Association between the AHA life's essential 8 and prediabetes/diabetes: a cross-sectional NHANES study

Background and aims

The American Heart Association (AHA) recently introduced the Life's Essential 8 (LE8) to improve cardiovascular health (CVH). However, the association between LE8 and the risk of prediabetes or diabetes is not yet fully understood. Consequently, this study aims to assess the association between CVH, as evaluated by LE8, and the risk of prediabetes and diabetes.

Methods and Results

This cross-sectional study encompassed 7,739 participants aged ≥20 years from the 2007-2018 National Health and Nutrition Examination Surveys (NHANES). The CVH of participants was evaluated using the LE8, combining four health behaviors and three health factors. Glucose metabolic status categories included normal glucose metabolism, prediabetes including isolated impaired fasting glucose, isolated impaired glucose tolerance, both IFG and IGT, and diabetes. The associations between CVH and prediabetes and diabetes were analyzed using logistic regression, linear regression, restricted cubic splines, and subgroup analyses. Among 7,739 participants, 1,949 had iIFG, 1,165 were diagnosed with iIGT, 799 were IFG+IGT, and 537 were diagnosed with diabetes. After multivariable adjustments, CVH scores were inversely associated with prediabetes and diabetes, with the most robust inverse association observed between IFG+IGT and CVH across all prediabetes subgroups. Of all CVH components not directly in the causal pathway, body mass index (BMI) had the most robust associations with prediabetes and diabetes. Subgroup analyses indicated that the negative correlation between CVH and prediabetes was stronger among those with university or higher education.

Conclusion

CVH, as defined by LE8, showed a significant negative association with prediabetes and diabetes.

Extracellular Vesicles in Diabetic Cardiomyopathy-State of the Art and Future Perspectives

Cardiovascular complications are the most deadly and cost-driving effects of diabetes mellitus (DM). One of them, which is steadily attracting attention among scientists, is diabetes-induced heart failure, also known as diabetic cardiomyopathy (DCM). Despite significant progress in the research concerning the disease, a universally accepted definition is still lacking. The pathophysiology of the processes accelerating heart insufficiency in diabetic patients on molecular and cellular levels also remains elusive. However, the recent interest concerning extracellular vesicles (EVs) has brought promise to further clarifying the pathological events that lead to DCM. In this review, we sum up recent investigations on the involvement of EVs in DCM and show their therapeutic and indicatory potential.

A review of air pollution as a driver of cardiovascular disease risk across the diabetes spectrum

The prevalence of diabetes is estimated to reach almost 630 million cases worldwide by the year 2045; of current and projected cases, over 90% are type 2 diabetes. Air pollution exposure has been implicated in the onset and progression of diabetes. Increased exposure to fine particulate matter air pollution (PM2.5) is associated with increases in blood glucose and glycated hemoglobin (HbA1c) across the glycemic spectrum, including normoglycemia, prediabetes, and all forms of diabetes. Air pollution exposure is a driver of cardiovascular disease onset and exacerbation and can increase cardiovascular risk among those with diabetes. In this review, we summarize the literature describing the relationships between air pollution exposure, diabetes and cardiovascular disease, highlighting how airborne pollutants can disrupt glucose homeostasis. We discuss how air pollution and diabetes, via shared mechanisms leading to endothelial dysfunction, drive increased cardiovascular disease risk. We identify portable air cleaners as potentially useful tools to prevent adverse cardiovascular outcomes due to air pollution exposure across the diabetes spectrum, while emphasizing the need for further study in this particular population. Given the enormity of the health and financial impacts of air pollution exposure on patients with diabetes, a greater understanding of the interventions to reduce cardiovascular risk in this population is needed.

The Impact of Glucagon-Like Peptide-1 Receptor Agonist on the Cardiovascular Outcomes in Patients With Type 2 Diabetes Mellitus: A Meta-Analysis and Systematic Review

Background

Since 2005, the cardioprotective effects of glucagon-like peptide 1 receptor agonists (GLP-1 RAs) have garnered attention. The cardioprotective effect could be an added benefit to the use of GLP-1 RA. This systematic review and meta-analysis aimed at summarizing observational studies that recruited type 2 diabetes individuals with fewer cardiovascular (CV) events before enrolling in the research.

Methods

Systematically, the databases were searched for observational studies reporting compound CV events and deaths in type 2 diabetics without having the risk of cardiovascular diseases (CVDs) compared to other glucose-lowering agents. A meta-analysis was carried out using random effects model to estimate the overall hazard ratio (HR) with a 95% confidence interval (CI). Five studies were found eligible for the systematic review including a total of 64,452 patients receiving either liraglutide (three studies) or exenatide (two studies).

Results

The pooled HR for major adverse cardiac event (MACE) and extended MACE was 0.72 (95% CI: 0.65 - 0.93, I2 = 68%) and 0.93 (95% CI: 0.89 - 0.98, I2 = 29%), respectively. The pooled HR for hospitalization due to heart failure (HHF) and occurrence of HF was 0.84 (95% CI: 0.77 - 0.91, I2 = 79%) and 0.83 (95% CI: 0.75 - 0.94, I2 = 95%), respectively. For stroke, GLP-1 RA was associated with a significant risk reduction of 0.86 (95% CI: 0.75 - 0.98, I2 = 81%). There was no significant myocardial infarction (MI) risk reduction with GLP-1 RA. As for all-cause mortality, the pooled HR for the occurrence of all-cause mortality was 0.82 (95% CI: 0.76 - 0.88, I2 = 0%). The pooled HR for the occurrence of CV death was 0.75 (95% CI: 0.65 - 0.85, I2 = 38%). GLP-1 RA therapy was associated with a significantly low risk of MACE, extended MACE, all-cause mortality, and CV mortality. Except for MACE, the heterogenicity among the studies was low.

Conclusion

We conclude that GLP-1 RA is associated with a low risk of CV events composites and mortality. The findings support the cardioprotective effect of GLP-1 RA.

(Poly)phenol intake, plant-rich dietary patterns and cardiometabolic health: a cross-sectional study

Diet is an important modifiable risk factor for cardiometabolic diseases. Plant foods contain a complex mixture of nutrients and bioactive compounds such as (poly)phenols. Plant-rich dietary patterns have been associated with reduced cardiometabolic risk in epidemiological studies. However, studies have not fully considered (poly)phenols as a mediating factor in the relationship. A cross-sectional analysis was conducted in 525 healthy participants, aged 41.6 ± 18.3 years. Volunteers completed the validated European Prospective Investigation into Diet and Cancer (EPIC) Norfolk Food Frequency Questionnaire (FFQ). We investigated the associations between plant-rich dietary patterns, (poly)phenol intake, and cardiometabolic health. Positive associations were found between (poly)phenols and higher adherence to dietary scores, except for the unhealthy Plant-based Diet Index (uPDI), which was negatively associated with (poly)phenol intake. Correlations were significant for healthy PDI (hPDI), with positive associations with proanthocyanidins (r = 0.39, p < 0.01) and flavonols (r = 0.37, p < 0.01). Among dietary scores, Dietary Approaches to Stop Hypertension (DASH) showed negative associations with diastolic blood pressure (DBP), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and non-high-density lipoprotein cholesterol (Non-HDL-C) (stdBeta -0.12 to -0.10, p < 0.05). The Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) score was positively associated with flow-mediated dilation (FMD, stdBeta = 0.10, p = 0.02) and negatively associated with the 10-year Atherosclerotic Cardiovascular Disease (ASCVD) risk score (stdBeta = -0.12, p = 0.01). Higher intake of flavonoids, flavan-3-ols, flavan-3-ol monomers, theaflavins, and hydroxybenzoic acids (stdBeta: -0.31 to -0.29, p = 0.02) also showed a negative association with a 10-year ASCVD risk score. Flavanones showed significant associations with cardiometabolic markers such as fasting plasma glucose (FPG) (stdBeta = -0.11, p = 0.04), TC (stdBeta = -0.13, p = 0.03), and the Homeostasis Model Assessment (HOMA) of beta cell function (%B) (stdBeta = 0.18, p = 0.04). Flavanone intake was identified as a potential partial mediator in the negative association between TC and plant-rich dietary scores DASH, Original Mediterranean diet scores (O-MED), PDI, and hPDI (proportion mediated = 0.01% to 0.07%, p < 0.05). Higher (poly)phenol intake, particularly flavanone intake, is associated with higher adherence to plant-rich dietary patterns and favourable biomarkers of cardiometabolic risk indicating (poly)phenols may be mediating factors in the beneficial effects.

Food insecurity and atherosclerotic cardiovascular disease risk in adults with diabetes

OBJECTIVES

Adults with diabetes are at an increased risk of atherosclerotic cardiovascular disease (ASCVD), and food insecurity may be a major and underappreciated risk compounder in this population. We sought to analyze the prevalence of food insecurity and its association with ASCVD in adults with diabetes.

METHODS

A total of 6424 participants with diabetes were included from the 2019 and 2020 National Health Interview Survey. Food insecurity was determined with a 10-question U.S. Adult Food Security Survey Module, and classified as high, marginal, low, and very low. ASCVD was defined as a self-reported history of coronary artery disease, myocardial infarction, or stroke.

RESULTS

Of the 6424 included participants (weighted: n = 21 690 217), 5 405 543 (24.4%) reported a history of ASCVD and 2 946 061 (13.3%) were identified as food insecure (low or very low food security). Adults with food insecurity were more likely to have ASCVD than adults who were food secure (28.9% vs 23.7%; P = 0.008). In the multivariate analyses adjusted for traditional cardiovascular risk factors, all levels of food insecurity were associated with ASCVD compared with food-secure adults (marginal security: odds ratio [OR]: 1.60; 95% confidence interval [CI], 1.18-2.18]; P = 0.003; low security: OR: 2.09; 95% CI, 1.58-2.74]; P < 0.001; very low security: OR: 1.69; 95% CI, 1.22-2.34]; P = 0.001). The association persisted when adjusted for income, location, education, and insurance status. In adults with diabetes and ASCVD, income was a negative factor for food insecurity (OR: 0.71; 95% CI, 0.62-0.80; P < 0.001), but female sex and smoking were positive factors (OR: 1.90; 95% CI, 1.29-2.80; P = 0.001; and OR: 1.97; 95% CI, 1.23-3.18; P = 0.005; respectively). At younger ages, the prevalence of food insecurity increased, especially in adults with ASCVD.

CONCLUSIONS

We showed that 13% of U.S. adults with diabetes are food insecure, which was associated with ASCVD independent of traditional and socioeconomic risk factors. Our findings emphasize the importance of recognizing food insecurity as a driver of ASCVD in adults with diabetes, and encourage future efforts at reducing this disparity.

The clinical implications of pre-liver transplant diabetes on post-liver transplant outcomes in patients with NASH: analysis of the UNOS database

BACKGROUND AND AIMS

The presence of perioperative diabetes may lead to increased mortality risks following liver transplant (LT) in patients with non-alcoholic steatohepatitis (NASH). This risk factor was evaluated using a UNOS-STAR national database.

METHODS

The UNOS-STAR liver transplant registry 2005-2019 was used to select patients with NASH (including cryptogenic liver disease). The following populations were excluded: those younger than 18 years old and those with living donors/dual transplants. Selected patients were stratified into those with and without pre-LT diabetes and compared to the individual mortality endpoints using iterative Cox analyses.

RESULTS

6324 recipients with and 8251 without diabetes were selected. The median follow-up time was 3.07 years. Those with diabetes were older (58.50 vs. 54.50 years, p < 0.001), were more likely to be Hispanic or Asian, and had higher BMI than the non-diabetics (31.10 vs. 29.70 kg/m² p < 0.001); however, there was no difference in gender (female 41.9 vs. 43.1% p = 0.170). Compared to non-diabetics, recipients with diabetes had a higher rate of all-cause mortality (61.68 vs. 47.80 per 1000 person-years). In multivariate iterations, pre-LT diabetes was associated with all-cause mortality (aHR 1.19 95% CI 1.11-1.27) as well as deaths due to cardiac (p = 0.014 aHR 1.24 95% CI 1.04-1.46) and renal causes (p = 0.039 aHR 1.38 95% CI 1.02-1.87).

CONCLUSION

The presence of pre-LT diabetes is associated with all-cause mortality and deaths due to cardiac and renal causes following LT. The findings warrant an early preoperative screening procedure to ensure that patients with diabetes have their metabolic risk factors optimized prior to LT.

Factors Associated With Discordant A1C-Estimated and Measured Average Glucose Among Hospitalized Patients With Diabetes

In this retrospective analysis, we explored the correlation between measured average glucose (mAG) and A1C-estimated average glucose (eAG) in hospitalized patients with diabetes and identified factors associated with discordant mAG and eAG at the transition from home to hospital. Having mAG lower than eAG was associated with Black race, other race, increasing length of stay, community hospital setting, surgery, fever, metformin use, certain inpatient diets, home antihyperglycemic treatment, and coded type 1 or type 2 diabetes. Having mAG higher than eAG was associated with certain discharge services (e.g., intensive care unit), higher BMI, hypertension, tachycardia, higher albumin, higher potassium, anemia, inpatient glucocorticoid use, and treatment with home insulin, secretagogues, and glucocorticoids. These factors should be considered when using patients' A1C as an indicator of outpatient glycemic control to determine the inpatient antihyperglycemic regimens.

Sodium and Health: Old Myths and a Controversy Based on Denial

PURPOSE OF REVIEW

The scientific consensus on which global health organizations base public health policies is that high sodium intake increases blood pressure (BP) in a linear fashion contributing to cardiovascular disease (CVD). A moderate reduction in sodium intake to 2000 mg per day helps ensure that BP remains at a healthy level to reduce the burden of CVD.

RECENT FINDINGS

Yet, since as long ago as 1988, and more recently in eight articles published in the European Heart Journal in 2020 and 2021, some researchers have propagated a myth that reducing sodium does not consistently reduce CVD but rather that lower sodium might increase the risk of CVD. These claims are not well-founded and support some food and beverage industry's vested interests in the use of excessive amounts of salt to preserve food, enhance taste, and increase thirst. Nevertheless, some researchers, often with funding from the food industry, continue to publish such claims without addressing the numerous objections. This article analyzes the eight articles as a case study, summarizes misleading claims, their objections, and it offers possible reasons for such claims. Our study calls upon journal editors to ensure that unfounded claims about sodium intake be rigorously challenged by independent reviewers before publication; to avoid editorial writers who have been co-authors with the subject paper's authors; to require statements of conflict of interest; and to ensure that their pages are used only by those who seek to advance knowledge by engaging in the scientific method and its collegial pursuit. The public interest in the prevention and treatment of disease requires no less.

Mortality, Cardiovascular and Limb Events in Patients With Symptomatic Lower Extremity Artery Disease and Diabetes

The aim of this study was to compare the prognosis of patients according to diabetes status, during a 1-year follow-up after hospital admission for lower extremity artery disease, in the prospective COPART (COhorte de Patients ARTériopathes) registry. Inclusion criteria were intermittent claudication, ischemic rest pain, tissue loss, or acute limb ischemia, with radiological and hemodynamic confirmation. Among 2494 patients, 1235 (49.5%) had diabetes. Incidence rates for major adverse cardiovascular events (MACE) were 18.0/100 person-years (95% confidence interval [CI], 15.4-21.0) for the diabetes group and 11.1/100 person-years (95% CI, 9.2-13.4) for the non-diabetes group. Incidence rates of all-cause mortality were 29.8/100 person-years (95% CI, 26.5-33.4) for the diabetes group and 19.7/100 person-years (95% CI, 17.2-22.7) for the non-diabetes group. Incidence rates of major limb amputation were 24.2/100 person-years (95% CI, 21.1-27.8) for the diabetes group and 11.6/100 person-years (95% CI, 9.6-14.0) for the non-diabetes group. Diabetes was associated with MACE, adjusted hazard ratio 1.60 (95% CI, 1.16-2.22), and all-cause mortality, unadjusted HR 1.49 (95% CI, 1.24-1.78). In the multivariate analysis, diabetes was no longer associated with major amputation, adjusted HR 1.15 (95% CI, .87-1.51). Patients hospitalized for LEAD with diabetes had a higher risk of MACE than those without diabetes.

Targeting the microRNAs in exosome: A potential therapeutic strategy for alleviation of diabetes-related cardiovascular complication

Diabetes-related cardiovascular disease (CVD) is a global health issue that causes thousands of people's death around the world annually. Diabetes-related CVD is still prevailing despite the progression being made in its diagnosis and treatment. Therefore it is urgent to find therapeutic strategies.to prevent it. MicroRNA (miRNA) is a single-stranded non-coding RNA involved in the process of post-transcriptional control of gene expression in eukaryotes. A large number of literatures reveal that miRNAs are implicated in diabetes-related CVD. The increase of miRNAs in exosomes may promote the occurrence and development of diabetes-related cardiovascular complication. However, some other studies identify that miRNAs in exosomes are supposed to be involved in cardiac regeneration and confer cardiac protection effect. Therefore, targeting the miRNA in exosome is regarded as a potent therapeutic measure to alleviate diabetes-related CVD. In this article, we review current knowledge about the role of exosomal miRNAs in diabetes-related cardiovascular complication, such as coronary heart disease, Peripheral artery disease, stroke, diabetic cardiomyopathy, diabetic nephropathy and diabetic retinopathy. Exosomal miRNAs are considered to be central regulators of diabetes-Related CVD and provide a therapeutic tool for diagnosis and treatment of diabetes-related cardiovascular complication.

Phenotyping the Prediabetic Population-A Closer Look at Intermediate Glucose Status and Cardiovascular Disease

Even though the new thresholds for defining prediabetes have been around for more than ten years, there is still controversy surrounding the precise characterization of this intermediate glucose metabolism status. The risk of developing diabetes and macro and microvascular disease linked to prediabetes is well known. Still, the prediabetic population is far from being homogenous, and phenotyping it into less heterogeneous groups might prove useful for long-term risk assessment, follow-up, and primary prevention. Unfortunately, the current definition of prediabetes is quite rigid and disregards the underlying pathophysiologic mechanisms and their potential metabolic progression towards overt disease. In addition, prediabetes is commonly associated with a cluster of risk factors that worsen the prognosis. These risk factors all revolve around a common denominator: inflammation. This review focuses on identifying the population that needs to be screened for prediabetes and the already declared prediabetic patients who are at a higher risk of cardiovascular disease and require closer monitoring.

Early arteriosclerosis and its risk factors in subjects with prediabetes and new-onset diabetes

BACKGROUND

We aimed to investigate early arteriosclerosis and its risk factors in populations with prediabetes and new-onset diabetes.

MATERIALS AND METHODS

A total of 148 participants who did not have diabetes mellitus were assigned to three groups through an oral glucose tolerance test: the normal glucose tolerance (NGT) group; the impaired glucose regulation, also known as prediabetes group and the new-onset type 2 diabetes mellitus group. The insulin resistance index was assessed using the homeostatic model assessment of insulin resistance (HOMA-IR). An ELISA was used to determine the level of fibroblast growth factor 21 (FGF21). An arteriosclerosis detector was used to measure the brachial-ankle pulse wave velocity (baPWV) and ankle-brachial index (ABI). The baPWV, ABI, and FGF21 were used to assess early arteriosclerosis.

RESULTS

Significant differences in age, systolic blood pressure (SBP), fasting plasma glucose (FPG), 2-h plasma glucose (2hPG), 2-h insulin (2hINS), and HOMA-IR were found between the NGT group and the prediabetes and new-onset diabetes groups. All of the above, except 2hINS, showed an increasing trend. Moreover, the FGF21 was higher in the new-onset diabetes group than in the NGT group. The baPWV was higher in the new-onset diabetes group than in the other two groups, but no significant difference was noted in the ABI. Age, SBP, diastolic blood pressure, FPG, 2hPG, and FGF21 were positively correlated with the baPWV. In addition, FPG, SBP, FGF21, and HOMA-IR were independent risk factors for the baPWV.

CONCLUSIONS

Patients with prediabetes and new-onset diabetes may have more significant early arteriosclerosis. The blood glucose level and insulin resistance index may be independent risk factors for early arteriosclerosis.

Coronary slow flow in patients with impaired glucose tolerance and insulin resistance

Background

The relationship between coronary slow flow (CSF) and insulin resistance (IR) is still a subject of debate with conflicting data. So the aim was to assess the relationship between IR as measured by IR index (HOMA-IR) and coronary slow flow as measured by the TIMI frame count in patients which (impaired glucose tolerance (IGT) and IR.

Results

Out of 87 patients enrolled, 64 (73.6%) patients were assigned to the IGT group while 23 (26.4%) patients were assigned to the NGT group. There were significantly higher BMI (30.15 ± 2.29 vs 23.90 ± 2.5, P < 0.001), waist circumference (105.05 ± 9.0.06 vs 92.92 ± 16.5, P < 0.001), and frequency of hypertension (60.9% vs 34.8, P = 0.03). Also, there were significantly higher 2-h post-prandial (hPP) glucose (161 ± 30 vs 110 ± 20, P < 0.05), fasting serum insulin level (9.56 ± 2.5 vs 7.03 ± 2.1, P < 0.001), HDL (40 ± 6.5 vs 49 ± 5.6, P < 0.001), HOMA-IR index (2.84 ± 0.03 vs 1.6 ± 0.05, P < 0.05), and mean TIMI frame count (33 ± 5 vs 26 ± 4, P < 0.001) among the IGT group, while HDL was significantly lower in the IGT group (40 ± 6.5 vs 49 ± 5.6, P < 0.001). There was a highly significant positive correlation between TIMI frame count and HOMA-IR (r = 0.43, P < 0.001); predictors that add significance to the model were age > 50 years, hypertension, high waist circumference, HDL < 35, and HOMA-IR. For HOMA-IR (OR 95% CI = 1.9 (1.05–3.49), P = 0.02 demonstrating that HOMA-IR is a powerful independent predictor of high TIMI frame count (Table 4).

Conclusion

IR is an independent risk factor for slow coronary flow in patients with IGT. Those with evident coronary slow flow, IGT should be managed aggressively even before any evidence of frank diabetes. Also, IR workup should be recommended among the other standard workup for those patients; if documented, targeting IR in such patients should be a priority (whenever possible) while selecting medications for comorbid cardiac disease, as well as using interventions targeted against IR should be considered among the other standard management for slow flow.

External Validation of the Core Obesity Model to Assess the Cost-Effectiveness of Weight Management Interventions

BACKGROUND

For economic models to be considered fit for purpose, it is vital that their outputs can be interpreted with confidence by clinicians, budget holders and other stakeholders. Consequently, thorough validation of models should be carried out to enhance confidence in their predictions. Here, we present results of external dependent and independent validations of the Core Obesity Model (COM), which was developed to assess the cost-effectiveness of weight management interventions.

OBJECTIVE

The aim was to assess the external validity of the COM (version 6.1), in line with best practice guidance from the International Society for Pharmacoeconomics and Outcomes Research and the Society for Medical Decision Making.

METHODS

For validation, suitable sources and outcomes were identified, and used to populate the COM with relevant inputs to allow prediction of study outcomes. Study characteristics were entered into the COM to replicate either the studies used to develop the model (dependent validation) or those not included in the model (independent validation). The concordance between predicted and observed outcomes was then assessed using established statistical methods and generation of mean error estimates.

RESULTS

For most outcomes, the predictions of the COM showed good linear correlation with observed outcomes, as evidenced by the high coefficients of determination (R² values). The independent validation revealed a degree of underestimation in predictions of cardiovascular (CV) disease and mortality, and type 2 diabetes.

CONCLUSION

The predictions generated by the risk equations used in the COM showed good concordance both with the studies used to develop the model and with studies not included in the model. In particular, the concordance observed in the external dependent validation suggests that the COM accurately predicts obesity-related event rates observed in the studies used to develop the model. However, the impact of existing CV risk, as well as mortality, is a key area for future refinement of the COM. Our results should increase confidence in the estimates derived from the COM and reduce uncertainty associated with analyses using this model.

Cardiovascular risk and the implications for clinical practice of cardiovascular outcome trials in type 2 diabetes

Cardiovascular disease (CVD) is the primary cause of morbidity and mortality in patients with type 2 diabetes (T2D). This review examines the impact of cardiovascular outcome trials (CVOTs) on clinical practice. To date, all CVOTs have shown non-inferiority versus placebo (both added to standard of care) against a primary endpoint of 3- or 4-point major adverse cardiovascular event (MACE), confirming CV safety of these treatments. Additionally, some CVOTs have shown superiority to placebo against the same MACE endpoint, suggesting a cardioprotective action for these treatments. This is reflected in guideline updates, which primary care physicians should consider when personalizing treatments.

Nomogram Based on Risk Factors for Type 2 Diabetes Mellitus Patients with Coronary Heart Disease

INTRODUCTION

This study aimed to study risk factors for coronary heart disease (CHD) in type 2 diabetes mellitus (T2DM) patients and establish a clinical prediction model.

RESEARCH DESIGN AND METHODS

A total of 3402 T2DM patients were diagnosed by clinical doctors and recorded in the electronic medical record system (EMRS) of six Community Health Center Hospitals from 2015 to 2017, including the communities of Huamu, Jinyang, Yinhang, Siping, Sanlin and Daqiao. From September 2018 to September 2019, 3361 patients (41 patients were missing) were investigated using a questionnaire, physical examination, and biochemical index test. After excluding the uncompleted data, 3214 participants were included in the study and randomly divided into a training set (n = 2252) and a validation set (n = 962) at a ratio of 3:1. Through lead absolute shrinkage and selection operator (LASSO) regression analysis and logistic regression analysis of the training set, risk factors were determined and included in a nomogram. The C-index, receiver operating characteristic (ROC) curve, calibration plot and decision curve analysis (DCA) were used to validate the distinction, calibration and clinical practicality of the model.

RESULTS

Age, T2DM duration, hypertension (HTN), hyperuricaemia (HUA), body mass index (BMI), glycosylated haemoglobin A1c (HbA1c), high-density lipoprotein (HDL-C) and low-density lipoprotein (LDL-C) were significant factors in this study. The C-index was 0.750 (0.724-0.776) based on the training set and 0.767 (0.726-0.808) based on the validation set. Through ROC analysis, the set area was 0.750 for the training set and 0.755 for the validation set. The calibration test indicated that the S:P of the prediction model was 0.982 in the training set and 0.499 in the validation set. The decision curve analysis showed that the threshold probability of the model was 16-69% in the training set and 16-73% in the validation set.

CONCLUSION

Based on community surveys and data analysis, a prediction model of CHD in T2DM patients was established.

Fasting Blood Glucose and HbA1c Correlate With Severity of Coronary Artery Disease in Elective PCI Patients With HbA1c 5.7% to 6.4

Diabetes mellitus, and even prediabetes, has been shown to be independently associated with cardiovascular disease. Our study explored whether the combination of glycosylated hemoglobin (HbA_1c) and fasting blood glucose (FBG) can better assess the severity of coronary heart disease (CHD) in elective percutaneous coronary intervention (PCI) patients. We consecutively enrolled 1006 prediabetic patients with HbA_1c 5.7% to 6.4% who underwent elective PCI. Patients were divided into 2 groups: a normal fasting glucose (NFG) group (FBG <6.1 mmol/L) and an impaired fasting glucose (IFG) group (6.1 ≤FBG<7.0 mmol/L) with defined values. Baseline characteristics and angiography data of the 2 groups were compared. The prevalence of 3-vessel disease (P = .002), the GENSINI (the score is named after a professor) score (P = .002), and the SYNTAX (SYNergy between PCI with TAXUS™ and Cardiac Surgery) score (P = .002) of the IFG group was significantly higher compared to the NFG group. After multiple regression analysis, FBG was found to be independently associated with prevalence of 3-vessel disease (adjusted odds ratio: 1.62; 95% confidence interval: 1.21-2.36; P = .013), the GENSINI score (standardized β = .138, P = .008), and the SYNTAX score (standardized β = .145, P = .005). In addition, HbA_{1 c} was independently associated with the prevalence of 3-vessel disease, the GENSINI, score, and the SYNTAX score (P < .05). Both FBG and HbA_1c are independently correlated with the severity of CHD in prediabetic patients with HbA_1c 5.7% to 6.4%.

Comparison of the Effects of Fasting Glucose, Hemoglobin A1c, and Triglyceride-Glucose Index on Cardiovascular Events in Type 2 Diabetes Mellitus

The triglyceride–glucose (TyG) index has been correlated with insulin resistance. We aim to investigate the role of the TyG index on cardiovascular (CV) events in type 2 diabetes mellitus and compare the roles of fasting glucose, hemoglobin A_1c, and the TyG index in predicting CV events. This retrospective study enrolled 3524 patients with type 2 diabetes from the Kaohsiung Medical University Research Database in 2009 in this longitudinal study and followed them until 2015. The TyG index was calculated as log (fasting triglyceride level (mg/dL) × fasting glucose level (mg/dL)/2). CV events included myocardial infarction, unstable angina, stroke, hospitalization for coronary artery disease, peripheral artery disease, and CV-related death. The association between variables and CV events was assessed using a multivariable stepwise Cox proportional hazard analysis. Two hundred and fifteen CV events (6.1%) were recorded during a follow-up period of 5.93 years. The multivariable stepwise analysis showed that high fasting glucose (HR, 1.007; p < 0.001) and a high TyG index (HR, 1.521; p = 0.004) but not hemoglobin A_1c or triglycerides were associated with a higher rate of CV events. Adding fasting glucose and the TyG index to the basic model improved the predictive ability of progression to a CV event (p < 0.001 and p = 0.018, respectively), over that of hemoglobin A_1c (p = 0.084) and triglyceride (p = 0.221). Fasting glucose and the TyG index are useful parameters and stronger predictive factors than hemoglobin A_1c and triglyceride for CV events and may offer an additional prognostic benefit in patients with type 2 diabetes.

Diabetes as a cardiovascular risk factor: An overview of global trends of macro and micro vascular complications

The global prevalence of diabetes is predicted to increase dramatically in the coming decades as the population grows and ages, in parallel with the rising burden of overweight and obesity, in both developed and developing countries. Cardiovascular disease represents the principal cause of death and morbidity among people with diabetes, especially in those with type 2 diabetes mellitus. Adults with diabetes have 2–4 times increased cardiovascular risk compared with adults without diabetes, and the risk rises with worsening glycaemic control. Diabetes has been associated with 75% increase in mortality rate in adults, and cardiovascular disease accounts for a large part of the excess mortality. Diabetes-related macrovascular and microvascular complications, including coronary heart disease, cerebrovascular disease, heart failure, peripheral vascular disease, chronic renal disease, diabetic retinopathy and cardiovascular autonomic neuropathy are responsible for the impaired quality of life, disability and premature death associated with diabetes. Given the substantial clinical impact of diabetes as a cardiovascular risk factor, there has been a growing focus on diabetes-related complications. While some population-based studies suggest that the epidemiology of such complications is changing and that rates of all-cause and cardiovascular mortality among individuals with diabetes are decreasing in high-income countries, the economic and social burden of diabetes is expected to rise due to changing demographics and lifestyle especially in middle- and low-income countries. In this review we outline data from population-based studies on recent and long-term trends in diabetes-related complications.

The ratio of fasting plasma glucose to hemoglobin A1c as a predictor of all-cause mortality in individuals with normal glucose levels: The Jichi Medical School cohort study

OBJECTIVES

The fasting plasma glucose/hemoglobin A1c ratio is considered a marker associated with glucose metabolism disorders, including fasting hyperglycemia. However, it remains unclear whether this ratio can be used for the prevention of deaths in individuals with normal fasting plasma glucose levels. This study aimed to see the predictive value of the fasting plasma glucose/hemoglobin A1c ratio for all-cause mortality in a general population with normal fasting plasma glucose levels.

METHODS

The study investigated prospectively a cohort of 1087 multi-regional, community-dwelling Japanese participants (women, 69.2%) for a follow-up period of 11.3 years. We included individuals with fasting plasma glucose levels <6.11 mmol/L and excluded those meeting the diabetes criteria. All-cause mortality was the primary outcome and hazard ratios were calculated using the Cox proportional hazard model after dividing the fasting plasma glucose/hemoglobin A1c ratios into tertiles.

RESULTS

There were 54 deaths (25 women) during the follow-up period. The high tertile group had a significantly higher hazard ratio for all-cause mortality than the low tertile group in women (multivariate-adjusted hazard ratio = 4.45; 95% confidence interval = 1.26-15.72), but not clearly in men.

CONCLUSION

The data of the population-based cohort study suggest that a high fasting plasma glucose/hemoglobin A1c ratio can predict all-cause mortality in women with normal fasting plasma glucose levels.

An Overall Glance of Evidence Supportive of One-Hour and Two-Hour Postload Plasma Glucose Levels as Predictors of Long-Term Cardiovascular Events

This review summarizes the vast literature describing the long-term epidemiological studies with emphasis on postprandial glucose as a stronger predictor of cardiovascular complications as compared to fasting glucose and HbA1c. Many molecular studies also supported this fact by illustrating that postchallenge hyperglycemia is associated with elevated biomarkers of systemic inflammation in the plasma and thus increasing the chances of vascular damage. Large-scale studies have proved that vascular stiffness, brachial-ankle pulse-wave velocity, carotid intima thickness, and left ventricular hypertrophy have been associated with postprandial glucose as compared to fasting glucose or glycosylated hemoglobin.

Population dietary salt reduction and the risk of cardiovascular disease. A scientific statement from the European Salt Action Network

The publication in the last few years of a number of prospective observational studies suggesting a J-shaped association between levels of salt (sodium) consumption and cardiovascular outcomes has opened a debate on the pertinence of population-wide salt reduction policies to reduce cardiovascular disease burden, and some have even questioned the global World Health Organization guidelines, that recommend a 30% reduction in salt consumption by 2025, aiming at an ideal target of no more than 5 g of salt consumption per day. In September 2018 the European Salt Action Network (E.S.A.N.), after appraising the quality of publications questioning the appropriateness of population salt reduction, discussed the scientific evidence and identified the pitfalls of recent data. The new evidence was deemed inadequate and, in places, biased by flawed methodology. These were identified in the biased assessment of sodium intake from spot urine and the use of the Kawasaki formula, the biased assessment of the sodium-outcome relationships in prospective observational studies using spot urine samples, the impact of reverse causality in such studies, the inadequate analytical approaches to data analysis, the lack of biological plausibility and the lack of precision in assessing long-term salt consumption, as recently demonstrated in studies using more stringent quality features in their study designs. On the basis of such appraisal, the E.S.A.N. agreed a statement confirming the support to the implementation of national and regional programmes of moderate reduction in salt intake, as recommended by the World Health Organization.

Varying Effects of Body Mass Index and Mortality in Different Risk Groups

It is unclear why high body mass index (BMI) is associated with a lower risk of death in patients with cardiovascular disease (CVD). We hypothesized that the impact of higher BMI varies by the patient's baseline risk of death. We analyzed data from 14 prospective studies conducted by us in 50 countries of 170,470 patients: 22.8% without CVD, 29.4% with stable CVD and 47.8% with acute coronary syndromes (ACS). Compared with overweight (BMI 25 to 29.9 kg/m²), normal weight (BMI 20 to 24.9 kg/m²), and underweight (BMI < 20 kg/m²) were associated with higher mortality in all cohorts. Compared with overweight, the risk of death among those with obesity (BMI ≥ 30 kg/m²) varied depending on the population studied: HR (95% confidence interval) in those without CVD, with stable CVD, and with ACS were 1.20 (1.01 to 1.45; p = 0.04), 1.08 (1.02 to 1.15; p = 0.01), and 1.01 (0.93 to 1.10; p = 0.72), respectively. The BMI associated with lowest mortality increased as cohort risk increased (no-CVD 27.2 kg/m², stable CVD 28.1 kg/m², and ACS 30.9 kg/m²; p <0.001). Within each cohort, the optimal BMI value was higher in the high-risk subgroup. In the ACS cohort, low-risk patients had an optimal BMI value of 29.1 kg/m² while in the high-risk group higher BMI was associated with lower risk of death (interaction-p <0.001). In conclusion, between and within cohorts of people without CVD, stable CVD, and ACS, higher BMI was associated with lower risk of death in higher risk groups. The benefits of increased body fat (i.e., increased caloric reserve) may counteract the hazards in high-risk groups, suggesting an alternative explanation of the obesity paradox.

Biomarkers of cardiovascular disease: contributions to risk prediction in individuals with diabetes

Cardiovascular disease is a leading cause of death, especially in individuals with diabetes mellitus, whose risk of morbidity and mortality due to cardiovascular disease is markedly increased compared with the general population. There has been growing interest in the identification of biomarkers of cardiovascular disease in people with diabetes. The present review focuses on the current and potential contributions of these biomarkers to predicting cardiovascular risk in individuals with diabetes. At present, certain biomarkers and biomarker combinations can lead to modest improvements in the prediction of cardiovascular disease in diabetes beyond traditional cardiovascular risk factors. Emerging technologies may enable the discovery of novel biomarkers and generate new information about known biomarkers (such as new combinations of biomarkers), which could lead to significant improvements in cardiovascular disease risk prediction. A critical question, however, is whether improvements in risk prediction will affect processes of care and decision making in clinical practice, as this will be required to achieve the ultimate goal of improving clinical outcomes in diabetes.

Penetrance of Polygenic Obesity Susceptibility Loci across the Body Mass Index Distribution

A growing number of single-nucleotide polymorphisms (SNPs) have been associated with body mass index (BMI) and obesity, but whether the effects of these obesity-susceptibility loci are uniform across the BMI distribution remains unclear. We studied the effects of 37 BMI-associated SNPs in 75,230 adults of European ancestry across BMI percentiles by using conditional quantile regression (CQR) and meta-regression (MR) models. The effects of nine SNPs (24%)-rs1421085 (FTO; p = 8.69 × 10-15), rs6235 (PCSK1; p = 7.11 × 10-6), rs7903146 (TCF7L2; p = 9.60 × 10-6), rs11873305 (MC4R; p = 5.08 × 10-5), rs12617233 (FANCL; p = 5.30 × 10-5), rs11672660 (GIPR; p = 1.64 × 10-4), rs997295 (MAP2K5; p = 3.25 × 10-4), rs6499653 (FTO; p = 6.23 × 10-4), and rs3824755 (NT5C2; p = 7.90 × 10-4)-increased significantly across the sample BMI distribution. We showed that such increases stemmed from unadjusted gene interactions that enhanced the effects of SNPs in persons with a high BMI. When 125 height-associated SNPs were analyzed for comparison, only one (<1%), rs6219 (IGF1, p = 1.80 × 10-4), showed effects that varied significantly across height percentiles. Cumulative gene scores of these SNPs (GS-BMI and GS-height) showed that only GS-BMI had effects that increased significantly across the sample distribution (BMI: p = 7.03 × 10-37; height: p = 0.499). Overall, these findings underscore the importance of gene-gene and gene-environment interactions in shaping the genetic architecture of BMI and advance a method for detecting such interactions by using only the sample outcome distribution.

Benefits of Nut Consumption on Insulin Resistance and Cardiovascular Risk Factors: Multiple Potential Mechanisms of Actions

Epidemiological and clinical studies have indicated that nut consumption could be a healthy dietary strategy to prevent and treat type 2 diabetes (T2DM) and related cardiovascular disease (CVD). The objective of this review is to examine the potential mechanisms of action of nuts addressing effects on glycemic control, weight management, energy balance, appetite, gut microbiota modification, lipid metabolism, oxidative stress, inflammation, endothelial function and blood pressure with a focus on data from both animal and human studies. The favourable effects of nuts could be explained by the unique nutrient composition and bioactive compounds in nuts. Unsaturated fatty acids (monounsaturated fatty acids and polyunsaturated fatty acids) present in nuts may play a role in glucose control and appetite suppression. Fiber and polyphenols in nuts may also have an anti-diabetic effect by altering gut microbiota. Nuts lower serum cholesterol by reduced cholesterol absorption, inhibition of HMG-CoA reductase and increased bile acid production by stimulation of 7-α hydroxylase. Arginine and magnesium improve inflammation, oxidative stress, endothelial function and blood pressure. In conclusion, nuts contain compounds that favourably influence glucose homeostasis, weight control and vascular health. Further investigations are required to identify the most important mechanisms by which nuts decrease the risk of T2DM and CVD.

The genetic basis of antiplatelet and anticoagulant therapy: A pharmacogenetic review of newer antiplatelets (clopidogrel, prasugrel and ticagrelor) and anticoagulants (dabigatran, rivaroxaban, apixaban and edoxaban)

INTRODUCTION

The study of pharmacogenomics presents the possibility of individualised optimisation of drug therapy tailored to each patients' unique physiological traits. Both antiplatelet and anticoagulant drugs play a key role in the management of cardiovascular disease. Despite their importance, there is a substantial volume of literature to suggest marked person-to-person variability in their effect. Areas covered: This article reviews the data available for the genetic cause for this inter-patient variability of antiplatelet and anticoagulant drugs. The genetic basis for traditional antiplatelets (i.e. aspirin) is compared with the newly available antiplatelet medicines (clopidogrel, prasugrel and ticagrelor). Similarly, the pharmacogenetics of warfarin is compared with the newer direct oral anticoagulants (DOACs) in detail. Expert Opinion: We identify strengths and weaknesses in the research thus far; including shortcomings in trial design and a review of newer analytical techniques. The direction of this research and its real-world implications are discussed.

Influence of depression on genetic predisposition to type 2 diabetes in a multiethnic longitudinal study

We assessed the association between depression status and prevalent and incident type 2 diabetes (T2D) as well as the interaction between depression and a genetic risk score (GS) based on 20 T2D single-nucleotide polymorphisms (SNPs) in a multi-ethnic longitudinal study. We studied 17,375 participants at risk for dysglycemia. All participants had genotypic and phenotypic data collected at baseline and 9,930 participants were followed-up for a median of 3.3 years. Normal glucose tolerance (NGT), impaired fasting glucose (IFG)/impaired glucose tolerance (IGT) and T2D statuses were determined using an oral glucose tolerance test and the 2003 American Diabetes Association criteria. Depression was diagnosed at baseline using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV). Multivariate logistic regression models were adjusted for age, sex, ethnicity and body-mass index and an interaction term GS X depression was added to the model. After appropriate Bonferroni correction, no significant association between depression and T2D-related traits (IFG/IGT, T2D and dysglycemia), and no significant interaction between the GS and depression status was observed at baseline or follow-up. Our longitudinal data do not support an association between depression and abnormal glycemic status. Moreover, depression does not modify the effect of T2D predisposing gene variants.

Diabetes control: Incidence of acute myocardial infarction and all-cause mortality among patients with 3-6 years' disease duration

Background Optimal glycated haemoglobin (HbA1c) concentrations to minimize large vessel complications and prolong life in diabetes patients are not well established. Design A retrospective cohort study from 2010 to 2012 using data from the Clalit Health Service (Clalit) integrated healthcare system's electronic data warehouse. Patients included had newly incident diabetes, had at least two HbA1c measurements during the 3 years prior to 1 January 2010 without any disruption(s) in Clalit membership between 2010 and 2014. Methods Time-dependent variables were utilized for HbA1c concentration exposure at three time periods. Diabetes control was evaluated taking average HbA1c measures per time period. Unadjusted and adjusted extended Cox regression analyses assessed the association between time-dependent average HbA1c level and acute myocardial infarction and all-cause mortality. Results Among our 61,971 participants, 2.0% experienced acute myocardial infarction and 6.9% died. Compared to patients with HbA1c 7.0 to < 7.5%, a higher risk of myocardial infarction was found with 8.5 to < 9.0% (hazard ratio (HR) 1.42, 95% confidence interval (CI) 1.05-1.91) and ≥9.0% (HR 1.87, 95% CI 1.50-2.33) groups; a lower risk was found among <6.0% (HR 0.74, 95% CI 0.59-0.93), 6.0 to < 6.5% (HR 0.77, 95% CI 0.64-0.94) and 6.5 to < 7.0% (HR 0.73, 95% CI 0.60-0.88) groups. The association with all-cause mortality was J-shaped, demonstrating a higher risk in those <6.0% (HR 1.20, 95% CI 1.06-1.34), 7.5 to < 8.0% (HR 1.17, 95% CI 1.02-1.35), 8.0 to < 8.5% (HR 1.38, 95% CI 1.16-1.64), 8.5 to < 9.0% (HR 1.36, 95% CI 1.10-1.67) and ≥9.0% (HR 1.74, 95% CI 1.49-2.04) groups. Conclusions HbA1c concentration below 6.0% may be associated with an excess risk for all-cause mortality. Clinicians must be aware of this association when treating individual patients.

Dysglycemia associations with adipose tissue among HIV-infected patients after 2 years of antiretroviral therapy in Mwanza: a follow-up cross-sectional study

BACKGROUND

Data on the burden of dysglycemia among HIV-infected patients on antiretroviral therapy (ART) in Africa are limited. We determined the prevalence of pre-diabetes and diabetes among HIV-infected patients who started ART when malnourished 2 to 3 years previously and investigated the association of dysglycemia with body composition.

METHODS

Malnourished (body mass index (BMI) < 18.5 kg/m2) HIV-infected patients who were enrolled in the Nutritional Support for Africans Starting Antiretroviral Therapy (NUSTART) trial from 2011 to 2013 were followed-up from March to August 2015. Anthropometric, fat mass and fat-free mass by bioelectrical impedance, and C-reactive protein (CRP) data were collected at baseline and follow-up. At follow-up, we defined fasting glucose of 6.1-6.9 mmol/L as impaired fasting glucose (IFG) and 2-h oral glucose tolerance test (OGTT) glucose of ≥7.8 to <11.1 mmol/L as impaired glucose tolerance (IGT). Both of these were considered pre-diabetes. Fasting glucose of ≥7.0 mmol/L or impaired glucose tolerance of ≥11.1 mmol/L was defined as diabetes mellitus. The relation of pre-diabetes and diabetes with body composition was assessed using logistic regression.

RESULTS

Two hundred seventy-three (57%) of 478 patients who were alive at trial conclusion were followed-up. The mean age was 41.5 (SD 9.8) years and 65.2% (178) were females. The mean follow-up BMI was 19.9 (SD 2.8) kg/m2, 12 (4.4%) were either overweight or obese, and 61 (22.3%) patients had pre-diabetes or diabetes. In multiple regression, upper tertiles of baseline hip circumference (OR: 0.41, 95% CI: 0.2, 0.8) and fat mass index (OR: 0.20 (0.1, 0.5), and upper tertiles of follow-up waist circumference (OR: 0.22 (0.1, 0.5), BMI (OR: 0.32 (0.1, 0.7), fat mass index (OR: 0.19 (0.1, 0.5) and the middle tertile of follow-up fat-free mass (OR: 0.36, 95% CI: 0.1, 0.8) were associated with lower risk of pre-diabetes and diabetes (P < 0.05 for all). Baseline and follow-up CRP were not predictors.

CONCLUSIONS

Low rather than high measures of adipose tissue were associated with increased risk of pre-diabetes and diabetes. Additional studies are needed to further investigate the role of body composition and control of glucose metabolism in the pathogenesis of diabetes among persons living with HIV in Africa.

Fasting glucose levels, incident diabetes, subclinical atherosclerosis and cardiovascular events in apparently healthy adults: A 12-year longitudinal study

We aimed to study the association between fasting plasma glucose, diabetes incidence and cardiovascular burden after 10-12 years. We evaluated diabetes and cardiovascular events incidences, carotid intima-media thickness and coronary artery calcium scores in ELSA-Brasil (the Brazilian Longitudinal Study of Adult Health) baseline (2008-2010) of 1536 adults without diabetes in 1998. We used regression models to estimate association with carotid intima-media thickness (in mm), coronary artery calcium scores (in Agatston points) and cardiovascular events according to fasting plasma glucose in 1998. Adjusted diabetes incidence rate was 9.8/1000 person-years (95% confidence interval: 7.7-13.6/1000 person-years). Incident diabetes was positively associated with higher fasting plasma glucose. Fasting plasma glucose levels 110-125 mg/dL were associated with higher carotid intima-media thickness (β = 0.028; 95% confidence interval: 0.003-0.053). Excluding those with incident diabetes, there was a borderline association between higher carotid intima-media thickness and fasting plasma glucose 110-125 mg/dL (β = 0.030; 95% confidence interval: -0.005 to 0.065). Incident diabetes was associated with higher carotid intima-media thickness (β = 0.034; 95% confidence interval: 0.015-0.053), coronary artery calcium scores ⩾400 (odds ratio = 2.84; 95% confidence interval: 1.17-6.91) and the combined outcome of a coronary artery calcium scores ⩾400 or incident cardiovascular event (odds ratio = 3.50; 95% confidence interval: 1.60-7.65). In conclusion, fasting plasma glucose in 1998 and incident diabetes were associated with higher cardiovascular burden.

Evaluating the transferability of 15 European-derived fasting plasma glucose SNPs in Mexican children and adolescents

Genome wide association studies (GWAS) have identified single-nucleotide polymorphisms (SNPs) that are associated with fasting plasma glucose (FPG) in adult European populations. The contribution of these SNPs to FPG in non-Europeans and children is unclear. We studied the association of 15 GWAS SNPs and a genotype score (GS) with FPG and 7 metabolic traits in 1,421 Mexican children and adolescents from Mexico City. Genotyping of the 15 SNPs was performed using TaqMan Open Array. We used multivariate linear regression models adjusted for age, sex, body mass index standard deviation score, and recruitment center. We identified significant associations between 3 SNPs (G6PC2 (rs560887), GCKR (rs1260326), MTNR1B (rs10830963)), the GS and FPG level. The FPG risk alleles of 11 out of the 15 SNPs (73.3%) displayed significant or non-significant beta values for FPG directionally consistent with those reported in adult European GWAS. The risk allele frequencies for 11 of 15 (73.3%) SNPs differed significantly in Mexican children and adolescents compared to European adults from the 1000G Project, but no significant enrichment in FPG risk alleles was observed in the Mexican population. Our data support a partial transferability of European GWAS FPG association signals in children and adolescents from the admixed Mexican population.

Carotid Artery Intima-Media Thickness Predicts Major Cardiovascular Events During 7-Year Follow-Up in 64-Year-Old Women Irrespective of Other Glucometabolic Factors

Cardiovascular (CV) disease (CVD) is a leading cause of morbidity and mortality worldwide. Most CV events are caused by atherosclerosis. Diabetes and impaired glucose tolerance are associated with greater carotid intima-media thickness (IMT) and increased risk for CVD. The present study examined if common carotid artery IMT (CCAIMT) is predictive of CVD irrespective of glucose tolerance category and glycated hemoglobin (HbA1c) in a sample of 639 women with different glucose tolerance categories. During 7-year follow-up, 30 events in the cardiac and 32 events in the cerebral territory were documented. Unadjusted Cox hazard models showed that CCAIMT, glucose tolerance category, and HbA1c were associated with increased risk. An adjusted and extended model, including CCAIMT, glucose tolerance category, and HbA1c, showed that CCAIMT was still associated with events with an almost unchanged hazard ratio. In conclusion, this study suggests that CCAIMT is predictive of major CV events during 7-year follow-up, irrespective of glucose tolerance category, HbA1c, and other established risk factors in a cohort of 64-year-old women.

Longitudinal relationships between glycemic status and body mass index in a multiethnic study: evidence from observational and genetic epidemiology

We investigated the relationship between glycemic status and BMI and its interaction with obesity single-nucleotide polymorphisms (SNPs) in a multi-ethnic longitudinal cohort at high-risk for dysglycemia. We studied 17 394 participants from six ethnicities followed-up for 3.3 years. Twenty-three obesity SNPs were genotyped and an unweighted genotype risk score (GRS) was calculated. Glycemic status was defined using an oral glucose tolerance test. Linear regression models were adjusted for age, sex and population stratification. Normal glucose tolerance (NGT) to dysglycemia transition was associated with baseline BMI and BMI change. Impaired fasting glucose/impaired glucose tolerance to type 2 diabetes transition was associated with baseline BMI but not BMI change. No simultaneous significant main genetic effects and interactions between SNPs/GRS and glycemic status or transition on BMI level and BMI change were observed. Our data suggests that the interplay between glycemic status and BMI trajectory may be independent of the effects of obesity genes. This implies that individuals with different glycemic statuses may be combined together in genetic association studies on obesity traits, if appropriate adjustments for glycemic status are performed. Implementation of population-wide weight management programs may be more beneficial towards individuals with NGT than those at a later disease stage.

Association of statin use and stress-induced hyperglycemia in patients with acute ST-elevation myocardial infarction

Background

Only a few information is available on the risk of stress hyperglycemia following acute myocardial infarction after statin use. We investigate the association of stress-induced hyperglycemia following statin use in patients with acute myocardial infarction.

Methods

An observational analysis of 476 consecutive patients who suffered acute myocardial infarction was carried out. All selected patients were divided into diabetes mellitus and non-diabetes based on the presence or absence of diabetes. The cardiac incidence of in-hospital and stress-induced hyperglycemia was recorded.

Results

Among patients with stress hyperglycemia in non-diabetes mellitus subgroups, the average fasting plasma glucose values in statin users were higher than in non-statin users (P < 0.05). But in diabetes mellitus subgroups, the average fasting plasma glucose did not have a significant difference between statin users and non-statin users (P > 0.05). In non-diabetes mellitus patients, the incidence of stress hyperglycemia with statin therapy was significantly higher than with non-statin therapy (P = 0.003). But in diabetes mellitus patients group, there is no significant difference in incidence of stress hyperglycemia between patients with statin therapy and patients without statin therapy (P = 0.902).The incidence of heart failure and in-hospital mortality of acute myocardial infarction in patients with stress-induced hyperglycemia was significantly higher than in non-hyperglycemia patients (P < 0.05).

Conclusion

Statins are related to higher stress hyperglycemia and cardiac incidences after acute myocardial infarction.

Metabolic syndrome, glucose tolerance categories and the cardiovascular risk in Spanish population

We examined the prevalence of metabolic syndrome (MetS), glucose tolerance categories and risk factors of cardiovascular-disease (CVD) in the general Spanish population. We studied 3844 randomly sampled subjects (46% males) aged 35-74 years. Glucose tolerance categories were defined according to the 2003 ADA and MetS according to the Harmonized Consensus Criteria with waist circumference (WC) cut-off-points previously reported in Spanish population (≥94.5/≥89.5cm for males/females). The prevalences of normoglycemia (NG), impaired fasting glucose (IFG), impaired glucose tolerance (IGT), IFG and IGT considered together (IFG/IGT), and diabetes mellitus (DM) were 67.6/16.6/5.0/3.3, and 7.5%, respectively. The overall prevalence of MetS was 31.2%. In subjects with NG, IFG, IGT, IFG/IGT, and DM the MetS prevalence's were 16.3/57.1/31.5/66.1, and 74.4% (p<0.001), respectively. MetS was more common in males, older subjects, smokers, and/or individuals with obesity, IFG, IFG/IGT, DM, or insulin resistance (HOMA-IR ≥3.8). MetS was less prevalent in individuals with low alcohol intake and/or high education level. Regarding the risk level of CVD estimated by Framingham and SCORE risk charts, IGT had higher estimated CVD-risk than IFG and IFG/IGT. The presence of MetS increases the risk 4.85 times by Framingham and 2.43 times by SCORE. Prevalence of prediabetes (IFG/IGT) and MetS were 25% and 31.2% respectively. Prevalence of MetS has not changed in the past decade in Spanish females, but has slightly increased in males. We found that subjects with IGT showed a higher risk of CVD than IFG and IFG/IGT according to the Framingham and SCORE. MetS increased the CVD-risk previously estimated by Framingham and SCORE.

Meta-analysis indicates that SNP rs9939609 within FTO is not associated with major depressive disorder (MDD) in Asian population

BACKGROUND

Major depressive disorder (MDD) is one of the most prevalent psychiatric illnesses with heritability of up to 38%. The fat mass- and obesity-associated (FTO) gene, in particular the single nucleotide polymorphism (SNP) rs9939609, has been identified as a genetic risk loci associated with MDD. However, most prior studies have involved European and American populations. Whether rs9939609 is an true risk SNP for MDD in Asian populations remains inconclusive.

METHODS

In the present study, we conducted a meta-analysis of the association between rs9939609 and MDD in Asian populations by combining 5 available case-control samples totaling 6531 cases and 12,359 controls.

RESULTS

Our meta-analysis suggests that rs9939609 is not a risk SNP for MDD in Asian populations by fixed effect model (Z=1.04, P=0.30, OR=0.96, 95% CI=0.90-1.03).

LIMITATIONS

The age distribution and gender ratios were not matched well in the combined samples of cases and controls. Publication bias might be also considered with only a relatively small number of association studies of FTO rs9939609 with MDD in Asian populations.

CONCLUSIONS

The absence of association of rs9939609 with MDD in our Asian populations suggests a potential genetic heterogeneity in the susceptibility of MDD on this locus.

Physical activity and genetic predisposition to obesity in a multiethnic longitudinal study

Physical activity (PA) has been shown to reduce the impact of FTO variation and obesity genetic risk scores (GRS) on BMI. We examined this interaction using a quantitative measure of PA and two adiposity indexes in a longitudinal multi-ethnic study. We analyzed the impact of PA on the association between 14 obesity predisposing variants (analyzed independently and as a GRS) and baseline/follow-up obesity measures in the multi-ethnic prospective cohort EpiDREAM (17423 participants from six ethnic groups). PA was analyzed using basic (low-moderate-high) and quantitative measures (metabolic equivalents (METS)), while BMI and the body adiposity index (BAI) were used to measure obesity. Increased PA was associated with decreased BMI/BAI at baseline/follow-up. FTO rs1421085, CDKAL1 rs2206734, TNNl3K rs1514176, GIPR rs11671664 and the GRS were associated with obesity measures at baseline and/or follow-up. Risk alleles of three SNPs displayed nominal associations with increased (NTRK2 rs1211166, BDNF rs1401635) or decreased (NPC1 rs1805081) basic PA score independently of BMI/BAI. Both basic and quantitative PA measures attenuated the association between FTO rs1421085 risk allele and BMI/BAI at baseline and follow-up. Our results show that physical activity can blunt the genetic effect of FTO rs1421085 on adiposity by 36–75% in a longitudinal multi-ethnic cohort.

Identifying Novel Biomarkers for Cardiovascular Events or Death in People With Dysglycemia

BACKGROUND

Serum biomarkers may identify people at risk for cardiovascular (CV) outcomes. Biobanked serum samples from 8494 participants with dysglycemia in the completed Outcome Reduction With Initial Glargine Intervention trial were assayed for 284 biomarkers to identify those that could identify people at risk for a CV outcome or death when added to clinical measurements.

METHODS AND RESULTS

A multiplex analysis measured a panel of cardiometabolic biomarkers in 1 mL of stored frozen serum from every participant who provided biobanked blood. After eliminating undetectable or unanalyzable biomarkers, 8401 participants who each had a set of 237 biomarkers were analyzed. Forward-selection Cox regression models were used to identify biomarkers that were each independent determinants of 3 different incident outcomes: (1) the composite of myocardial infarction, stroke, or CV death; (2) these plus heart failure hospitalization or revascularization; and (3) all-cause death. When added to clinical variables, 10 biomarkers were independent determinants of the 1405 CV composite outcomes observed during follow-up; 9 biomarkers (including 8 of these 10) were independent determinants of the 2435 expanded composite outcomes; and 15 (including the 10 CV composite biomarkers) were independent determinants of the 1340 deaths. Adjusted C statistics increased from 0.64 for the clinical variables to 0.71 and 0.68 for the 2 CV composite outcomes, respectively, with the greatest increase to 0.75 for death (P<0.001 for the change).

CONCLUSIONS

A systematic hypothesis-free approach identified combinations of up to 15 cardiometabolic biomarkers as independent determinants of CV outcomes or death in people with dysglycemia.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00069784.

Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of Recent Evidence: A Scientific Statement From the American Heart Association and the American Diabetes Association

Cardiovascular disease risk factor control as primary prevention in patients with type 2 diabetes mellitus has changed substantially in the past few years. The purpose of this scientific statement is to review the current literature and key clinical trials pertaining to blood pressure and blood glucose control, cholesterol management, aspirin therapy, and lifestyle modification. We present a synthesis of the recent literature, new guidelines, and clinical targets, including screening for kidney and subclinical cardiovascular disease for the contemporary management of patients with type 2 diabetes mellitus.

Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of Recent Evidence: A Scientific Statement From the American Heart Association and the American Diabetes Association

Cardiovascular disease risk factor control as primary prevention in patients with type 2 diabetes mellitus has changed substantially in the past few years. The purpose of this scientific statement is to review the current literature and key clinical trials pertaining to blood pressure and blood glucose control, cholesterol management, aspirin therapy, and lifestyle modification. We present a synthesis of the recent literature, new guidelines, and clinical targets, including screening for kidney and subclinical cardiovascular disease for the contemporary management of patients with type 2 diabetes mellitus.

Lack of association between type 2 diabetes and major depression: epidemiologic and genetic evidence in a multiethnic population

The positive association between depression and type 2 diabetes (T2D) has been controversial, and little is known about the molecular determinants linking these disorders. Here we investigated the association between T2D and depression at the clinical and genetic level in a multiethnic cohort. We studied 17,404 individuals from EpiDREAM (3209 depression cases and 14,195 controls) who were at risk for T2D and had both phenotypic and genotypic information available at baseline. The glycemic status was determined using the 2003 American Diabetes Association criteria and an oral glucose tolerance test. Major depressive episode during the previous 12 months was diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnostic criteria. Twenty single-nucleotide polymorphisms (SNPs) previously associated with T2D were genotyped using the cardiovascular gene-centric 50-K SNP array and were analyzed separately and in combination using an unweighted genotype score (GS). Multivariate logistic regression models adjusted for age, sex, ethnicity and body mass index were performed. Newly diagnosed impaired fasting glucose (IFG)/impaired glucose tolerance (IGT), T2D and dysglycemia status were not associated with major depression (0.30 ⩽ P ⩽ 0.65). Twelve out of twenty SNPs and the GS were associated with IFG/IGT, T2D and/or dysglycemia status (6.0 × 10(-35) ⩽ P ⩽ 0.048). In contrast, the 20 SNPs and GS were not associated with depression (P ⩾ 0.09). Our cross-sectional data do not support an association between T2D and depression at the clinical and genetic level in a multiethnic population at risk for T2D.

Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association

The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of stroke among individuals who have not previously experienced a stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches to atherosclerotic disease of the cervicocephalic circulation, and antithrombotic treatments for preventing thrombotic and thromboembolic stroke. Further recommendations are provided for genetic and pharmacogenetic testing and for the prevention of stroke in a variety of other specific circumstances, including sickle cell disease and patent foramen ovale.

Revising the fasting glucose threshold for detection of cardiovascular risk factors: analysing two representative population-based studies of more than 50,000 Iranians in 3 years: The National Survey of Risk Factors for Non-Communicable Diseases of Iran

OBJECTIVES

To study the prevalence of cardiovascular risk factors across different glycaemia strata and to assess the optimal cut-off value of fasting plasma glucose (FPG) to identify the constellation of cardiovascular risk factors.

METHODS

Data of the National Survey of Risk Factors for Non-Communicable Diseases of Iran (SURFNCD 2005-2007) were analysed. Prevalence rates of obesity, central obesity, hypertension and hypercholesterolemia of individuals with Impaired Fasting Glucose (IFG) were compared with those of individuals with normal fasting glycaemia and newly diagnosed diabetes. Optimal FPG cut-point to diagnose subjects with cardiovascular risk factors was assessed.

RESULTS

Prevalence of each and combinations of cardiovascular risk factors were higher among subjects with IFG compared to those with normal fasting glycaemia. The areas under the curve (AUC) for detecting cardiovascular risk were highest at FPG values of 90 mg/dL. FPG of 90 mg/dL was the optimal cut-off and, in comparison to 100 mg/dL, corresponds to correct detection of 26-29% of obese, 22-27% of centrally obese, 26-29% of hypertensive and 25-30% of hypercholesterolemic individuals.

CONCLUSIONS

IFG and even lower levels of FPG are associated with high prevalence of cardiovascular risk factors in Iranian adults. This study suggests the FPG cut-off to be revised at 90 mg/dL to identify people with increased cardiovascular risk.

Oscillating high glucose enhances oxidative stress and apoptosis in human coronary artery endothelial cells

PURPOSE

To investigate the toxic effect of oscillating high glucose (OHG) versus persistent high glucose (PHG) in inducing oxidative stress and cellular apoptosis in human coronary artery endothelial cells (HCAECs) in vitro.

METHODS

HCAECs were incubated for 72 h continuously in normal glucose (5.5 mmol/L glucose), PHG (25 mmol/L glucose), OHG (5.5 mmol and 25 glucose mmol/L alternating every 6 h) and mannitol, respectively. Cellular viability, concentration of oxidative stress biomarkers (MDA and GSH) in the supernatants of cell culture, and intracellular ROS level were quantitated after exposure to different concentrations of glucose for a total 72 h. Apoptosis of HCAECs cultured with various glucose levels was evaluated by annexin V-FITC and PI staining followed by analysis with flow cytometry. The expressions of HO-1 and Nrf2 were measured by RT-qPCR and Western blotting at the end of the experiment.

RESULTS

HCAECs cultured with PHG showed decreased cellular viability compared to those with normal level of glucose (p < 0.05). The decrease was more pronounced under OHG condition (p < 0.05). Cellular oxidative stress was provoked in HCAECs exposed to PHG with marked increased MDA level, reduced GSH concentration and elevated ROS production (p < 0.05). The stress was further amplified in the setting of OHG (p < 0.05). The cellular apoptosis was enhanced by culturing with PHG, and to a greater extent when incubated with OHG. Both expressions of HO-1 and Nrf2 were suppressed in HCAECs in persistent hyperglycemia condition, while the inhibition was more intense in the fluctuating hyperglycemia condition (p < 0.05).

CONCLUSIONS

These findings indicate that OHG could be more detrimental to HCAECs than PHG. This is probably due to the enhancement of oxidative stress and cellular apoptosis induced by frequent glucose swings through the inhibition of Nrf2/HO-1 pathway.