Influence of diabetes mellitus on heart failure risk and outcome

Temporal trends on the prevalence of renal disease and outcomes among patients with diabetes mellitus hospitalized by heart failure: findings from INCAex

BACKGROUND

To assess 20-year time trends in the prevalence of diabetes mellitus (DM) among inpatients with heart failure (HF) and the influence of coexisting DM and kidney disease (KD) on outcomes.

RESEARCH DESIGN AND METHODS

A retrospective study of patients was admitted due to HF, during the period 2000/2019. The period of follow-up was divided into three intervals according to the European Medical Agency approval of newer hypoglycemic drugs. We analyzed in-hospital mortality and outcomes during the follow-up period.

RESULTS

A total of 4959 patients were included. Over time, prevalence of DM was significantly raising among women with HF (50 to 53.2%) and descending among men (50% to 46.8%, p = 0.02). Total mortality and readmissions were higher in patients with DM during the and second periods. However, no significant differences were found in the third-one (HR 1.14, 95% CI 0.94-1.39, p = 0.181). A protector role of oral hypoglycemic medications was observed in this last period. According to the presence of KD, the patients with both DM and KD were who presented most of the events.

CONCLUSIONS

Over the time analyzed, the prevalence of DM raised among women and decreased among men. DM influenced the prognosis of HF except in the third period when more protective hypoglycemic drugs started to be used.

Statin therapy impact on Long-Term outcomes in acute heart Failure: Retrospective analysis of hospitalized patients

Background

Statin therapy is well-established for treating hyperlipidemia and ischemic heart disease (IHD), but its role in Acute Decompensated Heart Failure (ADHF) remains less clear. Despite varying clinical guidelines, the actual utilization and impact of statin therapy initiation in patients with ADHF with an independent indication for statin therapy have not been thoroughly explored.

Methods

We conducted a retrospective observational study on 5978 patients admitted with ADHF between January 1st, 2007, and December 31st, 2017. Patients were grouped based on their statin therapy status at admission and discharge. We performed multivariable analyses to identify independent predictors of short-term, intermediate-term, and long-term mortality. A sensitivity analysis was also conducted on patients with an independent indication for statin therapy but who were not on statins at admission.

Results

Of the total patient cohort, 73.9% had an indication for statin therapy. However, only 38.2% were treated with statins at admission, and 56.1% were discharged with a statin prescription. Patients discharged with statins were younger, predominantly male, and had a higher prevalence of IHD and other comorbidities. Statin therapy at discharge was an independent negative predictor of 5-year all-cause mortality (hazard ratio 0.80, 95% confidence interval 0.76-0.85). The sensitivity analysis confirmed these findings, demonstrating higher mortality rates in patients not initiated on statins during admission.

Conclusions

The study highlights significant underutilization of statin therapy among patients admitted with ADHF, even when there's an independent indication for such treatment. Importantly, initiation of statin therapy during hospital admission was independently associated with improved long-term survival.

Immunomodulatory, Antioxidant, and Potential Anticancer Activity of the Polysaccharides of the Fungus Fomitiporia chilensis

Fomitiporia species have aroused the interest of numerous investigations that reveal their biological activity and medicinal potential. The present investigation shows the antioxidant, anticancer, and immunomodulatory activity of acidic polysaccharides obtained from the fungus Fomitiporia chilensis. The acidic polysaccharides were obtained for acidic precipitation with 2% O-N-cetylpyridinium bromide. Chemical analysis was performed using FT-IR and GC-MS methods. The antioxidant capacity of acidic polysaccharides from F. chilensis was evaluated by scavenging free radicals with an ABTS assay. Macrophage proliferation and cytokine production assays were used to determine the immunomodulatory capacity of the polysaccharides. Anti-tumor and cytotoxicity activity was evaluated with an MTT assay in the U-937, HTC-116, and HGF-1 cell lines. The effect of polysaccharides on the cell cycle of the HCT-116 cell line was determined for flow cytometry. Fourier Transform-infrared characterization revealed characteristic absorption peaks for polysaccharides, whereas the GC-MS analysis detected three peaks corresponding to D-galactose, galacturonic acid, and D-glucose. The secreted TNF-α concentration was increased when the cell was treated with 2 mg mL-1 polysaccharides, whereas the IL-6 concentration was increased with all of the evaluated polysaccharide concentrations. A cell cycle analysis of HTC-116 treated with polysaccharides evidenced that the acidic polysaccharides from F. chilensis induce an increase in the G0/G1 cell cycle phase, increasing the apoptotic cell percentage. Results from a proteomic analysis suggest that some of the molecular mechanisms involved in their antioxidant and cellular detoxifying effects and justify their traditional use in heart diseases. Proteomic data are available through ProteomeXchange under identifier PXD048361. The study on acidic polysaccharides from F. chilensis has unveiled their diverse biological activities, including antioxidant, anticancer, and immunomodulatory effects. These findings underscore the promising therapeutic applications of acidic polysaccharides from F. chilensis, warranting further pharmaceutical and medicinal research exploration.

Diabetes mellitus in patients with heart failure and effect modification of risk factors for short-term mortality: An observational study from the Registro Colombiano de Falla Cardíaca (RECOLFACA)

INTRODUCTION

Heart failure and type 2 diabetes mellitus are critical public health issues.

OBJECTIVE

To characterize the risk factors for mortality in patients with heart failure and type 2 diabetes mellitus from a large registry in Colombia and to evaluate the potential effect modifications by type 2 diabetes mellitus over other risk factors.

MATERIALS AND METHODS

Heart failure patients with and without type 2 diabetes mellitus enrolled in the Registro Colombiano de Falla Cardíaca (RECOLFACA) were included. RECOLFACA enrolled adult patients with heart failure diagnosis from 60 medical centers in Colombia during 2017-2019. The primary outcome was all-cause mortality. Survival analysis was performed using adjusted Cox proportional hazard models.

RESULTS

A total of 2514 patients were included, and the prevalence of type 2 diabetes mellitus was 24.7% (n = 620). We found seven independent predictors of short-term mortality for the general cohort, chronic obstructive pulmonary disease, sinus rhythm, triple therapy, nitrates use, statins use, anemia, and hyperkalemia. In the type 2 diabetes mellitus group, only the left ventricle diastolic diameter was an independent mortality predictor (HR = 0.96; 95% CI: 0.93-0.98). There was no evidence of effect modification by type 2 diabetes mellitus on the relationship between any independent predictors and all-cause mortality. However, a significant effect modification by type 2 diabetes mellitus between smoking and mortality was observed.

CONCLUSIONS

Patients with type 2 diabetes mellitus had higher mortality risk. Our results also suggest that type 2 diabetes mellitus diagnosis does not modify the effect of the independent risk factors for mortality in heart failure evaluated. However, type 2 diabetes mellitus significantly modify the risk relation between mortality and smoking in patients with heart failure.

Assessment of new-onset heart failure prediction in a diabetic population using left ventricular global strain: a prospective cohort study based on UK Biobank

Background

Impaired glucose utilization influences myocardial contractile function. However, the prognostic importance of left ventricular global radial strain (LV-GRS), left ventricular global circumferential strain (LV-GCS), and left ventricular global longitudinal strain (LV-GLS) in predicting new-onset heart failure (HF) in a population with diabetes is unclear.

Methods

The study design is prospective cohort from the UK Biobank. Totally 37,899 participants had a complete data of cardiac magnetic resonance (CMR), of which 940 patients with diabetes were included, and all the participants completed follow-up. LV-GRS, LV-GCS, and LV-GLS were measured by completely automated CMR with tissue tagging. Cox proportional hazards regression analysis and C-index was performed to evaluate the association between the strain parameters and the new-onset HF in patients suffering from diabetes.

Results

The average age of the 940 participants was 57.67 ± 6.97 years, with males comprising 66.4% of the overall population. With an average follow-up period of 166.82 ± 15.26 months, 35 (3.72%) patients reached the endpoint (emergence of new-onset HF). Significant associations were found for the three strain parameters and the new-onset HF (LV-GRS-hazard ratio [HR]: 0.946, 95% CI: 0.916-0.976; LV-GCS-HR: 1.162, 95% CI: 1.086-1.244; LV-GCS-HR: 1.181, 95% CI: 1.082-1.289). LV-GRS, LV-GCS, and LV-GLS were closely related to the related indicators to HF, and showed a high relationship to new-onset HF in individuals with diabetes at 5 and 10 years: LV-GRS: 0.75 (95% CI, 0.41-0.94) and 0.76 (95% CI, 0.44-0.98), respectively; LV-GCS: 0.80 (95% CI, 0.50-0.96) and 0.75 (95% CI, 0.41-0.98), respectively; LV-GLS: 0.72 (95% CI, 0.40-0.93) and 0.76 (95% CI, 0.48-0.97), respectively. In addition, age, sex, body mass index (BMI), and presence of hypertension or coronary artery disease (CAD) made no impacts on the association between the global strain parameters and the incidence of HF.

Conclusion

LV-GRS, LV-GCS, and LV-GLS is significantly related to new-onset HF in patients with diabetes at 5 and 10 years.

Type 1 diabetes, its complications, and non-ischemic cardiomyopathy: a mendelian randomization study of European ancestry

BACKGROUND

Type 1 diabetes (T1D) is a significant risk factor for a range of cardiovascular diseases. Nonetheless, the causal relationship between T1D and non-ischemic cardiomyopathy (NICM) remains to be elucidated. Furthermore, the mechanisms responsible for the progression from T1D to NICM have not been definitively characterized.

OBJECTIVE

The aim of this study was to conduct a Mendelian randomization (MR) study to investigate the causal effects of T1D and its complications on the development of NICM. Additionally, this study aimed to conduct a mediation analysis to identify potential mediators within this correlation.

METHODS

Genetic variants were used as instrumental variables for T1D. The summary data for T1D were obtained from two genome-wide association study datasets. The summary data for T1D with complications and NICM were obtained from the Finnish database. Two-sample MR, multivariable MR and mediation MR were conducted in this study.

RESULTS

The study revealed a causal association between T1D, T1D with complications, and NICM (with odds ratios of 1.02, 95% CI 1.01-1.04, p = 1.17e-04 and 1.03, 95% CI 1.01-1.05, p = 3.15e-3). Even after adjusting for confounding factors such as body mass index and hypertension, T1D remained statistically significant (with odds ratio of 1.02, 95% CI 1.01-1.04, p = 1.35e-4). Mediation analysis indicated that monokine induced by gamma interferon may play a mediating role in the pathogenesis of T1D-NICM (mediation effect indicated by odds ratio of 1.005, 95% CI 1.001-1.01, p = 4.9e-2).

CONCLUSION

The study demonstrates a causal relationship between T1D, its complications, and NICM. Additionally, monokine induced by gamma interferon may act as a potential mediator in the pathogenesis of T1D-NICM.

Assessment of prevalence and risk factors of isolated coronary artery ectasia: A 5-year double-center retrospective study in Yazd, Iran

Background

The prevalence of Coronary artery ectasia (CAE) varies from 0.‌3 to 5% in different countries. The prevalence of CAE has varied in different parts of the world and the study of risk factors can be effective in the process of diagnosis and treatment of patients, we reviewed patients who underwent coronary angiography for 5 years to determine the prevalence of isolated CAE and its associated risk factors.

Methods

A retrospective analysis was conducted on 16600 patients who underwent coronary angiography at Shahid Sadoughi and Afshar hospitals between March 2015 to April 2020. Diagnosis and confirmation of CAE was defined as a vessel diameter greater than 1.5 times the normal diameter of the vessel, which must be confirmed by at least two cardiologists. Demographic variables, angiography and echocardiography reports were included in our final analysis.

Results

Isolated CAE was diagnosed in 287 (1.7%) patients. After triple-vessel disease (53%), the left anterior descending artery (LAD) was the commonest affected vessel by ectasia 16% (46 cases). Diffuse isolated CAE was diagnosed in 52% of LAD, 76.6% of Right coronary artery (RCA), and 74.1% of left circumflex artery. A significant association was seen between the vessel involved and the nature of ectasia (p<0.001).

Conclusion

In our study, the occurrence of isolated CAE was similar to other studies. This condition often affects all three major vessels of the coronary arteries, and is commonly categorized as type 1, which involves diffuse involvement of the arteries based on the Markis and Harikrishnan Classification.

Prioritizing the primary prevention of heart failure: Measuring, modifying and monitoring risk

With the rising incidence of heart failure (HF) and increasing burden of morbidity, mortality, and healthcare expenditures, primary prevention of HF targeting individuals in at-risk HF (Stage A) and pre-HF (Stage B) Stages has become increasingly important with the goal to decrease progression to symptomatic (Stage C) HF. Identification of risk based on traditional risk factors (e.g., cardiovascular health which can be assessed with the American Heart Association's Life's Essential 8 framework), adverse social determinants of health, inherited risk of cardiomyopathies, and identification of risk-enhancing factors, such as patients with viral disease, exposure to cardiotoxic chemotherapy, and history of adverse pregnancy outcomes should be the first step in evaluation for HF risk. Next, use of guideline-endorsed risk prediction tools such as Pooled Cohort Equations to Prevent Heart Failure provide quantification of absolute risk of HF based in traditional risk factors. Risk reduction through counseling on traditional risk factors is a core focus of implementation of prevention and may include the use of novel therapeutics that target specific pathways to reduce risk of HF, such as mineralocorticoid receptor agonists (e.g., fineronone), angiotensin-receptor/neprolysin inhibitors, and sodium glucose co-transporter-2 inhibitors. These interventions may be limited in at-risk populations who experience adverse social determinants and/or individuals who reside in rural areas. Thus, strategies like telemedicine may improve access to preventive care. Gaps in the current knowledge base for risk-based prevention of HF are highlighted to outline future research that may target approaches for risk assessment and risk-based prevention with the use of artificial intelligence, genomics-enhanced strategies, and pragmatic trials to develop a guideline-directed medical therapy approach to reduce risk among individuals with Stage A and Stage B HF.

Impact of inflammation and anti-inflammatory modalities on diabetic cardiomyopathy healing: From fundamental research to therapy

Diabetic cardiomyopathy (DCM) is a prevalent cardiovascular complication of diabetes mellitus, characterized by high morbidity and mortality rates worldwide. However, treatment options for DCM remain limited. For decades, a substantial body of evidence has suggested that the inflammatory response plays a pivotal role in the development and progression of DCM. Notably, DCM is closely associated with alterations in inflammatory cells, exerting direct effects on major resident cells such as cardiomyocytes, vascular endothelial cells, and fibroblasts. These cellular changes subsequently contribute to the development of DCM. This article comprehensively analyzes cellular, animal, and human studies to summarize the latest insights into the impact of inflammation on DCM. Furthermore, the potential therapeutic effects of current anti-inflammatory drugs in the management of DCM are also taken into consideration. The ultimate goal of this work is to consolidate the existing literature on the inflammatory processes underlying DCM, providing clinicians with the necessary knowledge and tools to adopt a more efficient and evidence-based approach to managing this condition.

Interaction of the AKT and β-catenin signalling pathways and the influence of photobiomodulation on cellular signalling proteins in diabetic wound healing

The induction of a cells destiny is a tightly controlled process that is regulated through communication between the matrix and cell signalling proteins. Cell signalling activates distinctive subsections of target genes, and different signalling pathways may be used repeatedly in different settings. A range of different signalling pathways are activated during the wound healing process, and dysregulated cellular signalling may lead to reduced cell function and the development of chronic wounds. Diabetic wounds are chronic and are characterised by the inability of skin cells to act in response to reparative inducements. Serine/threonine kinase, protein kinase B or AKT (PKB/AKT), is a central connection in cell signalling induced by growth factors, cytokines and other cellular inducements, and is one of the critical pathways that regulate cellular proliferation, survival, and quiescence. AKT interacts with a variety of other pathway proteins including glycogen synthase kinase 3 beta (GSK3β) and β-catenin. Novel methodologies based on comprehensive knowledge of activated signalling pathways and their interaction during normal or chronic wound healing can facilitate quicker and efficient diabetic wound healing. In this review, we focus on interaction of the AKT and β-catenin signalling pathways and the influence of photobiomodulation on cellular signalling proteins in diabetic wound healing.

Marital status impact on the outcomes of patients admitted for acute decompensation of heart failure: A retrospective, single-center, analysis

BACKGROUND

Conflicting evidence exists regarding the association between marital status and outcomes in patients with heart failure (HF). Further, it is not clear whether type of unmarried status (never married, divorced, or widowed) disparities exist in this context.

HYPOTHESIS

We hypothesized that marital status will be associated with better outcomes in patients with HF.

METHODS

This single-center retrospective study utilized a cohort of 7457 patients admitted with acute decompensated HF (ADHF) between 2007 and 2017. We compared baseline characteristics, clinical indices, and outcomes of these patients grouped by their marital status. Cox regression analysis was used to explore the independency of the association between marital status and long-term outcomes.

RESULTS

Married patients accounted for 52% of the population while 37%, 9%, and 2% were widowed, divorced, and never married, respectively. Unmarried patients were older (79.8 ± 11.5 vs. 74.8 ± 11.1 years; p < 0.001), more frequently women (71.4% vs. 33.2%; p < 0.001), and less likely to have traditional cardiovascular comorbidities. Compared with married patients, all-cause mortality incidence was higher in unmarried patients at 30 days (14.7% vs. 11.1%, p < 0.001), 1 year, and 5 years (72.9% vs. 68.4%, p < 0.001). Nonadjusted Kaplan-Meier estimates for 5-year all-cause mortality by sex, demonstrated the best prognosis for married women, and by marital status in unmarried patients, the best prognosis was demonstrated in divorced patients while the worst was recorded in widowed patients. After adjustment for covariates, marital status was not found to be independently associated with ADHF outcomes.

CONCLUSIONS

Marital status is not independently associated with outcomes of patients admitted for ADHF. Efforts for outcomes improvement should focus on other, more traditional risk factors.

Comorbidity profile and outcomes in patients with chronic heart failure in a Latin American country: Insights from the Colombian heart failure registry (RECOLFACA)

BACKGROUND

Heart failure (HF) is usually accompanied by cardiovascular and non-cardiovascular comorbidities, which may significantly impact its prognosis. In this study we aimed to characterize the comorbidity profile and its impact in mortality in patients with HF diagnosis from the Colombian Heart Failure Registry (RECOLFACA).

METHODS

RECOLFACA enrolled adult patients with HF diagnosis from 60 centers in Colombia during the period 2017-2019. The primary outcome was all-cause mortality. A Cox proportional hazards regression model was used to assess the impact of the comorbidities in mortality. A p-value of <0.05 was considered significant.

RESULTS

From the total 2528 patients included in the registry, 2514 patients (58% males, mean age 68 years) had information regarding comorbidity diagnoses. 2321 patients (92.3%) reported at least one comorbidity. Arterial hypertension was the most frequent individual diagnosis (72%; n = 1811), followed by anemia (30.1%, n = 726). The most frequently observed coexisting comorbidities were coronary disease (CHD) with dyslipidemia, and chronic kidney disease (CKD) with type 2 Diabetes Mellitus (T2DM). Different patterns of comorbidity coexistence were observed when comparing HF patients by sex and left-ventricular ejection fraction (LVEF) classification. The only comorbidities that were significantly associated with mortality after multivariate adjustment were T2DM (HR 1.45. 95% CI 1.01-2.12), anemia (HR 1.48. 95% CI 1.02-2.16), and CHD (HR 1.59. 95% CI 1.09-2.33).

CONCLUSION

Multiple comorbidities were frequently observed in the patients from the RECOLFACA. T2DM, anemia and CHD were significantly associated with a higher risk of mortality, highlighting the importance of promoting an optimal follow-up and control of these conditions.

Combined treatment with sacubitril/valsartan plus dapagliflozin in patients affected by heart failure with reduced ejection fraction

Background

Data about real-world effects of combined therapy with sacubitril/valsartan plus dapagliflozin in patients affected by heart failure (HF) with reduced ejection fraction (HFrEF) has not been widely reported. In this article, the benefits of dapagliflozin and sacubitril/valsartan respect to improvements of cardiac function in patients with HFrEF would be investigated.

Methods

HF patients prescribed sacubitril/valsartan between January 2020 and January 2022 in a tertiary teaching hospital were selected using the Computerized Patient Record System. Patients were divided into two groups according to whether they were taking dapagliflozin. Clinical parameters at baseline and during follow-up were retrospectively collected and analyzed.

Results

Total of 136 consecutive patients were recruited for this study. 72 patients treated with sacubitril/valsartan and dapagliflozin were assigned to Group A, and another 64 patients receiving sacubitril/valsartan monotherapy were assigned to Group B. After treatment with sacubitril/valsartan plus dapagliflozin for a median follow-up period of 189 days (IQR, 180-276), significant improvements of cardiac function were achieved in Group A. Median N-terminal pro-B-type natriuretic peptide (NT-proBNP) level was significantly decreased from 2585 pg/ml (1014-3702.5) to 1260.5 pg/ml (439.8-2214.3) (P < 0.001). Mean left ventricular ejection fraction (LVEF) improved from 34.7 ± 4.6% to 39.2 ± 7.5% (P < 0.001). Mean daily dose of loop diuretics decreased from 37.1 ± 17.3 mg/day to 25.9 ± 18.5 mg/day (P < 0.001). Regarding safety, both systolic blood pressure (P = 0.002) and diastolic blood pressure (P = 0.002) significantly decreased. For patients in Group B, significant improvements in mean LVEF (P < 0.001), decreases in mean daily dose of loop diuretics (P = 0.001) and reductions in diastolic blood pressure (P = 0.023) were observed. Strikingly, both median Δ NT-proBNP (P = 0.04) and median Δ LAD (P = 0.006) in Group A were more pronounced in comparison with those seen in Group B.

Conclusions

The combined use of sacubitril/valsartan and dapagliflozin was associated with improved cardiac function in patents with HFrEF, and led to greater reductions in LAD and NT-proBNP levels compared to sacubitril/valsartan monotherapy. These findings suggest that the combination therapy may offer more potent cardiovascular benefits.

Different profiles of advanced heart failure among patients with and without diabetes mellitus. Findings from the EPICTER study

AIM

This work aims to compare the characteristics of advanced heart failure (HF) in patients with and without type 2 diabetes mellitus (DM) and to determine the relevance of variables used to define advanced HF.

PATIENTS AND METHODS

This cross-sectional, multicenter study included patients hospitalized for HF. They were classified into four groups according to presence/absence of advanced HF, determined based on general and cardiac criteria, and presence/absence of DM. To analyze the importance of variables, we grew a random forest algorithm (RF) based on mortality at six months.

RESULTS

A total of 3153 patients were included. The prevalence of advanced HF among patients with DM was 24% compared to 23% among those without DM (p=0.53). Patients with advanced HF and DM had more comorbidity related to cardiovascular and renal diseases; their prognosis was the poorest (log-rank &lt;0.0001) though the adjusted hazard ratio by group in the Cox regression analysis was not significant. The variables that were significantly related to mortality were the number of comorbidities (p=0.005) and systolic blood pressure (p=0.024). The RF showed that general criteria were more important for defining advanced HF than cardiac criteria.

CONCLUSIONS

Patients with advanced HF and DM were characterized by DM in progression with macro and microvascular complications. The outcomes among advanced HF patients were poor; patients with advanced HF and DM had the poorest outcomes. General criteria were the most important to establish accurately a definition of advanced HF, being decisive the evidence of disease progression in patients with DM.

Protective effects of combining SERMs with estrogen on metabolic parameters in postmenopausal diabetic cardiovascular dysfunction: The role of cytokines and angiotensin II

INTRODUCTION

The beneficial effects of the administration of selective estrogen receptor modulators (SERMs) and estrogen (E2), alone or in combination with each other, have been reported in postmenopausal diabetic cardiovascular dysfunction. In the present study, we determined the mechanism of action of SERMs and E2 on inflammatory balance, angiotensin II (Ang II) serum levels, and glycemic profile in a postmenopausal diabetic rat model.

METHODS

Ovariectomized rats with type 2 diabetes received daily SERMs (tamoxifen and raloxifene) and E2 for one month. After treatment, cardiovascular risk indices, glycemic profile, and serum Ang II, TNF-α and IL-10 levels were measured.

RESULTS

Type 2 diabetes caused an abnormal glycemic profile, which was exacerbated by ovariectomy. All treatments inhibited the effects of diabetes and ovariectomy on the glycemic profile, with combined treatments (SERMs + E2) showing stronger effects. Cardiovascular risk indices that became abnormal by diabetes and worsened by ovariectomy were improved in all treatment modalities. Also, combined treatment reduced serum Ang II, TNF-α, and the ratio of TNF-α to IL-10, indicating an improvement in inflammatory balance.

CONCLUSION

Our study showed the administration of SERMs and E2, alone or in combination, could be an effective alternative in the treatment of menopausal diabetes, and generally, the beneficial effects of combined treatments were more effective than the effects of E2 or SERMs alone. It appears that E2 or SERMs benefit the cardiovascular system by improving inflammatory balance and reducing Ang II levels.

Impact of insulin therapy on outcomes of diabetic patients with heart failure: A systematic review and meta-analysis

OBJECTIVE

To compare clinical outcomes in diabetic patients with heart failure managed by insulin with those managed by non-insulin (oral hypoglycemic agents and/or lifestyle modification) based therapy.

METHODS

PubMed and Scopus databases were searched for studies conducted on diabetic patients with heart failure. Studies were to compare outcomes of patients managed by insulin versus non-insulin therapies.

RESULTS

15 studies were included. Compared to those who were managed using non-insulin therapy, insulin-treated patients had increased risk of all-cause mortality (RR 1.46, 95% CI: 1.14, 1.88) and cardiovascular specific mortality (RR 1.62, 95% CI: 1.33, 1.96). Those managed using insulin also had increased risk of hospitalization (RR 1.45, 95% CI: 1.09, 1.93) and readmission (RR 1.49, 95% CI: 1.32, 1.67). There was no additional risk for stroke (RR 1.07, 95% CI: 0.91, 1.27) or myocardial infarction (MI) (RR 1.10, 95% CI: 0.96, 1.27) between the two groups of patients.

CONCLUSIONS

Receipt of insulin among diabetic patients with heart failure was associated with an increased risk of mortality, hospitalization and readmission compared to management using oral hypoglycemic agents and/or lifestyle modification. Such patients should be closely monitored for any adverse events.

Diabetes Increases Risk of Cardiovascular Events in Patients Receiving Permanent Pacemaker: A Propensity Score-Matched Cohort Study

BACKGROUND

Type 2 diabetes was associated with a higher risk for permanent pacemaker (PPM) treatment. The difference in cardiovascular outcomes between patients with and without diabetes receiving PPM treatment remains unexplored.

METHOD

Between January 2003 and December 2017, 1742 patients receiving naïve PPM treatment comprised this retrospective cohort study and were categorized into two groups by the diagnosis of diabetes: group with diabetes (n = 632, 36.3%) and group without diabetes (n = 1110, 63.7%). The primary outcome was cardiovascular events including heart failure (HF) hospitalization and acute myocardial infarction (AMI). The secondary outcomes of this study included pacemaker infection, pacing-induced cardiomyopathy, cerebrovascular accident, cardiovascular mortality, and all-cause mortality. Propensity score matching (PSM) was applied to reduce selection bias between the study groups.

RESULT

During a mean follow-up period of 7.8 ± 4.8 years, 264 patients had a cardiovascular event. Before PSM, the incidence of cardiovascular events was higher in patients with diabetes compared to patients without diabetes (19.8% vs. 12.5%, P < 0.001), and the incidences of pacing-induced cardiomyopathy, cardiovascular mortality, and all-cause mortality were all higher in patients with diabetes compared to patients without diabetes. After PSM, the incidence of cardiovascular events was higher in patients with diabetes compared to patients without diabetes (18.8% vs. 12.3%, P = 0.015). The incidence of HF hospitalization was higher in patients with diabetes compared to patients without diabetes (15.3% vs. 10.2%, P = 0.037), whereas the incidence of AMI did not differ between the two groups. Moreover, after PSM, patients with diabetes had higher cumulative incidences of pacing-induced cardiomyopathy and all-cause mortality compared to patients without diabetes.

CONCLUSIONS

The prevalence of diabetes was over one-third of naïve PPM recipients of this cohort, and diabetes increased the risk of cardiovascular events in PPM recipients, especially for HF hospitalization.

Influence of diabetes mellitus interactions with cardiovascular risk factors on post-myocardial infarction heart failure hospitalizations

OBJECTIVE

There is a paucity of information regarding how cardiovascular risk factors (RF) modulate the impact of diabetes mellitus (DM) on the heart failure hospitalization (HFH) risk following an acute myocardial infarction (AMI).

METHODS

Adult survivors of an AMI were retrospectively identified from the 2014 US Nationwide Readmissions Database. The impact of DM on the risk for a 6-month HFH was studied in subgroups of RFs using multivariable logistic regression to adjust for baseline risk differences. Individual interactions of DM with RFs were tested.

RESULTS

Of 237,549 AMI survivors, 37.2% patients had DM. Primary outcome occurred in 12,934 patients (5.4%), at a 106% higher rate in DM patients (7.9% vs 4.0%, p < 0.001), which was attenuated to a 45% higher adjusted risk. Higher HFH risk in DM patients was consistent across subgroups and significant interactions were present between DM and other RFs. The increased HFH risk with DM was more pronounced in patients without certain HF RFs compared with those with these RFs [age < 65: OR for DM 1.84 (1.58-2.13) vs age ≥ 65: OR 1.34 (1.24-1.45); HF absent during index AMI: OR for DM 1.87 (1.66-2.10) vs HF present: OR 1.24 (1.14-1.34); atrial fibrillation absent: OR for DM 1.57 (1.46-1.68) vs present: OR 1.19 (1.06-1.33); P_interaction < 0.001 for all]. Similar results were noted for hypertension and chronic kidney disease.

CONCLUSIONS

AMI survivors with DM had a higher risk of 6-month HFHs. The impact of DM on the increased HFH risk was more pronounced in patients without certain RFs suggesting that more aggressive preventive strategies related to DM and HF are needed in these subgroups to prevent or delay the onset of HFHs.

High prevalence of fragmented QRS on electrocardiography in Japanese patients with diabetes irrespective of metabolic syndrome

AIMS/INTRODUCTION

Fragmented QRS (fQRS) on electrocardiography is a marker of myocardial fibrosis and myocardial scar formation. This study aimed to clarify the relationship of fQRS with diabetes mellitus and metabolic syndrome (MetS) in Japanese patients.

MATERIALS AND METHODS

Approximately 702 individuals who had a routine health checkup at the Hokuriku Health Service Association (Toyama, Japan) in October 2014 were enrolled and categorized into one of the following four groups based on MetS and diabetes mellitus status: with diabetes mellitus (+) MetS+ (164 participants); diabetes mellitus+ without MetS (Mets-; 103 participants); diabetes mellitus- MetS+ (133 participants); and diabetes mellitus- MetS- (302 participants). fQRS was assessed using the results of electrocardiography.

RESULTS

The prevalence of fQRS was statistically higher in patients with diabetes mellitus+ MetS+ (37%) and diabetes mellitus+ MetS- (35%), than those with diabetes mellitus- MetS+ (14%) or diabetes mellitus- MetS- (10%; P < 0.0001). Significant differences were observed between the fQRS(+) and fQRS(-) groups for age, sex, waist circumference, heart rate, hypertension, hemoglobin A1c, total cholesterol, MetS and diabetes mellitus. The area under the receiver operating characteristic curve for traditional risk factors and diabetes mellitus was 0.72 (P = 0.0007, 95% confidence interval 0.67-0.76), and for traditional risk factors and MetS it was 0.67 (P = 0.28, 95% confidence interval 0.62-0.72). Patients with diabetes mellitus had more than threefold higher likelihood of showing fQRS (odds ratio 3.41; 95% confidence interval 2.25-5.22; P < 0.0001) compared with the reference group without diabetes mellitus, after adjusting for age, sex, dyslipidemia, hypertension and waist circumference.

CONCLUSIONS

fQRS was observed more frequently in diabetes mellitus patients than in MetS and control individuals. Diabetes mellitus was the most significant determinant for fQRS among MetS and other traditional metabolic risk factors.

Compared Impact of Diabetes on the Risk of Heart Failure from Acute Myocardial Infarction to Chronic Coronary Artery Disease

AIM

. - We attempted to describe the risk of heart failure (HF) occurrence according to diabetes mellitus (DM) status in patients with coronary artery disease (CAD) over time, from acute myocardial infarction (MI) to the chronic stable phase.

METHODS

. - For the acute and subacute MI phases, we analysed the FAST-MI cohort restricted to patients without history of HF (n=12,473). The analysis on 1-year outcomes after MI was further restricted to patients who were discharged alive and without history of HF and/or HF symptoms during the index hospitalisation for MI (n=9,181). To analyse the chronic phase, we analysed the CORONOR cohort restricted to patients without history of HF (n=3,871). The primary endpoint was HF occurrence according to DM status. We also analysed the composite of all-cause death or HF.

RESULTS

. - Killip-Kimball class ≥II during the index MI hospitalisation was more frequent in DM patients compared to non-DM patients (29% vs. 15.3%, adjusted OR=1.60). At one year after MI, hospitalisation for HF was more frequent in DM patients (3.3% vs. 1.2%, adjusted HR=1.73). At the chronic phase (5-year outcomes), hospitalisation for HF was more frequent in DM patients (8.5% vs. 4.3%, adjusted HR=1.70). Results focusing on the composite endpoint (all-cause death or HF) were consistent.

CONCLUSION

. - DM was associated with a very constant near 2-fold increase in the risk of HF whatever the presentation of CAD. Avoiding the risk of HF occurrence in CAD patients with DM is critical in daily practice and should be a constant life-long endeavour.

The Comprehensive Machine Learning Analytics for Heart Failure

Background: Early detection of heart failure is the basis for better medical treatment and prognosis. Over the last decades, both prevalence and incidence rates of heart failure have increased worldwide, resulting in a significant global public health issue. However, an early diagnosis is not an easy task because symptoms of heart failure are usually non-specific. Therefore, this study aims to develop a risk prediction model for incident heart failure through a machine learning-based predictive model. Although African Americans have a higher risk of incident heart failure among all populations, few studies have developed a heart failure risk prediction model for African Americans. Methods: This research implemented the Least Absolute Shrinkage and Selection Operator (LASSO) logistic regression, support vector machine, random forest, and Extreme Gradient Boosting (XGBoost) to establish the Jackson Heart Study's predictive model. In the analysis of real data, missing data are problematic when building a predictive model. Here, we evaluate predictors' inclusion with various missing rates and different missing imputation strategies to discover the optimal analytics. Results: According to hundreds of models that we examined, the best predictive model was the XGBoost that included variables with a missing rate of less than 30 percent, and we imputed missing values by non-parametric random forest imputation. The optimal XGBoost machine demonstrated an Area Under Curve (AUC) of 0.8409 to predict heart failure for the Jackson Heart Study. Conclusion: This research identifies variations of diabetes medication as the most crucial risk factor for heart failure compared to the complete cases approach that failed to discover this phenomenon.

Use of sodium-glucose co-transporter 2 inhibitors in patients with heart failure and type 2 diabetes mellitus: data from the Swedish Heart Failure Registry

AIMS

Use of sodium-glucose co-transporter 2 inhibitors (SGLT2i) in real-world heart failure (HF) is poorly characterised. In contemporary patients with HF and type 2 diabetes mellitus (T2DM) we assessed over time SGLT2i use, clinical characteristics and outcomes associated with SGLT2i use.

METHODS AND RESULTS

Type 2 diabetes patients enrolled in the Swedish HF Registry between 2016-2018 were considered. We performed multivariable logistic regression models to assess the independent predictors of SGLT2i use and Cox regression models in a 1:3 propensity score-matched cohort and relevant subgroups to investigate the association between SGLT2i use and outcomes. Of 6805 eligible HF patients with T2DM, 376 (5.5%) received SGLT2i, whose use increased over time with 12% of patients on treatment at the end of 2018. Independent predictors of SGLT2i use were younger age, HF specialty care, ischaemic heart disease, preserved kidney function, and absence of anaemia. Over a median follow-up of 256 days, SGLT2i use was associated with a 30% lower risk of cardiovascular (CV) death/first HF hospitalisation (hazard ratio 0.70, 95% confidence interval 0.52-0.95), which was consistent regardless of ejection fraction, background metformin treatment and kidney function. SGLT2i use was also associated with a lower risk of all-cause and CV death, HF and CV hospitalisation, and CV death/myocardial infarction/stroke.

CONCLUSION

In a contemporary HF cohort with T2DM, SGLT2i use increased over time, was more common with specialist care, younger age, ischaemic heart disease, and preserved renal function, and was associated with lower mortality and morbidity.

Beneficial Effects of Echinacoside on Diabetic Cardiomyopathy in Diabetic Db/Db Mice

Purpose

In this study, we investigated the protective effects and mechanism of action of echinacoside (ECH) from cistanche tubulosa extract in cardiomyocytes of db/db diabetic mice.

Methods

Twenty healthy male db/db mice aged 8 weeks were randomly divided into db/db+ECH (n=10, ECH, 300 mg/(kg/d)), db/db (n=10, saline), and db/m control groups (n=9). Mice were monitored weekly for diet and activity. Mice were injected with 2% of pentobarbital sodium in week 10 and executed. Weight and free blood glucose (FBG) were measured weekly. Echocardiographs were used to detect cardiac function. HE staining, Sudan II staining, Masson’s trichrome staining and Tunel assays were used to evaluate myocardial tissue pathological changes, collagen fiber deposition, lipid accumulation and apoptosis rates in cardiomyocytes, respectively. Western blot and RT-PCR analysis were used to detect the expression of components of the PPAR-α/M-CPT-1 and p53/p38MAPK signaling axis.

Results

Compared to db/db mice, ECH groups showed lower blood glucose and lipid levels. Deterioration in cardiac function was also delayed following ECH treatment. Histopathological analysis showed that ECH significantly improved myocardial tissue in db/db mice, including reduced intercellular spaces, regular arrangements, improved extracellular matrix deposition, and reduced lipid accumulation. ECH also significantly reduced oxidative stress levels in myocardial tissue in db/db mice. Moreover, ECH inhibited PPAR-α/M-CPT-1 signaling, downregulated CD36, and upregulated glucose transporter type 4 (GLUT-4) expression in db/db mouse models of DCM. ECH also inhibited p53/p38MAPK signaling, downregulated caspase-3 and caspase-8, and upregulated Bcl-2/Bax in db/db mouse models of DCM.

Conclusion

ECH displays protective effects in DCM, including the inhibition of cardiac apoptosis and oxidative stress, and improved lipid metabolism in cardiomyocytes. ECH also inhibits cardiac apoptosis through its regulation of p53/p38MAPK signaling, and prevents lipid accumulation through suppression of the PPAR-α/M-CPT-1 signaling axis.

The impact of diabetes mellitus on health-related quality of life in Saudi Arabia

Objective

To evaluate the effect of different demographic, clinical and social factors on diabetic patients' quality of life (QOL).

Research design and methods

A cross sectional study conducted on patients with type 2 diabetes who attended King Abdulaziz University Hospital outpatient clinics between February and March 2017. The patients were asked about sociodemographic data including age, sex, educational level, exercise history and marital status in addition to clinical data such as duration of diabetes, presence of comorbidities as well as medication history. The patients' QOL were assessed using EQ-5D-5L Arabic version.

Results

131 participants were included in the study with a median age 55 years old. Forty five percent of participants were male. Regarding EQ-5D scores, there were significant correlation with gender, exercise, hypertension, heart disease, marital status, educational level and duration of diabetes while there was a significant difference in EQ-VAS scores with respect to heart disease, level of education and duration of diabetes.

Conclusion

More attention needs to be given to the assessment of the QOL of diabetic patients and assessing the effect of different treatment modalities on improvement of patients’ QOL.

Diabetes and Heart Failure: Is it Hyperglycemia or Hyperinsulinemia?

The cardiac effects of exogenously administered insulin for the treatment of diabetes (DM) have recently attracted much attention. In particular, it has been questioned whether insulin is the appropriate treatment for patients with type 2 diabetes mellitus and heart failure. While several old and some new studies suggested that insulin treatment has beneficial effects on the heart, recent observational studies indicate associations of insulin treatment with an increased risk of developing or worsening of pre-existing heart failure and higher mortality rates. However, there is actually little evidence that the associations of insulin administration with any adverse outcomes are causal. On the other hand, insulin clearly causes weight gain and may also cause serious episodes of hypoglycemia. Moreover, excess of insulin (hyperinsulinemia), as often seen with the use of injected insulin, seems to predispose to inflammation, hypertension, dyslipidemia, atherosclerosis, heart failure, and arrhythmias. Nevertheless, it should be stressed that most of the data concerning the effects of insulin on cardiac function derive from in vitro studies with isolated animal hearts. Therefore, the relevance of the findings of such studies for humans should be considered with caution. In the present review, we summarize the existing data about the potential positive and negative effects of insulin on the heart and attempt to answer the question whether any adverse effects of insulin or the consequences of hyperglycemia are more important and may provide a better explanation of the close association of DM with heart failure.

Blood pressure control in type 2 diabetes mellitus with arterial hypertension. The important ancillary role of SGLT2-inhibitors and GLP1-receptor agonists

Type 2 diabetes mellitus and arterial hypertension are major cardiovascular risks factors which shares metabolic and haemodynamic abnormalities as well as pathophysiological mechanisms. The simultaneous presence of diabetes and arterial hypertension increases the risk of left ventricular hypertrophy, congestive heart failure, and stroke, as compared to either condition alone. A number of guidelines recommend lifestyle measures such as salt restriction, weight reduction and ideal body weight mainteinance, regular physical activity and smoking cessation, together with moderation of alcohol consumption and high intake of vegetables and fruits, as the basis for reduction of blood pressure and prevention of CV diseases. Despite the availability of multiple drugs effective for hypertension, BP targets are reached in only 50 % of patients, with even fewer individuals with T2DM-achieving goals. It is established that new emerging classes of type 2 diabetes mellitus treatment, SGLT2 inhibitors and GLP1-receptor agonists, are efficacious on glucose control, and safe in reducing HbA1c significantly, without increasing hypoglycemic episodes. Furthermore, in recent years, many CVOT trials have demonstrated, using GLP1-RA or SGLT2-inihibitors compared to placebo (in combination with the usual diabetes medications) important benefits on reducing MACE (cardio-cerebral vascular events) in the diabetic population. In this hypothesis-driven review, we have examined the anti-hypertensive effects of these novel molecules of the two different classes, in the diabetic population, and suggest that they could have an interesting ancillary role in controlling blood pressure in type 2 diabetic patients.

A review of fibroblast growth factor 21 in diabetic cardiomyopathy

FGF21 (fibroblast growth factor 21) is a regulator of metabolism and performs an important role in glucose and lipid metabolism and the maintenance of energy balance. FGF21 is principally expressed in the liver, but it can also be found in the pancreas, skeletal muscle, and adipose tissue. It is known that levels of serum FGF21 are significantly elevated in obese, insulin-resistant patients, and those with metabolic syndrome. Elevated levels of FGF21 in serum during the early stages of various metabolic diseases are considered a compensatory response by the organism. Therefore, FGF21 is considered a hormone in response to stress and an early diagnostic marker of disease. Diabetic cardiomyopathy is a special type of cardiac complication, characterized as a chronic myocardial disorder caused by diabetes. The pathological process includes increased oxidative stress, energy metabolism in myocardial cells, an inflammatory response, and myocardial cell apoptosis. A growing body of evidence suggests that FGF21 has the potential to be an effective drug for the treatment of diabetic cardiomyopathy. Here, we review recent progress on the characteristics of FGF21 in its protective role, especially in pathological processes such as suppressing apoptosis in the myocardium, reducing inflammation in cardiomyocytes, reducing oxidative stress, and promoting fatty acid oxidation. In addition, we explore the possibility that diabetic cardiomyopathy can be delayed through the application of FGF21, providing possible therapeutic targets of the disease.

Impact of diabetes mellitus on mortality in patients with acute heart failure: a prospective cohort study

Background

Although more than one-third of the patients with acute heart failure (AHF) have diabetes mellitus (DM), it is unclear if DM has an adverse impact on clinical outcomes. This study compared the outcomes in patients hospitalized for AHF stratified by DM and left ventricular ejection fraction (LVEF).

Methods

The Korean Acute Heart Failure registry prospectively enrolled and followed 5625 patients from March 2011 to February 2019. The primary endpoints were in-hospital and overall all-cause mortality. We evaluated the impact of DM on these endpoints according to HF subtypes and glycemic control.

Results

During a median follow-up of 3.5 years, there were 235 (4.4%) in-hospital mortalities and 2500 (46.3%) overall mortalities. DM was significantly associated with increased overall mortality after adjusting for potential confounders (adjusted hazard ratio [HR] 1.11, 95% confidence interval [CI] 1.03–1.22). In the subgroup analysis, DM was associated with higher a risk of overall mortality in heart failure with reduced ejection fraction (HFrEF) only (adjusted HR 1.14, 95% CI 1.02–1.27). Inadequate glycemic control (HbA1c ≥ 7.0% within 1 year after discharge) was significantly associated with a higher risk of overall mortality compared with adequate glycemic control (HbA1c < 7.0%) (44.0% vs. 36.8%, log-rank p = 0.016).

Conclusions

DM is associated with a higher risk of overall mortality in AHF, especially HFrEF. Well-controlled diabetes (HbA1c < 7.0%) is associated with a lower risk of overall mortality compared to uncontrolled diabetes.

Trial registration ClinicalTrial.gov, NCT01389843. Registered July 6, 2011. https://clinicaltrials.gov/ct2/show/NCT01389843

Human induced pluripotent stem cell-derived cardiomyocytes reveal abnormal TGFβ signaling in type 2 diabetes mellitus

Diabetes mellitus is a serious metabolic condition associated with a multitude of cardiovascular complications. Moreover, the prevalence of diabetes in heart failure populations is higher than that in control populations. However, the role of cardiomyocyte alterations in type 2 diabetes mellitus (T2DM) has not been well characterized and the underlying mechanisms remain elusive. In this study, two patients who were diagnosed as T2DM were recruited and patient-specific induced pluripotent stem cells (iPSCs) were generated from urine epithelial cells using nonintegrated Sendai virus. The iPSC lines derived from five healthy subjects were used as controls. All iPSCs were differentiated into cardiomyocytes (iPSC-CMs) using the monolayer-based differentiation protocol. T2DM iPSC-CMs exhibited various disease phenotypes, including cellular hypertrophy and lipid accumulation. Moreover, T2DM iPSC-CMs exhibited higher susceptibility to high-glucose/high-lipid challenge than control iPSC-CMs, manifesting an increase in apoptosis. RNA-Sequencing analysis revealed a differential transcriptome profile and abnormal activation of TGFβ signaling pathway in T2DM iPSC-CMs. We went on to show that inhibition of TGFβ significantly rescued the hypertrophic phenotype in T2DM iPSC-CMs. In conclusion, we demonstrate that the iPSC-CM model is able to recapitulate cellular phenotype of T2DM. Our results indicate that iPSC-CMs can therefore serve as a suitable model for investigating molecular mechanisms underlying diabetic cardiomyopathies and for screening therapeutic drugs.

Mitochondrial ROS Formation in the Pathogenesis of Diabetic Cardiomyopathy

Diabetic cardiomyopathy is a result of diabetes-induced changes in the structure and function of the heart. Hyperglycemia affects multiple pathways in the diabetic heart, but excessive reactive oxygen species (ROS) generation and oxidative stress represent common denominators associated with adverse tissue remodeling. Indeed, key processes underlying cardiac remodeling in diabetes are redox sensitive, including inflammation, organelle dysfunction, alteration in ion homeostasis, cardiomyocyte hypertrophy, apoptosis, fibrosis, and contractile dysfunction. Extensive experimental evidence supports the involvement of mitochondrial ROS formation in the alterations characterizing the diabetic heart. In this review we will outline the central role of mitochondrial ROS and alterations in the redox status contributing to the development of diabetic cardiomyopathy. We will discuss the role of different sources of ROS involved in this process, with a specific emphasis on mitochondrial ROS producing enzymes within cardiomyocytes. Finally, the therapeutic potential of pharmacological inhibitors of ROS sources within the mitochondria will be discussed.

Predictors of cardiomyopathy in patients with type-2 diabetes mellitus with and without cardiovascular complications: A cross-sectional study

AIM

This study was aimed to evaluate the cardiomyopathy in patients with type 2 diabetes mellitus (T2DM) who live with or without cardiovascular complications by estimating different cardiac biomarkers.

METHODS

This cross-sectional study enrolled 125 participants including 25 healthy volunteers and 100 T2DM patients. After meeting all inclusion criteria, the participants were categorized into five groups (N = 25 in each) as; healthy volunteers (I), T2DM (II), T2DM with hypertension (III), T2DM with dyslipidemia (IV), T2DM with hypertension and dyslipidemia (V). Pearson's correlation analysis was performed to assess the significant association between cardiac biomarkers other biochemical parameters. P-values <0.05 were considered statistically significant.

RESULTS

The average age of the participants was found to be 55.04 ± 7.51 years. The positive correlation was found between HbA1c and calcium or BNP levels however, a negative association was observed with zinc level. Group V showed higher mean of BNP (pg/mL) as 86.73 ± 64.49 followed by Group III (61.02 ± 53.69), IV (33.88 ± 33.71), II (13.49 ± 11.67) and I (5.54 ± 1.49) which predicts the subclinical cardiomyopathies in the respective groups. Serum zinc (µg/dL) level were significantly lower in Group V (52.72 ± 12.16) followed by III (56.15 ± 9.64), IV (58.10 ± 10.05), II (59.49 ± 11.33) and I (73.96 ± 21.91).

CONCLUSIONS

In summary, BNP and calcium levels were significantly elevated while zinc was significantly reduced in T2DM patients with cardiovascular complication. Results from the study also shown positive correlation between BNP, calcium, Troponin-I levels and blood pressure. However, further longitudinal studies required to confirm these findings.

Heart Failure With Preserved Ejection Fraction: Prevention and Management

Heart failure with preserved ejection fraction (HFpEF) is a complex clinical syndrome that constitutes nearly half of all heart failure cases. Because of lack of effective pharmacological targets to improve outcomes, the emphasis of the management and prevention of HFpEF should be through control of risk factors. This review will use the framework proposed by the American Heart Association on 7 simple measures ("Life's Simple 7") that involves diet and lifestyle changes to achieve ideal cardiovascular health. These 7 measures include (1) smoking, (2) obesity, (3) exercise, (4) diet, (5) blood pressure, (6) cholesterol, and (7) glucose control, which can help control the most common comorbidities and risk factors associated with HFpEF, such as hypertension, diabetes, and obesity. Therefore, application of these 7 simple measures would be a patient-centered and cost-effective way of prevention and management of HFpEF.

Gender-Dependent Alteration of Ca2+ and TNFα Signaling in db/db Mice, an Obesity-Linked Type 2 Diabetic Model

Cardiovascular complications are the primary death cause in type 2 diabetes, where inflammation can play a role. We, and others, have previously shown that, in diabetic cardiomyopathy, cardiac dysfunction is associated with Ca²⁺ mishandling. It is possible that diabetic cardiomyopathy differently affects men and women, as the latter present higher risk to develop heart failure and a higher plasmatic level of the pro-inflammatory cytokine, tumor necrosis factor alpha (TNFα), than men. However, the gender-dependent regulation of Ca²⁺ signaling in diabetes and its relationship with TNFα signaling are still unclear. Here, we analyzed TNFα signaling pathway and its role in Ca²⁺ signaling dysfunction in male and female rodent models of type 2 diabetes linked to obesity (db/db mice) using confocal microscopy in freshly isolated cardiomyocytes. TNFα increased [Ca²⁺]_i transient amplitude and accelerated its decay without affecting SR Ca²⁺ load or Ca²⁺ spark frequency in cells from control mice. All TNFα effects on Ca²⁺ handling were prevented by the inhibition of the ceramidase and the phospholipase A2 (PLA2). While the plasmatic level of TNFα was similar in male and female db/db mice, only male db/db hearts over-expressed both TNFα converting enzyme (TACE) and the protective TNFα receptors 2 (TNF-R2). TNFα receptor 1 (TNF-R1) expression, involved in negative inotropic response of TNFα, was unchanged in both male and female db/db mice compared to controls. We found that male db/db mice cardiomyocytes presented a decrease in [Ca²⁺]_i transient amplitude associated to a drop of sarcoplasmic reticulum Ca²⁺ load, not seen in female db/db mice. Interestingly, sustained incubation with TNFα did not restored Ca²⁺ signaling alteration observed in male db/db mice but still induces an increase in Ca²⁺ spark frequency as seen in control littermates. In cardiomyocytes from female db/db mice, TNFα had no visible effects on Ca²⁺ handling. In conclusion, our study shows that the alteration of Ca²⁺ signaling and TNFα, seen in db/db mice, is gender specific presenting an increase in TNFα cardio-protective pathway in male mice.

Review on sodium-glucose cotransporter 2 inhibitor (SGLT2i) in diabetes mellitus and heart failure

SGLT-2 inhibitors are a novel class of anti-diabetic agents which act by inhibiting glucose reabsorption in proximal convoluted tubules of kidney. Apart from maintaining glucose homeostasis they exert a number of positive effects on the cardiovascular system like weight loss, decreasing blood pressure, preserving renal function, reducing triglycerides, natriuresis and improving endothelial dysfunction. In large clinical trials, all the three prototype agents – Empaglifozin, Canaglifozin and dapaglifozin have shown reductions in major adverse cardiovascular events including cardiovascular deaths, non fatal MI, stroke and heart failure (HF) hospitalizations. The reduction in heart failure hospitalization is a surprising finding and trials of these drug are now underway for HF also. More surprising is the fact that the benefits are comparable or even better that achieved by recently approved novel drugs for HF. In this review, we briefly discuss the pathophysiology of HF in diabetes, describe the prototype SGLT-2 molecules available, their data from large cardiovascular outcome trials till date and their role in current practice of diabetes management.

Right ventricular dysfunction and remodeling in diabetic cardiomyopathy

The increasing prevalence of diabetic cardiomyopathy (DCM) is an important threat to health worldwide. While left ventricular (LV) dysfunction in DCM is well recognized, the accurate detection, diagnosis, and treatment of changes in right ventricular (RV) structure and function have not been well characterized. The pathophysiology of RV dysfunction in DCM may share features with LV diastolic and systolic dysfunction, including pathways related to insulin resistance and oxidant injury, although the RV has a unique cellular origin and composition and unique biomechanical properties and is coupled to the lower-impedance pulmonary vascular bed. In this review, we discuss potential mechanisms responsible for RV dysfunction in DCM and review the imaging approaches useful for early detection, protection, and intervention strategies. Additional data are required from animal models and clinical trials to better identify the onset and features of altered RV and pulmonary vascular structure and function during the onset and progression of DCM and to determine the efficacy of early detection and treatment of RV dysfunction on clinical symptoms and outcomes.

Diabetes mellitus, blood glucose and the risk of heart failure: A systematic review and meta-analysis of prospective studies

BACKGROUND AND AIM

The strength of the association between diabetes and risk of heart failure has differed between previous studies and the available studies have not been summarized in a meta-analysis. We therefore quantified the association between diabetes and blood glucose and heart failure in a systematic review and meta-analysis.

METHODS AND RESULTS

PubMed and Embase databases were searched up to May 3rd 2018. Prospective studies on diabetes mellitus or blood glucose and heart failure risk were included. A random effects model was used to calculate summary relative risks (RRs) and 95% confidence intervals (CIs). Seventy seven studies were included. Among the population-based prospective studies, the summary RR for individuals with diabetes vs. no diabetes was 2.06 (95% CIs: 1.73-2.46, I² = 99.8%, n = 30 studies, 401495 cases, 21416780 participants). The summary RR was 1.23 (95% CI: 1.15-1.32, I² = 78.2%, n = 10, 5344 cases, 91758 participants) per 20 mg/dl increase in blood glucose and there was evidence of a J-shaped association with nadir around 90 mg/dl and increased risk even within the pre-diabetic blood glucose range. Among the patient-based studies the summary RR was 1.69 (95% CI: 1.57-1.81, I² = 85.5%, p_{heterogeneity}<0.0001) for diabetes vs. no diabetes (n = 41, 100284 cases and >613925 participants) and 1.25 (95% CI: 0.89-1.75, I² = 95.6%, p_{heterogeneity}<0.0001) per 20 mg/dl increase in blood glucose (1016 cases, 34309 participants, n = 2). In the analyses of diabetes and heart failure there was low or no heterogeneity among the population-based studies that adjusted for alcohol intake and physical activity and among the patient-based studies there was no heterogeneity among studies with ≥10 years follow-up.

CONCLUSIONS

These results suggest that individuals with diabetes are at an increased risk of developing heart failure and there is evidence of increased risk even within the pre-diabetic range of blood glucose.

Current Modalities and Mechanisms Underlying Cardioprotection by Ischemic Conditioning

Ischemic preconditioning is a process which serves to mitigate reperfusion injury. Preconditioning of the heart can be achieved through natural, pharmacological, and mechanical means. Mechanical preconditioning appears to have the greatest chance of good outcomes while methods employing pharmacologic preconditioning have been largely unsuccessful. Remote ischemic preconditioning achieves a cardioprotective effect by applying cycles of ischemia and reperfusion in a distal limb, stimulating the release of a neurohumoral cardioprotective factor incited by stimulation of afferent neurons. The cardioprotective factor stimulates the reperfusion injury salvage kinase (RISK) and survivor activator factor enhancement (SAFE) signaling cascades in cardiomyocytes which promote cell survival by the expression of anti-apoptotic genes and inhibition of the opening of mitochondrial permeability transition pores. Clinical application of ischemic preconditioning involving targets in the RISK and SAFE signaling appears promising in the treatment of acute myocardial infarction; however, clinical trials have yet to demonstrate additional benefit to current therapy.

Therapeutic Potential of Ginsenosides as an Adjuvant Treatment for Diabetes

Ginseng, one of the oldest traditional Chinese medicinal herbs, has been used widely in China and Asia for thousands of years. Ginsenosides extracted from ginseng, which is derived from the roots and rhizomes of Panax ginseng C. A. Meyer, have been used in China as an adjuvant in the treatment of diabetes mellitus. Owing to the technical complexity of ginsenoside production, the total ginsenosides are generally extracted. Accumulating evidence has shown that ginsenosides exert antidiabetic effects. In vivo and in vitro tests revealed the potential of ginsenoside Rg1, Rg3, Rg5, Rb1, Rb2, Rb3, compound K, Rk1, Re, ginseng total saponins, malonyl ginsenosides, Rd, Rh2, F2, protopanaxadiol (PPD) and protopanaxatriol (PPT)-type saponins to treat diabetes and its complications, including type 1 diabetes mellitus, type 2 diabetes mellitus, diabetic nephropathy, diabetic cognitive dysfunction, type 2 diabetes mellitus with fatty liver disease, diabetic cerebral infarction, diabetic cardiomyopathy, and diabetic erectile dysfunction. Many effects are attributed to ginsenosides, including gluconeogenesis reduction, improvement of insulin resistance, glucose transport, insulinotropic action, islet cell protection, hepatoprotective activity, anti-inflammatory effect, myocardial protection, lipid regulation, improvement of glucose tolerance, antioxidation, improvement of erectile dysfunction, regulation of gut flora metabolism, neuroprotection, anti-angiopathy, anti-neurotoxic effects, immunosuppression, and renoprotection effect. The molecular targets of these effects mainly contains GLUTs, SGLT1, GLP-1, FoxO1, TNF-α, IL-6, caspase-3, bcl-2, MDA, SOD, STAT5-PPAR gamma pathway, PI3K/Akt pathway, AMPK-JNK pathway, NF-κB pathway, and endoplasmic reticulum stress. Rg1, Rg3, Rb1, and compound K demonstrated the most promising therapeutic prospects as potential adjuvant medicines for the treatment of diabetes. This paper highlights the underlying pharmacological mechanisms of the anti-diabetic effects of ginsenosides.

Glucose-Lowering Therapies and Heart Failure in Type 2 Diabetes Mellitus: Mechanistic Links, Clinical Data, and Future Directions

Diabetes mellitus independently increases the risk of and mortality from heart failure in a manner that is well established but inadequately understood. Glycemic optimization does not eliminate this risk, and measures of glycemic control are insufficient markers of cardiovascular risk. In response to a regulatory guidance from the US Food and Drug Administration, glucose-lowering agents are now routinely evaluated in large cardiovascular outcome trials. These recent trial experiences of novel and established glucose-lowering therapies have shown variable risks and benefits with respect to heart failure. Cardiovascular outcome trials have increasingly included heart failure events as either a component of the primary end point or a secondary adjudicated end point. We comprehensively review each established and novel currently marketed glucose-lowering therapy, their biological targets, mechanisms of action, and relationships with heart failure. We then highlight gaps in available evidence and directions for future research regarding the ascertainment of heart failure-related data in the evaluation of emerging glucose-lowering therapies.

Exploring heart failure events in contemporary cardiovascular outcomes trials in type 2 diabetes mellitus

INTRODUCTION

Type 2 diabetes mellitus (DM) and heart failure (HF) are closely related, with the onset of one serving as an independent risk factor for the development or progression of the other. The true impact of their relationship is poorly understood. Since various classes of glucose-lowering therapies have been shown to have differing impact on cardiovascular outcomes, cardiovascular effects of such therapies have been increasingly formally evaluated. Areas covered: With the increasing prevalence of concomitant HF and type 2 DM, HF outcomes serve as important endpoints in trials of glucose-lowering therapies. A thorough literature search of recent cardiovascular outcome trials of glucose-lowering therapies was performed. The authors focus on the availability and extent of ascertainment of data related to HF outcomes in these contemporary clinical trial experiences. Expert commentary: Although early cardiovascular outcome trials did not focus on HF events, these outcomes have been increasingly recognized as meaningful end points in cardiovascular outcome trials. The ascertainment of HF end point data needs to become routine and standardized.

Cardiac Insulin Signaling Regulates Glycolysis Through Phosphofructokinase 2 Content and Activity

BACKGROUND

The healthy heart has a dynamic capacity to respond and adapt to changes in nutrient availability. Diabetes mellitus disrupts this metabolic flexibility and promotes cardiomyopathy through mechanisms that are not completely understood. Phosphofructokinase 2 (PFK-2) is a primary regulator of cardiac glycolysis and substrate selection, yet its regulation under normal and pathological conditions is unknown. This study was undertaken to determine how changes in insulin signaling affect PFK-2 content, activity, and cardiac metabolism.

METHODS AND RESULTS

Streptozotocin-induced diabetes mellitus, high-fat diet feeding, and fasted mice were used to identify how decreased insulin signaling affects PFK-2 and cardiac metabolism. Primary adult cardiomyocytes were used to define the mechanisms that regulate PFK-2 degradation. Both type 1 diabetes mellitus and a high-fat diet induced a significant decrease in cardiac PFK-2 protein content without affecting its transcript levels. Overnight fasting also induced a decrease in PFK-2, suggesting it is rapidly degraded in the absence of insulin signaling. An unbiased metabolomic study demonstrated that decreased PFK-2 in fasted animals is accompanied by an increase in glycolytic intermediates upstream of phosphofructokianse-1, whereas those downstream are diminished. Mechanistic studies using cardiomyocytes showed that, in the absence of insulin signaling, PFK-2 is rapidly degraded via both proteasomal- and chaperone-mediated autophagy.

CONCLUSIONS

The loss of PFK-2 content as a result of reduced insulin signaling impairs the capacity to dynamically regulate glycolysis and elevates the levels of early glycolytic intermediates. Although this may be beneficial in the fasted state to conserve systemic glucose, it represents a pathological impairment in diabetes mellitus.

Dietary Patterns and Cardiovascular Disease Risk in People with Type 2 Diabetes

PURPOSE OF REVIEW

The primary objective of this review is to identify dietary patterns with beneficial effects on cardiovascular health of adults with type 2 diabetes.

RECENT FINDINGS

The prevalence of diabetes is increasing globally. People with diabetes have a greater risk for cardiovascular disease. Mediterranean diet, dietary approaches to stop hypertension diet, vegetarian diet, traditional Korean diet, Japanese diet, and low-glycemic-index diet can reduce cardiovascular disease risk in people with diabetes. Dietary intake is a key modifiable factor in the management of diabetes and plays a significant role in limiting the incidence of cardiovascular diseases.

Long-term survival following the development of heart failure in an elderly hypertensive population

BACKGROUND

Available data on the prognosis of heart failure (HF) patients are predominantly limited to patients diagnosed at time of hospitalization.

AIMS

To describe the long-term survival of incident HF patients and identify clinical characteristics associated with mortality.

METHODS

The Second Australian National Blood Pressure Study (ANBP2) randomized 6083 hypertensive subjects aged 65-84 years to angiotensin-converting enzyme (ACE) inhibitor or thiazide diuretic-based therapy and followed them for a median of 4.1 years. One hundred forty-five participants who developed HF and 5938 who remained free from HF during the trial period were followed for a median of 6.7 years during a posttrial follow-up.

RESULTS

Three quarters, 110 (76%) of HF patients had died at the end of the follow-up. The five- and ten-year survival rates following HF diagnosis during the trial period were 37% and 15%, respectively, in men, compared with 60% and 33%, respectively, in women. In non-heart failure participants, the five- and ten-year survival rates, following enrollment into the study, were 92% and 76%, respectively. Mortality following HF diagnosis increased with advancing age (HR = 1.09, 95% CI: 1.04-1.33). In addition, male gender and preexisting diabetes were predictive of mortality, while ACE inhibitor-based therapy for the initial trial was associated with 39% decrease (HR = 0.61, 95% CI: 0.41-0.91) in mortality compared with a thiazide diuretic-based regimen.

CONCLUSIONS

Long-term survival in elderly HF patients is poor, especially in men. Mortality in HF patients increased progressively with advancing age, while allocation to the ACE inhibitor-based regimen for the initial trial significantly improved HF outcome.

Rutin alleviates diabetic cardiomyopathy and improves cardiac function in diabetic ApoEknockout mice

Rutin, a natural bioflavonoid, has demonstrated anti-diabetic and anti-oxidative bioactivity. Oxidative stress is a potential therapeutic target for diabetic cardiomyopathy. We investigated whether rutinadministration (60mg/kg body weight) reduces diabetic cardiomyopathy in a diabetic ApoE knock out mouse model. Diabetes was induced in ApoEknockout mice (male, C57BL/6 background) with a high fat diet combined with injection of streptozotocin. Cardiac function was evaluated by echocardiography and cardiac catheter hemodynamic analysis. Cardiac myocardial hypertrophy, myocardial fibrosis, lipid content, myocardial capillary density, and oxidative stress were detected by a series of histopathological analyses, western blotting, and reactive oxygen species analysis. Diabetic mice showed myocardial hypertrophy, lipid accumulation, myocardial fibrosis, elevated collagen content, deteriorating oxidative stress, and left ventricular systolic and diastolic dysfunction. Rutin reversed the myocardial hypertrophy, alleviated extracellular collagen deposition, and lipid accumulation, but increased capillary density in diabetic myocardial tissues. Moreover, rutin substantially improved cardiac function while decreasing blood glucose and lipid content. Therapeutic rutin administration reduced cardiac remodeling and improved myocardial function in diabetic mice, at least in part by reducing oxidative damage and ectopic lipid deposition, inhibiting fibrosis, and promoting angiogenesis. Thus, rutin may represent a potential therapeutic agent for diabetic cardiomyopathy.

Ginsenoside Rh2 Improves Cardiac Fibrosis via PPARδ-STAT3 Signaling in Type 1-Like Diabetic Rats

Ginsenoside Rh2 (Rh2) is an active principal ingredient contained in ginseng (Panax ginseng Meyer), a medicinal herb used to enhance health worldwide. The present study is designed to investigate the effect of Rh2 on myocardial fibrosis in diabetic rats. In a streptozotocin-induced model of type-1 diabetic rats (STZ-diabetic rats), the increased fasting blood glucose levels and heart weight/body weight (HW/BW) ratio were substantially alleviated by Rh2. Moreover, Rh2 improved cardiac performance in STZ-diabetic rats. Histological results from Masson staining showed that Rh2 attenuated cardiac fibrosis in STZ-diabetic rats. The effects of Rh2 were reversed by GSK0660 at a dose sufficient to inhibit peroxisome proliferator-activated receptor δ (PPARδ) in STZ-diabetic rats. The role of PPARδ was subsequently investigated in vitro. Rh2 restored the decreased PPARδ expression level in high glucose-cultured cardiomyocytes. Moreover, increased protein levels of fibrotic signals, including signal transducer and activator of transcription 3 (STAT3), connective tissue growth factor (CCN2) and fibronectin, were reduced by Rh2 in high glucose-cultured cardiomyocytes. These effects of Rh2 were reversed by GSK0660 or siRNA specific for PPARδ Taken together, PPARδ activation may inhibit STAT3 activation to reduce CCN2 and fibronectin expression in diabetic rats with cardiac fibrosis. Moreover, Rh2 improves cardiac function and fibrosis by increasing PPARδ signaling. Therefore, Rh2 is suitable to develop as an alternative remedy for cardiac fibrosis.

Prevalence of QT prolongation and associated LVEF changes in diabetic patients over a four-year retrospective time period

Aim: To evaluate the prevalence and longitudinal changes of prolonged QTc in DM patients admitted to our community hospital, and to determine, if any, its correlation with changes of left ventricular ejection fraction (LVEF). Methods: A retrospective chart review of patients with Type 1 (T1DM) and Type 2 (T2DM) with at least two admissions during a four-year period was performed to identify QTc interval, and LVEF, as measured on transthoracic echocardiogram. Changes in QTc and LVEF between patient hospital admissions were compared. Results: A prolonged QTc interval was found in 66.7% (n = 24) of type 1 and 51.3% (n = 154) type 2 diabetic patients. The QTc interval is progressively increased in both type 1 and type 2 diabetes during follow-up, although it did not reach statistical significance. A total of 62% patients (23 out 37 patients) had a reduction of LVEF during follow-up. Conclusion and Discussion: High prevalence of QTc prolongation was confirmed in hospitalized patients with in both T1DM and T2DM. Significant reduction of LVEF correlated with QTc prolongation over a mean of 17.3 months in T2DM patients, and may have implications for interventions.

Abbreviations CHF: Congestive heart failure LVEF: Left ventricular ejection fraction

Can the onset of heart failure be delayed by treating diabetic cardiomyopathy?

The pathophysiology of diabetic cardiomyopathy (DC) is not fully understood. This frequently undiagnosed complication of chronic hyperglycemia leads to heart failure (HF). However, it is suggested that an appropriate metabolic control of diabetes at an early stage of this deleterious disease, is able to inhibit the development and progression of DC to HF. Recently, it has been postulated that myocardial ischaemia plays an important role in the development of this pathology. Results of the antianginal pharmacological treatment and revascularization are unsatisfactory and reveal a gap in our knowledge and current approaches to treating DC. Most recent studies emphasize the ischaemic component of DC as a key target for therapeutic strategies, which could change its unfavorable history. More stress is put on an early diagnosis of coronary artery disease (CAD), promoting prompt revascularization. Choosing the accurate time of surgical revascularization, with the inclusion of the metabolic background, can ensure complete revascularization with better prognosis. This review will focus on the complexity of DC and summarize contemporary knowledge of treatment strategies for patients with diabetes and CAD.