Role of Tight Glycemic Control during Acute Coronary Syndrome on CV Outcome in Type 2 Diabetes

Association of sodium-glucose cotransporter 2 inhibitors with risk of major adverse cardiovascular events in type 2 diabetes patients with acute coronary syndrome: a propensity score‑matched analysis

BACKGROUND

This study aimed to investigate the association of sodium-glucose cotransporter 2 inhibitors (SGLT2i) use with cardiovascular (CV) clinical outcomes in type 2 diabetes (T2D) patients with acute coronary syndrome (ACS).

METHODS

Data of T2D patients hospitalized for ACS at Civil Aviation General Hospital from January 2019 to December 2022 were collected. Based on SGLT2i use or not, patients were stratified as SGLT2i group and SGLT2i-free group. A 1:1 nearest-neighbor propensity score-matched (PSM) was performed to adjust for the confounding factors and facilitate the robust comparisons between groups. The first occurrence of major adverse cardiovascular events (MACE) with 1 year follow-up, which consisted of CV death, all cause death, non-fatal myocardial infarction or stroke, coronary revascularization or heart failure readmission, was assessed. Kaplan-Meier analysis and Cox regressions were conducted to evaluate the prognostic significance of SGLT2i use. Subgroup analyses were performed to assess the interaction between subgroups and SGLT2i use.

RESULTS

A total of 925 patients were included, and the SGLT2i use increased from 9.9% in 2019 to 43.8% in 2022. 226 pairs were finally matched using the PSM model. During 1 year follow-up period, a total of 110 patients experienced MACE in the matched cohort, with a rate of 24.3%. Survival analyses showed cumulative incidence of MACE, CV death, and heart failure readmission in the SGLT2i group were significantly lower than the SGLT2i-free group. Additionally, the adjusted Cox analyses demonstrated that SGLT2i was associated with a 34.1% lower risk of MACE (HR 0.659, 95% CI 0.487-0.892, P = 0.007), which was primarily driven by a decrease in the risk of CV death by 12.0% (HR 0.880, 95% CI 0.7830.990, P = 0.033), and heart failure readmission by 45.5% (HR 0.545, 95% CI 0.332-0.893, P = 0.016). This MACE preventive benefit was consistent across different subgroups (P interaction > 0.05 for all comparisons).

CONCLUSIONS

In T2D patients with ACS, there was a clear increasing trend in SGLT2i use. SGLT2i was associated with a significantly lower risk of MACE, driven by the decrease in the risk of CV death, and heart failure readmission. Our study confirmed real-world use and efficacy of SGLT2i in a general T2D population with ACS.

Predictive value of bilirubin and serum γ-glutamyltranspeptidase levels in type-2 diabetes mellitus patients with acute coronary syndrome

BACKGROUND

Cardiovascular disease is a major complication of diabetes mellitus (DM). Type-2 DM (T2DM) is associated with an increased risk of cardiovascular events and mortality, while serum biomarkers may facilitate the prediction of these outcomes. Early differential diagnosis of T2DM complicated with acute coronary syndrome (ACS) plays an important role in controlling disease progression and improving safety.

AIM

To investigate the correlation of serum bilirubin and γ-glutamyltranspeptidase (γ-GGT) with major adverse cardiovascular events (MACEs) in T2DM patients with ACS.

METHODS

The clinical data of inpatients from January 2022 to December 2022 were analyzed retrospectively. According to different conditions, they were divided into the T2DM complicated with ACS group (T2DM + ACS, n = 96), simple T2DM group (T2DM, n = 85), and simple ACS group (ACS, n = 90). The clinical data and laboratory indices were compared among the three groups, and the correlations of serum total bilirubin (TBIL) levels and serum γ-GGT levels with other indices were discussed. T2DM + ACS patients received a 90-day follow-up after discharge and were divided into event (n = 15) and nonevent (n = 81) groups according to the occurrence of MACEs; Univariate and multivariate analyses were further used to screen the independent influencing factors of MACEs in patients.

RESULTS

The T2DM + ACS group showed higher γ-GGT, total cholesterol, low-density lipoprotein cholesterol (LDL-C) and glycosylated hemoglobin (HbA1c) and lower TBIL and high-density lipoprotein cholesterol levels than the T2DM and ACS groups (P < 0.05). Based on univariate analysis, the event and nonevent groups were significantly different in age (t = 3.3612, P = 0.0011), TBIL level (t = 3.0742, P = 0.0028), γ-GGT level (t = 2.6887, P = 0.0085), LDL-C level (t = 2.0816, P = 0.0401), HbA1c level (t = 2.7862, P = 0.0065) and left ventricular ejection fraction (LEVF) levels (t=3.2047, P = 0.0018). Multivariate logistic regression analysis further identified that TBIL level and LEVF level were protective factor for MACEs, and age and γ-GGT level were risk factors (P < 0.05).

CONCLUSION

Serum TBIL levels are decreased and γ-GGT levels are increased in T2DM + ACS patients, and the two indices are significantly negatively correlated. TBIL and γ-GGT are independent influencing factors for MACEs in such patients.

Prognostic implications of stress hyperglycemia ratio in patients with myocardial infarction with nonobstructive coronary arteries

BACKGROUND

The role of stress hyperglycemia in acute myocardial infarction (AMI) has long been emphasized. Recently, the stress hyperglycemia ratio (SHR), a novel index reflecting an acute glycemia rise, has shown a good predictive value in AMI. However, its prognostic power in myocardial infarction with nonobstructive coronary arteries (MINOCA) remains unclear.

METHODS

In a prospective cohort of 1179 patients with MINOCA, relationships between SHR levels and outcomes were analyzed. SHR was defined as acute-to-chronic glycemic ratio using admission blood glucose (ABG) and glycated hemoglobin. The primary endpoint was defined as major adverse cardiovascular events (MACE), including all-cause death, nonfatal MI, stroke, revascularization, and hospitalization for unstable angina or heart failure. Survival analyses and receiver-operating characteristic (ROC) curve analyses were performed.

RESULTS

Over the median follow-up of 3.5 years, the incidence of MACE markedly increased with higher SHR tertile levels (8.1%, 14.0%, 20.5%; p < 0.001). At multivariable Cox analysis, elevated SHR was independently associated with an increased risk of MACE (HR 2.30, 95% CI: 1.21-4.38, p = 0.011). Patients with rising tertiles of SHR also had a significantly higher risk of MACE (tertile 1 as reference; tertile 2: HR 1.77, 95% CI: 1.14-2.73, p = 0.010; tertile 3: HR 2.64, 95% CI: 1.75-3.98, p < 0.001). SHR remained a robust predictor of MACE in patients with and without diabetes; whereas ABG was no longer associated with the MACE risk in diabetic patients. SHR showed an area under the curve of 0.63 for MACE prediction. By incorporating SHR to TIMI risk score, the combined model further improved the discrimination for MACE.

CONCLUSIONS

The SHR independently confers the cardiovascular risk after MINOCA, and may serve as a better predictor than glycemia at admission alone, particularly in those with diabetes.KEY MESSAGESStress hyperglycemia ratio (SHR) is independently associated with the prognosis in a distinct population with myocardial infarction with nonobstructive coronary arteries (MINOCA).SHR is a better predictor of prognosis than admission glycemia alone, especially in diabetic patients with MINOCA.SHR may serve as a prognostic marker for risk stratification as well as a potential target for tailored glucose-lowering treatment in MINOCA.

Acute hyperglycemia, a rabble-rouser or innocent bystander? A prospective analysis of clinical implications of acute hyperglycemia in STE-ACS patients

BACKGROUND

Acute hyperglycemia is considered an independent prognosticator of both in-hospital and long-term outcomes in patients with acute coronary syndrome (ACS). This study aimed To analyze the incidence of acute hyperglycemia and its impact on the adverse in-hospital outcome in patients with STE-ACS undergoing primary percutaneous coronary intervention (PCI).

METHODS

In this study, we enrolled patients presenting with STE-ACS and undergoing primary PCI at a tertiary care cardiac center. Acute hyperglycemia was defined as random plasma glucose (RBS) > 200 mg/dl at the time of presentation to the emergency room.

RESULTS

Of the 4470 patients, 78.8% were males, and the mean age was 55.52 ± 11 years. In total, 39.4% (1759) were found to have acute hyperglycemia, and of these, 59% (1037) were already diagnosed with diabetes. Patients with acute hyperglycemia were observed to have a higher incidence of heart failure (8.2% vs. 5.5%; p < 0.001), contrast-induced nephropathy (10.9% vs. 7.4%; p < 0.001), and in-hospital mortality (5.7% vs. 2.5%; p < 0.001). On multivariable analysis, acute hyperglycemia was found to be an independent predictor of mortality with an adjusted odds ratio of 1.81 [1.28-2.55]. Multi-vessel disease (1.73 [1.17-2.56]), pre-procedure left ventricular end-diastolic pressure (LVEDP) (1.02 [1.0-1.03]), and Killip class III/IV (4.55 [3.09-6.71]) were found to be the additional independent predictors of in-hospital mortality.

CONCLUSIONS

Acute hyperglycemia, regardless of diabetic status, is an independent predictor of in-hospital mortality among patients with STE-ACS undergoing primary PCI. Acute hyperglycemia, along with other significant predictors such as multi-vessel involvement, LVEDP, and Killip class III/IV, can be considered for the risk stratification of these patients.

The impact of fasting stress hyperglycemia ratio, fasting plasma glucose and hemoglobin A1c on in-hospital mortality in patients with and without diabetes: findings from the China acute myocardial infarction registry

BACKGROUND

Stress hyperglycemia was positively associated with poor prognosis in individuals with acute myocardial infarction (AMI). However, admission glucose and stress hyperglycemia ratio (SHR) may not be the best indicator of stress hyperglycemia. We performed this study to evaluate the comparative prognostic value of different measures of hyperglycemia (fasting SHR, fasting plasma glucose [FPG], and hemoglobin A1c [HbA1c]) for in-hospital mortality in AMI patients with or without diabetes.

METHODS

In this prospective, nationwide, multicenter China Acute Myocardial Infarction (CAMI) registry, 5,308 AMI patients including 2081 with diabetes and 3227 without diabetes were evaluated. Fasting SHR was calculated using the formula [(first FPG (mmol/l))/(1.59×HbA1c (%)-2.59)]. According to the quartiles of fasting SHR, FPG and HbA1c, diabetic and non-diabetic patients were divided into four groups, respectively. The primary endpoint was in-hospital mortality.

RESULTS

Overall, 225 (4.2%) patients died during hospitalization. Individuals in quartile 4 had a significantly higher rate of in-hospital mortality compared with those in quartile 1 in diabetic cohort (9.7% vs. 2.0%; adjusted odds ratio [OR] 4.070, 95% CI 2.014-8.228) and nondiabetic cohort (8.8% vs. 2.2%; adjusted OR 2.976, 95% CI 1.695-5.224). Fasting SHR was also correlated with higher in-hospital mortality when treated as a continuous variable in diabetic and nondiabetic patients. Similar results were observed for FPG either as a continuous variable or a categorical variable. In addition, fasting SHR and FPG, rather than HbA1c, had a moderate predictive value for in-hospital mortality in patients with diabetes (areas under the curve [AUC] for fasting SHR: 0.702; FPG: 0.689) and without diabetes (AUC for fasting SHR: 0.690; FPG: 0.693). The AUC for fasting SHR was not significantly different from that of FPG in diabetic and nondiabetic patients. Moreover, adding fasting SHR or FPG to the original model led to a significant improvement in C-statistic regardless of diabetic status.

CONCLUSIONS

This study indicated that, in individuals with AMI, fasting SHR as well as FPG was strongly associated with in-hospital mortality regardless of glucose metabolism status. Fasting SHR and FPG might be considered as a useful marker for risk stratification in this population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01874691.

Fasting stress hyperglycemia ratio and in-hospital mortality after acute myocardial infarction in patients with different glucose metabolism status: Results from China acute myocardial infarction registry

AIMS

To evaluate the predictive value of fasting stress hyperglycemia ratio (SHR) for in-hospital mortality in patients with acute myocardial infarction (AMI) under different glucose metabolism status.

METHODS

We evaluated 5,308 AMI patients from the prospective, nationwide, multicenter China Acute Myocardial Infarction (CAMI) registry, of which 2,081 had diabetes. Fasting SHR was calculated by the formula [(first fasting plasma glucose (mmol/l))/(1.59 × HbA1c (%)-2.59)]. Patients were divided into high and low fasting SHR groups according to the optimal fasting SHR thresholds to predict in-hospital mortality for patients with and without diabetes, respectively. The primary endpoint was in-hospital mortality.

RESULTS

The optimal cutoff values of SHR were 1.06 and 1.26 for patients with and without diabetes. Patients with high fasting SHR presented higher in-hospital mortality than those with low fasting SHR in both cohorts with diabetes (7.9% vs 2.2%; OR _adjusted 3.159, 95% CI 1.932-5.165; OR _IPTW 3.311, 95%CI 2.326-4.713) and without diabetes (10.1% vs 2.5%; OR _adjusted 3.189, 95%CI 2.161-4.705; OR _IPTW 3.224, 95%CI 2.465-4.217). The prognostic powers of fasting SHR for in-hospital mortality were similar in patients with different glucose metabolism status. Moreover, adding fasting SHR to the original model led to a significant improvement in C-statistic, net reclassification, and integrated discrimination regardless of diabetes status.

CONCLUSIONS

This study firstly demonstrated a strong positive association between fasting SHR and in-hospital mortality in AMI patients with and without diabetes. Fasting SHR should be considered as a useful marker for risk stratification in AMI patients regardless of glucose metabolism status.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01874691.

Diet supplemented with boiled unripe plantain (Musa paradisiaca) exhibited antidiabetic potentials in streptozotocin-induced Wistar rats

The ameliorating effect and antidiabetic properties of diets augmented with boiled unripe plantain (20%-40%) in high fat fed/low dose of streptozotocin induced diabetic rats in comparison with the administration of acarbose were evaluated in this study using standard methods. High fat fed/low dose of streptozotocin (25 mg/kg body weight) was given to twenty-five male Wistar rats to induce diabetes leaving out 5 normal rats to serve as control. The animals were separated into five with six rats in each group and the experiment continued for 14 days. Investigations on the blood glucose concentration, enzymes (α-amylase, α-glucosidase, angiotensin I converting enzyme), thiobarbituric reaction substance (TBARS), High-density lipoprotein-cholesterol (HDL-c), and antioxidant status were determined. The findings revealed a rise in blood glucose level and the activities of α-amylase, α-glucosidase, angiotensin I converting enzyme, thiobarbituric reaction substance (TBARS) in untreated diabetic rats in group II while a reverse was observed in diabetic rats (Group IV and V) on exposure to diets augmented with boiled unripe plantain. The obtained overall results in diet treated groups are similar to that of acarbose treated groups. The untreated diabetic rats (Group II) exhibited contrary results of the biochemical assays. This finding showed that boiled unripe plantain can provide the therapeutic measures that needed to be further explored as possible future economic means of managing diabetes in developing nations. PRACTICAL APPLICATIONS: As diabetes has been implicated to disrupt various pathways involved in the metabolism of macromolecules, there are proposed adoptive methods of preventing them among which is the inhibition of starch hydrolyzing enzymes, increasing the enzymatic antioxidant status and prevention of lipid peroxidation, Plantain by-product which is known as an inexpensive food can be prepared to manage the condition of diabetes in patients. Our former in vitro findings have revealed the bioactive contents of unripe plantain product which has been further explored in vivo to experiment is nutritional benefits. The study therefore proposes that unripe plantains, when boiled, can provide the necessary natural therapeutic measures to be considered as a potential economic means of managing diabetes in underdeveloped countries.

Glycated hemoglobin level dynamics in COVID-19 survivors: 12 months follow-up study after discharge from hospital

INTRODUCTION

One of the stages of reproduction of SARS-CoV-2 is the S-protein glycosylation to facilitate penetration into target cells. It has been suggested that SARS-CoV-2 is able to enter erythrocytes, interact with heme and porphyrin, which could influence HbA1c levels. Assessment of HbA1c levels in individuals with acute COVID-19 and after recovery may show clinical relevance of this hypothesis.

AIM

To assess HbA1c levels in patients with COVID-19 in the acute phase and in early (6-8 weeks) and late (52±2 weeks) periods after recovery.

MATERIALS AND METHODS

We conducted a multicenter prospective study, which included patients hospitalized in Endocrinology Research Centre and the City Clinical Hospital № 52" diagnosed with COVID-19, virus identified/ not identified. Patients were divided into three groups according to baseline HbA1c level and the presence or absence of previous history of diabetes previous history of diabetes mellitus (DM): HbA1c ≤ 6.0%, HbA1c > 6.0% and patients with DM. Patients were examined during the acute COVID-19 phase and in early (6-8 weeks) and late (52±2 weeks) periods after recovery. Oral glucose tolerance test was performed in the group with initial HbA1c > 6.0% to clarify the diagnosis.

RESULTS

We included 194 patients in the study. During the follow-up, 52 patients were examined in 6-8 week period: 7 with HbA1c ≤ 6.0%, 34 with HbA1c > 6.0%, 11-with previously diagnosed DM. Carbohydrate metabolism assessment in the later stages (52±2 weeks) after recovery was performed in 78 patients: 33 patients with HbA1c ≤ 6.0%, 36 patients with HbA1c > 6.0% and 9 patients with previously established diabetes. HbA1c median in patients with HbA1c ≤ 6.0% was 5.7% [5.3;5.8], with HbA1c>6.0% -6.4% [6.2; 6.6], with previously diagnosed DM-7.7% [7.2; 8.9]. Statistically significant decrease in HbA1c over time 6-8 weeks after extracts were obtained in both groups of individuals without a history of DM (Wilcoxon test, p<0.05). After 52±2 weeks we observed HbA1c decrease in all three groups (Fridman test, p<0.05): in patients with HbA1c ≤ 6.0% median HbA1c was 5.5[5.3;5.7], with HbA1c>6.0% - 6.1[6.15;6.54], with previously diagnosed DM-7.8 [5.83; 8.08]. Development of DM after 52±2 weeks was recorded in 7.24% of all examined patients without a history of DM, which is 16.6% of the total number of patients examined in dynamics with HbA1c > 6.0%.

CONCLUSION

HbA1c elevation during the acute phase of COVID-19 may be false due to the effect of SARS-CoV-2 on hemoglobin kinetics and/or detection on the surface of the SARS-CoV-2 virion highly glycosylated S-proteins by high performance liquid chromatography determinations. Upon detection HbA1c > 6.0% in patients with COVID-19 in the active phase of the disease without concomitant hyperglycemia re-determine the level of HbA1c after recovery is recommended.

Prognostic impact of stress hyperglycemia ratio in acute myocardial infarction patients with and without diabetes mellitus

BACKGROUND AND AIMS

Stress hyperglycemia ratio (SHR) is associated with increased in-hospital morbidity and mortality in patients with acute myocardial infarction (AMI). We aimed to investigate the impact of stress "hyperglycemia" on long-term mortality after AMI in patients with and without diabetes mellitus (DM).

METHODS AND RESULTS

We included 2089 patients with AMI between February 2014 and March 2018. SHR was measured with the fasting glucose divided by the estimated average glucose derived from glycosylated hemoglobin (HbA1c). The primary endpoint was all-cause death. Of 2 089 patients (mean age: 65.7 ± 12.4, 76.7% were men) analyzed, 796 (38.1%) had DM. Over a median follow-up of 2.7 years, 141 (6.7%) and 150 (7.2%) all-cause deaths occurred in the diabetic and nondiabetic cohorts, respectively. Compared with participants with low SHR (<1.24 in DM; <1.14 in non-DM), the hazard ratios and 95% confidence intervals for those with high SHR (≥1.24 in DM; ≥1.14 in non-DM) for all-cause mortality were 2.23 (1.54-3.23) and 1.79 (1.15-2.78); for cardiovascular mortality were 2.42 (1.63-3.59) and 2.10 (1.32-3.35) in DM and non-DM subjects, respectively. The mortality prediction was improved in the diabetic individuals with the incorporation of SHR into the Global Registry of Acute Coronary Events (GRACE) score, showing an increase in a continuous net reclassification index of 0.184 (95%CI: 0.003-0.365) and an absolute integrated discrimination improvement of 0.014 (95%CI: 0.002-0.025).

CONCLUSION

The improvement in the prediction of long-term mortality beyond the GRACE score indicates the potential of SHR as a biomarker for post-MI risk stratification among patients with DM.

REGISTRATION NUMBER FOR CLINICAL TRIALS

NCT03533543.

Effects of DPP4 Inhibitor in Platelet Reactivity and Other Cardiac Risk Markers in Patients with Type 2 Diabetes and Acute Myocardial Infarction

Background: The management of acute myocardial infarction (AMI) presents several challenges in patients with diabetes, among them the higher rate of recurrent thrombotic events, hyperglycemia and risk of subsequent heart failure (HF). The objective of our study was to evaluate effects of DPP-4 inhibitors (DPP-4i) on platelet reactivity (main objective) and cardiac risk markers. Methods: We performed a single-center double-blind randomized trial. A total of 70 patients with type 2 diabetes (T2DM) with AMI Killip ≤2 on dual-antiplatelet therapy (aspirin plus clopidogrel) were randomized to receive sitagliptin 100 mg or saxagliptin 5 mg daily or matching placebo. Platelet reactivity was assessed at baseline, 4 days (primary endpoint) and 30 days (secondary endpoint) after randomization, using VerifyNow Aspirin™ assay, expressed as aspirin reaction units (ARUs); B-type natriuretic peptide (BNP) in pg/mL was assessed at baseline and 30 days after (secondary endpoint). Results: Mean age was 62.6 ± 8.8 years, 45 (64.3%) male, and 52 (74.3%) of patients presented with ST-segment elevation MI. For primary endpoint, there were no differences in mean platelet reactivity (p = 0.51) between the DPP-4i (8.00 {−65.00; 63.00}) and placebo (−14.00 {−77.00; 52.00}) groups, as well in mean BNP levels (p = 0.14) between DPP-4i (−36.00 {−110.00; 15.00}) and placebo (−13.00 {−50.00; 27.00}). There was no difference between groups in cardiac adverse events. Conclusions: DPP4 inhibitor did not reduce platelet aggregation among patients with type 2 diabetes hospitalized with AMI. Moreover, the use of DPP-4i did not show an increase in BNP levels or in the incidence of cardiac adverse events. These findings suggests that DPP-4i could be an option for management of T2DM patients with acute MI.

Cardiovascular complications of diabetes

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is the ninth leading cause of mortality globally, and the prevalence continues to rise. Among individuals with T2DM, over two-thirds of deaths are caused by the cardiovascular complications of diabetes. These complications include atherosclerosis, coronary artery disease, nephropathy, stroke, thromboembolism, peripheral vascular disease. They have been long studied, and there are several theories as to the pathophysiology of how diabetes leads to these complications. The least understood mechanism is the pathophysiology linking diabetes to heart failure.

AREAS COVERED

This review focuses on the mechanisms of how T2DM leads to the aforementioned complications, particularly highlighting the development of heart failure. An extensive literature review of novel therapeutic options targeting the cardiovascular effects of T2DM was completed and summarized in this review.

EXPERT OPINION

This review finds that most studies to date have focused on the atherosclerotic vascular complications of diabetes. The pathophysiology between T2DM and heart failure is even less understood. Currently therapies that aim to decrease the risk of heart failure in diabetes are sparse. More research is required in order to better understand the changes at a cellular level and subsequently help providers to choose therapeutics that better target cardiovascular complications.

Impact of diabetes and on-arrival hyperglycemia on short-term outcomes in acute heart failure patients

The impact of diabetes mellitus (DM) and hyperglycemia on short-term prognosis in patients with acute heart failure (AHF) remains controversial as most data comes from series of hospitalized patients. Our purpose was to analyze outcomes in a nation-wide registry of AHF patients attended in emergency department (ED). ED AHF patients were prospectively enrolled, with the index event and the vulnerable post-discharge phase outcomes recorded. The influence of presenting hyperglycemia (> 180 mg/dL) and DM treatment on prognosis were also investigated. All results were adjusted (a) for baseline characteristics. Of 9192 enrolled AHF patients, 4544 (49,4%) were diabetic, with 24% of diabetics and 25.1% of non-diabetic (p = 0.247) directly discharged from the ED also included. Diabetics had higher rates of comorbidities, but were slightly younger and had lower in-hospital and 30 day all-cause mortality than non-diabetics (a-OR = 0.827, 95% CI = 0.690-0980; and a-HR = 0.850, 95% CI = 0.814-1.071, respectively). Conversely, hyperglycemia on-arrival was associated with increased in-hospital, and 30 day all-cause mortality, in both DM (a-OR = 1.933, 95% CI = 1.378-2.712, and a-HR = 1.590, 95% CI = 1.304-1.938, respectively) and non-DM patients (a-OR = 1.498, 95% CI = 1.175-1.909, and a-HR = 1.719, 95% CI = 1.306-2.264, respectively). However, during the vulnerable phase, diabetics had worse short-term outcomes, with higher rates of ED-revisit and rehospitalization. These worse outcomes seemed to be unrelated to the severity of DM. In patients with AHF attended in ED, diabetes was associated with lower index event case fatality, but higher rates of rehospitalization and re-consultation in the vulnerable post-discharge period. Conversely, hyperglycemia at hospital arrival was strongly associated with early mortality, regardless of diabetes status.

Race-Ethnic Differences of ST-Elevation Myocardial Infarction: Findings from a New York Health System Registry

Background

Race and ethnicity are major considerations in the incidence, management, and long-term outcome of ST-elevation myocardial infarction (STEMI) in the United States, but there is limited existing comparative data.

Methods

We assembled a registry in a health system serving Bronx, NY of STEMI patients from 2008-2014 and analyzed differences in presentation, treatment and mortality between Hispanic/Latino (H/L), non-Hispanic Black (NHB) and non-Hispanic White (NHW). Upon discharge post-treatment for STEMI, all patients were followed for a median of 4.4 years (interquartile range 2.5, 6.0). Out of 966 STEMI patients, mean age was 61 years, 46% were H/L and 65% were male. H/Ls and NHBs had a higher prevalence of hypertension and diabetes mellitus than their NHW counterparts, coinciding with a lower socioeconomic status (SES).

Results

The number of critically diseased vessels found at cardiac catheterization and mean troponin levels did not vary by race-ethnicity; neither did the adjusted hazard ratios (HR) for death. However, age-sex adjusted rates of general hospital readmission were higher in NHBs vs NHWs (HR 1.30, P=.03). Age-sex adjusted cardiovascular readmissions rates were higher in H/Ls than NHWs (HR 1.42, P=.03). Age-sex adjusted heart failure readmissions were increased for both H/Ls (HR 2.14, P=.01) and NHBs (HR 2.12, P=.02) over NHWs.

Conclusions

Among STEMI patients, a higher prevalence of modifiable cardiovascular risk factors and a lower SES was seen among NHBs and H/Ls compared to NHWs. Despite similar coronary disease severity and in-hospital death, NHBs and H/Ls had a greater risk of general, cardiovascular and heart failure readmissions post-STEMI compared to NHWs.

Refeeding Syndrome: A Critical Reality in Patients with Chronic Disease

Malnutrition is one of the most frequent metabolic challenges in the population of chronically ill patients. This results in increased administration of nutritional therapy in inpatient settings, which poses the risk of side effects, in particular, the development of refeeding syndrome. If not managed accordingly, it leads to a significant rise in morbidity and mortality. However, despite its importance, evidence-based recommendations on the management of refeeding syndrome are largely lacking, and only a few randomized controlled trials have been conducted. In light of this, the aim of this review is to raise awareness of refeeding syndrome in chronically ill patients by critically reviewing recent literature and providing a short overview as well as diagnosis and treatment algorithms of this underreported metabolic condition. In summary, recent findings suggest undergoing risk assessment and stratification for every patient receiving nutritional therapy. According to this, adaptation of energy and fluid support during the replenishment phase should be implemented in the nutritional therapy for patients at high risk. Additionally, continuous monitoring should take place, and appropriate actions should be initiated when necessary.

Glycemic control in newly insulin-initiated patients with type 2 diabetes mellitus: A retrospective follow-up study at a university hospital in Ethiopia

Background

Though many trials had examined the effectiveness of taking insulin with or without oral agents, there are limited real-world data, particularly among patients with type 2 diabetes mellitus (T2DM) in the resource limited settings. This study aimed to examine level of glycemic control among patients with T2DM after initiation of insulin and factors associated with poor glycemic control.

Methods

An analysis of retrospective medical records of patients with T2DM who initiated insulin due to uncontrolled hyperglycemia by oral agents was conducted from 2015–2020 in the University of Gondar Comprehensive Specialized Hospital. Difference in median fasting plasma glucose (FPG) before and after insulin initiations was examined by a Wilcoxon signed-rank test. Kruskal Wallis test was performed to explore difference in the median level of FPG among treatment groups. A logistic regression model was also used to identify associated factors of poor glycemic control after insulin initiation. Statistical significance was declared at p < 0.05.

Results

Of 424 enrolled patients with T2DM, 54.7% were males and the mean age was 59.3±9.3 years. A Wilcoxon signed-rank test showed that there was significant deference in FPG before and after insulin initiation (P < 0.001). A declining trend of blood glucose was observed during the 1-year follow-up period of post-initiation. However, majority of the participants did not achieve target glucose levels. Participants who had higher FPG and systolic blood pressure (SBP) before insulin initiation were found more likely to have poor glycemic control after insulin initiation. Similarly, patients who received atorvastatin compared with simvastatin were found to have poor glycemic control in the post-period of initiation (P = 0.04). Premixed insulin was associated with a lower likelihood of poor glycemic control than neutral protamine Hagedorn (NPH) insulin (P < 0.001).

Conclusion

Following insulin initiation, a significant change in glycemic level and declining trend of FPG was observed during a 1-year follow-up period. However, the majority of patients still had a poorly controlled glycemic level. Appropriate management focusing on predictors of glycemic control would be of a great benefit to achieve glycemic control.

The Impact of Hypoglycemic Therapy on the Prognosis for Acute Coronary Syndrome in Patients with Type 2 Diabetes

The article discusses particular circumstances of acute coronary syndrome (ACS) in patients with type 2 diabetes (T2D). In addition, the available literature data and clinical guidelines reflecting the role of hypoglycemic therapy as a cardioprotection factor in ACS are analyzed. The article considers possible protective molecular mechanisms of various groups of drugs in ischemic cardiomyocytes.

Selenium Supplementation Improved Cardiac Functions by Suppressing DNMT2-Mediated GPX1 Promoter DNA Methylation in AGE-Induced Heart Failure

Objective

Advanced glycation end products (AGEs) are featured metabolites associated with diabetic cardiomyopathy which is characterized by heart failure caused by myocyte apoptosis. Selenium was proved cardioprotective. This study was aimed at investigating the therapeutic effects and underlying mechanisms of selenium supplementation on AGE-induced heart failure.

Methods

Rats and primary myocytes were exposed to AGEs. Selenium supplementation was administrated. Cardiac functions and myocyte apoptosis were evaluated. Oxidative stress was assessed by total antioxidant capacity (TAC), reactive oxygen species (ROS) generation, and GPX activity. Expression levels of DNA methyltransferases (DNMTs) and glutathione peroxidase 1 (GPX1) were evaluated. DNA methylation of the GPX1 promoter was analyzed.

Results

AGE exposure elevated intracellular ROS generation, induced myocyte apoptosis, and impaired cardiac functions. AGE exposure increased DNMT1 and DNMT2 expression, leading to the reduction of GPX1 expression and activity in the heart. Selenium supplementation decreased DNMT2 expression, recovered GPX1 expression and activity, and alleviated intracellular ROS generation and myocyte apoptosis, resulting in cardiac function recovery. DNA methylation analysis in primary myocytes indicated that selenium supplementation or DNMT inhibitor AZA treatment reduced DNA methylation of the GPX1 gene promoter. Selenium supplementation and AZA administration showed synergic inhibitory effect on GPX1 gene promoter methylation.

Conclusions

Selenium supplementation showed cardioprotective effects on AGE-induced heart failure by suppressing ROS-mediated myocyte apoptosis. Selenium supplementation suppressed ROS generation by increasing GPX1 expression via inhibiting DNMT2-induced GPX1 gene promoter DNA methylation in myocytes exposed to AGEs.

Review of Immune-Related Adverse Events (irAEs) in Non-Small-Cell Lung Cancer (NSCLC)—Their Incidence, Management, Multiorgan irAEs, and Rechallenge

Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of advanced malignancies, including non-small cell lung cancer (NSCLC). These agents have improved clinical outcomes and have become quite an attractive alternative alone or combined with other treatments. Although ICIs are tolerated better, they also lead to unique toxicities, termed immune-related adverse events (irAEs). A reconstituted immune system may lead to dysregulation in normal immune self-tolerance and cause inflammatory side effects (irAEs). Although any organ system can be affected, immune-related adverse events most commonly involve the gastrointestinal tract, endocrine glands, skin, and liver. They can occur anytime during the treatment course and rarely even after completion. Owen and colleagues showed that approximately 30% of patients with NSCLC treated with ICIs develop irAEs. Kichenadasse et al. conducted a thorough evaluation of multiorgan irAEs, which is of particular interest because information regarding these types of irAEs is currently sparse. It is important to delineate between infectious etiologies and symptom progression during the management of irAEs. Close consultation with disease-specific subspecialties is encouraged. Corticosteroids are the mainstay of treatment of most irAEs. Early intervention with corticosteroids is crucial in the general management of immune-mediated toxicity. Grade 1–2 irAEs can be closely monitored; hypothyroidism and other endocrine irAEs may be treated with hormone supplementation without the need for corticosteroid therapy. Moderate- to high-dose steroids and other additional immunosuppressants such as tocilizumab and cyclophosphamide might be required in severe, grade 3–4 cases. Recently, increasing research on irAEs after immunotherapy rechallenge has garnered much attention. Dolladille and colleagues assessed the safety in patients with cancer who resumed therapy with the same ICIs and found that rechallenge was associated with about 25–30% of the same irAEs experienced previously (4). However, such data should be carefully considered. Further pooled analyses may be required before we conclude about ICIs’ safety in rechallenge.

An Overview of the Cardiorenal Protective Mechanisms of SGLT2 Inhibitors

Sodium-glucose co-transporter 2 (SGLT2) inhibitors block glucose reabsorption in the renal proximal tubule, an insulin-independent mechanism that plays a critical role in glycemic regulation in diabetes. In addition to their glucose-lowering effects, SGLT2 inhibitors prevent both renal damage and the onset of chronic kidney disease and cardiovascular events, in particular heart failure with both reduced and preserved ejection fraction. These unexpected benefits prompted changes in treatment guidelines and scientific interest in the underlying mechanisms. Aside from the target effects of SGLT2 inhibition, a wide spectrum of beneficial actions is described for the kidney and the heart, even though the cardiac tissue does not express SGLT2 channels. Correction of cardiorenal risk factors, metabolic adjustments ameliorating myocardial substrate utilization, and optimization of ventricular loading conditions through effects on diuresis, natriuresis, and vascular function appear to be the main underlying mechanisms for the observed cardiorenal protection. Additional clinical advantages associated with using SGLT2 inhibitors are antifibrotic effects due to correction of inflammation and oxidative stress, modulation of mitochondrial function, and autophagy. Much research is required to understand the numerous and complex pathways involved in SGLT2 inhibition. This review summarizes the current known mechanisms of SGLT2-mediated cardiorenal protection.

The Other Face of Insulin—Overdose and Its Effects

Insulin is the most effective glycemic-lowering drug, and for people suffering from type 1 diabetes it is a life-saving drug. Its self-dosing by patients may be associated with a higher risk of overdose, both accidental and deliberate. Insulin-induced hypoglycemia causes up to 100,000 emergency department calls per year. Cases of suicide attempts using insulin have been described in the literature since its introduction into therapy, and one of the important factors in their occurrence is the very fact of chronic disease. Up to 90% of patients who go to toxicology wards overdose insulin consciously. Patients with diabetes are burdened with a 2–3 times higher risk of developing depression compared to the general population. For this reason, it is necessary to develop an effective system for detecting a predisposition to overdose, including the assessment of the first symptoms of depression in patients with diabetes. A key role is played by a risk-conscious therapeutic team, as well as education. Further post-mortem testing is also needed for material collection and storage, as well as standardization of analytical methods and interpretation of results, which would allow for more effective detection and analysis of intentional overdose—both by the patient and for criminal purposes.

Echocardiographic study of myocardial work in patients with type 2 diabetes mellitus

Background

A noninvasive left ventricular (LV) pressure-strain loop (PSL) provides a new method to quantify myocardial work (MW) by combining global longitudinal strain (GLS) and LV pressure, which exerts potential advantages over traditional GLS. We studied the LV PSL and MW in patients with type 2 diabetes mellitus (T2DM).

Methods

This cross-sectional study included 201 subjects (54 healthy controls and 147 T2DM patients) who underwent complete two-dimensional echocardiography (2DE), including 2D speckle-tracking echocardiography (STE), as well as brachial artery pulse pressure measurement. The PSL was used to determine the global myocardial work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE) of all study participants. The association between T2DM and LV function was evaluated according to these MW indices.

Results

The GLS was significantly lower in the T2DM group than in the control group (P < 0.001), indicating that the LV myocardium had been damaged, although the LV ejection fraction (LVEF) was still normal. The GWI and GWE were decreased (P = 0.022) and the GWW was increased (P < 0.001) in diabetic patients compared with controls, but the GCW was comparable in the two groups (P = 0.160). In all diabetic patients, age, body mass index, systolic blood pressure, smoking history, and LVEF were correlated with GWI, GWW and GWE.

Conclusions

The use of LV PSL is a novel noninvasive technique that could help to depict the relationship between LV myocardial damage and MW in patients with T2DM.

Diabetes and restenosis

Restenosis, defined as the re-narrowing of an arterial lumen after revascularization, represents an increasingly important issue in clinical practice. Indeed, as the number of stent placements has risen to an estimate that exceeds 3 million annually worldwide, revascularization procedures have become much more common. Several investigators have demonstrated that vessels in patients with diabetes mellitus have an increased risk restenosis. Here we present a systematic overview of the effects of diabetes on in-stent restenosis. Current classification and updated epidemiology of restenosis are discussed, alongside the main mechanisms underlying the pathophysiology of this event. Then, we summarize the clinical presentation of restenosis, emphasizing the importance of glycemic control in diabetic patients. Indeed, in diabetic patients who underwent revascularization procedures a proper glycemic control remains imperative.

Sex-Specific Impact of Different Obesity/Metabolic Phenotypes on Long-Term Cardiovascular Outcomes in Acute Coronary Syndrome Patients

Obesity, a major risk factor for acute coronary syndrome (ACS), is a multifaceted disease with different metabolic phenotypes and sex-specific features. Here, we evaluated the long-term cardiovascular risk by different obesity/metabolic phenotypes and by sex in ACS patients. The occurrence of the composite outcome of death, nonfatal reinfarction with or without PCI and/or stroke was evaluated in 674 patients (504 men; 170 women), consecutively hospitalized for ACS and followed-up for 7 years, who were stratified in metabolically healthy (MHNW) and unhealthy normal weight (MUNW), and in metabolically healthy (MHO) and unhealthy obese (MUO) groups. At baseline, 54.6% of patients were included in the MHNW group, 26.4% in the MUNW, 5.9% in the MHO and 13.1% in the MUO, with no sex-differences in the distribution of phenotypes. The overall rate of major outcome (100 person-years) in the reference group (MHNW) was higher in men than in women (RR: 1.19 vs. 0.6). The Kaplan–Meier curves for cumulative survival free from cardiovascular events according to obesity/metabolic status diverged significantly according to sex (log rank test, p = 0.006), this effect being more prominent in men (log 11.20; p = 0.011), than in women (log 7.98; p = 0.047). Compared to MHNW, the risk increased in obese men (RR: 2.2; 95% 1.11–1.54 in MUO group), whereas in women the risk was confined to metabolically unhealthy subjects (RR: 3.2; 95% CI 1.23–9.98, MUNW group). Our data show a sex-specific impact of obesity phenotypes on long-term cardiovascular risk in patients hospitalized for ACS.

Dysregulated Epicardial Adipose Tissue as a Risk Factor and Potential Therapeutic Target of Heart Failure with Preserved Ejection Fraction in Diabetes

Cardiovascular (CV) disease and heart failure (HF) are the leading cause of mortality in type 2 diabetes (T2DM), a metabolic disease which represents a fast-growing health challenge worldwide. Specifically, T2DM induces a cluster of systemic metabolic and non-metabolic signaling which may promote myocardium derangements such as inflammation, fibrosis, and myocyte stiffness, which represent the hallmarks of heart failure with preserved ejection fraction (HFpEF). On the other hand, several observational studies have reported that patients with T2DM have an abnormally enlarged and biologically transformed epicardial adipose tissue (EAT) compared with non-diabetic controls. This expanded EAT not only causes a mechanical constriction of the diastolic filling but is also a source of pro-inflammatory mediators capable of causing inflammation, microcirculatory dysfunction and fibrosis of the underlying myocardium, thus impairing the relaxability of the left ventricle and increasing its filling pressure. In addition to representing a potential CV risk factor, emerging evidence shows that EAT may guide the therapeutic decision in diabetic patients as drugs such as metformin, glucagon-like peptide‑1 (GLP-1) receptor agonists and sodium-glucose cotransporter 2 inhibitors (SGLT2-Is), have been associated with attenuation of EAT enlargement.

Greater Glycemic Burden Is Associated with Further Poorer Glycemic Control in Newly-Diagnosed Type 2 Diabetes Mellitus Patients

Aims: hyperglycemia impairs pancreatic β-cell function instantly, also known as glucotoxicity. It is unknown whether this insult is temporary or sustained, and little real-world evidence needs to reflect the relationship between hyperglycemic burden, per se, and glycemic durability. Materials and Methods: a retrospective observational cohort study was conducted to recruit newly-diagnosed type 2 diabetes mellitus (T2DM) patients. Durability was defined as the episode from first glycated hemoglobin A1c (HbA1c) below 7.0% to where it exceed 8.0% (with treatment failure) or where study ended (without treatment failure). Glycemic burden was defined with the area above a burden value line (HbA1c = 6.5%) but under the HbA1c curve (AUC), and it was then divided into two compartments with the demarcation timepoint once HbA1c was treated below or equal to 7.0%; the former AUC' represented the initial insult; the latter AUC" represented the residual part. Multivariable regression models assessed factors associated with durability in whole participants and two distinct subgroups: patients with baseline HbA1c > 7.0% or ≤7.0%. Results: 1048 eligible participants were recruited and analyzed: 291 patients with treatment failure (durability 26.8 ± 21.1 months); 757 patients without treatment failure (durability 45.1 ± 31.8 months). Besides age, glycemic burden was the only constant determinant in the two subgroups. AUC' or AUC" increased treatment failure, respectively, in baseline HbA1c > 7.0% or ≤7.0% subgroup [per 1%/90 days hazard ratio (95% confidence interval): 1.026 (1.018-1.034) and 1.128 (1.016-1.253)]. Other determinants include baseline HbA1c, initial OAD, and education level. Conclusions: in patients with newly-diagnosed T2DM, glycemic durability was negatively associated with greater glycemic burden.

Factors affecting long-term changes of liver stiffness in direct-acting anti-hepatitis C virus therapy: A multicentre prospective study

The long-term changes of liver stiffness (LS) in patients who achieve viral clearance after direct-acting anti-HCV therapy remain undefined. We conducted a multicentre prospective study to investigate this aspect. Patients with HCV infection treated with DAAs were enrolled from six Italian centres; they underwent clinical, biochemical, ultrasound and transient elastography evaluations before treatment (T0), 12 weeks (SVR12) and 24 months (T24) after the end of therapy. Among the 516 consecutive patients enrolled, 301 had cirrhosis. LS significantly decreased from T0 to SVR (14.3 vs 11.1 kPa, p = .002), with a progressive reduction until T24 (8.7 kPa, p < .001). However, only patients with steatosis and those who developed HCC did not experience a late improvement in LS. Multivariate analysis of baseline and follow-up variables identified steatosis as the only independent predictor of failure of LS improvement (OR 1.802, p = .013). ROC curve analysis of the association of LS with the risk of developing HCC showed that SVR12 ≥14.0 kPa had the highest accuracy (sensitivity 82%, specificity 99%; AUC: 0.774). Multivariate analysis revealed that LS was the only variable independently associated with an increased risk of developing HCC (OR 6.470, p = .035). Achieving an SVR was associated with a progressive, long-term decline of LS, suggesting a late improvement in liver fibrosis, besides the resolution of inflammation. Fatty liver and the development of HCC interfered with late reduction of LS. Patients with an LS ≥14 kPa at 12 weeks after the end of treatment were at higher risk for developing HCC.

Effects of SGLT-2 Inhibitors on Vascular Endothelial Function and Arterial Stiffness in Subjects With Type 2 Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the effects of SGLT-2 inhibitors (SGLT-2i) on endothelial function and arteriosclerosis in diabetic patients.

METHODS

Randomized controlled trials (RCTs) were retrieved from PubMed, Embase, Cochrane Library, and Web of Science databases to evaluate the effects of SGLT-2i on endothelial function and atherosclerosis in type 2 diabetic patients.

RESULTS

We selected 9 RCTs and 2 cohort studys involving 868 patients. Of these, six studies provided flow-mediated dilation (FMD) levels before and after the intervention. The pooled analysis showed that SGLT-2i could significantly improve the FMD compared to the control group (SMD: 0.18, 95% CI: 0.02 ~ 0.34, P = 0.03). Three studies provided the change in FMD before and after the intervention. Pooled analysis showed no significant differences in FMD change between the SGLT-2i group and the control group. (MD: 2.1, 95%-CI: -0.11~4.31, P = 0.06). Five studies showed pulse wave velocity (PWV) results. Pooled analysis showed no significant differences in the change in PWV between the SGLT-2i group and the control group (SMD: 0.11, 95%-CI: - 0.15 ~ 0.37, P = 0.4).

CONCLUSIONS

The ability of SGLT-2 inhibitors to improve FMD was significant, but there was no significant effect on PWV levels. SGLT-2i was superior to other antidiabetic agents in improving arterial endothelial function.

Management of chronic kidney disease in type 2 diabetes: screening, diagnosis and treatment goals, and recommendations

Patients with chronic kidney disease (CKD) and type 2 diabetes (T2D) are at high risk of CKD progression and cardiovascular (CV) disease. Prevalence of CKD in patients with T2D is currently around 40% and continues to grow. The increasing number of people with CKD and T2D will ultimately have a significant impact upon health resource use and costs of care for people with T2D. Management of CKD in patients with T2D aims to preserve kidney function to reduce the risk of end-stage kidney disease, CV events, and mortality. Evidence-based recommendations for the treatment of patients with CKD and T2D are provided by several international and national organizations and recommend several lifestyle and pharmacological approaches to help prevent or delay the progression of CKD in patients with T2D. Guidelines include regular screening of patients with T2D for CKD using spot urine albumin-to-creatinine ratio (UACR) and estimated glomerular filtration rate (at least annually and at least twice a year if UACR >300 mg/g). Additionally, assessment of vascular complications, together with interventions designed to improve glycemic control and lipid levels, maintain healthy body weight, and optimize blood pressure should be performed. Medications shown to slow progression of CKD include renin-angiotensin system inhibitors, sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide 1 receptor agonists, and, more recently, selective, non-steroidal mineralocorticoid receptor antagonists. This review highlights the ongoing challenges facing primary care providers in the management of CKD in patients with T2D including the consideration of comorbidities, adoption of new treatment options, and implementation of individualized care. Achieving consensus for optimal treatment of this disease is critical in providing consistent and appropriate care for all patients. Strategies to improve outcomes should also include use of clear referral criteria, use of a multi-disciplinary approach, and patient education.

Effects of Metformin in Heart Failure: From Pathophysiological Rationale to Clinical Evidence

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.

Intraoperative Hyperglycemia May Be Associated with an Increased Risk of Myocardial Injury after Non-Cardiac Surgery in Diabetic Patients

BACKGROUND

Hyperglycemia in surgical candidates is associated with increased mortality and morbidity. We aimed to evaluate the effect of intraoperative blood glucose level on the incidence of myocardial injury after non-cardiac surgery (MINS) in diabetic patients.

METHODS

Diabetic patients with available intraoperative blood glucose measurement during non-cardiac surgery were enrolled in this study. Based on the highest intraoperative blood glucose level, patients were stratified into two groups: the blood sugar glucose (BST) < 180 group (intraoperative peak glucose < 180 mg/dL) and BST ≥ 180 group (intraoperative peak glucose ≥ 180 mg/dL). The primary outcome was the incidence of MINS, and secondary outcomes were in-hospital and 30-day mortalities.

RESULTS

Of the 11,302 diabetic patients, 8337 were in the BST < 180 group (73.8%) and 2965 in the BST ≥ 180 group (26.2%). After adjustment with inverse probability weighting, MINS was significantly higher in the BST ≥ 180 group (24.0% vs. 17.2%; odds ratio (OR), 1.26; 95% confidence interval (CI), 1.14-1.40; p < 0.001). In addition, in-hospital and 30-day mortalities were also higher in the BST ≥ 180 group compared to the BST < 180 group (4.2% vs. 2.3%, hazard ratio (HR), 1.39; 95% CI, 1.07-1.81; p = 0.001, and 3.1% vs. 1.8%; HR, 1.76; 95% CI, 1.31-2.36; p < 0.001, respectively). Receiver-operating characteristic plots showed that the threshold of glucose level associated with MINS was 149 mg/dL.

CONCLUSION

Intraoperative hyperglycemia was associated with an increased MINS incidence and postoperative mortality in diabetic patients. Close monitoring of intraoperative blood glucose level may be helpful in detection and management of MINS.

Admission hyperglycemia and all-cause mortality in diabetic and non-diabetic patients with acute myocardial infarction: a tertiary center analysis

Admission hyperglycemia (AH) is associated with worse prognosis in patients with acute myocardial infarction (AMI). Controversy remains whether the impact of AH differs among patients previously diagnosed with diabetes mellitus (DM). We retrospectively evaluated consecutive patients admitted in a coronary care unit with AMI, from 2006 to 2014. Patients were divided into 4 groups: patients without known DM with admission glycemia (AG) ≤ 143 mg/dL (group 1), patients without known DM with AG > 143 mg/dL (group 2), known DM with AG ≤ 213 mg/dL (group 3), and known DM with AG > 213 mg/dL (group 4). Primary outcome was defined as all-cause mortality during follow-up. A total of 2768 patients were included: 1425 in group 1, 426 in group 2, 593 in group 3, and 325 in group 4. After a median follow-up of 5.6 years, 1047 (37.8%) patients reached primary outcome. After multivariate analysis, group 4 was associated with the worst prognosis (HR 3.103, p < 0.001) followed by group 3 (HR 1.639, p = 0.002) and group 2 (HR 1.557, p = 0.039), when compared to group 1. When groups were stratified by type of AMI, patients in group 2 had a worse prognosis than patients in group 3 in the case of non-ST-segment elevation AMI. AH is associated with higher all-cause mortality in patients with AMI, irrespective of previous diabetic status.

The Effect of Aerobic Exercise Training Frequency on Arterial Stiffness in a Hyperglycemic State in Middle-Aged and Elderly Females

The frequency of aerobic exercise training in reducing the increase in arterial stiffness during acute hyperglycemia, a risk factor for cardiovascular disease, is unknown. The aim of the study was to determine the aerobic exercise training frequency on arterial stiffness in a hyperglycemic state in middle-aged and elderly females. Twenty healthy elderly people were randomly assigned to a two-times-a-week (T2, n = 10) and four-times-a-week (T4, n = 10) exercise group. All participants exercised for 35 min per session, which consisted of jogging exercises with a heart rate intensity of 65%. Brachial-ankle (ba), and heart-brachial (hb) pulse wave velocity (PWV) were measured before, 4 and 8 weeks after intervention; before the oral ingestion of 75-g of glucose; and 30, 60, and 90 min after ingestion. The baPWV before and 4 weeks after the intervention increased in both groups (p < 0.05), but only increased 8 weeks after intervention in the T2 group. hbPWV was unchanged before, 4 and 8 weeks after intervention in both groups. These findings show that frequent aerobic exercise suppresses the increase in arterial stiffness following glucose intake. The results of this study can be used to support the implementation of exercise programs for middle-aged and elderly patients.

Cardiovascular Benefits from Gliflozins: Effects on Endothelial Function

Type 2 diabetes mellitus (T2DM) is a known independent risk factor for atherosclerotic cardiovascular disease (CVD) and solid epidemiological evidence points to heart failure (HF) as one of the most common complications of diabetes. For this reason, it is imperative to consider the prevention of CV outcomes as an effective goal for the management of diabetic patients, as important as lowering blood glucose. Endothelial dysfunction (ED) is an early event of atherosclerosis involving adhesion molecules, chemokines, and leucocytes to enhance low-density lipoprotein oxidation, platelet activation, and vascular smooth muscle cell proliferation and migration. This abnormal vascular phenotype represents an important risk factor for the genesis of any complication of diabetes, contributing to the pathogenesis of not only macrovascular disease but also microvascular damage. Gliflozins are a novel class of anti-hyperglycemic agents used for the treatment of Type 2 diabetes mellitus (T2DM) that selectively inhibit the sodium glucose transporter 2 (SGLT2) in the kidneys and have provoked large interest in scientific community due to their cardiovascular beneficial effects, whose underlying pathophysiology is still not fully understood. This review aimed to analyze the cardiovascular protective mechanisms of SGLT2 inhibition in patients T2DM and their impact on endothelial function.

HCC and Molecular Targeting Therapies: Back to the Future

Hepatocellular carcinoma (HCC) is one of the leading causes of death from cancer in the world. Recently, the effectiveness of new antiviral therapies and the HBV vaccine have reduced HCC’s incidence, while non-alcoholic steato-hepatitis is an emerging risk factor. This review focuses on antiangiogenic molecules and immune checkpoint inhibitors approved for HCC treatment and possible future approaches. Sorafenib was the first drug approved for the treatment of advanced HCC (aHCC) and it has been shown to increase survival by a few months. Lenvatinib, a multikinase inhibitor, has shown non-inferiority in survival compared with sorafenib and an improvement in progression-free survival (PFS). The combination of atezolizumab (an anti-PDL1 antibody) and bevacizumab (an anti-VEGF antibody) was the first drug combination approved for HCC, demonstrating improved survival compared with sorafenib (19.2 vs. 13.4 months). As a second line of therapy, three regimens (regorafenib, cabozantinib, and ramucirumab) have been approved for the treatment of aHCC after progression on sorafenib according to guidelines. Furthermore, nivolumab, pembrolizumab, and nivolumab plus ipilimumab have been approved by the FDA (2017, 2018, and 2020, respectively). Finally, immune target therapy, cancer vaccines, and epigenetic drugs represent three new possible weapons for the treatment of HCC.

Risk factors for revascularization and in-stent restenosis in patients with triple-vessel disease after second-generation drug-eluting stent implantation: a retrospective analysis

Objectives

Coronary artery disease (CAD) is a common cardiac disease with high morbidity and mortality, and triple-vessel disease (TVD) is a severe type of CAD. This study investigated risk factors for revascularization and in-stent restenosis (ISR) in TVD patients who underwent second-generation drug-eluting stent implantation.

Methods

A retrospective clinical study was conducted, and 246 triple-vessel disease (TVD) patients with 373 vessels after second-generation drug-eluting stent (DES) implantation who received follow-up coronary angiography (CAG) were consequently enrolled. According to the follow-up angiography, patients were categorized into the revascularization group and nonrevascularization group as well as the in-stent restenosis (ISR) group and non-ISR group. Univariate and multivariate logistic regression analyses were used to identify risk factors for revascularization and ISR. Receiver operating characteristic (ROC) curve with area under the curve (AUC) analysis was performed to assess the predictive power of these risk factors.

Results

In the median follow-up period of 28.0 (14.0, 56.0) months, 142 TVD patients (57.7%) with 168 vessels underwent revascularization, and ISR occurred in 43 TVD patients (17.5%) with 47 vessels after second-generation DES implantation. Compared to the nonrevascularization group, the revascularization group presented with an increased rate of current smoking and higher levels of TC, LDL-C, HDL-C, non-HDL-c, ApoB, neutrophils, and Hs-CRP as well as a longer follow-up of months but with a lower level of HDL-C. In addition, patients in the ISR group had an older age, longer follow-up (months) and elevated rates of current smoking and stage 4–5 chronic kidney disease (CKD4-5). In multivariate analysis, current smoking and higher non-HDL-c were independent risk factors for revascularization. In addition, older age, current smoking and CKD4-5 were considered independent risk factors for ISR. Importantly, the receiver operating characteristic curve showed that non-HDL-C and age displayed predictive power for revascularization and ISR, respectively.

Conclusion

Current smoking is an independent risk factor for both revascularization and in-stent restenosis. Higher non-HDL-c is independently related to revascularization; moreover, increased age and CKD4-5 are potential risk factors for ISR in TVD patients after second-generation drug-eluting stent implantation.

Development and validation of a risk prediction nomogram for in-stent restenosis in patients undergoing percutaneous coronary intervention

Background

This study aimed to develop and validate a nomogram to predict probability of in-stent restenosis (ISR) in patients undergoing percutaneous coronary intervention (PCI).

Methods

Patients undergoing PCI with drug-eluting stents between July 2009 and August 2011 were retrieved from a cohort study in a high-volume PCI center, and further randomly assigned to training and validation sets. The least absolute shrinkage and selection operator (LASSO) regression model was used to screen out significant features for construction of nomogram. Multivariable logistic regression analysis was applied to build a nomogram-based predicting model incorporating the variables selected in the LASSO regression model. The area under the curve (AUC) of the receiver operating characteristics (ROC), calibration plot and decision curve analysis (DCA) were performed to estimate the discrimination, calibration and utility of the nomogram model respectively.

Results

A total of 463 patients with DES implantation were enrolled and randomized in the development and validation sets. The predication nomogram was constructed with five risk factors including prior PCI, hyperglycemia, stents in left anterior descending artery (LAD), stent type, and absence of clopidogrel, which proved reliable for quantifying risks of ISR for patients with stent implantation. The AUC of development and validation set were 0.706 and 0.662, respectively, indicating that the prediction model displayed moderate discrimination capacity to predict restenosis. The high quality of calibration plots in both datasets demonstrated strong concordance performance of the nomogram model. Moreover, DCA showed that the nomogram was clinically useful when intervention was decided at the possibility threshold of 9%, indicating good utility for clinical decision-making.

Conclusions

The individualized prediction nomogram incorporating 5 commonly clinical and angiographic characteristics for patients undergoing PCI can be conveniently used to facilitate early identification and improved screening of patients at higher risk of ISR.

Accuracy of neutrophil to lymphocyte and monocyte to lymphocyte ratios as new inflammatory markers in acute coronary syndrome

Background

Inflammation plays a key role in the development of atherosclerosis and in the pathogenesis of acute coronary syndrome (ACS). Leukocytes and leukocytes ratios were recognized as inflammatory markers in predicting the presence and severity of ACS.

Methods

This study aimed to investigate the diagnostic accuracy of neutrophil to lymphocyte ratio (NLR) and monocyte to lymphocyte ratio (MLR) with ACS. One hundred patients admitted to the Cardiac Center who were confirmed to have ACS and 100 healthy controls confirmed not to have ACS were enrolled in this study. ECG and troponin I test were used as gold standards to make sure that the participants with or without ACS. Total white blood cells (WBCs) count, NLR, and MLR values were estimated.

Results

Total WBCs, neutrophil, and monocyte counts were significantly higher while lymphocyte counts were significantly lower in ACS patients than in the healthy controls (p < 0.001). NLR and MLR were significantly higher in ACS patients than in the healthy controls (p < 0.001). Among all the studied markers, NLR was found to be the strongest predictive marker of ACS (OR: 3.3, p < 0.001), whereas MLR was non-significant (p > 0.05). A cut-off value of 2.9 of NLR had 90% sensitivity and 88% specificity while 0.375 cut-off value of MLR had 79% sensitivity, 91% specificity for predicting ACS presence.

Conclusions

NLR is a simple, widely available, and inexpensive inflammatory marker which can be an auxiliary biomarker in the diagnosis of ACS with a cut-off value of 2.9 in our population.

Clinical Impact of Thrombus Aspiration and Interaction With D-Dimer Levels in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Objectives: To evaluate the effect of thrombus aspiration (TA) strategy on the outcomes and its interaction with D-dimer levels in patients with ST-segment elevation myocardial infarction (STEMI) during primary percutaneous coronary intervention (PCI) in "real-world" settings. Materials and Methods: This study included 1,295 patients with STEMI who had undergone primary PCI with or without TA between January 2013 and June 2017. Patients were first divided into a TA+PCI group and a PCI-only group, and the baseline characteristics and long-term mortality between the two groups were analyzed. Furthermore, we studied the effect of TA on the clinical outcomes of patients grouped according to quartiles of respective D-dimer levels. The primary outcome was all-cause mortality, and the secondary outcomes were new-onset heart failure (HF), rehospitalization, re-PCI, and stroke. Results: In the original cohort, there were no significant differences in all-cause mortality between the TA+PCI and PCI-only groups (hazard ratio, 0.789; 95% confidence interval, 0.556-1.120; p = 0.185). After a mean follow-up of 2.5 years, the all-cause mortality rates of patients in the TA + PCI and PCI-only groups were 8.5 and 16.2%, respectively. Additionally, differences between the two groups in terms of the risk of HF, re-PCI, rehospitalization, and stroke were non-significant. However, after dividing into quartiles, as the D-dimer levels increased, the all-cause mortality rate in the PCI group gradually increased (4.3 vs. 6.0 vs. 7.0 vs. 14.7%, p < 0.001), while the death rate in the TA+PCI group did not significantly differ (4.6 vs. 5.0 vs. 4.0 vs. 3.75%, p = 0.85). Besides, in the quartile 3 (Q3) and quartile 4 (Q4) groups, the PCI-only group was associated with a higher risk of all-cause mortality than that of the TA+PCI group (Q3: 4.0 vs. 7.0%, p = 0.029; Q4: 3.75 vs. 14.7%, p < 0.001). Moreover, the multivariate logistic regression analysis demonstrated that TA is inversely associated with the primary outcome in the Q4 group [odds ratio (OR), 0.395; 95% CI, 0.164-0.949; p = 0.038]. Conclusions: The findings of our real-world study express that routine manual TA during PCI in STEMI did not improve clinical outcomes overall. However, patients with STEMI with a higher concentration of D-dimer might benefit from the use of TA during primary PCI. Large-scale studies are recommended to confirm the efficacy of TA.

Admission Hyperglycemia is Associated with Global Registry of Acute Coronary Events Score and Complications Following Acute Myocardial Infarction During 1-Year Follow-Up

We explored the effect of admission hyperglycemia (AH) on the Global Registry of Acute Coronary Events (GRACE) risk score and major adverse cardiovascular and cerebrovascular event (MACCE) incidence during 1-year follow-up in acute myocardial infarction (AMI) patients. In this retrospective observational study enrolling 1098 AMI patients, hyperglycemia was defined as blood glucose level ≥180 mg/dl at admission. Overall, 158 and 84 patients of 272 diabetic and 826 non-diabetic patients were diagnosed with AH, respectively. Glucose levels at admission were closely associated with the GRACE score in patients with/without diabetes. MACCEs occurred in 222 patients; patients with AH showed significantly higher MACCE incidence (28.1%). Multivariate Cox logistic regression analysis indicated that AH was an independent risk factor for 1-year MACCEs. Subgroup analysis demonstrated that hyperglycemia increases MACCE risk in non-diabetic patients but not in diabetic patients. The admission glucose level combined with GRACE risk score showed a certain predictive value for MACCE incidence according to ROC analysis (OR = 0.798, p < .001). AH was strongly associated with a higher GRACE risk score in ST-segment elevation myocardial infarction patients. Thus, AH was an independent risk factor and had a high predictive value for MACCE during 1-year follow-up after AMI.

Association of stent diameter and target vessel revascularization in patients undergoing percutaneous coronary intervention: a secondary retrospective analysis based on a Chinese cohort study

Background

In the treatment of coronary heart disease, target vessel revascularization (TVR) has attracted increasing attention as an efficient means of percutaneous coronary intervention (PCI). The purpose of this study was to explore the association between stent diameter and TVR in patients undergoing PCI.

Methods

This was a secondary retrospective analysis involving patients with PCI with at least one stent implanted. Information was obtained from the Dryad Digital Repository. Multivariable logistic regression models, interaction analyses, subgroup analyses and piecewise linear regression models were used to evaluate the association between stent diameter and TVR.

Results

A total of 2522 patients were eventually enrolled in this study, of which 122 (4.8%) had undergone TVR. Significant positive associations were observed between stent diameter and TVR (continuous: odds ratio [OR] 0.485, 95% confidence interval [CI] 0.305–0.773, P = 0.002; categorical variable: T2 vs. T1, OR 0.541, 95% CI 0.348–0.843; T3 vs. T1, OR 0.520, 95% CI 0.334–0.809; P for trend = 0.005). The association remained stable in the fully adjusted model (continuous: OR 0.526, 95% CI 0.306–0.902, P = 0.020; categorical variable: T2 vs. T1, OR 0.510, 95% CI 0.310–0.839; T3 vs. T1, OR 0.585, 95% CI 0.352–0.973; P for trend = 0.042). Among the subgroups of differing clinical presentations, stent diameter was a powerful protective factor for TVR, especially in the delayed PCI group (P for interaction = 0.002). The association was highly consistent across all the other subgroups studied (all P for interaction > 0.05). In the piecewise linear regression model, the need for TVR decreased with an increase in stent diameter when this ranged between 2.5 and 2.9 mm (OR 0.01, 95% CI: 0.01–0.13, P < 0.001).

Conclusions

A large stent diameter is a powerful protective factor for TVR in PCI patients, especially in the delayed PCI group. This “bigger-is-better” protective effect is remarkable in stents with diameter 2.5–2.9 mm.

Influence of Hyperglycemia and Diabetes on Cardioprotection by Humoral Factors Released after Remote Ischemic Preconditioning (RIPC)

Remote ischemic preconditioning (RIPC) protects hearts from ischemia-reperfusion (I/R) injury in experimental studies; however, clinical RIPC trials were unsatisfactory. This discrepancy could be caused by a loss of cardioprotection due to comorbidities in patients, including diabetes mellitus (DM) and hyperglycemia (HG). RIPC is discussed to confer protective properties by release of different humoral factors activating cardioprotective signaling cascades. Therefore, we investigated whether DM type 1 and/or HG (1) inhibit the release of humoral factors after RIPC and/or (2) block the cardioprotective effect directly at the myocardium. Experiments were performed on male Wistar rats. Animals in part 1 of the study were either healthy normoglycemic (NG), type 1 diabetic (DM1), or hyperglycemic (HG). RIPC was implemented by four cycles of 5 min bilateral hind-limb ischemia/reperfusion. Control (Con) animals were not treated. Blood plasma taken in vivo was further investigated in isolated rat hearts in vitro. Plasma from diseased animals (DM1 or HG) was administered onto healthy (NG) hearts for 10 min before 33 min of global ischemia and 60 min of reperfusion. Part 2 of the study was performed vice versa-plasma taken in vivo, with or without RIPC, from healthy rats was transferred to DM1 and HG hearts in vitro. Infarct size was determined by TTC staining. Part 1: RIPC plasma from NG (NG Con: 49 ± 8% vs. NG RIPC 29 ± 6%; p < 0.05) and DM1 animals (DM1 Con: 47 ± 7% vs. DM1 RIPC: 38 ± 7%; p < 0.05) reduced infarct size. Interestingly, transfer of HG plasma showed comparable infarct sizes independent of prior treatment (HG Con: 34 ± 9% vs. HG RIPC 35 ± 9%; ns). Part 2: No infarct size reduction was detectable when transferring RIPC plasma from healthy rats to DM1 (DM1 Con: 54 ± 13% vs. DM1 RIPC 53 ± 10%; ns) or HG hearts (HG Con: 60 ± 16% vs. HG RIPC 53 ± 14%; ns). These results suggest that: (1) RIPC under NG and DM1 induces the release of humoral factors with cardioprotective impact, (2) HG plasma might own cardioprotective properties, and (3) RIPC does not confer cardioprotection in DM1 and HG myocardium.

Does a strict glycemic control during acute coronary syndrome play a cardioprotective effect? Pathophysiology and clinical evidence

A hyperglycemic state, also in non-diabetic subjects, may be associated with acute coronary syndrome (ACS). Aim of this review is to describe the pathophysiologic association between ACS and hyperglycemic state, the protective mechanisms of a tight glycaemic control in ACS on CV outcomes, and the supporting clinical evidence. Several mechanisms may be responsible of a poor CV outcome in subjects with hyperglycemia during ACS. Endothelial NAPDH oxidase-2 (NOX2) activation in response to high glucose alters the balance between Raf/MAPK-dependent vasoconstriction and PI3K/Akt-dependent vasodilation in favour of constriction. Hyperglycaemia induces an overproduction of superoxide by the mitochondrial electron transport chain through different molecular mechanisms. Moreover, hyperglycaemia increases the size of the infarct by causing myocardial cell death through apoptosis and reducing the collateral blood flow. High FFA concentrations lead to toxicity mechanisms in acutely ischemic myocardium. On the other hand, a tight glycaemic control in ACS exerts a cardioprotective action by anti-inflammatory and anti-apoptotic mechanisms, anti-oxidative stress, endothelium protection, FFA reduction, anti-glucotoxic effect, IR and cardiac fuel metabolisms improvement, heart stem cells protection and reduced activation of adrenergic system. Unfortunately, the clinical studies supporting the above pathophysiological background are few and sometimes controversial, more likely due the risk of hypoglycemia linked to the insulin therapy generally used during ACS. Intriguingly, GLP-1 RA and SGLT2i, demonstrated highly effective in the cardiovascular prevention in high-risk subjects without the risk of hypoglycemia, might keep this cardioprotective effect even in acute conditions such as ASC.

Sugar- and Artificially Sweetened Beverages Consumption Linked to Type 2 Diabetes, Cardiovascular Diseases, and All-Cause Mortality: A Systematic Review and Dose-Response Meta-Analysis of Prospective Cohort Studies

Although studies have examined the association between habitual consumption of sugar- (SSBs) and artificially sweetened beverages (ASBs) and health outcomes, the results are inconclusive. Here, we conducted a dose-response meta-analysis of prospective cohort studies in order to summarize the relationship between SSBs and ASBs consumption and risk of type 2 diabetes (T2D), cardiovascular diseases (CVDs), and all-cause mortality. All relevant articles were systematically searched in PubMed, Embase, and Ovid databases until 20 June 2020. Thirty-four studies met the inclusion criteria and were eligible for analysis. Summary relative risks (RRs) and 95% confidence intervals (95% CI) were estimated using random effects or fixed-effects model for highest versus lowest intake categories, as well as for linear and non-linear relationships. With each additional SSB and ASB serving per day, the risk increased by 27% (RR: 1.27, 95%CI: 1.15–1.41, I² = 80.8%) and 13% (95%CI: 1.03–1.25, I² = 78.7%) for T2D, 9% (RR: 1.09, 95%CI: 1.07–1.12, I² = 42.7%) and 8% (RR: 1.08, 95%CI: 1.04–1.11, I² = 45.5%) for CVDs, and 10% (RR: 1.10, 95%CI: 0.97–1.26, I² = 86.3%) and 7% (RR: 1.07, 95%CI: 0.91–1.25, I² = 76.9%) for all-cause mortality. Linear relationships were found for SSBs with T2D and CVDs. Non-linear relationships were found for ASBs with T2D, CVDs, and all-cause mortality and for SSBs with all-cause mortality. The findings from the current meta-analysis indicate that increased consumption of SSBs and ASBs is associated with the risk of T2D, CVDs, and all-cause mortality.

Cardioprotection by SGLT2 Inhibitors-Does It All Come Down to Na+?

Sodium-glucose co-transporter 2 inhibitors (SGLT2i) are emerging as a new treatment strategy for heart failure with reduced ejection fraction (HFrEF) and—depending on the wistfully awaited results of two clinical trials (DELIVER and EMPEROR-Preserved)—may be the first drug class to improve cardiovascular outcomes in patients suffering from heart failure with preserved ejection fraction (HFpEF). Proposed mechanisms of action of this class of drugs are diverse and include metabolic and hemodynamic effects as well as effects on inflammation, neurohumoral activation, and intracellular ion homeostasis. In this review we focus on the growing body of evidence for SGLT2i-mediated effects on cardiac intracellular Na⁺ as an upstream mechanism. Therefore, we will first give a short overview of physiological cardiomyocyte Na⁺ handling and its deterioration in heart failure. On this basis we discuss the salutary effects of SGLT2i on Na⁺ homeostasis by influencing NHE1 activity, late I_Na as well as CaMKII activity. Finally, we highlight the potential relevance of these effects for systolic and diastolic dysfunction as well as arrhythmogenesis.

Efficacy and durability of multifactorial intervention on mortality and MACEs: a randomized clinical trial in type-2 diabetic kidney disease

BACKGROUND

Multiple modifiable risk factors for late complications in patients with diabetic kidney disease (DKD), including hyperglycemia, hypertension and dyslipidemia, increase the risk of a poor outcome. DKD is associated with a very high cardiovascular risk, which requires simultaneous treatment of these risk factors by implementing an intensified multifactorial treatment approach. However, the efficacy of a multifactorial intervention on major fatal/non-fatal cardiovascular events (MACEs) in DKD patients has been poorly investigated.

METHODS

Nephropathy in Diabetes type 2 (NID-2) study is a multicentre, cluster-randomized, open-label clinical trial enrolling 395 DKD patients with albuminuria, diabetic retinopathy (DR) and negative history of CV events in 14 Italian diabetology clinics. Centres were randomly assigned to either Standard-of-Care (SoC) (n = 188) or multifactorial intensive therapy (MT, n = 207) of main cardiovascular risk factors (blood pressure < 130/80 mmHg, glycated haemoglobin < 7%, LDL, HDL and total cholesterol < 100 mg/dL, > 40/50 mg/dL for men/women and < 175 mg/dL, respectively). Primary endpoint was MACEs occurrence by end of follow-up phase. Secondary endpoints included single components of primary endpoint and all-cause death.

RESULTS

At the end of intervention period (median 3.84 and 3.40 years in MT and SoC group, respectively), targets achievement was significantly higher in MT. During 13.0 years (IQR 12.4-13.3) of follow-up, 262 MACEs were recorded (116 in MT vs. 146 in SoC). The adjusted Cox shared-frailty model demonstrated 53% lower risk of MACEs in MT arm (adjusted HR 0.47, 95%CI 0.30-0.74, P = 0.001). Similarly, all-cause death risk was 47% lower (adjusted HR 0.53, 95%CI 0.29-0.93, P = 0.027).

CONCLUSION

MT induces a remarkable benefit on the risk of MACEs and mortality in high-risk DKD patients. Clinical Trial Registration ClinicalTrials.gov number, NCT00535925. https://clinicaltrials.gov/ct2/show/NCT00535925.

The Diabetic Cardiomyopathy: The Contributing Pathophysiological Mechanisms

Individuals with diabetes mellitus (DM) disclose a higher incidence and a poorer prognosis of heart failure (HF) than non-diabetic people, even in the absence of other HF risk factors. The adverse impact of diabetes on HF likely reflects an underlying “diabetic cardiomyopathy” (DM–CMP), which may by exacerbated by left ventricular hypertrophy and coronary artery disease (CAD). The pathogenesis of DM-CMP has been a hot topic of research since its first description and is still under active investigation, as a complex interplay among multiple mechanisms may play a role at systemic, myocardial, and cellular/molecular levels. Among these, metabolic abnormalities such as lipotoxicity and glucotoxicity, mitochondrial damage and dysfunction, oxidative stress, abnormal calcium signaling, inflammation, epigenetic factors, and others. These disturbances predispose the diabetic heart to extracellular remodeling and hypertrophy, thus leading to left ventricular diastolic and systolic dysfunction. This Review aims to outline the major pathophysiological changes and the underlying mechanisms leading to myocardial remodeling and cardiac functional derangement in DM-CMP.

Association between Hyperglycemia at Hospital Presentation and Hospital Outcomes in COVID-19 Patients with and without Type 2 Diabetes: A Retrospective Cohort Study of Hospitalized Inner-City COVID-19 Patients

This study aimed to determine the relationships among hyperglycemia (HG), the presence of type 2 diabetes (T2D), and the outcomes of COVID-19. Demographic data, blood glucose levels (BG) measured on admission, and hospital outcomes of COVID-19 patients hospitalized at Boston University Medical Center from 1 March to 4 August 2020 were extracted from the hospital database. HG was defined as BG > 200 mg/dL. Patients with type 1 diabetes or BG < 70 mg/dL were excluded. A total of 458 patients with T2D and 976 patients without T2D were included in the study. The mean ± SD age was 56 ± 17 years and 642 (45%) were female. HG occurred in 193 (42%) and 42 (4%) of patients with and without T2D, respectively. Overall, the in-hospital mortality rate was 9%. Among patients without T2D, HG was statistically significantly associated with mortality, ICU admission, intubation, acute kidney injury, and severe sepsis/septic shock, after adjusting for potential confounders (p < 0.05). However, only ICU admission and acute kidney injury were associated with HG among patients with T2D (p < 0.05). Among the 235 patients with HG, the presence of T2D was associated with decreased odds of mortality, ICU admission, intubation, and severe sepsis/septic shock, after adjusting for potential confounders, including BG (p < 0.05). In conclusion, HG in the subset of patients without T2D could be a strong indicator of high inflammatory burden, leading to a higher risk of severe COVID-19.

Relation of insulin treatment for type 2 diabetes to the risk of major adverse cardiovascular events after acute coronary syndrome: an analysis of the BETonMACE randomized clinical trial

Background

In stable patients with type 2 diabetes (T2D), insulin treatment is associated with elevated risk for major adverse cardiovascular events (MACE). Patients with acute coronary syndrome (ACS) and T2D are at particularly high risk for recurrent MACE despite evidence-based therapies. It is uncertain to what extent this risk is further magnified in patients with recent ACS who are treated with insulin. We examined the relationship of insulin use to risk of MACE and modification of that risk by apabetalone, a bromodomain and extra-terminal (BET) protein inhibitor.

Methods

The analysis utilized data from the BETonMACE phase 3 trial that compared apabetalone to placebo in patients with T2D, low HDL cholesterol, andACS. The primary MACE outcome (cardiovascular death, myocardial infarction, or stroke) was examined according to insulin treatment and assigned study treatment. Multivariable Cox regression was used to determine whether insulin use was independently associated with the risk of MACE.

Results

Among 2418 patients followed for median 26.5 months, 829 (34.2%) were treated with insulin. Despite high utilization of evidence-based treatments including coronary revascularization, intensive statin treatment, and dual antiplatelet therapy, the 3-year incidence of MACE in the placebo group was elevated among insulin-treated patients (20.4%) compared to those not-treated with insulin (12.8%, P = 0.0001). Insulin treatment remained strongly associated with the risk of MACE (HR 2.10, 95% CI 1.42–3.10, P = 0.0002) after adjustment for demographic, clinical, and treatment variables. Apabetalone had a consistent, favorable effect on MACE in insulin-treated and not insulin-treated patients.

Conclusion

Insulin-treated patients with T2D, low HDL cholesterol, and ACS are at high risk for recurrent MACE despite the use of evidence-based, contemporary therapies. A strong association of insulin treatment with risk of MACE persists after adjustment for other characteristics associated with MACE. There is unmet need for additional treatments to mitigate this risk.

Trial registration ClinicalTrials.gov NCT02586155, registered October 26, 2015

Impact of SGLT2 Inhibitors on Heart Failure: From Pathophysiology to Clinical Effects

Heart failure (HF) affects up to over 20% of patients with type 2 diabetes (T2DM), even more in the elderly. Although, in T2DM, both hyperglycemia and the proinflammatory status induced by insulin resistance are crucial in cardiac function impairment, SGLT2i cardioprotective mechanisms against HF are several. In particular, these beneficial effects seem attributable to the significant reduction of intracellular sodium levels, well-known to exert a cardioprotective role in the prevention of oxidative stress and consequent cardiomyocyte death. From a molecular perspective, patients’ exposure to gliflozins’ treatment mimics nutrient and oxygen deprivation, with consequent autophagy stimulation. This allows to maintain the cellular homeostasis through different degradative pathways. Thus, since their introduction in the clinical practice, the hypotheses on SGLT2i mechanisms of action have changed: from simple glycosuric drugs, with consequent glucose lowering, erythropoiesis enhancing and ketogenesis stimulating, to intracellular sodium-lowering molecules. This provides their consequent cardioprotective effect, which justifies its significant reduction in CV events, especially in populations at higher risk. Finally, the updated clinical evidence of SGLT2i benefits on HF was summarized. Thus, this review aimed to analyze the cardioprotective mechanisms of sodium glucose transporter 2 inhibitors (SGLT2i) in patients with HF, as well as their clinical impact on cardiovascular events.

The association between glycaemic control during hospitalization and risk of adverse events: A retrospective cohort study

Introduction

Hyperglycaemia is common during hospitalization; glycaemic targets in non‐critical care settings have not been well studied. We assessed associations between inpatient glycaemic control and adverse events.

Methods

We conducted a retrospective cohort study on non‐critically ill medical patients hospitalized in a tertiary care hospital between 2015 and 2018. Mean glycaemia during the first four days of hospitalization was categorized as 4.0–7.0 mmol/L, 7.1–10.0 mmol/L and >10.0 mmol/L. The primary outcome was a composite of adverse events including mortality, infections, acute kidney injury, thromboembolic and cardiovascular events. The secondary outcome was hypoglycaemia, defined as any glycaemia <4.0 mmol/L. Logistic regression was used to assess adverse events, and a Cox proportional hazards model was used to estimate hypoglycaemia risk.

Results

Our cohort included 1,368 patients, of whom 407 (29.8%) experienced an adverse event. We did not find associations between glycaemia of 4.0–7.0 mmol/L (adjusted odds ratio [OR]: 0.88, 95% confidence interval [CI]: 0.63–1.23) or glycaemia of >10.0 mmol/L (adjusted OR: 0.98, 95% CI: 0.75–1.28) and the occurrence of adverse events, compared to a glycaemia of 7.1–10.0 mmol/L. Glycaemia of >10.0 mmol/L was associated with an increased risk of hypoglycaemia (adjusted hazard ratio [HR]: 1.72, 95% CI: 1.21–2.45). Hypoglycaemia was associated with adverse events (adjusted OR 1.85, 95% CI 1.31–2.60).

Conclusions

Neither glycaemia of 4.0–7.0 mmol/L nor glycaemia of >10.0mmol/L during non‐critical care hospitalization was associated with increased adverse events. Glycaemia of >10.0 mmol/L was associated with increased hypoglycaemia, likely due to aggressive glucose lowering. These findings highlight the need for further studies to discern optimal inpatient glycaemic targets.