Thrombus aspiration in hyperglycemic ST-elevation myocardial infarction (STEMI) patients: clinical outcomes at 1-year follow-up

Association between stress hyperglycemia ratio with short-term and long-term mortality in critically ill patients with ischemic stroke

AIMS

Hyperglycemia on admission is associated with poor prognosis in ischemic stroke (IS) patients. We aimed to investigate the relationship between stress hyperglycemia ratio (SHR) and short-term or long-term mortality in IS patients in the ICU and to explore whether this relationship is influenced by diabetes status.

MATERIALS AND METHODS

We collected patients with severe IS requiring ICU admission in the Medical Information Mart for Intensive Care (MIMIC-IV) database and calculated SHR. Outcomes included 30-day, 90-day, and 1-year mortality. The association between SHR and mortality in patients with critical IS was elucidated using Multivariate Cox regression and subgroup analysis for diabetes.

RESULTS

A total of 1376 patients were recruited. After adjusting for potential confounders, patients in the third and fourth quartiles had a significantly increased risk of death at 30 days, 90 days, and 1 year compared to the first quartile of SHR (Q3 vs. Q1: HR 1.56-1.80, all p < 0.02; Q4 vs. Q1: HR 1.75-2.15, all p < 0.001; all p for trend < 0.001). In addition, the highest quartile of SHR was significantly associated with short-term or long-term mortality compared with the first quartile, regardless of diabetes status.

CONCLUSIONS

Our results suggest that stress hyperglycemia, defined by the glucose/HbA1c ratio, is associated with increased short-term and long-term mortality in patients with ischemic stroke, independent of the patient's diabetes status.

High stress hyperglycemia ratio predicts adverse clinical outcome in patients with coronary three-vessel disease: a large-scale cohort study

BACKGROUND

Coronary three-vessel disease (CTVD) accounts for one-third of the overall incidence of coronary artery disease, with heightened mortality rates compared to single-vessel lesions, including common trunk lesions. Dysregulated glucose metabolism exacerbates atherosclerosis and increases cardiovascular risk. The stress hyperglycemia ratio (SHR) is proposed as an indicator of glucose metabolism status but its association with cardiovascular outcomes in CTVD patients undergoing percutaneous coronary intervention (PCI) remains unclear.

METHODS

10,532 CTVD patients undergoing PCI were consecutively enrolled. SHR was calculated using the formula: admission blood glucose (mmol/L)/[1.59×HbA1c (%)-2.59]. Patients were divided into two groups (SHR Low and SHR High) according to the optimal cutoff value of SHR. Multivariable Cox regression models were used to assess the relationship between SHR and long-term prognosis. The primary endpoint was cardiovascular (CV) events, composing of cardiac death and non-fatal myocardial infarction (MI).

RESULTS

During the median follow-up time of 3 years, a total of 279 cases (2.6%) of CV events were recorded. Multivariable Cox analyses showed that high SHR was associated with a significantly higher risk of CV events [Hazard Ratio (HR) 1.99, 95% Confidence interval (CI) 1.58-2.52, P < 0.001). This association remained consistent in patients with (HR 1.50, 95% CI 1.08-2.10, P = 0.016) and without diabetes (HR 1.97, 95% CI 1.42-2.72, P < 0.001). Additionally, adding SHR to the base model of traditional risk factors led to a significant improvement in the C-index, net reclassification and integrated discrimination.

CONCLUSIONS

SHR was a significant predictor for adverse CV outcomes in CTVD patients with or without diabetes, which suggested that it could aid in the risk stratification in this particular population regardless of glucose metabolism status.

Impact of stress hyperglycemia ratio on mortality in patients with cardiac arrest: insight from American MIMIC-IV database

Background

Stress hyperglycemia ratio (SHR) has shown a predominant correlation with transient adverse events in critically ill patients. However, there remains a gap in comprehensive research regarding the association between SHR and mortality among patients experiencing cardiac arrest and admitted to the intensive care unit (ICU).

Methods

A total of 535 patients with their initial ICU admission suffered cardiac arrest, according to the American Medical Information Mart for Intensive Care (MIMIC)-IV database. Patients were stratified into four categories based on quantiles of SHR. Multivariable Cox regression models were used to evaluate the association SHR and mortality. The association between SHR and mortality was assessed using multivariable Cox regression models. Subgroup analyses were conducted to determine whether SHR influenced ICU, 1-year, and long-term all-cause mortality in subgroups stratified according to diabetes status.

Results

Patients with higher SHR, when compared to the reference quartile 1 group, exhibited a greater risk of ICU mortality (adjusted hazard ratio [aHR] = 3.029; 95% CI: 1.802-5.090), 1-year mortality (aHR = 3.057; 95% CI: 1.885-4.958), and long-term mortality (aHR = 3.183; 95% CI: 2.020-5.015). This association was particularly noteworthy among patients without diabetes, as indicated by subgroup analysis.

Conclusion

Elevated SHR was notably associated with heightened risks of ICU, 1-year, and long-term all-cause mortality among cardiac arrest patients. These findings underscore the importance of considering SHR as a potential prognostic factor in the critical care management of cardiac arrest patients, warranting further investigation and clinical attention.

Angiotensin II reduces glyoxalase 1 activity and expression in vascular smooth muscle cells: Implications for diabetic vascular complications

Angiotensin II (Ang II), a key mediator of vascular diseases, is linked to methylglyoxal (MGO) formation, a by-product of glucose metabolism implicated in vascular complications. The glyoxalase system, consisting of glyoxalase 1 (Glo1) and reduced glutathione (GSH), is responsible for detoxifying MGO. This study investigated the effect of Ang II on Glo1 activity and expression in vascular smooth muscle cells (VSMCs). Primary VSMCs were isolated from rat aortas and exposed to Ang II under standard or high glucose conditions. We examined Glo1 activity, expression, intracellular GSH, and methylglyoxal-derived hydroimidazolone 1 (MG-H1) levels. We also analyzed the expressions of nuclear factor-κB (NF-κB) p65 and nuclear factor erythroid 2-related factor 2 (Nrf2) as potential regulators of Glo1 expression. The results demonstrated that Ang II reduced Glo1 activity, expression, and GSH levels while increasing MG-H1 levels in VSMCs. Telmisartan and irbesartan, AT1R blockers, restored Glo1 activity, expression, and GSH levels and alleviated MG-H1 levels. Treatment with AT1R blockers or inhibitors targeting signaling pathways involved in Ang II-induced responses mitigated these effects. High glucose exacerbated the reduction in Glo1 activity and expression. In conclusion, this study provides evidence that Ang II reduces Glo1 activity and expression in VSMCs, which may contribute to developing vascular complications in diabetes. AT1R blockers and inhibitors targeting specific signaling pathways show potential in restoring Glo1 function and mitigating MGO-associated damage. These findings highlight the complex interactions between RAS, MGO, and vascular diseases, highlighting potential therapeutic targets for diabetic vascular complications.

Association between stress hyperglycaemia and in-hospital cardiac events after coronary artery bypass grafting in patients without diabetes: A retrospective observational study of 5450 patients

AIMS

To investigate the impact of stress hyperglycaemia (SH) on in-hospital adverse cardiac events after coronary artery bypass grafting (CABG) in patients without diabetes.

MATERIALS AND METHODS

In total, 5450 patients without diabetes who underwent CABG were analysed. SH was defined as any two instances in which the random blood glucose level was >7.8 mmol/L after CABG in the intensive care unit (ICU). The primary outcome was major adverse cardiac events (MACEs), including in-hospital mortality, acute myocardial infarction, stroke and acute renal failure. Secondary outcomes included surgical site infection (SSI) and length of ICU stay.

RESULTS

Patients with SH had higher rates of MACEs (5.7% vs. 2.3%, p < .0001) and higher SSI (3.3% vs. 1.4%, p = .0003) and longer ICU stays (2.6 ± 2.0 vs. 1.3 ± 1.3 days, p < .0001) than those without SH. Furthermore, SH was associated with a higher risk of MACEs [odds ratio (OR): 2.32, 95% confidence interval (CI): 1.38-3.90], SSI (OR: 2.21, 95% CI: 1.20-3.95) and longer ICU stay (OR: 12.27, 95% CI: 9.41-16.92) after adjusting for confounders. Subgroup analysis showed that patients with SH >10 mmol/L or SH that occurred in the ICU and lasted more than 48 h had increased risks of postoperative complications (p < .05).

CONCLUSIONS

SH was significantly associated with an increased risk of MACEs, SSI and longer ICU stay after CABG in patients without diabetes. In addition, SH >10 mmol/L or that occurred in the ICU and lasted more than 48 h increased the risk of adverse outcomes.

Relationship between stress hyperglycemia ratio and allcause mortality in critically ill patients: Results from the MIMIC-IV database

BACKGROUND

Stress hyperglycemia ratio (SHR) was developed to reduce the impact of long-term chronic glycemic factors on stress hyperglycemia levels, which have been linked to clinical adverse events. However, the relationship between SHR and the short- and long-term prognoses of intensive care unit (ICU) patients remains unclear.

METHODS

We retrospectively analyzed 3,887 ICU patients (cohort 1) whose initial fasting blood glucose and hemoglobin A1c data within 24 hours of admission were available and 3,636 ICU patients (cohort 2) who were followed-up for 1-year using the Medical Information Mart for Intensive Care IV v2.0 database. Patients were divided into two groups based on the optimal cutoff value of SHR, which was determined using the receiver operating characteristic (ROC) curve.

RESULTS

There were 176 ICU deaths in cohort 1 and 378 patients experienced all-cause mortality during 1 year of follow-up in cohort 2. The results of logistic regression revealed that SHR was associated with ICU death (odds ratio 2.92 [95% confidence interval 2.14-3.97] P < 0.001), and non-diabetic patients rather than diabetic patients showed an increased risk of ICU death. As per the Cox proportional hazards model, the high SHR group experienced a higher incidence of 1-year all-cause mortality (hazard ratio 1.55 [95% confidence interval 1.26-1.90] P < 0.001). Moreover, SHR had an incremental effect on various illness scores in predicting ICU all-cause mortality.

CONCLUSION

SHR is linked to ICU death and 1-year all-cause mortality in critically ill patients, and it has an incremental predictive value in different illness scores. Moreover, we found that non-diabetic patients, rather than diabetic patients, showed an increased risk of all-cause mortality.

Effect of Intensive Glycemic Control on Myocardial Infarction Outcome in Patients with Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis

BACKGROUND

The effect of intensive glucose-lowering treatment on the risk of cardiovascular events in type 2 diabetes remains uncertain, especially the effect on the occurrence of myocardial infarction in patients with type 2 diabetes is still unclear. The purpose of this study was to conduct a systematic review and meta-analysis of relevant RCTs.

METHODS

We performed a systematic review of randomized clinical trials (RCTS) and observational studies relevant to this study question. We searched the PubMed and Cochrane databases until June 2022.

RESULTS

We included data on 14 RCTs and 144,334 patients, all of whom had type 2 diabetes. When all studies were considered, intensive glucose-lowering treatment significantly reduced the incidence of MI compared with conventional therapy and the total OR value is 0.90 (CI 0.84, 0.97; P = 0.004) when considering all the studies. When the target value of intensive glucose-lowering treatment was considered as HbA1c decrease of more than 0.5%, there was no significant protective effect on MI, the total OR value is 0.88 (CI 0.81, 0.96; P = 0.003). When considering all available RCTS, the intensive glucose-lowering treatment group had a protective effect for MACE compared to the conventional treatment group, and the total OR value is 0.92 (CI 0.88, 0.96; P < 0.00001). In the available RCTs, for the patients with a history of prior CAD, the total OR value is 0.94 (CI 0.89, 0.99; P = 0.002). And there was no difference in the incidence of hypoglycemic events between the intensive and conservative treatment groups.

CONCLUSION

Our data support the positive protective effect of glucose-lowering therapy on MI in patients with T2DM, but there is no significant effect of intensive glucose-lowering. In addition, we found no greater protective effect of enhanced glucose control in the HbA1c reduction of more than 0.5%, and no difference in the incidence of adverse events compared with the HbA1c reduction of less than 0.5%.

Prognostic value of stress hyperglycemia ratio on short- and long-term mortality after acute myocardial infarction

AIMS

Prior studies demonstrated an association between hospital admission blood glucose and mortality in acute myocardial infarction (AMI). Because stress hyperglycemia ratio (SHR) has been suggested as a more reliable marker of stress hyperglycemia this study investigated to what extent SHR in comparison with admission blood glucose is associated with short- and long-term mortality in diabetic and non-diabetic AMI patients.

METHODS

The analysis was based on 2,311 AMI patients aged 25-84 years from the population-based Myocardial Infarction Registry Augsburg (median follow-up time 6.5 years [IQR: 4.9-8.1]). The SHR was calculated as admission glucose (mg/dl)/(28.7 × HbA1c (%)-46.7). Using logistic and COX regression analyses the associations between SHR and admission glucose and mortality were investigated.

RESULT

Higher admission glucose and higher SHR were significantly and nonlinearly associated with higher 28-day mortality in AMI patients with and without diabetes. In patients without diabetes, the AUC for SHR was significantly lower than for admission glucose (SHR: 0.6912 [95%CI 0.6317-0.7496], admission glucose: 0.716 [95%CI 0.6572-0.7736], p-value: 0.0351). In patients with diabetes the AUCs were similar for SHR and admission glucose. Increasing admission glucose and SHR were significantly nonlinearly associated with higher 5-year all-cause mortality in AMI patients with diabetes but not in non-diabetic patients. AUC values indicated a comparable prediction of 5-year mortality for both measures in diabetic and non-diabetic patients.

CONCLUSIONS

Stress hyperglycemia in AMI patients plays a significant role mainly with regard to short-term prognosis, but barely so for long-term prognosis, underlining the assumption that it is a transient dynamic disorder that occurs to varying degrees during the acute event, thereby affecting prognosis.

Association of stress induced hyperglycemia with angiographic findings and clinical outcomes in patients with ST-elevation myocardial infarction

BACKGROUND

Stress induced hyperglycemia (SIH) is common among patients with ST-elevation myocardial infarction (STEMI), even in patients without diabetes mellitus. However, evidence regarding its role on the angiographic outcomes and the prognosis of patients presenting with STEMI is scarce.

METHODS

This study included 309 consecutively enrolled STEMI patients undergoing primary percutaneous coronary intervention (pPCI). Patients were diagnosed with SIH if blood glucose on admission was > 140 mg/dl. Also, patients had to fast for at least 8 hours before blood sampling. The objective was to assess whether SIH was associated with major adverse cardiovascular and cerebrovascular (MACCE) events and explore its relationship with angiographic predictors of worse prognosis such as poor initial TIMI flow, intracoronary thrombus burden, distal embolization, and presence of residual thrombus after pPCI.

RESULTS

SIH in diabetic and non-diabetic patients was associated with a higher incidence of LTB (aOR = 2.171, 95% CI 1.27-3.71), distal embolization (aOR = 2.71, 95% CI 1.51-4.86), and pre-procedural TIMI flow grade = 0 (aOR = 2.69, 95% CI 1.43-5.04) after adjusting for relevant clinical variables. Importantly, during a median follow-up of 1.7 years STEMI patients with SIH with or without diabetes experienced increased occurrence of MACCE both in univariate (HR = 1.92, 95% CI 1.19-3.01) and multivariate analysis (aHR = 1.802, 95% CI 1.01-3.21).

CONCLUSIONS

SIH in STEMI patients with or without diabetes was independently associated with increased MACCE. This could be attributed to the fact that SIH was strongly correlated with poor pre-procedural TIMI flow, LTB, and distal embolization. Large clinical trials need to validate SIH as an independent predictor of adverse angiographic and clinical outcomes to provide optimal individualized care for patients with STEMI.

Short and long-term prognosis of admission hyperglycemia in patients with and without diabetes after acute myocardial infarction: a retrospective cohort study

OBJECTIVE

Admission hyperglycemia is associated with poor prognosis in patients with acute myocardial infarction (AMI), but the effects of baseline diabetes status on this association remain elusive. We aim to investigate the impact of admission hyperglycemia on short and long-term outcomes in diabetic and non-diabetic AMI patients.

METHODS

In this retrospective cohort study, 3330 patients with regard to first-time AMI between July 2012 and July 2020 were identified. Participants were divided into two groups according to diabetes status (1060 diabetic patients and 2270 non-diabetic patients). Thereafter, they were divided into four groups according to diabetes status-specific cutoff values of fasting blood glucose (FBG) identified by restricted cubic spline. Short-term outcomes included in-hospital death and cardiac complications. Long-term outcomes were all-cause mortality and major adverse cardiovascular events (MACE). Inverse probability of treatment weighting (IPTW) was conducted to adjust for baseline differences among the groups, followed by a weighted Cox proportional hazards regression analysis to calculate hazard ratios and 95% confidence intervals for all-cause mortality associated with each FBG category. Subgroup analysis and sensitivity analysis were performed to test the robustness of our findings.

RESULTS

During a median follow-up of 3.2 years, 837 patients died. There was a significant interaction between diabetes status and FBG levels for all-cause mortality during long-term follow-up (p-interaction < 0.001). Moreover, restricted cubic spline curves for the association between FBG and all-cause mortality followed a J shape in patients with diabetes and a non-linear in patients without diabetes. Kaplan-Meier analysis demonstrated greater survival in non-hyperglycemia patients compared to hyperglycemia patients for both diabetic and non-diabetic patients groups. Survival of hyperglycemia patients without diabetes greater than in hyperglycemia patients with diabetes. In the weighted Multivariable cox analysis, admission hyperglycemia predicted higher short and long-term mortality. Subgroup analysis and sensitivity analysis showed the robustness of the results.

CONCLUSIONS

The inflection points of FBG level for poor prognosis were 5.60 mmol/L for patients without diabetes and 10.60 mmol/L for patients with diabetes. Admission hyperglycemia was identified as an independent predictor of worse short and long-term outcomes in AMI patients, with or without diabetes. These findings should be explored further.

Assessment of medical management in Coronary Type 2 Diabetic patients with previous percutaneous coronary intervention in Spain: A retrospective analysis of electronic health records using Natural Language Processing

INTRODUCTION AND OBJECTIVES

Patients with type 2 diabetes (T2D) and stable coronary artery disease (CAD) previously revascularized with percutaneous coronary intervention (PCI) are at high risk of recurrent ischemic events. We aimed to provide real-world insights into the clinical characteristics and management of this clinical population, excluding patients with a history of myocardial infarction (MI) or stroke, using Natural Language Processing (NLP) technology.

METHODS

This is a multicenter, retrospective study based on the secondary use of 2014-2018 real-world data captured in the Electronic Health Records (EHRs) of 1,579 patients (0.72% of the T2D population analyzed; n = 217,632 patients) from 12 representative hospitals in Spain. To access the unstructured clinical information in EHRs, we used the EHRead® technology, based on NLP and machine learning. Major adverse cardiovascular events (MACE) were considered: MI, ischemic stroke, urgent coronary revascularization, and hospitalization due to unstable angina. The association between MACE rates and the variables included in this study was evaluated following univariate and multivariate approaches.

RESULTS

Most patients were male (72.13%), with a mean age of 70.5±10 years. Regarding T2D, most patients were non-insulin-dependent T2D (61.75%) with high prevalence of comorbidities. The median (Q1-Q3) duration of follow-up was 1.2 (0.3-4.5) years. Overall, 35.66% of patients suffered from at least one MACE during follow up. Using a Cox Proportional Hazards regression model analysis, several independent factors were associated with MACE during follow up: CAD duration (p < 0.001), COPD/Asthma (p = 0.021), heart valve disease (p = 0.031), multivessel disease (p = 0.005), insulin treatment (p < 0.001), statins treatment (p < 0.001), and clopidogrel treatment (p = 0.039).

CONCLUSIONS

Our results showed high rates of MACE in a large real-world series of PCI-revascularized patients with T2D and CAD with no history of MI or stroke. These data represent a potential opportunity to improve the clinical management of these patients.

Effect of n-3 polyunsaturated fatty acids on ischemic heart disease and cardiometabolic risk factors: a two-sample Mendelian randomization study

BACKGROUND

The cardioprotective ability of n-3 polyunsaturated fatty acids (PUFAs) is controversial. Most studies suggest a specific role for PUFAs in cardioprotection from ischemic heart disease (IHD). However, few studies have used genetic biomarkers of n-3 PUFAs to examine their potential relationships with IHD. This study aimed to use Mendelian randomization to evaluate whether genetically-predicted n-3 PUFAs affect IHD and cardiometabolic risk factors (CRFs).

METHODS

Genetic variants strongly (p < 5 × 10^-8) and independently (r² > 0.1) associated with n-3 PUFAs were derived from the CHARGE Consortium (including 8,866 subjects of European ancestry) and were used as instrumental variables (IVs) for evaluating the effect of n-3 PUFAs, including α-linolenic acid (ALA), docosapentaenoic acid (DPA), docosahexaenoic acid (DHA), and eicosapentaenoic acid (EPA). Data on the associations between the IVs and IHD, myocardial infarction, and CRFs (including diabetes, lipids, blood pressure, body mass index, and waist-to-hip ratio (WHR)) were obtained from the UK Biobank SOFT CAD GWAS with the CARDIoGRAMplusC4D 1000 Genomes-based GWAS (113,937 IHD cases and 339,115 controls), the Myocardial Infarction Genetics and CARDIoGRAM Exome consortia (42,335 MI cases and 78,240 controls), the DIAbetes Genetics Replication And Meta-analysis consortium (26,676 diabetes mellitus cases and 132,532 controls), the Global Lipids Genetics Consortium (n = 196,475), the International Consortium for Blood Pressure (n = 69,395), and the meta-analysis of GWAS for body fat distribution in the UK Biobank and Genetic Investigation of Anthropometric Traits (n = 694,649).

RESULTS

Genetically-predicted higher ALA was associated with lower risk of IHD, type 2 diabetes (T2D), and lower serum lipids. The effect size per 0.05-unit increase (about 1 standard deviation) in plasma ALA level) was - 1.173 (95% confidence interval - 2.214 to - 0.133) for IHD. DPA and EPA had no association with IHD but were associated with a higher risk of T2D, higher levels of lipids or WHR. DHA had no association with IHD or CRFs.

CONCLUSIONS

Our study suggests a benefit of ALA for IHD and its main risk factors. DHA, DPA, and EPA had no association with IHD but were partly associated with increasing cardiometabolic risk factors.

Hospital related hyperglycemia as a predictor of mortality in non-diabetes patients: A systematic review

BACKGROUND AND AIMS

Hyperglycemia is a condition often found in hospitalized patients due to stress injury, parenteral nutrition or medications administered during hospitalization. According to previous studies, hyperglycemia could be an independent predictor of mortality. The objective of the study is to assess the risk of mortality in non-diabetic patients with hyperglycemia during hospitalization.

METHODS

In this systematic review, we conducted literature reviews on several databases. Twelve studies were retrieved and critically reviewed using NOS.

RESULTS

A majority of the studies reported that hospital related hyperglycemia increased the mortality rate.

CONCLUSIONS

Hospital related hyperglycemia is an independent predictor factor for both in-hospital and long-term mortality.

Impact of thrombus aspiration in frail STEMI patients

BACKGROUND

Despite primary percutaneous coronary intervention (PPCI) is generally considered the best therapy in older frail adults with ST-segment elevation myocardial infarction (STEMI), the incidence of re-hospitalization for cardiovascular diseases remains significant in these patients.

AIMS

We hypothesized that thrombus aspiration (TA) before PPCI could be a useful treatment for reducing mortality and rehospitalizations in frail patients undergoing PPCI for STEMI.

METHODS

We conducted a study comparing PPCI alone vs TA + PPCI in frail STEMI patients. We examined a cohort of consecutive frail patients aged ≥ 65 years with first STEMI treated with PPCI between February 2008 and July 2015 at the Department of Cardiology of the "Cardarelli" Hospital in Naples, Italy.

RESULTS

The study was completed by 389 patients (PPCI: 195, TA + PPCI: 194). At 1-month follow-up, the rate of death from any cause was 7.0% in patients treated with PPCI alone vs 3.0% in patients treated with TA + PPCI (p 0.036), whereas death from cardiovascular causes was 6.0% in the PPCI group vs 3.0% in the TA + PPCI group (p 0.028). Equally important, the rate of re-hospitalization due to heart failure was 7.5% in the PPCI group vs 4.0% in TA + PPCI group (p 0.025) and the rate of re-hospitalization due to acute coronary syndrome was 10.0% in the PPCI group vs 4.5% in the TA + PPCI group (p 0.016).

CONCLUSION

These results indicate the importance of TA in the treatment of STEMI in a group of high-risk patients such as elderly with frailty.

Metformin in cardiovascular diabetology: a focused review of its impact on endothelial function

As a first-line treatment for diabetes, the insulin-sensitizing biguanide, metformin, regulates glucose levels and positively affects cardiovascular function in patients with diabetes and cardiovascular complications. Endothelial dysfunction (ED) represents the primary pathological change of multiple vascular diseases, because it causes decreased arterial plasticity, increased vascular resistance, reduced tissue perfusion and atherosclerosis. Caused by “biochemical injury”, ED is also an independent predictor of cardiovascular events. Accumulating evidence shows that metformin improves ED through liver kinase B1 (LKB1)/5'-adenosine monophosphat-activated protein kinase (AMPK) and AMPK-independent targets, including nuclear factor-kappa B (NF-κB), phosphatidylinositol 3 kinase-protein kinase B (PI3K-Akt), endothelial nitric oxide synthase (eNOS), sirtuin 1 (SIRT1), forkhead box O1 (FOXO1), krüppel-like factor 4 (KLF4) and krüppel-like factor 2 (KLF2). Evaluating the effects of metformin on endothelial cell functions would facilitate our understanding of the therapeutic potential of metformin in cardiovascular diabetology (including diabetes and its cardiovascular complications). This article reviews the physiological and pathological functions of endothelial cells and the intact endothelium, reviews the latest research of metformin in the treatment of diabetes and related cardiovascular complications, and focuses on the mechanism of action of metformin in regulating endothelial cell functions.

St-Elevation Myocardial Infarction Patients with Hyperglycemia: Effects of Intravenous Adenosine

BACKGROUND

Admission hyperglycemia is common in subjects with acute myocardial infarction (AMI). Reperfusion therapy with primary percutaneous coronary intervention (PPCI) represents the leading therapeutic choice, in particular in ST-segment elevation myocardial infarction (STEMI). Despite this, mortality, re-hospitalizations and complications remain a relevant problem. Adenosine, a purine nucleoside, may reduce no-reflow. Therefore, we studied the effects of intravenous infusion of adenosine in addition to primary percutaneous coronary intervention (PPCI) in hyperglycemic patients with STEMI.

METHODS

We evaluated 836 patients with STEMI and admission hyperglycemia (glycemia > 140 mg/dL). At the end, 399 patients were entered into the database. Patients were grouped on the basis of whether they received adenosine or not.

RESULTS

A total of 199 patients received intravenous adenosine infusion and PPCI and 200 patients did not. Kaplan-Meier analysis demonstrated significant differences in all death, cardiac death, re-hospitalization for heart failure and for acute coronary syndrome in the adenosine treated group.

CONCLUSIONS

The effects of intravenous infusion of adenosine and PPCI on clinical outcomes are significant but we need future larger studies with larger follow-up and statistical analysis to confirm our results.

Impact of admission hyperglycemia on short and long-term prognosis in acute myocardial infarction: MINOCA versus MIOCA

Background

The prognostic role of hyperglycemia in patients with myocardial infarction and obstructive coronary arteries (MIOCA) is acknowledged, while data on non-obstructive coronary arteries (MINOCA) are still lacking. Recently, we demonstrated that admission stress-hyperglycemia (aHGL) was associated with a larger infarct size and inflammatory response in MIOCA, while no differences were observed in MINOCA. We aim to investigate the impact of aHGL on short and long-term outcomes in MIOCA and MINOCA patients.

Methods

Multicenter, population-based, cohort study of the prospective registry, designed to evaluate the prognostic information of patients admitted with acute myocardial infarction to S. Orsola-Malpighi and Maggiore Hospitals of Bologna metropolitan area. Among 2704 patients enrolled from 2016 to 2020, 2431 patients were classified according to the presence of aHGL (defined as admission glucose level ≥ 140 mg/dL) and AMI phenotype (MIOCA/MINOCA): no-aHGL (n = 1321), aHGL (n = 877) in MIOCA and no-aHGL (n = 195), aHGL (n = 38) in MINOCA. Short-term outcomes included in-hospital death and arrhythmias. Long-term outcomes were all-cause and cardiovascular mortality.

Results

aHGL was associated with a higher in-hospital arrhythmic burden in MINOCA and MIOCA, with increased in-hospital mortality only in MIOCA. After adjusting for age, gender, hypertension, Killip class and AMI phenotypes, aHGL predicted higher in-hospital mortality in non-diabetic (HR = 4.2; 95% CI 1.9–9.5, p = 0.001) and diabetic patients (HR = 3.5, 95% CI 1.5–8.2, p = 0.003). During long-term follow-up, aHGL was associated with 2-fold increased mortality in MIOCA and a 4-fold increase in MINOCA (p = 0.032 and p = 0.016). Kaplan Meier 3-year survival of non-hyperglycemic patients was greater than in aHGL patients for both groups. No differences in survival were found between hyperglycemic MIOCA and MINOCA patients. After adjusting for age, gender, hypertension, smoking, LVEF, STEMI/NSTEMI and AMI phenotypes (MIOCA/MINOCA), aHGL predicted higher long-term mortality.

Conclusions

aHGL was identified as a strong predictor of adverse short- and long-term outcomes in both MIOCA and MINOCA, regardless of diabetes. aHGL should be considered a high-risk prognostic marker in all AMI patients, independently of the underlying coronary anatomy.

Trial registration data were part of the ongoing observational study AMIPE: Acute Myocardial Infarction, Prognostic and Therapeutic Evaluation. ClinicalTrials.gov Identifier: NCT03883711.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-021-01384-6.

Reducing Cardiac Injury during ST-Elevation Myocardial Infarction: A Reasoned Approach to a Multitarget Therapeutic Strategy

The significant reduction in ‘ischemic time’ through capillary diffusion of primary percutaneous intervention (pPCI) has rendered myocardial-ischemia reperfusion injury (MIRI) prevention a major issue in order to improve the prognosis of ST elevation myocardial infarction (STEMI) patients. In fact, while the ischemic damage increases with the severity and the duration of blood flow reduction, reperfusion injury reaches its maximum with a moderate amount of ischemic injury. MIRI leads to the development of post-STEMI left ventricular remodeling (post-STEMI LVR), thereby increasing the risk of arrhythmias and heart failure. Single pharmacological and mechanical interventions have shown some benefits, but have not satisfactorily reduced mortality. Therefore, a multitarget therapeutic strategy is needed, but no univocal indications have come from the clinical trials performed so far. On the basis of the results of the consistent clinical studies analyzed in this review, we try to design a randomized clinical trial aimed at evaluating the effects of a reasoned multitarget therapeutic strategy on the prevention of post-STEMI LVR. In fact, we believe that the correct timing of pharmacological and mechanical intervention application, according to their specific ability to interfere with survival pathways, may significantly reduce the incidence of post-STEMI LVR and thus improve patient prognosis.

Primary Percutaneous Coronary Intervention in Patients With Type 2 Diabetes With Late/Very Late Stent Thrombosis and de novo Lesions: A Single-Center Observational Cohort Study of Clinical Outcomes and Influencing Factors

Background: This study compared differences in the risk factors and clinical outcomes of primary percutaneous coronary intervention (PCI) in type 2 diabetes mellitus (DM) and non-DM patients with de novo lesions (DNLs) and late or very late stent thrombosis (LST/VLST).

Methods: We used angiography to screen 4,151 patients with acute coronary syndrome for DNL and LST/VLST lesions. Overall, 3,941 patients were included in the analysis and were allocated to the DM (n = 1,286) or non-DM (n = 2,665) group at admission. The primary endpoint was a composite of major adverse cardiovascular events (MACEs), defined as death, myocardial infarction, revascularization, and ischemic stroke, within a median follow-up period of 698 days.

Results: In the group with a total white blood cell count >10 × 10⁹/L (P = 0.004), a neutral granular cell count >7 × 10⁹/L (P = 0.030), and neutrophil–lymphocyte ratio >1.5 (P = 0.041), revascularization was better for DNL than for LST/VLST lesions. Among DM patients with DNLs, each unit increase in age was associated with a 53.6% increase in the risk of MACEs [hazard ratio (HR): 1.536, 95% confidence interval (CI), 1.300–1.815, P < 0.0001]. Older age (≥65 years) was associated with a significantly greater risk of MACEs (P < 0.0001). Furthermore, each standard deviation (SD) increase in the level of peak white blood cell counts was associated with a 50.1% increase in the risk of MACEs (HR, 1.501; 95% CI, 1.208–1.864; P = 0.0002). When stratifying the DM population with DNLs according to the D-dimer baseline and peak levels <0.5 vs. ≥0.5 mg/L, the high D-dimer group at baseline had a 2.066-fold higher risk of MACEs (P < 0.0001), and the high peak level D-dimer group had a 1.877-fold higher risk of MACEs (P = 0.001) compared to the low-level groups. Among DM patients with LST/VLST, each unit increase in age was associated with a 75.9% increase in the risk of MACEs (HR: 1.759, 95% CI, 1.052–2.940, P = 0.032). Furthermore, for each SD increase in the peak D-dimer level, the risk of MACEs increased by 59.7% (HR, 1.597; 95% CI, 1.110–2.295; P = 0.041).

Conclusion: Following successful primary PCI, the measurement of baseline and peak D-dimer values may help identify individuals at high cardiovascular risk. This suggests a potential benefit of lowering D-dimer levels among T2DM patients with DNL. Furthermore, age and the peak D-dimer values may facilitate the risk stratification of T2DM patients with LST/VLST.

Microbiota thrombus colonization may influence athero-thrombosis in hyperglycemic patients with ST segment elevation myocardialinfarction (STEMI). Marianella study

OBJECTIVES

We examined the association of the coronary thrombus microbiota and relative metabolites with major adverse cardiovascular events (MACE) in hyperglycemic patients with ST segment elevation myocardial infarction (STEMI).

BACKGROUND

Hyperglycemia during STEMI may affect both development and progression of coronary thrombus via gut and thrombus microbiota modifications.

METHODS

We undertook an observational cohort study of 146 first STEMI patients treated with primary percutaneous coronary intervention (PPCI) and thrombus-aspiration (TA). Patients were clustered, based on admission blood glucose levels, in hyperglycemic (≥140 mg/dl) and normoglycemic (<140 mg/dl). We analyzed gut and thrombus microbiota in all patients. Moreover, we assessed TMAO, CD40L and von Willebrand Factor (vWF) in coronary thrombi. Cox regressions were used for the association between Prevotellaspp. and TMAO terziles and MACE. MACE endpoint at 1 year included death, re-infarction, unstable angina.

RESULTS

In fecal and thrombus samples, we observed a significantly different prevalence of both Prevotellaspp. and Alistipesspp. between patients with hyperglycemia (n = 56) and those with normal glucose levels (n = 90). The abundance of Prevotella increased in hyperglycemic vs normoglycemic patients whereas the contrary was observed for Alistipes. Interestingly, in coronary thrombus, the content of Prevotella was associated with admission blood glucose levels (p < 0.01), thrombus dimensions (p < 0.01), TMAO, CDL40 (p < 0.01) and vWF (p < 0.01) coronary thrombus contents. Multivariate Cox-analysis disclosed a reduced survival in patients with high levels of Prevotella and TMAO in coronary thrombus as compared to patients with low levels of Prevotella and TMAO, after 1-year follow up.

CONCLUSIONS

Hyperglycemia during STEMI may increase coronary thrombus burden via gut and thrombus microbiota dysbiosis characterized by an increase of Prevotella and TMAO content in thrombi.

CLINICAL TRIAL REGISTRATION

NCT03439592. September 30, 2016. Ethic Committee Vanvitelli University: 268/2016.

In-hospital and 30-day major adverse cardiac events in patients referred for ST-segment elevation myocardial infarction in Dhaka, Bangladesh

BACKGROUND

There is a paucity of data regarding acute phase (in-hospital and 30-day) major adverse cardiac events (MACE) following ST-segment elevation myocardial infarction (STEMI) in Bangladesh. This study aimed to document MACE during the acute phase post-STEMI to provide information.

METHODS

We enrolled STEMI patients of the National Institute of Cardiovascular Disease, Dhaka, Bangladesh, from August 2017 to October 2018 and followed up through 30 days post-discharge for MACE, defined as the composite of all-cause death, myocardial infarction, and coronary revascularization. Demographic information, cardiovascular risk factors, and clinical data were registered in a case report form. The Cox proportional hazard model was used for univariate and multivariate analysis to identify potential risk factors for MACE.

RESULTS

A total of 601 patients, mean age 51.6 ± 10.3 years, 93% male, were enrolled. The mean duration of hospital stay was 3.8 ± 2.4 days. We found 37 patients (6.2%) to experience an in-hospital event, and 45 (7.5%) events occurred within the 30 days post-discharge. In univariate analysis, a significantly increased risk of developing 30-day MACE was observed in patients with more than 12 years of formal education, diabetes mellitus, or a previous diagnosis of heart failure. In a multivariate analysis, the risk of developing 30-day MACE was increased in patients with heart failure (hazard ratio = 4.65; 95% CI 1.64-13.23).

CONCLUSIONS

A high risk of in-hospital and 30-day MACE in patients with STEMI exists in Bangladesh. Additional resources should be allocated providing guideline-recommended treatment for patients with myocardial infarction in Bangladesh.

Stress-Induced Hyperglycaemia in Non-Diabetic Patients with Acute Coronary Syndrome: From Molecular Mechanisms to New Therapeutic Perspectives

Stress-induced hyperglycaemia (SIH) at hospital admission for acute coronary syndrome is associated with poor outcome, especially in patients without known diabetes. Nevertheless, insulin treatment in these subjects was not correlated with the reduction of mortality. This is likely due to the fact that SIH in the context of an acute coronary syndrome, compared to that in known diabetes, represents an epiphenomenon of other pathological conditions, such as adrenergic and renin-angiotensin system over-activity, hyperglucagonaemia, increase of circulating free fatty acids and pancreatic beta-cell dysfunction, which are not completely reversed by insulin therapy and so worsen the prognosis. Thus, SIH may be considered not only as a biomarker of organ damage, but also as an indicator of a more complex therapeutic strategy in these subjects. The aim of this review is to analyse the molecular mechanisms by which SIH may favour a worse prognosis in non-diabetic patients with acute coronary syndrome and identify new therapeutic strategies, in addition to insulin therapy, for a more appropriate treatment and improved outcomes.

Oral Health Messiers: Diabetes Mellitus Relevance

This article aims to narrate the various oral complications in individuals suffering from diabetes mellitus. Google search for "diabetes mellitus and oral complications" was done. The search was also carried out for "diabetes mellitus" and its oral complications individually. Diabetes mellitus is a chronic metabolic disorder that is a global epidemic and a common cause of morbidity and mortality in the world today. Currently, there are about 422 million cases of diabetes mellitus worldwide. Diabetic patients can develop different complications in the body such as retinopathy, neuropathy, nephropathy, cardiovascular disease. Complications in the oral cavity have been observed in individuals suffering from diabetes mellitus. A study noted that more than 90% of diabetic patients suffered from oral complications. Another research has shown a greater prevalence of oral mucosal disorders in patients with diabetes mellitus than non-diabetic population: 45-88% in patients with type 2 diabetes compared to 38.3-45% in non-diabetic subjects and 44.7% in type 1 diabetic individuals compared to 25% in the non-diabetic population. Oral complications in people with diabetes are periodontal disease, dental caries, oral infections, salivary dysfunction, taste dysfunction, delayed wound healing, tongue abnormalities, halitosis, and lichen planus. The high glucose level in saliva, poor neutrophil function, neuropathy, and small vessel damage contribute to oral complications in individuals with uncontrolled diabetes. Good oral health is imperative for healthy living. Oral complications cause deterioration to the quality of life in diabetic patients. Complications like periodontal disease having a bidirectional relationship with diabetes mellitus even contribute to increased blood glucose levels in people with diabetes. This article intends to promote awareness regarding the oral health of diabetics and to stress the importance of maintaining proper oral hygiene, taking preventive measures, early detection, and appropriate management of oral complications of these patients through a multidisciplinary approach.

Inflammatory Related Cardiovascular Diseases: From Molecular Mechanisms to Therapeutic Targets

Inflammation is a pathogenic response to multiple factors, that causes over-activation of different molecules and pro-inflammatory cellular lines. Different behavioral factors and risk factors might enhance the inflammatory stress, and this might cause cardiovascular disease (CVD). CVD is the world's leading cause of morbidity and mortality, and it is represented by hypertension, coronary heart disease, cerebrovascular disease, peripheral vascular disease, heart failure, rheumatic heart disease, congenital heart disease and cardiomyopathies. In this context, inflammation is both a cause and an aggravating factor in CVD, as well as a mediator of its worst prognostic. The mechanisms that link inflammation to CVD are multiple, complex and multi-factorial. To date, the role of inflammation in the genesis and progression of CVD has been extensively analyzed in recent studies. However, in the last decades, new biomarkers are joining the already known inflammatory biomarkers, such as Creactive protein, interleukins, tumor necrosis factor alpha and nitrotyrosine. Among these new biomarkers, we have to report sirtuins, microRNAs, ST2 protein, apolipoprotein E protein, adiponectin, and others. These biomarkers are preferentially expressed locally in the target tissue of inflammation, but also released in peripheral blood and then used as diagnostic and prognostic biomarkers. Indeed, these biomarkers might also predict future adverse cardiovascular events and worse prognosis in patients with CVD. Furthermore, these new inflammatory biomarkers can also be analyzed to evaluate therapeutic efficacy in patients with CVD. Furthermore, this might open up new fields and interesting research concerning the link between inflammation and CVD.

Establishment and validation of a risk model for prediction of in-hospital mortality in patients with acute ST-elevation myocardial infarction after primary PCI

Background

Currently, how to accurately determine the patient prognosis after a percutaneous coronary intervention (PCI) remains unclear and may vary among populations, hospitals, and datasets. The aim of this study was to establish a prediction model of in-hospital mortality risk after primary PCI in patients with acute ST-elevated myocardial infarction (STEMI).

Methods

This was a multicenter, observational study of patients with acute STEMI who underwent primary PCI. The outcome was in-hospital mortality. The least absolute shrinkage and selection operator (LASSO) method was used to select the features that were the most significantly associated with the outcome. A regression model was built using the selected variables to select the significant predictors of mortality. Receiver operating characteristic (ROC) curve and decision curve analysis (DCA) were used to evaluate the performance of the nomogram.

Results

Totally, 1169 and 316 patients were enrolled in the training and validation sets, respectively. Fourteen predictors were identified by the LASSO analysis: sex, Killip classification, left main coronary artery disease (LMCAD), grading of thrombus, TIMI classification, slow flow, application of IABP, administration of β-blocker, ACEI/ARB, symptom-to-door time (SDT), symptom-to-balloon time (SBT), syntax score, left ventricular ejection fraction (LVEF), and CK-MB peak. The mortality risk prediction nomogram achieved good discrimination for in-hospital mortality (training set: C-statistic = 0.987; model calibration: P = 0.722; validation set: C-statistic = 0.984, model calibration: P = 0.669). Area under the curve (AUC) values for the training and validation sets are 0.987 (95% CI: 0.981–0.994, P = 0.003) and 0.990 (95% CI: 0.987–0.998, P = 0.007), respectively. DCA shows that the nomogram can achieve good net benefit.

Conclusions

A novel nomogram was developed and is a simple and accurate tool for predicting the risk of in-hospital mortality in patients with acute STEMI who underwent primary PCI.

Prognostic impact of the atherogenic index of plasma in type 2 diabetes mellitus patients with acute coronary syndrome undergoing percutaneous coronary intervention

Background

The association of the atherogenic index of plasma (AIP), an emerging lipid index that can predict the risk for cardiovascular disease, with adverse outcomes in type 2 diabetes mellitus (T2DM) patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) has not been determined. Therefore, the aim of this study was to investigate whether the AIP could independently predict adverse cardiovascular events in T2DM patients with ACS undergoing PCI.

Methods

This study was a retrospective analysis of a single-centre prospective registry involving 826 consecutive T2DM patients who underwent primary or elective PCI for ACS from June 2016 to November 2017. This study ultimately included 798 patients (age, 61 ± 10 years; male, 72.7%). The AIP was calculated as the base 10 logarithm of the ratio of the plasma concentration of triglycerides to high-density lipoprotein-cholesterol (HDL-C). All the patients were divided into 4 groups based on the AIP quartiles. The primary endpoint was a composite of death from any cause, non-fatal spontaneous myocardial infarction (MI), non-fatal ischaemic stroke, and unplanned repeat revascularization. The key secondary endpoint was a composite of cardiovascular death, non-fatal MI, and non-fatal ischaemic stroke.

Results

During a median follow-up period of 927 days, 198 patients developed at least one event. An unadjusted Kaplan-Meier analysis showed that the incidence of the primary endpoint increased gradually with rising AIP quartiles (log-rank test, P = 0.001). A multivariate Cox proportional hazards analysis revealed that compared with the lowest AIP quartile, the top AIP quartile was associated with significantly increased risk for the primary and key secondary endpoints (hazard ratio [HR]: 2.249, 95% confidence interval [CI]: 1.438 to 3.517, P < 0.001; and HR: 2.571, 95% CI: 1.027 to 6.440, P = 0.044, respectively).

Conclusions

A higher AIP value on admission was independently and strongly associated with adverse cardiovascular events in T2DM patients with ACS undergoing PCI.

Aspiration Thrombectomy in Patients with Acute Myocardial Infarction-5-Year Analysis Based on a Large National Registry (ORPKI)

Blood flow restoration after primary percutaneous coronary intervention (pPCI) in patients with acute myocardial infarction (AMI) may not always be achieved and could be complicated by the no-reflow phenomenon (NRP). The aim of the current study was to assess the frequency of thrombus aspirations (TAs) and NRPs in patients with AMI and treated with pPCI based on the data collected during a 5-year period in the national ORPKI registry, as well as the frequency of periprocedural strokes and predictors of TA and NRP. This retrospective analysis was performed on prospectively collected data gathered in the Polish National Registry of Percutaneous Coronary Interventions (ORPKI), which covered the period between January 2014 and December 2018, and included 200,991 patients treated due to AMI out of 535,857 patients treated using PCI. Among them, 16,777 patients underwent TA. TA was mainly used in the STEMI subgroup of 14,207 patients (84.8%). The frequency of NRP among AMI patients in the thrombectomy group was 2.75% and in the non-thrombectomy group 0.82%. Predictors of TA and NRP were also assessed using multivariate analysis. The percentage of patients treated with pPCI and with PCI alone increased significantly in all of the three selected groups of patients from 88.7% to 94.3% in the AMI group (p < 0.001), from 82.3% to 90.3% in the STEMI subgroup (p < 0.001), and from 96.3% to 98.2% in the NSTEMI subgroup (p < 0.001) during the analysed period. NRP occurred more often in the thrombectomy group for the NSTEMI (0.58% vs. 3.07%, p < 0.05) and STEMI (1.06% vs. 2.69%, p < 0.05) subgroups. Periprocedural stroke occurred more often in the thrombectomy group in comparison to the non-thrombectomy group with AMI (0.03% vs. 0.01%, p < 0.05) and the NSTEMI (0.16% vs. 0.02%, p < 0.05). In conclusion, the frequency of TA has been experiencing a steady decline in recent years, regardless of AMI type, among patients treated with pPCI.

Association of stress hyperglycemia ratio with intracoronary thrombus burden in diabetic patients with ST-segment elevation myocardial infarction

Background

Large intracoronary thrombus burden is not rare during primary percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI). Stress hyperglycemia is independently associated with poor prognosis. However, the underlying relationship between stress hyperglycemia and thrombus burden remains unknown. This study aims to investigate the association of stress hyperglycemia, evaluated by the combination of acute and chronic glycemic levels, with intracoronary thrombus burden in diabetic patients with STEMI.

Methods

We enrolled 227 consecutive diabetic patients with STEMI undergoing primary PCI within 12 hours after symptom onset. Stress hyperglycemia was estimated using the stress hyperglycemia ratio (SHR), which was calculated as admission glycemia divided by estimated average glucose derived from glycosylated hemoglobin. Based on reclassified angiographic thrombolysis in myocardial infarction (TIMI) thrombus grades, patients were divided into small thrombus burden (STB) group (TIMI thrombus grades <4) and large thrombus burden (LTB) group (TIMI thrombus grades 4 or 5).

Results

Of the entire study population, 77 (33.9%) patients were categorized as LTB group, whereas 150 (66.1%) patients presented with STB. The mean age was 64.1 years, and 80.6% of the patients were male. The SHR levels were significantly higher in patients with LTB than in those with STB [1.31; interquartile range (IQR): 1.13–1.48 versus 1.11; IQR: 0.96–1.32; P<0.001]. The predictive performance of SHR for LTB was moderate (area under the curve: 0.669; 95% confidence interval: 0.604–0.730; P<0.001), with the best cut-off value 1.19 (sensitivity 71.4%, specificity 64.7%). The incidence of LTB with SHR ≥1.19 was significantly higher compared with SHR <1.19 (50.9% versus 18.5%; P<0.001). Based on the multivariable logistic regression analysis, the high SHR (≥1.19) was found to be an independent predictor of LTB following adjustment for baseline clinical confounders.

Conclusions

A high SHR value was independently associated with large thrombus burden and has a better predictive value than glycemia at admission in diabetic patients with STEMI undergoing primary PCI. Stress hyperglycemia may play an important role on the intracoronary thrombus formation.

Visit-to-visit HbA1c variability is associated with in-stent restenosis in patients with type 2 diabetes after percutaneous coronary intervention

Background

Patients with type 2 diabetes are under substantially higher risk of in-stent restenosis (ISR) after coronary stent implantation. We sought to investigate whether visit-to-visit HbA_1c variability is a potential predictor of ISR in diabetic patients after stent implantation.

Methods

We consecutively enrolled type 2 diabetic patients who underwent successful elective percutaneous coronary intervention and performed follow-up coronary angiography after around 12 months. The incidence of ISR and its relationship with visit-to-visit HbA_1c variability, expressed as coefficient of variation (CV), standard deviation (SD) and variability independent of the mean (VIM), were studied. Multivariable Cox proportional hazards models were constructed to analyze the predictive value of HbA_1c variability for ISR.

Results

From September 2014 to July 2018 in Ruijin Hospital, a total of 420 diabetic patients (688 lesions) after stent implantation were included in the final analysis. During a mean follow-up of 12.8 ± 1.3 months, the incidence of ISR was 8.6%, which was significantly increased in patients with higher CV of HbA_1c (P = 0.001). The mean diameter stenosis (DS), net luminal loss and net luminal gain were 22.9 ± 16.8%, 0.42 ± 0.88 mm and 1.66 ± 0.83 mm, respectively. Greater DS was observed in subjects with higher tertiles of CV of HbA_1c (P < 0.001), and this trend was more prominent in patients with optimal glycemic control (HbA_1c ≤ 7%) in the baseline. In multivariate analysis, HbA_1c variability was independently associated with incidence of ISR after adjustment for traditional risk factors and mean HbA_1c (HR: 3.00 [95% CI 1.14–7.92] for highest vs. lowest tertile). Inclusion of CV of HbA_1c led to a better risk stratification accuracy. Assessing HbA_1c variability by SD or VIM yielded similar findings.

Conclusions

This study suggests that visit-to-visit HbA_1c variability is an independent predictor of incidence of ISR in patients with type 2 diabetes after stent implantation.

Trial registration NCT02089360: NCT

Evolutionary de Winter pattern: from de Winter ECG to STEMI-A case report

Background

De Winter pattern is associated with acute occlusion in the left anterior descending coronary artery combined with upsloping ST-segment depression at the J point in leads V₁ through V₆ without ST-segment elevation. The ECG changes in this case were illustrated by an up-sloping ST-segment depression in the V₁ to V₆ leads, followed by tall and symmetrical T waves. Changes from de Winter to ST-segment elevation myocardial infarction (STEMI) are rare.

Case presentation

Our case illustrated an evolutionary de Winter sign that changed to STEMI; the patient underwent cardiac catheterization in time.

Conclusions

Patients who have an electrocardiogram showing de Winter changes may require primary percutaneous coronary intervention. Emergency physicians and cardiologists should not ignore these changes.

Effect of continuous use of metformin on kidney function in diabetes patients with acute myocardial infarction undergoing primary percutaneous coronary intervention

BACKGROUND

Diabetes patients presenting with ST-segment elevation myocardial infarction (STEMI) scheduled for primary percutaneous coronary intervention (PCI) have an increased risk of contrast induced-acute kidney injury (CI-AKI). The effects of continuous use of metformin on kidney function are still controversial in patients submitted to primary PCI. This study aimed to assess continuous metformin therapy on kidney function in diabetic patients undergoing coronary intervention.

METHODS

Two hundred eighty-four patients with metformin-treated diabetes, who underwent coronary intervention within 24 h for STEMI, were enrolled in the retrospective study. All the patients had estimated glomerular filtration rate (eGFR) of > 30 mL/min/1.73 m2. According to the physicians' decisions after admission, 119 patients continued metformin treatment after primary PCI, while 165 patients discontinued it > 48 h after the procedure. Serum creatinine was collected at admission and within 48 h post primary PCI to evaluate the incidence of CI-AKI. We performed a multiple logistic regression analysis to examine the determinants of CI-AKI.

RESULTS

No statistical difference in CI-AKI incidence between the continuous and the discontinuous metformin group (12.6%vs10.3%, p = 0.545). Multivariable logistic regression analysis indicated eGFR ≤60 ml/min/1.73 m2[p = 0.025, OR: 3.131; 95% CI (1.156-8.482)] and contrast volume [p = 0.002, OR: 1.010; 95% CI (1.004-1.016)] were predictive factors of CI-AKI. Metformin therapy was irrelevant to CI-AKI [p = 0.365, OR: 0.698; 95% CI (0.320-1.521)]. No case of lactic acidosis was found in this study. Besides, the study supported discontinuation of metformin was not beneficial for patients' blood glucose control after admission.

CONCLUSIONS

The study indicated that the metformin continuation after primary PCI for STEMI in diabetic patients with eGFR > 30 ml/min / 1.73 m2 did not increase the risk of CI-AKI.

The predictive value of stress hyperglycemia on thrombus burden in nondiabetic patients with ST-segment elevation myocardial infarction

: It is established that hyperglycemia directly effects the platelet functions and fibrin structure. In this study, we aimed to investigate the predictive value of hyperglycemia on thrombus burden in nondiabetic patients with ST-segment elevation myocardial infarction (STEMI) who underwent to primer percutaneous coronary intervention (PPCI). We enrolled 619 nondiabetic patients with STEMI who received PPCI. Patients were divided two groups according to thrombus burden. Stress hyperglycemia was determined as blood glucose concentration more than 180 mg/dl and angiographic coronary thrombus burden was scored based on thrombolysis in myocardial infarction thrombus grades. Patients with thrombus grades 4 were defined as large thrombus burden (LTB), patients with thrombus burden less than thrombus grades 4 were defined as small thrombus burden. A total of 68 (11.0%) STEMI patients had stress hyperglycemia, while 223 (36.0%) patients had LTB. Sex, the prevalence of hypertension, smoking, and dyslipidemia were not different between the thrombus burden groups (P > 0.05 for all parameters). Compared with the patients with small thrombus burden, the patients with LTB were had significantly higher admission blood glucose concentrations (135 ± 39.1 mg/dl vs. 145.9 ± 43.1, P = 0.002, respectively). The multivariate logistic regression analysis demonstrated that stress hyperglycemia is an independent predictor of LTB (odds ratio: 3.025, confidence interval 1.200-7.622, P = 0.019). Admission hyperglycemia is associated with the LTB which cause adverse cardiac outcomes. Hyperglycemia may play a role on thrombus development.

Plasma omentin levels are inversely associated with atherosclerosis in type 2 diabetes patients with increased plasma adiponectin levels: a cross-sectional study

Background

Omentin and adiponectin are among the anti-inflammatory and anti-atherogenic adipokines that have potentially beneficial effects on cardiovascular disorders. Recent studies indicate a paradoxical relationship between adiponectin and cardiovascular mortality across many clinical settings including type 2 diabetes. In this study, we characterized the clinical features of type 2 diabetes patients with increased adiponectin levels and examined the association between omentin and atherosclerosis in those patients.

Methods

The subjects were 413 patients with type 2 diabetes. Fasting plasma omentin and total adiponectin levels were measured by enzyme-linked immunosorbent assay. The intima-media thickness (IMT) of the common carotid artery was measured by ultrasonography. The subjects were stratified according to the median value of plasma adiponectin.

Results

In high-adiponectin group, omentin levels were higher, while IMT tended to be greater than those in low-adiponectin group. The high-adiponectin group also exhibited older age, higher systolic blood pressure, lower kidney function, body mass index, and insulin resistance index compared to the low-adiponectin group. Multivariate analysis revealed that omentin levels were independently and negatively associated with IMT in high-adiponectin group, but not in low-adiponectin group, after adjusting for adiponectin levels and traditional cardiovascular risk factors. On the other hand, adiponectin levels were not significantly associated with IMT in either group.

Conclusions

Plasma omentin levels are inversely associated with IMT in type 2 diabetes patients with increased adiponectin levels and multiple cardiovascular risk factors. This study suggests a protective role of omentin against atherosclerosis in type 2 diabetes patients, which is potentially influenced by adiponectin level and cardiovascular risk status.

The dating of thrombus organization in cases of pulmonary embolism: an autopsy study

Background

Pulmonary embolism (PE) is associated to high mortality rate worldwide. However, the diagnosis of PE often results inaccurate. Many cases of PE are incorrectly diagnosed or missed and they are often associated to sudden unexpected death (SUD). In forensic practice, it is important to establish the time of thrombus formation in order to determine the precise moment of death. The autopsy remains the gold standard method for the identification of death cause allowing the determination of discrepancies between clinical and autopsy diagnoses. The aim of our study was to verify the morphological and histological criteria of fatal cases of PE and evaluate the dating of thrombus formation considering 5 ranges of time.

Methods

Pulmonary vessels sections were collected from January 2010 to December 2017. Sections of thrombus sampling were stained with hematoxylin and eosin. The content of infiltrated cells, fibroblasts and collagen fibers were scored using a semi-quantitative three-point scale of range values.

Results

The 30 autopsies included 19 males (63.3%) and 11 females (36.7%) with an average age of 64.5 ± 12.3 years. The time intervals were as follows: early (≤1 h), recent (> 1 h to 24 h), recent-medium (> 24 h to 48 h), medium (> 48 h to 72 h) and old (> 72 h). In the first hour, we histologically observed the presence of platelet aggregation by immunofluorescence method for factor VIII and fibrinogen. The presence of lymphocytes has been identified from recent thrombus (> 1 h to 24 h) and the fibroblast cells were peripherally located in vascular tissue between 48 and 72 h, whereas they resulted central and copious after 72 h.

Conclusions

After a macroscopic observation and a good sampling traditional histology, it is important to identify the time of thrombus formation. We identified histologically a range of time in the physiopathology of the thrombus (early, recent, recent-medium, medium, old), allowing to determine the dating of thrombus formation and the exact time of death.

Clinical trial number

NCT03887819.

Trial registration

The trial registry is Cliniclatrials.gov, with the unique identifying number NCT03887819. The date of registration was 03/23/2019 and it was “Retrospectively registered”.

Diabetes mellitus, frailty and prognosis in very elderly patients with acute coronary syndromes

BACKGROUND

The magnitude of the association between diabetes (DM) and outcomes in elderly patients with acute coronary syndromes (ACS) is controversial. No study assessed the prognostic impact of DM according to frailty status in these patients.

METHODS

The LONGEVO-SCA registry included unselected ACS patients aged ≥ 80 years. Frailty was assessed by the FRAIL scale. We evaluated the impact of previous known DM on the incidence of death or readmission at 6 months according to status frailty by the Cox regression method.

RESULTS

A total of 532 patients were included. Mean age was 84.3 years, and 212 patients (39.8%) had previous DM diagnosis. Patients with DM had more comorbidities and higher prevalence of frailty (33% vs 21.9%, p = 0.002). The incidence of death or readmission at 6 months was higher in patients with DM (HR 1.52, 95% CI 1.12-2.05, p 0.007), but after adjusting for potential confounders this association was not significant. The association between DM and outcomes was not significant in robust patients, but it was especially significant in patients with frailty [HR 1.72 (1.05-2.81), p = 0.030, p value for interaction = 0.049].

CONCLUSIONS

About 40% of elderly patients with ACS had previous known DM diagnosis. The association between DM and outcomes was different according to frailty status.

Diabetes and risk of peripheral artery disease in patients undergoing first-time coronary angiography between 2000 and 2012 - a nationwide study

Background

The risk of peripheral artery disease (PAD) in patients with diabetes mellitus (DM) and coronary artery disease (CAD) is an important and inadequately addressed issue. Our aim is to examine the impact of DM on risk of PAD in patients with different degrees of CAD characterized by coronary angiography (CAG).

Methods

Using nationwide registers we identified all patients aged ≥18 years, undergoing first time CAG between 2000 and 2012. Patients were categorized into DM/Non-DM group, and further classified into categories according to the degree of CAD i.e., no-vessel disease, single-vessel disease, double-vessel disease, triple-vessel disease, and diffuse disease. Risk of PAD was estimated by 5-year cumulative-incidence and adjusted multivariable Cox-regression models.

Results

We identified 116,491 patients undergoing first-time CAG. Among these, a total of 23.969 (20.58%) had DM. Cumulative-incidence of PAD among DM patients vs. non-DM were 8.8% vs. 4.9% for no-vessel disease, 8.2% vs. 4.8% for single-vessel disease, 10.2% vs. 6.0% for double-vessel disease, 13.0% vs. 8.4% for triple-vessel disease, and 6.8% vs. 6.1% for diffuse disease, respectively. For all patients with DM, the cox-regression analysis yielded significantly higher hazards of PAD compared with non-DM patients with HR 1.70 (no-vessel disease), 1.96 (single-vessel disease), 2.35 (double-vessel disease), 2.87 (triple-vessel disease), and 1.46 (diffuse disease), respectively (interaction-p 0.042).

Conclusion

DM appears to be associated with increased risk of PAD in patients with and without established CAD, with increasing risk in more extensive CAD. This observation indicates awareness on PAD risk in patients with DM, especially among patients with advanced CAD.

ECG analysis in patients with acute coronary syndrome undergoing invasive management: rationale and design of the electrocardiography sub-study of the MATRIX trial

BACKGROUND

The twelve‑lead electrocardiogram (ECG) has become an essential tool for the diagnosis, risk stratification, and management of patients with acute coronary syndromes (ACS). However, several areas of residual controversies or gaps in evidence exist. Among them, P-wave abnormalities identifying atrial ischemia/infarction are largely neglected in clinical practice, and their diagnostic and prognostic implications remain elusive; the value of ECG to identify the culprit lesion has been investigated, but validated criteria indicating the presence of coronary occlusion in patients without ST-elevation are lacking; finally, which criteria among the multiple proposed, better define pathological Q-waves or success of revascularisation deserve further investigations.

METHODS

The Minimizing Adverse hemorrhagic events via TRansradial access site and systemic Implementation of AngioX (MATRIX) trial was designed to test the impact of bleeding avoidance strategies on ischemic and bleeding outcomes across the whole spectrum of patients with ACS receiving invasive management. The ECG-MATRIX is a pre-specified sub-study of the MATRIX programme which aims at analyzing the clinical value of ECG metrics in 4516 ACS patients (with and without ST-segment elevation in 2212 and 2304 cases, respectively) with matched pre and post-treatment ECGs.

CONCLUSIONS

This study represents a unique opportunity to further investigate the role of ECGs in the diagnosis and risk stratification of ACS patients with or without ST-segment deviation, as well as to assess whether the radial approach and bivalirudin may affect post-treatment ECG metrics and patterns in a large contemporary ACS population.

Metabolic Disturbances Identified in Plasma Samples from ST-Segment Elevation Myocardial Infarction Patients

ST-segment elevation myocardial infarction (STEMI) is the most severe form of myocardial infarction (MI) and the main contributor to morbidity and mortality caused by MI worldwide. Frequently, STEMI is caused by complete and persistent occlusion of a coronary artery by a blood clot, which promotes heart damage. STEMI impairment triggers changes in gene transcription, protein expression, and metabolite concentrations, which grants a biosignature to the heart dysfunction. There is a major interest in identifying novel biomarkers that could improve the diagnosis of STEMI. In this study, the phenotypic characterization of STEMI patients (n = 15) and healthy individuals (n = 19) was performed, using a target metabolomics approach. Plasma samples were analyzed by UPLC-MS/MS (ultra-high-performance liquid chromatography-tandem mass spectrometry) and FIA-MS (MS-based flow injection analysis). The goal was to identify novel plasma biomarkers and metabolic signatures underlying STEMI. Concentrations of phosphatidylcholines, lysophosphatidylcholines, sphingomyelins, and biogenic amines were altered in STEMI patients in relation to healthy subjects. Also, after multivariate analysis, it was possible to identify alterations in the glycerophospholipids, alpha-linolenic acid, and sphingolipid metabolisms in STEMI patients.

Association of Serum miR-186-5p With the Prognosis of Acute Coronary Syndrome Patients After Percutaneous Coronary Intervention

Circulating miR-186-5p is an emerging biomarker for acute coronary syndrome (ACS) patients. However, its kinetic signatures and prognostic values in ACS patients undergoing percutaneous coronary intervention (PCI) remain unclear. Levels of serum miR-186-5p were determined in 96 healthy controls and 92 ACS patients before and after PCI by qRT-PCR, and the physiologic state of miR-186-5p was analyzed by comparing its absolute concentrations in isolated exosomes and exosome-depleted supernatants. An average of 1 year of follow-up for ACS patients after PCI was performed. MiR-186-5p levels in the myocardium and serum of rats following left anterior descending coronary artery (LAD) ligation were measured. Serum miR-186-5p levels were found to be significantly increased in ACS patients upon admission compared with those of controls, but these high miR-186-5p levels gradually decreased within 1 week after PCI. Serum miR-186-5p was mainly present in an exosome-free form rather than membrane-bound exosomes. Within 1 year of follow-up, ACS patients with higher miR-186-5p levels upon admission exhibited a higher incidence of MACE after PCI. Different statistical analyzes further validated the independent prognostic values of serum miR-186-5p in ACS patients after PCI. Serum miR-186-5p levels in rats following LAD ligation were increased, and there was a decrease in myocardial miR-186-5p levels. Kyoto encyclopedia of genes and genomes (KEGG) analysis was performed to predict the related pathways of target genes of miR-186-5p, which suggested that miR-186-5p might be involved in ACS by regulating the inflammatory status and D-glucose metabolism. In conclusion, a distinctive expression signature of serum miR-186-5p may contribute to monitoring the clinical condition and assessing the prognosis of ACS patients undergoing PCI.

Association between epicardial adipose tissue and adverse outcomes in coronary heart disease patients with percutaneous coronary intervention

We assessed the relationship between the volume of epicardial adipose tissue and long-term outcomes in patients with coronary heart disease (CHD) undergoing percutaneous coronary intervention (PCI). The patients with CHD were followed for at least 2 years after PCI. The epicardial adipose tissue volume (EATV) was measured using multi-slice computed tomography. Cox regression analysis was used to examine the relationship between EATV and clinical outcome. In this study, 500 patients were enrolled and followed up for a median of 25.2 months. The incidence of adverse cardiovascular events was 12.4%. No significant differences were observed in age, sex, proportion of patients with hypertension or diabetes, smoking, drinking, total cholesterol, triglyceride, high-density lipoprotein, or unstable angina pectoris among different EATV quartiles (P>0.05). The EATV was associated with body mass index (P<0.0001), low-density lipoprotein level (P=0.039), high-sensitivity C-reactive protein level (P<0.001), uric acid level (P=0.004), adiponectin level (P<0.001), and left ventricular ejection fraction (P<0.001). Kaplan–Meier analysis indicated a significant difference in survival rate of patients in EATV quartile 1 versus 4 (P=0.019). After adjusting for confounding factors, EATV quartile 4 (>216.15 cm³) was still associated with adverse cardiovascular outcomes (HR = 1.98, 95% CI: 1.15–4.47, P=0.023) compared with quartile 1 (<101.58 cm³). Our data suggest that EATV is an independent predictor of long-term major adverse cardiovascular events in CHD patients after PCI. Therefore, assessment of EATV using multi-slice computed tomography may contribute to risk stratification in these patients.

Impact of ischaemic heart disease severity and age on risk of cardiovascular outcome in diabetes patients in Sweden: a nationwide observational study

OBJECTIVES

To compare short-term cardiovascular (CV) outcome in type 2 diabetes (T2D) patients without ischaemic heart disease (IHD), with IHD but no prior myocardial infarction (MI), and those with prior MI; and assess the impact on risk of age when initiating first-time glucose-lowering drug (GLD).

DESIGN

Cohort study linking morbidity, mortality and medication data from Swedish national registries.

PARTICIPANTS

First-time users of GLD during 2007-2016.

OUTCOMES

Predicted cumulative incidence for the CV outcome (MI, stroke and CV mortality) was estimated. A Cox model was developed where age at GLD start and CV risk was modelled.

RESULTS

260 070 first-time GLD users were included, 221 226 (85%) had no IHD, 16 294 (6%) had stable IHD-prior MI and 22 550 (9%) had IHD+MI. T2D patients without IHD had a lower risk of CV outcome compared with the IHD populations (±prior MI), (3-year incidence 4.78% vs 5.85% and 8.04%). The difference in CV outcome was primarily driven by a relative greater MI risk among the IHD patients. For T2D patients without IHD, an almost linear association between age at start of GLD and relative risk was observed, whereas in IHD patients, the younger (<60 years) patients had a relative greater risk compared with older patients.

CONCLUSIONS

T2D patients without IHD had a lower risk of the CV outcome compared with the T2D populations with IHD, primarily driven by a greater risk of MI. For T2D patients without IHD, an almost linear association between age at start of GLD and relative risk was observed, whereas in IHD patients, the younger patients had a relative greater risk compared with older patients. Our findings suggest that intense risk prevention should be the key strategy in the management of T2D patients, especially for younger patients.

Perindopril and a Galectin-3 Inhibitor Improve Ischemic Heart Failure in Rabbits by Reducing Gal-3 Expression and Myocardial Fibrosis

Objective: Ventricular remodeling is considered the basis of heart failure and is involved in myocardial fibrosis. This study aimed to assess perindopril and a galectin-3 inhibitor (modified citrus pectin, MCP) for their effects on ventricular remodeling and myocardial fibrosis in rabbits with ischemic heart failure. Methods: Rabbits were divided into sham, heart failure (model), MCP, and perindopril groups, respectively. A rabbit model of ischemic heart failure was established by ligating the anterior descending coronary artery. Then, the rabbits were orally administered MCP, perindopril, or saline (all at 2 ml/kg/d) for 4 weeks. Sham animals only underwent open heart surgery without further treatment. After 4 weeks, cardiac function was examined by ultrasound, and myocardial Gal-3, collagen type I, and collagen type III expression was assessed, at the gene and protein levels, by real-time PCR and Western-Blot, respectively; serum Gal-3 was detected by ELISA, and fibrosis in the infarct zone was evaluated by H&E and Masson staining. Results: In model animals, myocardial Gal-3, collagen type I, and collagen type III gene and protein expression levels were increased compared with control values, as well as serum Gal-3 amounts. Treatment with perindopril and MCP significantly alleviated the above effects, with no significant differences between the treatment groups. Pathological analyses showed that compared with model animals, treatment with MCP or perindopril resulted in relatively neatly arranged myocardial cells in the infarct zone, with significantly decreased fibrosis. Conclusion: Perindopril and the galectin-3 inhibitor MCP comparably improve ischemic heart failure in rabbits, by downregulating Gal-3 and reducing myocardial fibrosis.

Insulin Glargine U100 Utilization in Patients with Type 2 Diabetes in an Italian Real-World Setting: A Retrospective Study

BACKGROUND

This study is aimed at estimating the proportion of type 2 diabetes mellitus (T2DM) patients treated with basal insulin (insulin glargine U100) and at evaluating daily insulin dose, treatment pattern, and adherence to treatment of these patients.

METHODS

Data from administrative and laboratory databases of 3 Italian Local Health Units were retrospectively collected and analyzed. All patients with a diagnosis of T2DM between 01/01/2012 and 31/12/2012 were considered, and those with at least a prescription of insulin glargine between 01/01/2013 and 31/12/2014 were included and followed up for one year. For each patient, we evaluated HbA1c levels both at baseline and during the follow-up period and the daily average dose of insulin. Medication adherence was defined by using medication possession ratio (MPR) and reported as proportion of patients with MPR ≥ 80%.

RESULTS

7,422 T2DM patients were available for the study. According to the antidiabetic medication prescribed, patients were categorized into four groups: insulin glargine only, insulin glargine plus oral glucose-lowering drugs, insulin glargine plus rapid-acting insulin, and insulin glargine plus DPP-4 inhibitors. Median daily dose of insulin among insulin glargine only patients was higher than in other groups (35 IU vs. 20 IU, p < 0.05), and a higher percentage of them achieved a target HbA1c value of less than 7.0% (53.8% vs. 30%, p < 0.001). Adherence to insulin treatment was lowest (41%) in the insulin glargine only group compared to other groups (ranging from 58.4% to 64.4%), p < 0.001.

CONCLUSIONS

A large proportion of T2DM patients treated with insulin fail in achieving the glycemic target of HbA1c level < 7%, irrespective of treatment regimen; however, basal insulin only is associated with lower therapeutic unsuccess. Adherence to antidiabetes medications is also suboptimal in these patients and should be addressed to improve long-term outcomes of reducing and preventing microvascular and macrovascular complications.