI (3.1%), and reinfarction (3.1%). Finally, the hospital mortality rate was 9.2%.

CONCLUSIONS

The study focuses our attention on the rising incidence of acute MI in young individuals. Smoking was the major risk factor followed by low HDL, high LDL and diabetes. These observations are important for primary prevention of such diseases in Saudi Arabia.

Statin therapy for the treatment of diabetic dyslipidemia

The increasing prevalence of type 2 diabetes is a major problem for healthcare providers globally, since it is associated with serious microvascular and macrovascular complications. Although microvascular complications can be largely reduced with strict glycemic control, prevention of macrovascular disease involves a multifaceted approach that addresses all major risk factors, including dyslipidemia, hypertension, and insulin insensitivity. In particular, the treatment of diabetic dyslipidemia is a major challenge for diabetologists and cardiologists, as it is characterized by an array of lipid abnormalities. The management of diabetic dyslipidemia should initially include lifestyle approaches such as improved nutrition and weight reduction; however, the majority of patients require the addition of pharmacotherapy. Whilst insulin and/or oral hypoglycemic drugs are generally prescribed for the treatment of hyperglycemia, the addition of lipid-lowering drugs may be necessary for the control of diabetic dyslipidemia. The American Diabetes Association guidelines recommend lowering of low-density lipoprotein cholesterol (LDL-C) as a first priority. Hydroxy-methylglutaryl coenzyme A reductase inhibitors (statins) are recommended for first-line therapy in diabetic patients, since these agents are effective at reducing LDL-C levels. Whilst statins provide effective control of dyslipidemia in the majority of patients, more efficacious treatment regimens would provide greater benefit to more patients. Combination therapies may provide one solution to obtaining maximal lipid profile modifications, although the introduction of new, more efficacious agents for use as monotherapy may provide a more acceptable option, as drug combinations are often associated with poor tolerability and patient compliance.

Preventable hospitalization among elderly Medicare beneficiaries with type 2 diabetes

OBJECTIVE

To examine the impact of comorbid conditions on preventable hospitalizations among Medicare beneficiaries aged > or =65 years with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Data were drawn from the 1999 Medicare Standard Analytic Files, a 5% nationally representative random sample of Medicare beneficiaries. The analysis sample included 193,556 Medicare beneficiaries aged > or =65 years with type 2 diabetes (ICD-9-CM codes 250.xx) who were enrolled in fee-for-service Medicare. Preventable hospitalization was assessed by measuring ambulatory care-sensitive conditions, an accepted measure of hospitalizations that could have been prevented with appropriate outpatient care. Multivariable analyses controlled for demographics; mortality; renal, ophthalmic, or neurological manifestations of diabetes; type of physician providing the outpatient care; and per capita community-level indicators of income and hospital beds.

RESULTS

Ninety-six percent of beneficiaries in the sample had a comorbidity, and 46% had five or more comorbidities. Among beneficiaries with type 2 diabetes, cardiovascular-related comorbidities were common and accounted for increased odds of preventable hospitalization, controlling for other factors. The likelihood of a preventable hospitalization increased in the presence of a claim for comorbid congestive heart failure, cardiomyopathy, coronary atherosclerosis, hypertension, or cardiac dysrythmias. Noncardiovascular comorbidities associated with a greater likelihood of preventable hospitalization included chronic obstructive pulmonary disease, asthma and lower respiratory disorders, Alzheimer's disease/dementia, personality/anxiety disorders, depression, and osteoporosis. Our data suggest that nearly 7% of all hospitalizations could be avoided.

CONCLUSIONS

These findings support the need for improved outpatient care strategies to reduce the impact of comorbidity on unnecessary hospitalization in patients aged > or =65 years with type 2 diabetes.

[Coronary artery surgery in diabetic patients]

Currently, 15% to 30% of the patients that undergo coronary artery surgery are diabetics. As a group, they have less favorable anatomic and clinical characteristics than the general population. Specifically, diabetics have more extensive coronary disease, more vessels involved, and more diffuse stenosis, so they need a higher number of distal anastomoses to achieve complete revascularization. In spite of these drawbacks, they can undergo coronary artery bypass procedures with an operative mortality similar to that of non-diabetic patients. However, some postoperative complications are significantly more prevalent among diabetics, mainly renal failure, neurological accidents, sternal dehiscence, and infection. In early studies of the late results of surgical revascularization, mainly based on venous grafts, late survival and clinical improvement were less satisfactory in diabetics than in non-diabetics. However, in recent experiences, in which the internal mammary artery has been used extensively, the clinical outcome of diabetics has been similar to that of non-diabetics, confirming this procedure as the preferred one in revascularizing the coronary arteries of diabetics with multivessel disease. Off-pump surgery and extensive use of arterial grafts are becoming established strategies for reducing operative risk and improving long-term clinical results. However, continuous, strict medical management of hyperglycemia and other known coronary risk factors, especially lipid levels, is essential.

Cardiac Outcomes After Myocardial Infarction in Elderly Patients With Diabetes Mellitus

• Objective To examine the association between (1) comorbid conditions related to diabetes mellitus, clinical findings on arrival at the hospital, and characteristics of the myocardial infarction and (2) risk of heart failure, recurrent myocardial infarction, and mortality in the year after myocardial infarction in elderly 30-day survivors of myocardial infarction who had non–insulin- or insulin-treated diabetes.

• Methods Medical records for June 1, 1992, through February 28, 1993, of Medicare beneficiaries (n = 1698), 65 years or older, hospitalized for acute myocardial infarction in Connecticut were reviewed by trained abstractors.

• Results One year after myocardial infarction, elderly patients with non–insulin- and insulin-treated diabetes mellitus had significantly greater risk for readmission for heart failure and recurrent myocardial infarction than did patients without diabetes mellitus, and risk was greater in patients treated with insulin than in patients not treated with insulin. Diabetes mellitus, comorbid conditions related to diabetes mellitus, clinical findings on arrival, and characteristics of the myocardial infarction, specifically measures of ventricular function, were important predictors of these outcomes. Mortality was greater in patients not treated with insulin than in patients treated with insulin; the increased risk was mostly due to comorbid conditions related to diabetes mellitus and poorer ventricular function.

• Conclusions Risk of heart failure, recurrent myocardial infarction, and mortality is elevated in elderly patients who have non–insulin- or insulin-treated diabetes mellitus. Comorbid conditions related to diabetes mellitus and ventricular function at the time of the index myocardial infarction are important contributors to poorer outcomes in patients with diabetes mellitus.