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Selvaraj S, Patel S, Sauer AJ, McGarrah RW, Jones P, Kwee LC, Windsor SL, Ilkayeva O, Muehlbauer MJ, Newgard CB, Borlaug BA, Kitzman DW, Shah SJ, Shah SH, Kosiborod MN. Targeted Metabolomic Profiling of Dapagliflozin in Heart Failure With Preserved Ejection Fraction: The PRESERVED-HF Trial. JACC. HEART FAILURE 2024; 12:999-1011. [PMID: 38639697 PMCID: PMC11153021 DOI: 10.1016/j.jchf.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/12/2024] [Accepted: 02/14/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Although sodium glucose co-transporter 2 inhibitors (SGLT2is) improve heart failure (HF)-related symptoms and outcomes in HF with preserved ejection fraction (HFpEF), underlying mechanisms remain unclear. In HF with reduced EF, dapagliflozin altered ketone and fatty acid metabolites vs placebo; however, metabolite signatures of SGLT2is have not been well elucidated in HFpEF. OBJECTIVES The goal of this study was to assess whether SGLT2i treatment altered systemic metabolic pathways and their relationship to outcomes in HFpEF. METHODS Targeted profiling of 64 metabolites was performed from 293 participants in PRESERVED-HF (Dapagliflozin in PRESERVED Ejection Fraction Heart Failure), a 12-week, placebo-controlled trial of dapagliflozin. Linear regression assessed changes in metabolite factors defined by principal components analysis (PCA) with dapagliflozin vs placebo. The relationship between changes in metabolite factors with changes in study endpoints was also assessed. RESULTS The mean age was 70 ± 11 years, 58% were female, and 29% were Black. There were no significant differences in 12 PCA-derived metabolite factors between treatment arms, including metabolites reflecting ketone, fatty acid, or branched-chain amino acid (BCAA) pathways. Combining treatment arms, changes in BCAAs and branched-chain ketoacids were negatively associated with changes in N-terminal pro-B-type natriuretic peptide; changes in medium-/long-chain acylcarnitines were positively associated with changes in N-terminal pro-B-type natriuretic peptide and negatively associated with changes in 6-minute walk test distance; and changes in ketones were negatively associated with changes in weight, without treatment interaction. CONCLUSIONS Leveraging targeted metabolomics in a placebo-controlled SGLT2i trial of HFpEF, dapagliflozin did not alter systemic metabolic as reflected by circulating metabolites, in contrast with reported effects in HF with reduced ejection fraction. Metabolite biomarkers reflecting BCAA, ketone, and fatty acid metabolism were associated with markers of disease severity, suggesting a role for potential novel treatment targets. (Dapagliflozin in PRESERVED Ejection Fraction Heart Failure [PRESERVED-HF]; NCT03030235).
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Affiliation(s)
- Senthil Selvaraj
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Molecular Physiology Institute, Durham, North Carolina, USA
| | - Shachi Patel
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Andrew J Sauer
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Robert W McGarrah
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Molecular Physiology Institute, Durham, North Carolina, USA
| | - Philip Jones
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | | | - Sheryl L Windsor
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Olga Ilkayeva
- Duke Molecular Physiology Institute, Durham, North Carolina, USA; Division of Endocrinology, Metabolism, and Nutrition, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Dalane W Kitzman
- Department of Internal Medicine, Sections on Cardiovascular Medicine and Geriatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Svati H Shah
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Molecular Physiology Institute, Durham, North Carolina, USA
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri-Kansas City, Kansas City, Missouri, USA.
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Aziri B, Begic E, Stanetic B, Mladenovic Z, Kovacevic-Preradovic T. Sodium-glucose cotransporter-2 inhibitors: a swinging pendulum in the treatment of acute myocardial infarction. Minerva Cardiol Angiol 2024; 72:237-250. [PMID: 37161919 DOI: 10.23736/s2724-5683.22.06200-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
INTRODUCTION Sodium-glucose cotransporter-2 (SGLT2) inhibitors are integral in treating patients with heart failure, regardless of the existence of diabetes mellitus. In light of their benefits on the heart muscle, the question of their effect on acute coronary syndrome is raised, and a hypothesis as to whether they can be implemented in its treatment is proposed. The aim of the article was to indicate the potential of using SGLT2 inhibitors in the treatment of myocardial infarction (MI). EVIDENCE ACQUISITION A PubMed search for articles published between October 2017 and May 2022 was conducted using the following keywords: "SGLT2 inhibitors," "Acute Coronary Syndrome," "Treatment," "Prognosis." Reference lists of identified articles were searched for further articles. EVIDENCE SYNTHESIS Reports from clinical trials and animal studies thus far investigating mechanistic pathways of SGLT2 inhibitors' effect in relation to acute myocardial infarction were interplayed to extract relevant findings and analyze the safety of this therapy in acute coronary syndrome (ACS) patients. CONCLUSIONS SGLT2 inhibitors indicate beneficial effects in acute cardiovascular incident by various mechanisms, and early initiation of therapy may improve outcomes for AMI survivors.
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Affiliation(s)
- Buena Aziri
- Department of Pharmacology, Sarajevo Medical School, Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina
| | - Edin Begic
- Department of Pharmacology, Sarajevo Medical School, Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina -
- Department of Cardiology, Prim. Dr. Abdulah Nakas General Hospital, Sarajevo, Bosnia and Herzegovina
| | - Bojan Stanetic
- Department of Cardiology, University Clinical Centre of the Republic of Srpska, Banja Luka, Bosnia and Herzegovina
- Department of Internal Medicine, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Zorica Mladenovic
- Department of Cardiology, Military Medical Academy, University of Defense, Belgrade, Serbia
| | - Tamara Kovacevic-Preradovic
- Department of Cardiology, University Clinical Centre of the Republic of Srpska, Banja Luka, Bosnia and Herzegovina
- Department of Internal Medicine, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
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O'Hara DV, Lam CSP, McMurray JJV, Yi TW, Hocking S, Dawson J, Raichand S, Januszewski AS, Jardine MJ. Applications of SGLT2 inhibitors beyond glycaemic control. Nat Rev Nephrol 2024:10.1038/s41581-024-00836-y. [PMID: 38671190 DOI: 10.1038/s41581-024-00836-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 04/28/2024]
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors were initially developed for their glucose-lowering effects and have shown a modest glycaemic benefit in people with type 2 diabetes mellitus (T2DM). In the past decade, a series of large, robust clinical trials of these therapies have demonstrated striking beneficial effects for various care goals, transforming the chronic disease therapeutic landscape. Cardiovascular safety studies in people with T2DM demonstrated that SGLT2 inhibitors reduce cardiovascular death and hospitalization for heart failure. Subsequent trials in participants with heart failure with reduced or preserved left ventricular ejection fraction demonstrated that SGLT2 inhibitors have beneficial effects on heart failure outcomes. In dedicated kidney outcome studies, SGLT2 inhibitors reduced the incidence of kidney failure among participants with or without diabetes. Post hoc analyses have suggested a range of other benefits of these drugs in conditions as diverse as metabolic dysfunction-associated steatotic liver disease, kidney stone prevention and anaemia. SGLT2 inhibitors have a generally favourable adverse effect profile, although patient selection and medication counselling remain important. Concerted efforts are needed to better integrate these agents into routine care and support long-term medication adherence to close the gap between clinical trial outcomes and those achieved in the real world.
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Affiliation(s)
- Daniel V O'Hara
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
- Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Carolyn S P Lam
- National Heart Centre Singapore, Duke-NUS Medical School, Singapore, Singapore
- Baim Institute for Clinical Research, Boston, MA, USA
| | - John J V McMurray
- School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
| | - Tae Won Yi
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
- The George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia
| | - Samantha Hocking
- Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia
- Boden Initiative, Charles Perkins Centre, University of Sydney, Camperdown, New South Wales, Australia
- Department of Endocrinology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Jessica Dawson
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
- Department of Nutrition and Dietetics, St George Hospital, Kogarah, New South Wales, Australia
| | - Smriti Raichand
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
- Centre for the Health Economy (MUCHE), Macquarie University, Macquarie Park, New South Wales, Australia
| | - Andrzej S Januszewski
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
- Department of Medicine (St. Vincent's Hospital), The University of Melbourne, Fitzroy, Victoria, Australia
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Meg J Jardine
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia.
- Department of Renal Medicine, Concord Repatriation General Hospital, Concord, New South Wales, Australia.
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Selvaraj S, Vidula MK, Claggett B, Rojulpote C, Bhattaru A, Clancy CB, Rossman M, Pryma DA, Goldberg LR, Bravo PE. Diagnostic Utility of SGLT2 Inhibitors to Facilitate Myocardial Glucose Suppression During Evaluation of Myocardial Inflammation. JACC Cardiovasc Imaging 2024:S1936-878X(24)00078-0. [PMID: 38573285 DOI: 10.1016/j.jcmg.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/29/2024] [Accepted: 02/14/2024] [Indexed: 04/05/2024]
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Luong TV, Pedersen MGB, Abild CB, Cunnane SC, Croteau E, Lauritsen KM, Kjaerulff MLG, Tolbod LP, Møller N, Søndergaard E, Gormsen LC. A ketogenic diet lowers myocardial fatty acid oxidation but does not affect oxygen consumption: a study in overweight humans. Obesity (Silver Spring) 2024; 32:506-516. [PMID: 38258448 DOI: 10.1002/oby.23967] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 11/10/2023] [Accepted: 11/12/2023] [Indexed: 01/24/2024]
Abstract
OBJECTIVE A ketogenic diet (KD) characterized by very low carbohydrate intake and high fat consumption may simultaneously induce weight loss and be cardioprotective. The "thrifty substrate hypothesis" posits that ketone bodies are more energy efficient compared with other cardiac oxidative substrates such as fatty acids. This work aimed to study whether a KD with presumed increased myocardial ketone body utilization reduces cardiac fatty acid uptake and oxidation, resulting in decreased myocardial oxygen consumption (MVO2 ). METHODS This randomized controlled crossover trial examined 11 individuals with overweight or obesity on two occasions: (1) after a KD and (2) after a standard diet. Myocardial free fatty acid (FFA) oxidation, uptake, and esterification rate were measured using dynamic [11 C]palmitate positron emission tomography (PET)/computed tomography, whereas MVO2 and myocardial external efficiency (MEE) were measured using dynamic [11 C]acetate PET. RESULTS The KD increased plasma β-hydroxybutyrate, reduced myocardial FFA oxidation (p < 0.01) and uptake (p = 0.03), and increased FFA esterification (p = 0.03). No changes were observed in MVO2 (p = 0.2) or MEE (p = 0.87). CONCLUSIONS A KD significantly reduced myocardial FFA uptake and oxidation, presumably by increasing ketone body oxidation. However, this change in cardiac substrate utilization did not improve MVO2 , speaking against the thrifty substrate hypothesis.
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Affiliation(s)
- Thien Vinh Luong
- Department of Nuclear Medicine and PET Center, Aarhus University Hospital, Aarhus N, Denmark
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus N, Denmark
| | - Mette Glavind Bülow Pedersen
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus N, Denmark
- Medical/Steno Aarhus Research Laboratory, Department of Clinical Medicine, Aarhus University, Denmark
| | - Caroline Bruun Abild
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus N, Denmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Stephen C Cunnane
- Department of Medicine and Research Center on Aging, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Etienne Croteau
- Sherbrooke Molecular Imaging Center Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Katrine Meyer Lauritsen
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus N, Denmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Mette Louise Gram Kjaerulff
- Department of Nuclear Medicine and PET Center, Aarhus University Hospital, Aarhus N, Denmark
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus N, Denmark
| | - Lars Poulsen Tolbod
- Department of Nuclear Medicine and PET Center, Aarhus University Hospital, Aarhus N, Denmark
| | - Niels Møller
- Medical/Steno Aarhus Research Laboratory, Department of Clinical Medicine, Aarhus University, Denmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Esben Søndergaard
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus N, Denmark
| | - Lars Christian Gormsen
- Department of Nuclear Medicine and PET Center, Aarhus University Hospital, Aarhus N, Denmark
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Dimitriadis K, Adamopoulou E, Pyrpyris N, Sakalidis A, Leontsinis I, Manta E, Mantzouranis E, Beneki E, Soulaidopoulos S, Konstantinidis D, Fragkoulis C, Aggeli K, Tsioufis K. The effect of SGLT2 inhibitors on the endothelium and the microcirculation: from bench to bedside and beyond. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023; 9:741-757. [PMID: 37500266 DOI: 10.1093/ehjcvp/pvad053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/22/2023] [Accepted: 07/26/2023] [Indexed: 07/29/2023]
Abstract
AIMS The beneficial cardiovascular effects of sodium-glucose cotransporter 2 (SGLT2) inhibitors irrespective of the presence of diabetes mellitus are nowadays well established and they already constitute a significant pillar for the management of heart failure, irrespective of the ejection fraction. The exact underlying mechanisms accountable for these effects, however, remain largely unknown. The direct effect on endothelial function and microcirculation is one of the most well studied. The broad range of studies presented in this review aims to link all available data from the bench to bedside and highlight the existing gaps as well as the future directions in the investigations concerning the effects of SGLT2 inhibitors on the endothelium and the microcirculation. METHODS AND RESULTS An extensive search has been conducted using the MEDLINE/PubMed database in order to identify the relevant studies. Preclinical data suggest that SGLT2 inhibitors directly affect endothelial function independently of glucose and specifically via several interplaying molecular pathways, resulting in improved vasodilation, increased NO production, enhanced mitochondrial homeostasis, endothelial cell viability, and angiogenesis as well as attenuation of oxidative stress and inflammation. Clinical data systematically confirm this beneficial effect on the endothelium, whereas the evidence concerning the effect on the microcirculation is conflicting. CONCLUSION Preclinical and clinical studies indicate that SGLT2 inhibitors attenuate endothelial and microvascular dysfunction via a combination of mechanisms, which play a role in their beneficial cardiovascular effect.
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Affiliation(s)
- Kyriakos Dimitriadis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27, Athens, Greece
| | - Eleni Adamopoulou
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27, Athens, Greece
| | - Nikolaos Pyrpyris
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27, Athens, Greece
| | - Athanasios Sakalidis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27, Athens, Greece
| | - Ioannis Leontsinis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27, Athens, Greece
| | - Eleni Manta
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27, Athens, Greece
| | - Emmanouil Mantzouranis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27, Athens, Greece
| | - Eirini Beneki
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27, Athens, Greece
| | - Stergios Soulaidopoulos
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27, Athens, Greece
| | - Dimitrios Konstantinidis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27, Athens, Greece
| | - Christos Fragkoulis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27, Athens, Greece
| | - Konstantina Aggeli
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27, Athens, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27, Athens, Greece
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7
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Su S, Ji X, Li T, Teng Y, Wang B, Han X, Zhao M. The changes of cardiac energy metabolism with sodium-glucose transporter 2 inhibitor therapy. Front Cardiovasc Med 2023; 10:1291450. [PMID: 38124893 PMCID: PMC10731052 DOI: 10.3389/fcvm.2023.1291450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 11/13/2023] [Indexed: 12/23/2023] Open
Abstract
Background/aims To investigate the specific effects of s odium-glucose transporter 2 inhibitor (SGLT2i) on cardiac energy metabolism. Methods A systematic literature search was conducted in eight databases. The retrieved studies were screened according to the inclusion and exclusion criteria, and relevant information was extracted according to the purpose of the study. Two researchers independently screened the studies, extracted information, and assessed article quality. Results The results of the 34 included studies (including 10 clinical and 24 animal studies) showed that SGLT2i inhibited cardiac glucose uptake and glycolysis, but promoted fatty acid (FA) metabolism in most disease states. SGLT2i upregulated ketone metabolism, improved the structure and functions of myocardial mitochondria, alleviated oxidative stress of cardiomyocytes in all literatures. SGLT2i increased cardiac glucose oxidation in diabetes mellitus (DM) and cardiac FA metabolism in heart failure (HF). However, the regulatory effects of SGLT2i on cardiac FA metabolism in DM and cardiac glucose oxidation in HF varied with disease types, stages, and intervention duration of SGLT2i. Conclusion SGLT2i improved the efficiency of cardiac energy production by regulating FA, glucose and ketone metabolism, improving mitochondria structure and functions, and decreasing oxidative stress of cardiomyocytes under pathological conditions. Thus, SGLT2i is deemed to exert a benign regulatory effect on cardiac metabolic disorders in various diseases. Systematic review registration https://www.crd.york.ac.uk/, PROSPERO (CRD42023484295).
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Affiliation(s)
- Sha Su
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Xiang Ji
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Tong Li
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Yu Teng
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Baofu Wang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Xiaowan Han
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
- Department of Cardiology, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Mingjing Zhao
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
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Jahangiri S, Malek M, Kalra S, Khamseh ME. The Effects of Sodium-Glucose Cotransporter 2 Inhibitors on Body Composition in Type 2 Diabetes Mellitus: A Narrative Review. Diabetes Ther 2023; 14:2015-2030. [PMID: 37837581 PMCID: PMC10597985 DOI: 10.1007/s13300-023-01481-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 09/25/2023] [Indexed: 10/16/2023] Open
Abstract
Body composition is related to cardiometabolic disorders and is a major driver of the growing incidence of type 2 diabetes mellitus (T2DM). Altered fat distribution and decreased muscle mass are related to dysglycemia and impose adverse health-related outcomes in people with T2DM. Hence, improving body composition and maintaining muscle mass is crucial in T2DM. Sodium-glucose cotransporter 2 (SGLT2) inhibitors are novel glucose-lowering medications gaining popularity because of their cardiorenal-protective effects and weight-lowering characteristics. However, reports on myopathy secondary to SGLT2 inhibitor treatment raised a safety concern. The importance of maintaining muscle mass in people with T2DM necessitates further investigation to explore the impact of novel medications on body composition. In this review, we discussed current evidence on the impact of SGLT2 inhibitors on body composition in people with T2DM.
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Affiliation(s)
- Soodeh Jahangiri
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
| | - Mojtaba Malek
- Research Center for Prevention of Cardiovascular Disease, Institute of Endocrinology & Metabolism, Iran University of Medical Sciences, Tehran, Iran
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, India
- University Center for Research & Development, Chandigarh University, Mohali, India
| | - Mohammad E Khamseh
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran.
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9
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Packer M. SGLT2 inhibitors: role in protective reprogramming of cardiac nutrient transport and metabolism. Nat Rev Cardiol 2023; 20:443-462. [PMID: 36609604 DOI: 10.1038/s41569-022-00824-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/29/2022] [Indexed: 01/09/2023]
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce heart failure events by direct action on the failing heart that is independent of changes in renal tubular function. In the failing heart, nutrient transport into cardiomyocytes is increased, but nutrient utilization is impaired, leading to deficient ATP production and the cytosolic accumulation of deleterious glucose and lipid by-products. These by-products trigger downregulation of cytoprotective nutrient-deprivation pathways, thereby promoting cellular stress and undermining cellular survival. SGLT2 inhibitors restore cellular homeostasis through three complementary mechanisms: they might bind directly to nutrient-deprivation and nutrient-surplus sensors to promote their cytoprotective actions; they can increase the synthesis of ATP by promoting mitochondrial health (mediated by increasing autophagic flux) and potentially by alleviating the cytosolic deficiency in ferrous iron; and they might directly inhibit glucose transporter type 1, thereby diminishing the cytosolic accumulation of toxic metabolic by-products and promoting the oxidation of long-chain fatty acids. The increase in autophagic flux mediated by SGLT2 inhibitors also promotes the clearance of harmful glucose and lipid by-products and the disposal of dysfunctional mitochondria, allowing for mitochondrial renewal through mitochondrial biogenesis. This Review describes the orchestrated interplay between nutrient transport and metabolism and nutrient-deprivation and nutrient-surplus signalling, to explain how SGLT2 inhibitors reverse the profound nutrient, metabolic and cellular abnormalities observed in heart failure, thereby restoring the myocardium to a healthy molecular and cellular phenotype.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Dallas, TX, USA.
- Imperial College London, London, UK.
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10
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Banerjee Y, Patti AM, Giglio RV, Ciaccio M, Vichithran S, Faisal S, Stoian AP, Rizvi AA, Rizzo M. The role of atherogenic lipoproteins in diabetes: Molecular aspects and clinical significance. J Diabetes Complications 2023; 37:108517. [PMID: 37329706 DOI: 10.1016/j.jdiacomp.2023.108517] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 05/21/2023] [Accepted: 05/21/2023] [Indexed: 06/19/2023]
Abstract
Dyslipidaemia plays a prominent role in the genesis of atherosclerotic plaque and the increased cardiovascular risk in diabetes. Macrophages readily take up atherogenic lipoproteins, transforming into foam cells and amplifying vascular damage in the presence of endothelial dysfunction. We discuss the importance of distinct lipoprotein subclasses in atherogenic diabetic dyslipidaemia as well as the effects of novel anti-diabetic agents on lipoprotein fractions and ultimately on cardiovascular risk prevention. In patients with diabetes, lipid abnormalities should be aggressively identified and treated in conjunction with therapeutical agents used to prevent cardiovascular disease. The use of drugs that improve diabetic dyslipidaemia plays a prominent role in conferring cardiovascular benefit in individuals with diabetes.
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Affiliation(s)
- Yajnavalka Banerjee
- Department of Basic Sciences, College of Medicine and Health Sciences, Mohammed Bin Rashid University (MBRU), Dubai, United Arab Emirates.
| | - Angelo M Patti
- Internal Medicine Unit, "Vittorio Emanuele II" Hospital, Castelvetrano, Trapani, Italy
| | - Rosaria V Giglio
- Department of Biomedicine, Neuroscience, and Advanced Diagnostics, Institute of Clinical Biochemistry, Clinical Molecular Medicine, and Laboratory Medicine, University of Palermo, Palermo, Italy; Department of Laboratory Medicine, University Hospital "P. Giaccone", Palermo, Italy
| | - Marcello Ciaccio
- Department of Biomedicine, Neuroscience, and Advanced Diagnostics, Institute of Clinical Biochemistry, Clinical Molecular Medicine, and Laboratory Medicine, University of Palermo, Palermo, Italy; Department of Laboratory Medicine, University Hospital "P. Giaccone", Palermo, Italy
| | - Suhina Vichithran
- Department of Basic Sciences, College of Medicine and Health Sciences, Mohammed Bin Rashid University (MBRU), Dubai, United Arab Emirates
| | - Shemima Faisal
- Department of Basic Sciences, College of Medicine and Health Sciences, Mohammed Bin Rashid University (MBRU), Dubai, United Arab Emirates
| | - Anca Panta Stoian
- Department of Diabetes, Nutrition, and Metabolic Diseases, Carol Davila University of Medicine, Bucharest, Romania; "Prof. Dr.N.C.Paulescu" National Institute of Diabetes, Nutrition and Metabolic Diseases, Bucharest, Romania
| | - Ali Abbas Rizvi
- Department of Medicine, University of Central Florida College of Medicine, Orlando, FL, USA
| | - Manfredi Rizzo
- Department of Basic Sciences, College of Medicine and Health Sciences, Mohammed Bin Rashid University (MBRU), Dubai, United Arab Emirates; Department of Diabetes, Nutrition, and Metabolic Diseases, Carol Davila University of Medicine, Bucharest, Romania; "Prof. Dr.N.C.Paulescu" National Institute of Diabetes, Nutrition and Metabolic Diseases, Bucharest, Romania; School of Medicine, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (Promise), University of Palermo, Italy
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11
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Farooq M, Jorde UP. Impact of Sodium-Glucose Cotransporter-2 Inhibitors on Cardiac Bioenergetic Properties and Cardiorespiratory Fitness: A Special Effect of SGLT2i In Heart Failure? Cardiol Rev 2023; 31:65-69. [PMID: 35191660 DOI: 10.1097/crd.0000000000000424] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Recent clinical trials have highlighted the profound benefits of sodium-glucose linked transporter 2 inhibitors (SGLT2i) on cardiovascular mortality and hospitalization for heart failure patients. Modest improvements in glycemic, lipid, or blood pressure control are unlikely to contribute to these significant beneficial outcomes, generating much interest in the relevant mechanisms leading to outcome improvements. In this review, we discuss the current evidence supporting a shift in myocardial substrate utilization from carbohydrates and fat oxidation toward energy efficient ketone bodies in the failing heart and the role of SGLT2i in this key metabolic adaptation to optimize myocardial fuel energetics. Further insights into the effect of SGLT2i on the indices of cardiorespiratory fitness are outlined and provide important clues into their mechanism of benefit. This mechanistic discussion in the context of recent trials of SGLT2i denotes a promising treatment paradigm of heart failure in individuals with and without diabetes.
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Affiliation(s)
- Muhammad Farooq
- From the Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY
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12
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Martín-Saladich Q, Simó R, Aguadé-Bruix S, Simó-Servat O, Aparicio-Gómez C, Hernández C, Ramirez-Serra C, Pizzi MN, Roque A, González Ballester MA, Herance JR. Insights into Insulin Resistance and Calcification in the Myocardium in Type 2 Diabetes: A Coronary Artery Analysis. Int J Mol Sci 2023; 24:ijms24043250. [PMID: 36834662 PMCID: PMC9959651 DOI: 10.3390/ijms24043250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/27/2023] [Accepted: 02/01/2023] [Indexed: 02/10/2023] Open
Abstract
Type 2 diabetes (T2D) is responsible for high incidence of cardiovascular (CV) complications leading to heart failure. Coronary artery region-specific metabolic and structural assessment could provide deeper insight into the extent of the disease and help prevent adverse cardiac events. Therefore, in this study, we aimed at investigating such myocardial dynamics for the first time in insulin-sensitive (mIS) and insulin-resistant (mIR) T2D patients. We targeted global and region-specific variations using insulin sensitivity (IS) and coronary artery calcifications (CACs) as CV risk factor in T2D patients. IS was computed using myocardial segmentation approaches at both baseline and after an hyperglycemic-insulinemic clamp (HEC) on [18F]FDG-PET images using the standardized uptake value (SUV) (ΔSUV = SUVHEC - SUVBASELINE) and calcifications using CT Calcium Scoring. Results suggest that some communicating pathways between response to insulin and calcification are present in the myocardium, whilst differences between coronary arteries were only observed in the mIS cohort. Risk indicators were mostly observed for mIR and highly calcified subjects, which supports previously stated findings that exhibit a distinguished exposure depending on the impairment of response to insulin, while projecting added potential complications due to arterial obstruction. Moreover, a pattern relating calcification and T2D phenotypes was observed suggesting the avoidance of insulin treatment in mIS but its endorsement in mIR subjects. The right coronary artery displayed more ΔSUV, whilst plaque was more present in the circumflex. However, differences between phenotypes, and therefore CV risk, were associated to left descending artery (LAD) translating into higher CACs regarding IR, which could explain why insulin treatment was effective for LAD at the expense of higher likelihood of plaque accumulation. Personalized approaches to assess T2D may lead to more efficient treatments and risk-prevention strategies.
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Affiliation(s)
- Queralt Martín-Saladich
- Medical Molecular Imaging Research Group, Nuclear Medicine, Radiology and Cardiology Departments, Vall d’Hebron Research Institute (VHIR), Vall d’Hebron University Hospital, Autonomous University Barcelona, 08035 Barcelona, Spain
- BCN Medtech, Department of Information and Communication Technologies, Pompeu Fabra University, 08018 Barcelona, Spain
| | - Rafael Simó
- Diabetes and Metabolism Research Group, VHIR, Department of Endocrinology, Vall d’Hebron University Hospital, Autonomous University Barcelona, 08035 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Santiago Aguadé-Bruix
- Medical Molecular Imaging Research Group, Nuclear Medicine, Radiology and Cardiology Departments, Vall d’Hebron Research Institute (VHIR), Vall d’Hebron University Hospital, Autonomous University Barcelona, 08035 Barcelona, Spain
| | - Olga Simó-Servat
- Diabetes and Metabolism Research Group, VHIR, Department of Endocrinology, Vall d’Hebron University Hospital, Autonomous University Barcelona, 08035 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Carolina Aparicio-Gómez
- Medical Molecular Imaging Research Group, Nuclear Medicine, Radiology and Cardiology Departments, Vall d’Hebron Research Institute (VHIR), Vall d’Hebron University Hospital, Autonomous University Barcelona, 08035 Barcelona, Spain
| | - Cristina Hernández
- Diabetes and Metabolism Research Group, VHIR, Department of Endocrinology, Vall d’Hebron University Hospital, Autonomous University Barcelona, 08035 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Clara Ramirez-Serra
- Clinical Biochemistry Research Group, Vall d’Hebron Research Institute (VHIR), Biochemical Core Facilities, Vall d’Hebron University Hospital, Autonomous University Barcelona, 08035 Barcelona, Spain
| | - María Nazarena Pizzi
- Department of Medicine, Autonomous University of Barcelona, 08193 Barcelona, Spain
- Cardiology Department, Vall d’Hebron Barcelona Hospital Campus, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Albert Roque
- Medical Molecular Imaging Research Group, Nuclear Medicine, Radiology and Cardiology Departments, Vall d’Hebron Research Institute (VHIR), Vall d’Hebron University Hospital, Autonomous University Barcelona, 08035 Barcelona, Spain
- Department of Medicine, Autonomous University of Barcelona, 08193 Barcelona, Spain
- Radiology Department, Vall d’Hebron Barcelona Hospital Campus, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Miguel A. González Ballester
- BCN Medtech, Department of Information and Communication Technologies, Pompeu Fabra University, 08018 Barcelona, Spain
- Catalan Institution for Research and Advanced Studies (ICREA), 08010 Barcelona, Spain
- Correspondence: (M.A.G.B.); (J.R.H.); Tel.: +34-(93)-542-2000 (ext. 2083) (M.A.G.B.); +34-(93)-489-3000 (ext. 4946) (J.R.H.)
| | - José Raul Herance
- Medical Molecular Imaging Research Group, Nuclear Medicine, Radiology and Cardiology Departments, Vall d’Hebron Research Institute (VHIR), Vall d’Hebron University Hospital, Autonomous University Barcelona, 08035 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Bioingeniería, Biomateriales y Nanomedicina (CIBERBBN), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Correspondence: (M.A.G.B.); (J.R.H.); Tel.: +34-(93)-542-2000 (ext. 2083) (M.A.G.B.); +34-(93)-489-3000 (ext. 4946) (J.R.H.)
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13
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The Therapeutic Role of SGLT-2 Inhibitors in Acute Heart Failure: From Pathophysiologic Mechanisms to Clinical Evidence with Pooled Analysis of Relevant Studies across Safety and Efficacy Endpoints of Interest. LIFE (BASEL, SWITZERLAND) 2022; 12:life12122062. [PMID: 36556427 PMCID: PMC9782870 DOI: 10.3390/life12122062] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 11/30/2022] [Accepted: 12/07/2022] [Indexed: 12/13/2022]
Abstract
(1) Background: Sodium-glucose co-transporter-2 (SGLT-2) inhibitors constitute a novel drug class with remarkable cardiovascular benefits for patients with chronic heart failure (HF). Recently, this class has been utilized in acute HF as an additional treatment option to classic diuretics, which remain the cornerstone of treatment. (2) Methods: We attempted to identify those pathophysiologic mechanisms targeted by SGLT-2 inhibitors, which could be of benefit to patients with acute HF. We then conducted a comprehensive review of the literature within the PubMed database in order to identify relevant studies, both randomized controlled trials (RCTs) and observational studies, assessing the safety and efficacy of SGLT-2 inhibitors in acute HF. (3) Results: SGLT-2 inhibitors induce significant osmotic diuresis and natriuresis, decrease interstitial fluid volume and blood pressure, improve left ventricular (LV) function, ameliorate LV remodeling and prevent atrial arrhythmia occurrence, mechanisms that seem to be beneficial in acute HF. However, currently available studies, including six RCTs and two real-world studies, provide conflicting results concerning the true efficacy of SGLT-2 inhibitors, including "hard" surrogate endpoints. (4) Conclusions: Current evidence appears insufficient to substantiate the use of SGLT-2 inhibitors in acute HF. Further trials are required to shed more light on this issue.
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Succurro E, Vizza P, Papa A, Miceli S, Cicone F, Fiorentino TV, Sciacqua A, Andreozzi F, Veltri P, Cascini GL, Sesti G. Effects of 26 weeks of treatment with empagliflozin versus glimepiride on the myocardial glucose metabolic rate in patients with type 2 diabetes: The randomized, open-label, crossover, active-comparator FIORE trial. Diabetes Obes Metab 2022; 24:2319-2330. [PMID: 35837991 PMCID: PMC9804559 DOI: 10.1111/dom.14816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 06/28/2022] [Accepted: 07/11/2022] [Indexed: 01/05/2023]
Abstract
AIM To determine whether treatment with empagliflozin was able to affect the myocardial glucose metabolic rate, as assessed by cardiac dynamic 18 F-fluorodeoxyglucose-positron emission tomography (18 F-FDG-PET) combined with euglycaemic-hyperinsulinaemic clamp compared with glimepiride in patients with type 2 diabetes. MATERIALS AND METHODS To further investigate the cardioprotective mechanism of sodium-glucose co-transporter-2 inhibitors, we performed a 26-week, randomized, open-label, crossover, active-comparator study to determine the effects of empagliflozin 10 mg versus glimepiride 2 mg daily on the myocardial glucose metabolic rate assessed by cardiac dynamic 18 F-FDG-PET combined with euglycaemic-hyperinsulinaemic clamp in 23 patients with type 2 diabetes. We also measured cardiac geometry and myocardial mechano-energetic efficiency, as well as systolic and diastolic function by echocardiography. RESULTS Compared with glimepiride, treatment with empagliflozin resulted in a greater reduction in the myocardial glucose metabolic rate from baseline to 26 weeks (adjusted difference -6.07 [-8.59, -3.55] μmol/min/100 g; P < .0001). Moreover, compared with glimepiride, empagliflozin led to significant reductions in left atrial diameter, left ventricular end-systolic and end-diastolic volumes, N-terminal pro b-type natriuretic peptide levels, blood pressure, heart rate, stroke work, and myocardial oxygen consumption estimated by the rate pressure product, and increases in ejection fraction, myocardial mechano-energetic efficiency, red blood cells, and haematocrit and haemoglobin levels. CONCLUSIONS The present study provides evidence that empagliflozin treatment in subjects with type 2 diabetes without coronary artery disease leads to a significant reduction in the myocardial glucose metabolic rate.
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Affiliation(s)
- Elena Succurro
- Department of Medical and Surgical SciencesUniversity Magna Graecia of CatanzaroCatanzaroItaly
- Research Center for the Prevention and Treatment of Metabolic Diseases (CR METDIS)University Magna Graecia of CatanzaroCatanzaroItaly
| | - Patrizia Vizza
- Department of Medical and Surgical SciencesUniversity Magna Graecia of CatanzaroCatanzaroItaly
| | - Annalisa Papa
- Department of Experimental and Clinical MedicineMagna Graecia University of CatanzaroCatanzaroItaly
| | - Sofia Miceli
- Department of Medical and Surgical SciencesUniversity Magna Graecia of CatanzaroCatanzaroItaly
| | - Francesco Cicone
- Department of Experimental and Clinical MedicineMagna Graecia University of CatanzaroCatanzaroItaly
| | | | - Angela Sciacqua
- Department of Medical and Surgical SciencesUniversity Magna Graecia of CatanzaroCatanzaroItaly
- Research Center for the Prevention and Treatment of Metabolic Diseases (CR METDIS)University Magna Graecia of CatanzaroCatanzaroItaly
| | - Francesco Andreozzi
- Department of Medical and Surgical SciencesUniversity Magna Graecia of CatanzaroCatanzaroItaly
- Research Center for the Prevention and Treatment of Metabolic Diseases (CR METDIS)University Magna Graecia of CatanzaroCatanzaroItaly
| | - Pierangelo Veltri
- Department of Medical and Surgical SciencesUniversity Magna Graecia of CatanzaroCatanzaroItaly
| | - Giuseppe Lucio Cascini
- Department of Experimental and Clinical MedicineMagna Graecia University of CatanzaroCatanzaroItaly
| | - Giorgio Sesti
- Department of Clinical and Molecular MedicineUniversity of Rome‐SapienzaRomeItaly
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15
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Yaribeygi H, Maleki M, Reiner Ž, Jamialahmadi T, Sahebkar A. Mechanistic View on the Effects of SGLT2 Inhibitors on Lipid Metabolism in Diabetic Milieu. J Clin Med 2022; 11:6544. [PMID: 36362772 PMCID: PMC9653639 DOI: 10.3390/jcm11216544] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 10/28/2022] [Accepted: 11/02/2022] [Indexed: 08/30/2023] Open
Abstract
Chronic hyperglycemia induces pathophysiologic pathways with negative effects on the metabolism of most substrates as well as lipids and lipoproteins, and thereby induces dyslipidemia. Thus, the diabetic milieu is commonly accompanied by different levels of atherogenic dyslipidemia, which is per se a major risk factor for subsequent complications such as atherosclerosis, coronary heart disease, acute myocardial infarction, ischemic stroke, and nephropathy. Therefore, readjusting lipid metabolism in the diabetic milieu is a major goal for preventing dyslipidemia-induced complications. Sodium-glucose cotransporter-2 (SGLT2) inhibitors are a class of relatively newly introduced antidiabetes drugs (including empagliflozin, canagliflozin, dapagliflozin, etc.) with potent hypoglycemic effects and can reduce blood glucose by inducing glycosuria. However, recent evidence suggests that they could also provide extra-glycemic benefits in lipid metabolism. It seems that they can increase fat burning and lipolysis, normalizing the lipid metabolism and preventing or improving dyslipidemia. Nevertheless, the exact mechanisms involved in this process are not well-understood. In this review, we tried to explain how these drugs could regulate lipid homeostasis and we presented the possible involved cellular pathways supported by clinical evidence.
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Affiliation(s)
- Habib Yaribeygi
- Research Center of Physiology, Semnan University of Medical Sciences, Semnan, Iran
| | - Mina Maleki
- Urology and Nephrology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Željko Reiner
- Department of Internal Medicine, University Hospital Center Zagreb, 1000 Zagreb, Croatia
| | - Tannaz Jamialahmadi
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amirhossein Sahebkar
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Biotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
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16
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Wu YJ, Wang SB, Wang LS. SGLT2 Inhibitors: New Hope for the Treatment of Acute Myocardial Infarction? Am J Cardiovasc Drugs 2022; 22:601-613. [PMID: 35947249 DOI: 10.1007/s40256-022-00545-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 11/01/2022]
Abstract
Among all of the new antidiabetic drugs, an increasing number of studies have evaluated the relationship between the sodium-glucose cotransporter 2 inhibitors (SGLT2i) and acute myocardial infarction (AMI). Since SGLT2i like empagliflozin, canagliflozin, and recently, dapagliflozin have shown impressive positive effects in patients with chronic heart failure with reduced ejection fraction (HFrEF), it has increased research interest to explore the cardiac molecular mechanisms underlying the clinical benefits and attracted more attention to the effects of SGLT2i on a series of cardiovascular events. Experimental and clinical data on SGLT2i treatment after AMI is limited. This is a review of the clinical and preclinical effects of SGLT2i, focusing on available data on the effects of SGLT2i in AMI patients with a brief overview of ongoing trials.
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Affiliation(s)
- Yu-Jie Wu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Si-Bo Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Lian-Sheng Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China.
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17
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Coronary Microvascular Dysfunction in Diabetes Mellitus: Pathogenetic Mechanisms and Potential Therapeutic Options. Biomedicines 2022; 10:biomedicines10092274. [PMID: 36140374 PMCID: PMC9496134 DOI: 10.3390/biomedicines10092274] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/04/2022] [Accepted: 09/09/2022] [Indexed: 11/16/2022] Open
Abstract
Diabetic patients are frequently affected by coronary microvascular dysfunction (CMD), a condition consisting of a combination of altered vasomotion and long-term structural change to coronary arterioles leading to impaired regulation of blood flow in response to changing cardiomyocyte oxygen requirements. The pathogenesis of this microvascular complication is complex and not completely known, involving several alterations among which hyperglycemia and insulin resistance play particularly central roles leading to oxidative stress, inflammatory activation and altered barrier function of endothelium. CMD significantly contributes to cardiac events such as angina or infarction without obstructive coronary artery disease, as well as heart failure, especially the phenotype associated with preserved ejection fraction, which greatly impact cardiovascular (CV) prognosis. To date, no treatments specifically target this vascular damage, but recent experimental studies and some clinical investigations have produced data in favor of potential beneficial effects on coronary micro vessels caused by two classes of glucose-lowering drugs: glucagon-like peptide 1 (GLP-1)-based therapy and inhibitors of sodium-glucose cotransporter-2 (SGLT2). The purpose of this review is to describe pathophysiological mechanisms, clinical manifestations of CMD with particular reference to diabetes, and to summarize the protective effects of antidiabetic drugs on the myocardial microvascular compartment.
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18
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Leccisotti L, Cinti F, Sorice GP, D'Amario D, Lorusso M, Guzzardi MA, Mezza T, Gugliandolo S, Cocchi C, Capece U, Indovina L, Ferraro PM, Iozzo P, Crea F, Giordano A, Giaccari A. Dapagliflozin improves myocardial flow reserve in patients with type 2 diabetes: the DAPAHEART Trial: a preliminary report. Cardiovasc Diabetol 2022; 21:173. [PMID: 36057768 PMCID: PMC9440459 DOI: 10.1186/s12933-022-01607-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/22/2022] [Indexed: 11/21/2022] Open
Abstract
Objective Cardiovascular (CV) outcome trials have shown that in patients with type 2 diabetes (T2D), treatment with sodium-glucose cotransporter-2 inhibitors (SGLT-2i) reduces CV mortality and hospital admission rates for heart failure (HF). However, the mechanisms behind these benefits are not fully understood. This study was performed to investigate the effects of the SGLT-2i dapagliflozin on myocardial perfusion and glucose metabolism in patients with T2D and stable coronary artery disease (coronary stenosis ≥ 30% and < 80%), with or without previous percutaneous coronary intervention (> 6 months) but no HF. Methods This was a single-center, prospective, randomized, double-blind, controlled clinical trial including 16 patients with T2D randomized to SGLT-2i dapagliflozin (10 mg daily) or placebo. The primary outcome was to detect changes in myocardial glucose uptake (MGU) from baseline to 4 weeks after treatment initiation by [(18)F]2-deoxy-2-fluoro-D-glucose (FDG) PET/CT during hyperinsulinemic euglycemic clamp. The main secondary outcome was to assess whether the hypothetical changes in MGU were associated with changes in myocardial blood flow (MBF) and myocardial flow reserve (MFR) measured by 13N-ammonia PET/CT. The study was registered at eudract.ema.europa.eu (EudraCT No. 2016-003614-27) and ClinicalTrials.gov (NCT 03313752). Results 16 patients were randomized to dapagliflozin (n = 8) or placebo (n = 8). The groups were well-matched for baseline characteristics (age, diabetes duration, HbA1c, renal and heart function). There was no significant change in MGU during euglycemic hyperinsulinemic clamp in the dapagliflozin group (2.22 ± 0.59 vs 1.92 ± 0.42 μmol/100 g/min, p = 0.41) compared with the placebo group (2.00 ± 0.55 vs 1.60 ± 0.45 μmol/100 g/min, p = 0.5). Dapagliflozin significantly improved MFR (2.56 ± 0.26 vs 3.59 ± 0.35 p = 0.006 compared with the placebo group 2.34 ± 0.21 vs 2.38 ± 0.24 p = 0.81; pint = 0.001) associated with a reduction in resting MBF corrected for cardiac workload (p = 0.005; pint = 0.045). A trend toward an increase in stress MBF was also detected (p = 0.054). Conclusions SGLT-2 inhibition increases MFR in T2D patients. We provide new insight into SGLT-2i CV benefits, as our data show that patients on SGLT-2i are more resistant to the detrimental effects of obstructive coronary atherosclerosis due to increased MFR, probably caused by an improvement in coronary microvascular dysfunction. Trial registration EudraCT No. 2016-003614-27; ClinicalTrials.gov Identifier: NCT03313752 Supplementary Information The online version contains supplementary material available at 10.1186/s12933-022-01607-4.
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Affiliation(s)
- Lucia Leccisotti
- UOC Di Medicina Nucleare, Dipartimento Di Diagnostica Per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS and Università Cattolica del Sacro Cuore, Rome, Italia
| | - Francesca Cinti
- Centro Malattie Endocrine E Metaboliche, Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS and Università Cattolica del Sacro Cuore, Rome, Italia
| | - Gian Pio Sorice
- Centro Malattie Endocrine E Metaboliche, Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS and Università Cattolica del Sacro Cuore, Rome, Italia.,Sezione Di Medicina Interna, Endocrinologia, Andrologia e Malattie Metaboliche, Dipartimento Dell'Emergenza E Dei Trapianti Di Organi (D.E.T.O.), Università Degli Studi Di Bari "Aldo Moro", Bari, Italia
| | - Domenico D'Amario
- UOC Di Cardiologia, Dipartimento Di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli IRCCS, and Università Cattolica del Sacro Cuore, Rome, Italia
| | - Margherita Lorusso
- UOC Di Medicina Nucleare, Dipartimento Di Diagnostica Per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS and Università Cattolica del Sacro Cuore, Rome, Italia
| | - Maria Angela Guzzardi
- Istituto Di Fisiologia Clinica, Consiglio Nazionale Delle Ricerche (CNR), Pisa, Italia
| | - Teresa Mezza
- Centro Malattie Endocrine E Metaboliche, Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS and Università Cattolica del Sacro Cuore, Rome, Italia
| | - Shawn Gugliandolo
- Centro Malattie Endocrine E Metaboliche, Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS and Università Cattolica del Sacro Cuore, Rome, Italia
| | - Camilla Cocchi
- Centro Malattie Endocrine E Metaboliche, Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS and Università Cattolica del Sacro Cuore, Rome, Italia
| | - Umberto Capece
- Centro Malattie Endocrine E Metaboliche, Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS and Università Cattolica del Sacro Cuore, Rome, Italia
| | - Luca Indovina
- UOSD Fisica Medica E Radioprotezione, Dipartimento Di Diagnostica Per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italia
| | - Pietro Manuel Ferraro
- U.O.S. Terapia Conservativa Della Malattia Renale Cronica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Patricia Iozzo
- Istituto Di Fisiologia Clinica, Consiglio Nazionale Delle Ricerche (CNR), Pisa, Italia
| | - Filippo Crea
- UOC Di Cardiologia, Dipartimento Di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli IRCCS, and Università Cattolica del Sacro Cuore, Rome, Italia
| | - Alessandro Giordano
- UOC Di Medicina Nucleare, Dipartimento Di Diagnostica Per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS and Università Cattolica del Sacro Cuore, Rome, Italia.
| | - Andrea Giaccari
- Centro Malattie Endocrine E Metaboliche, Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS and Università Cattolica del Sacro Cuore, Rome, Italia.
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19
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Thirumathyam R, Richter EA, Goetze JP, Fenger M, Van Hall G, Dixen U, Holst JJ, Madsbad S, Vejlstrup N, Madsen PL, Jørgensen NB. Investigating the roles of hyperglycaemia, hyperinsulinaemia and elevated free fatty acids in cardiac function in patients with type 2 diabetes via treatment with insulin compared with empagliflozin: protocol for the HyperCarD2 randomised, crossover trial. BMJ Open 2022; 12:e054100. [PMID: 35953245 PMCID: PMC9379482 DOI: 10.1136/bmjopen-2021-054100] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Type 2 diabetes (T2D) is characterised by elevated plasma glucose, free fatty acid (FFA) and insulin concentrations, and this metabolic profile is linked to diabetic cardiomyopathy, a diastolic dysfunction at first and increased cardiovascular disease (CVD) risk. Shifting cardiac metabolism towards glucose utilisation has been suggested to improve cardiovascular function and CVD risk, but insulin treatment increases overall glucose oxidation and lowers lipid oxidation, without reducing CVD risk, whereas SGLT2 inhibitors (SGLT2i) increase FFA, ketone body concentrations and lipid oxidation, while decreasing insulin concentrations and CVD risk. The aim of the present study is to elucidate the importance of different metabolic profiles obtained during treatment with a SGLT2i versus insulin for myocardial function in patients with T2D. METHODS AND ANALYSES Randomised, crossover study, where 20 patients with T2D and body mass index>28 kg/m2 receive 25 mg empagliflozin daily or NPH insulin two times per day first for 5 weeks followed by a 3-week washout before crossing over to the remaining treatment. Insulin treatment is titrated to achieve similar glycaemic control as with empagliflozin. In those randomised to insulin first, glycaemia during an initial empagliflozin run-in period prior to randomisation serves as target glucose. Metabolic and cardiac evaluation is performed before and at the end of each treatment period.The primary endpoint is change (treatment-washout) in left ventricular peak filling rate, as assessed by cardiac MRI with and without acute lowering of plasma FFAs with acipimox. Secondary and explorative endpoints are changes in left atrial passive emptying fraction, left ventricular ejection fraction, central blood volume and metabolic parameters. ETHICS AND DISSEMINATION This study is approved by the Danish Medicines Agency (ref. nr.: 2017061587), the Danish Data Protection Agency (ref. nr.: AHH-2017-093) and the Capital Region Ethics Committee (ref. nr.: H-17018846). The trial will be conducted in accordance with ICH-GCP guidelines and the Declaration of Helsinki and all participants will provide oral and written informed consent. Our results, regardless of outcome, will be published in relevant scientific journals and we also will seek to disseminate results through presentations at scientific meetings. TRIAL REGISTRATION NUMBER EudraCT: 2017-002101.
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Affiliation(s)
| | - Erik Arne Richter
- Department of Nutrition, Exercise and Sports, Section of Molecular Physiology, Faculty of Science, University of Copenhagen, Kobenhavn, Denmark
| | - Jens Peter Goetze
- Department of Clinical Biochemistry, Rigshospitalet, University of Copenhagen, Kobenhavn, Denmark
| | - Mogens Fenger
- Department of Clinical Biochemistry, Hvidovre Hospital, Hvidovre, Denmark
| | - Gerrit Van Hall
- Department of Clinical Biochemistry, Rigshospitalet, University of Copenhagen, Kobenhavn, Denmark
- Clinical Metabolomics Core Facility, Clinical Biochemistry, Rigshospitalet, Kobenhavn, Denmark
| | - Ulrik Dixen
- Department of Cardiology, Hvidovre University Hospital, Hvidovre, Denmark
| | - Jens Juul Holst
- Department of Biomedical Sciences, Faculty of Health Sciences, University of Copenhagen, Kobenhavn, Denmark
- NovoNordisk Center for Basic Metabolic Research, University of Copenhagen, Kobenhavn, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Hvidovre Hospital, Hvidovre, Denmark
| | - Niels Vejlstrup
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Per Lav Madsen
- Department of Cardiology, Herlev Hospital, Herlev, Denmark
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Jensen J, Omar M, Ali M, Frederiksen PH, Kistorp C, Tuxen C, Andersen CF, Larsen JH, Ersbøll MK, Køber L, Gustafsson F, Faber J, Forman JL, Møller JE, Schou M. The effect of empagliflozin on contractile reserve in heart failure: Prespecified sub-study of a randomized, double-blind, and placebo-controlled trial. Am Heart J 2022; 250:57-65. [PMID: 35513022 DOI: 10.1016/j.ahj.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 03/30/2022] [Accepted: 04/23/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Sodium-glucose co-transporter-2 inhibitors improve cardiac structure but most studies suggest no change in left ventricular (LV) systolic function at rest. Whether sodium-glucose co-transporter-2 inhibitors improve LV contractile reserve is unknown. We investigated the effect of empagliflozin on LV contractile reserve in patients with heart failure (HF) and reduced ejection fraction. METHODS Prespecified sub-study of the Empire HF trial, a double-blind, placebo-controlled, and randomized trial. Patients with LV ejection fraction (LVEF) ≤ 40% on guideline-directed HF therapy were randomized (1:1) to empagliflozin 10 mg or placebo for 12 weeks. The treatment effect on contractile reserve was assessed by low dose dobutamine stress echocardiography. RESULTS In total, 120 patients were included. The mean age was 68 (SD 10) years, 83% were male, and the mean LVEF was 38 (SD 10) %. Respectively 60 (100%) and 59 (98%) patients in the empagliflozin and placebo groups completed stress echocardiography. No statistically significant effect of empagliflozin was observed for the contractile reserve assessed by LV-GLS (adjusted mean absolute change, empagliflozin vs placebo, 0.7% [95% confidence interval {CI} -0.5 to 2.0, P = .25]) or LVEF (adjusted mean absolute change, empagliflozin vs placebo, 2.2% [95% CI -1.4 to 5.8, P = .22]) from baseline to 12 weeks. LV-GLS contractile reserve was associated with accelerometer-measured daily activity level (coefficient -24 accelerometer counts [95% CI -46 to -1.8, P = .03]). CONCLUSIONS Empagliflozin for 12 weeks added to guideline-directed HF therapy did not improve LV contractile reserve in patients with HF and reduced ejection fraction.
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Affiliation(s)
- Jesper Jensen
- Department of Cardiology, Herlev and Gentofte University Hospital, Herlev, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Massar Omar
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Steno Diabetes Center Odense, Odense, Denmark; Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Mulham Ali
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Peter H Frederiksen
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Caroline Kistorp
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Tuxen
- Department of Cardiology, Bispebjerg and Frederiksberg University Hospital, Copenhagen, Denmark
| | - Camilla F Andersen
- Department of Cardiology, Herlev and Gentofte University Hospital, Herlev, Denmark
| | - Julie H Larsen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | | | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jens Faber
- Department of Internal Medicine, Center of Endocrinology and Metabolism, Herlev and Gentofte University Hospital, Herlev, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Julie Lyng Forman
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Eifer Møller
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; Department of Cardiology, Rigshospitalet, Copenhagen, Denmark; Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev and Gentofte University Hospital, Herlev, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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21
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Lauritsen KM, Voigt JH, Pedersen SB, Hansen TK, Møller N, Jessen N, Gormsen LC, Søndergaard E. Effects of SGLT2 inhibition on lipid transport in adipose tissue in type 2 diabetes. Endocr Connect 2022; 11:e210558. [PMID: 35234661 PMCID: PMC9066578 DOI: 10.1530/ec-21-0558] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 03/01/2022] [Indexed: 11/08/2022]
Abstract
SGLT2 inhibition induces an insulin-independent reduction in plasma glucose causing increased lipolysis and subsequent lipid oxidation by energy-consuming tissues. However, it is unknown whether SGLT2 inhibition also affects lipid storage in adipose tissue. Therefore, we aimed to determine the effects of SGLT2 inhibition on lipid storage and lipolysis in adipose tissue. We performed a randomized, double-blinded, placebo-controlled crossover design of 4 weeks of empagliflozin 25 mg and placebo once-daily in 13 individuals with type 2 diabetes treated with metformin. Adipose tissue fatty acid uptake, lipolysis rate and clearance were measured by 11C-palmitate PET/CT. Adipose tissue glucose uptake was measured by 18F-FDG PET/CT. Protein and gene expression of pathways involved in lipid storage and lipolysis were measured in biopsies of abdominal s.c. adipose tissue. Subjects were weight stable, which allowed us to quantify the weight loss-independent effects of SGLT2 inhibition. We found that SGLT2 inhibition did not affect free fatty acids (FFA) uptake in abdominal s.c. adipose tissue but increased FFA uptake in visceral adipose tissue by 27% (P < 0.05). In addition, SGLT2 inhibition reduced GLUT4 protein (P = 0.03) and mRNA content (P = 0.01) in abdominal s.c. adipose tissue but without affecting glucose uptake. In addition, SGLT2 inhibition decreased the expression of genes involved in insulin signaling in adipose tissue. We conclude that SGLT2 inhibition reduces GLUT4 gene and protein expression in abdominal s.c. adipose tissue, which could indicate a rebalancing of substrate utilization away from glucose oxidation and lipid storage capacity through reduced glycerol formation.
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Affiliation(s)
- Katrine M Lauritsen
- Steno Diabetes Center Aarhus, Aarhus, Denmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Danish Diabetes Academy, Odense University Hospital, Odense, Denmark
| | | | - Steen Bønløkke Pedersen
- Steno Diabetes Center Aarhus, Aarhus, Denmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Niels Møller
- Steno Diabetes Center Aarhus, Aarhus, Denmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Jessen
- Steno Diabetes Center Aarhus, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Lars C Gormsen
- Department of Nuclear Medicine and PET Centre, Aarhus University Hospital, Aarhus, Denmark
| | - Esben Søndergaard
- Steno Diabetes Center Aarhus, Aarhus, Denmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Danish Diabetes Academy, Odense University Hospital, Odense, Denmark
- Correspondence should be addressed to E Søndergaard:
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22
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Luong TV, Abild CB, Bangshaab M, Gormsen LC, Søndergaard E. Ketogenic Diet and Cardiac Substrate Metabolism. Nutrients 2022; 14:nu14071322. [PMID: 35405935 PMCID: PMC9003554 DOI: 10.3390/nu14071322] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/16/2022] [Accepted: 03/19/2022] [Indexed: 02/07/2023] Open
Abstract
The ketogenic diet (KD) entails a high intake of fat, moderate intake of protein, and a very limited intake of carbohydrates. Ketogenic dieting has been proposed as an effective intervention for type 2 diabetes and obesity since glycemic control is improved and sustained weight loss can be achieved. Interestingly, hyperketonemia is also associated with beneficial cardiovascular effects, possibly caused by improved cardiac energetics and reduced oxygen use. Therefore, the KD has the potential to both treat and prevent cardiovascular disease. However, the KD has some adverse effects that could counteract the beneficial cardiovascular properties. Of these, hyperlipidemia with elevation of triglycerides and LDL cholesterol levels are the most important. In addition, poor diet adherence and lack of knowledge regarding long-term effects may also reduce the broader applicability of the KD. The objective of this narrative review is to provide insights into the KD and its effects on myocardial ketone body utilization and, consequently, cardiovascular health.
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Affiliation(s)
- Thien Vinh Luong
- Department of Nuclear Medicine & PET-Centre, Aarhus University Hospital, Palle Juul-Jensens Blvd. 165, 8200 Aarhus, Denmark; (T.V.L.); (L.C.G.)
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Hedeager 3, 8200 Aarhus, Denmark; (C.B.A.); (M.B.)
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Blvd. 82, 8200 Aarhus, Denmark
| | - Caroline Bruun Abild
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Hedeager 3, 8200 Aarhus, Denmark; (C.B.A.); (M.B.)
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Blvd. 82, 8200 Aarhus, Denmark
| | - Maj Bangshaab
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Hedeager 3, 8200 Aarhus, Denmark; (C.B.A.); (M.B.)
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Blvd. 82, 8200 Aarhus, Denmark
| | - Lars Christian Gormsen
- Department of Nuclear Medicine & PET-Centre, Aarhus University Hospital, Palle Juul-Jensens Blvd. 165, 8200 Aarhus, Denmark; (T.V.L.); (L.C.G.)
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Blvd. 82, 8200 Aarhus, Denmark
| | - Esben Søndergaard
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Hedeager 3, 8200 Aarhus, Denmark; (C.B.A.); (M.B.)
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Blvd. 82, 8200 Aarhus, Denmark
- Correspondence: ; Tel.: +45-28730943
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23
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Sodium-Glucose Cotransporter 2 Inhibitors and Cardiac Remodeling. J Cardiovasc Transl Res 2022; 15:944-956. [PMID: 35290593 DOI: 10.1007/s12265-022-10220-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 02/14/2022] [Indexed: 02/06/2023]
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors have evident cardiovascular benefits in patients with type 2 diabetes with or at high risk for atherosclerotic cardiovascular disease, heart failure with reduced ejection fraction, heart failure with preserved ejection fraction (only empagliflozin and dapagliflozin have been investigated in this group so far), and chronic kidney disease. Prevention and reversal of adverse cardiac remodeling is one of the mechanisms by which SGLT2 inhibitors may exert cardiovascular benefits, especially heart failure-related outcomes. Cardiac remodeling encompasses molecular, cellular, and interstitial changes that result in favorable changes in the mass, geometry, size, and function of the heart. The pathophysiological mechanisms of adverse cardiac remodeling are related to increased apoptosis and necrosis, decreased autophagy, impairments of myocardial oxygen supply and demand, and altered energy metabolism. Herein, the accumulating evidence from animal and human studies is reviewed investigating the effects of SGLT2 inhibitors on these mechanisms of cardiac remodeling.
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24
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Suhrs HE, Nilsson M, Bové KB, Zander M, Prescott E. Effect of empagliflozin on coronary microvascular function in patients with type 2 diabetes mellitus–A randomized, placebo-controlled cross-over study. PLoS One 2022; 17:e0263481. [PMID: 35148357 PMCID: PMC8836314 DOI: 10.1371/journal.pone.0263481] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 12/07/2021] [Indexed: 01/08/2023] Open
Abstract
Purpose Results from large scale cardiovascular outcome trials in patients with type 2 diabetes mellitus (DM2) have found that sodium-glucose cotransporter 2 inhibitors (SGLT2i) reduce cardiovascular death and hospitalization for heart failure, but the mechanisms behind the beneficial cardiovascular effects are not fully understood. We tested the hypothesis that the SGLT2i, empagliflozin, improves non-endothelial dependent coronary microvascular function, thereby leading to better cardiac function. Methods Patients with DM2 followed at the endocrinology outpatient clinic at Bispebjerg University Hospital were included in a double blinded, placebo-controlled cross-over study. Participants were allocated equally to each treatment sequence using simple randomization and treated with empagliflozin 25 mg and placebo for 12 weeks, interrupted by 2 weeks wash-out period. The primary outcome was coronary microvascular function, assessed as coronary flow velocity reserve (CFVR) and measured with transthoracic doppler echocardiography. Echocardiographic parameters of cardiac function were measured, and blood samples were analyzed for a broad panel of cardiovascular biomarkers. Results Thirteen patients were randomized to each sequence and 10 and 9 completed the study according to protocol, respectively, and were included in the analysis of outcome parameters. We found no improvement in CFVR (change in the empagliflozin period was -0.16 (SD 0.58)). There were no effects on cardiac systolic function or indicators of cardiac filling pressure. Well-known effects of empagliflozin were obtained, such as weight loss and reduction in Hba1c level. Creatinine level increased but remained within normal range. We observed a clear trend of reduction in cardiovascular biomarkers after empagliflozin treatment and increased levels after the placebo period. No serious adverse reactions were reported. Conclusions Despite effect on weight-loss, Hba1c and biomarkers, treatment with empagliflozin for 12 weeks did not improve CFVR in patients with DM2.
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Affiliation(s)
- Hannah Elena Suhrs
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
- * E-mail:
| | - Malin Nilsson
- Department of Endocrinology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Kira Bang Bové
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Mette Zander
- Department of Endocrinology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Eva Prescott
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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25
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Avagimyan A. THE PATHOPHYSIOLOGICAL BASIS OF DIABETIC CARDIOMYOPATHY DEVELOPMENT. Curr Probl Cardiol 2022; 47:101156. [DOI: 10.1016/j.cpcardiol.2022.101156] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 02/16/2022] [Indexed: 01/02/2023]
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26
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Metabolites and Genes behind Cardiac Metabolic Remodeling in Mice with Type 1 Diabetes Mellitus. Int J Mol Sci 2022; 23:ijms23031392. [PMID: 35163316 PMCID: PMC8835796 DOI: 10.3390/ijms23031392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 01/13/2022] [Accepted: 01/21/2022] [Indexed: 11/21/2022] Open
Abstract
Metabolic remodeling is at the heart of diabetic cardiomyopathy. High glycemic fluctuations increase metabolic stress in the type 1 diabetes mellitus (T1DM) heart. There is a lack of understanding on how metabolites and genes affect metabolic remodeling in the T1DM heart. We hypothesize that differential expression of metabolic genes and metabolites synergistically influence metabolic remodeling preceding T1DM cardiomyopathy. To test our hypothesis, we conducted high throughput analysis of hearts from adult male hyperglycemic Ins2+/− (Akita) and littermate normoglycemic Ins2+/+ (WT) mice. The Akita mouse is a spontaneous, genetic model of T1DM that develops increased levels of consistent glycemic variability without the off-target cardiotoxic effects present in chemically- induced models of T1DM. After validating the presence of a T1DM phenotype, we conducted metabolomics via LC-MS analysis and genomics via next-generation sequencing in left ventricle tissue from the Akita heart. Ingenuity Pathway Analyses revealed that 108 and 30 metabolic pathways were disrupted within the metabolomics and genomics datasets, respectively. Notably, a comparison between the two analyses showed 15 commonly disrupted pathways, including ketogenesis, ketolysis, cholesterol biosynthesis, acetyl CoA hydrolysis, and fatty acid biosynthesis and beta-oxidation. These identified metabolic pathways predicted by the differential expression of metabolites and genes provide the foundation for understanding metabolic remodeling in the T1DM heart. By limited experiment, we revealed a predicted disruption in the metabolites and genes behind T1DM cardiac metabolic derangement. Future studies targeting these genes and metabolites will unravel novel therapies to prevent/improve metabolic remodeling in the T1DM heart.
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27
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Ke Q, Shi C, Lv Y, Wang L, Luo J, Jiang L, Yang J, Zhou Y. SGLT2 inhibitor counteracts NLRP3 inflammasome via tubular metabolite itaconate in fibrosis kidney. FASEB J 2021; 36:e22078. [PMID: 34918381 DOI: 10.1096/fj.202100909rr] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 11/12/2021] [Accepted: 11/17/2021] [Indexed: 12/22/2022]
Abstract
Large clinical trials and real-world studies have demonstrated that the beneficial effects of sodium-glucose co-transporter 2 (SGLT2) inhibitors on renal outcomes regardless of the presence of diabetes. However, the mechanism remains obscure. Here, we analyze the anti-fibrotic and anti-inflammatory effects of dapagliflozin, a SGLT2 inhibitor, on renal alternations using the ischemia/reperfusion-induced fibrosis model. Transcriptome and metabolome analysis showed that the accumulation of tricarboxylic acid (TCA) cycle metabolites and upregulation of inflammation in fibrosis renal cortical tissue were mitigated by dapagliflozin treatment. Moreover, dapagliflozin markedly relieved the activation of mammalian target of rapamycin and hypoxia inducible factor-1α signaling and restored tubular cell-preferred fatty acid oxidation. Notably, NOD-, LRR-, and pyrin domain-containing protein 3 (NLRP3) inflammasome activation was strikingly blocked by dapagliflozin. We further demonstrated that the immunomodulatory metabolite itaconate derived from the TCA cycle was significantly boosted as a result of decreased isocitrate dehydrogenase 2 and increased immune-responsive gene 1 and mitochondrial citrate carrier in dapagliflozin-treated mice, which contributed to the inhibitory effect of dapagliflozin on NLRP3 inflammasome activation. Furthermore, administration of cell-permeable itaconate surrogate prevented activation of NLRP3 inflammasome and protected kidney against fibrosis development. Our results identify a novel mechanism coupling metabolism and inflammation for kidney benefits of SGLT2 inhibition in progressive chronic kidney disease.
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Affiliation(s)
- Qingqing Ke
- Center for Kidney Disease, Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Caifeng Shi
- Center for Kidney Disease, Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yunhui Lv
- Center for Kidney Disease, Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lulu Wang
- Center for Kidney Disease, Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Luo
- Center for Kidney Disease, Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lei Jiang
- Center for Kidney Disease, Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Junwei Yang
- Center for Kidney Disease, Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yang Zhou
- Center for Kidney Disease, Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Thirunavukarasu S, Jex N, Chowdhary A, Hassan IU, Straw S, Craven TP, Gorecka M, Broadbent D, Swoboda P, Witte KK, Cubbon RM, Xue H, Kellman P, Greenwood JP, Plein S, Levelt E. Empagliflozin Treatment Is Associated With Improvements in Cardiac Energetics and Function and Reductions in Myocardial Cellular Volume in Patients With Type 2 Diabetes. Diabetes 2021; 70:2810-2822. [PMID: 34610982 PMCID: PMC8660983 DOI: 10.2337/db21-0270] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 09/29/2021] [Indexed: 12/15/2022]
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce the risk of major adverse cardiovascular (CV) events and hospitalization for heart failure (HF) in patients with type 2 diabetes (T2D). Using CV MRI (CMR) and 31P-MRS in a longitudinal cohort study, we aimed to investigate the effects of the selective SGLT2 inhibitor empagliflozin on myocardial energetics and cellular volume, function, and perfusion. Eighteen patients with T2D underwent CMR and 31P-MRS scans before and after 12 weeks' empagliflozin treatment. Plasma N-terminal prohormone B-type natriuretic peptide (NT-proBNP) levels were measured. Ten volunteers with normal glycemic control underwent an identical scan protocol at a single visit. Empagliflozin treatment was associated with significant improvements in phosphocreatine-to-ATP ratio (1.52 to 1.76, P = 0.009). This was accompanied by a 7% absolute increase in the mean left ventricular ejection fraction (P = 0.001), 3% absolute increase in the mean global longitudinal strain (P = 0.01), 8 mL/m2 absolute reduction in the mean myocardial cell volume (P = 0.04), and 61% relative reduction in the mean NT-proBNP (P = 0.05) from baseline measurements. No significant change in myocardial blood flow or diastolic strain was detected. Empagliflozin thus ameliorates the "cardiac energy-deficient" state, regresses adverse myocardial cellular remodeling, and improves cardiac function, offering therapeutic opportunities to prevent or modulate HF in T2D.
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Affiliation(s)
- Sharmaine Thirunavukarasu
- Multidisciplinary Cardiovascular Research Centre and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
- Division of Cardiovascular and Diabetes Research, Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
| | - Nicholas Jex
- Multidisciplinary Cardiovascular Research Centre and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
- Division of Cardiovascular and Diabetes Research, Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
| | - Amrit Chowdhary
- Multidisciplinary Cardiovascular Research Centre and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
- Division of Cardiovascular and Diabetes Research, Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
| | - Imtiaz Ul Hassan
- Multidisciplinary Cardiovascular Research Centre and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
| | - Sam Straw
- Division of Cardiovascular and Diabetes Research, Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
| | - Thomas P Craven
- Multidisciplinary Cardiovascular Research Centre and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
- Division of Cardiovascular and Diabetes Research, Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
| | - Miroslawa Gorecka
- Multidisciplinary Cardiovascular Research Centre and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
- Division of Cardiovascular and Diabetes Research, Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
| | - David Broadbent
- Department of Medical Physics and Engineering, Leeds Teaching Hospitals NHS Trust, Leeds, U.K
| | - Peter Swoboda
- Multidisciplinary Cardiovascular Research Centre and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
| | - Klaus K Witte
- Division of Cardiovascular and Diabetes Research, Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
| | - Richard M Cubbon
- Division of Cardiovascular and Diabetes Research, Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
| | - Hui Xue
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Peter Kellman
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - John P Greenwood
- Multidisciplinary Cardiovascular Research Centre and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
- Division of Cardiovascular and Diabetes Research, Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
| | - Sven Plein
- Multidisciplinary Cardiovascular Research Centre and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
- Division of Cardiovascular and Diabetes Research, Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
| | - Eylem Levelt
- Multidisciplinary Cardiovascular Research Centre and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K.
- Division of Cardiovascular and Diabetes Research, Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
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Liu H, Sridhar VS, Montemayor D, Lovblom LE, Lytvyn Y, Ye H, Kim J, Ali MT, Scarr D, Lawler PR, Perkins BA, Sharma K, Cherney DZI. Changes in plasma and urine metabolites associated with empagliflozin in patients with type 1 diabetes. Diabetes Obes Metab 2021; 23:2466-2475. [PMID: 34251085 DOI: 10.1111/dom.14489] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 07/01/2021] [Accepted: 07/01/2021] [Indexed: 02/06/2023]
Abstract
AIM To examine the impact of the sodium-glucose co-transporter-2 inhibitor, empagliflozin, on plasma and urine metabolites in participants with type 1 diabetes. MATERIAL AND METHODS Participants (n = 40, 50% male, mean age 24.3 years) with type 1 diabetes and without overt evidence of diabetic kidney disease had baseline assessments performed under clamped euglycaemia and hyperglycaemia, on two consecutive days. Participants then proceeded to an 8-week, open-label treatment period with empagliflozin 25 mg/day, followed by repeat assessments under clamped euglycaemia and hyperglycaemia. Plasma and urine metabolites were first grouped into metabolic pathways using MetaboAnalyst software. Principal component analysis was performed to create a representative value for each sufficiently represented metabolic group (false discovery rate ≤ 0.1) for further analysis. RESULTS Of the plasma metabolite groups, tricarboxylic acid (TCA) cycle (P < .0001), biosynthesis of unsaturated fatty acids (P = .0045), butanoate (P < .0001), propanoate (P = .0053), and alanine, aspartate and glutamate (P < .0050) metabolites were increased after empagliflozin treatment under clamped euglycaemia. Of the urine metabolite groups, only butanoate metabolites (P = .0005) were significantly increased. Empagliflozin treatment also attenuated the increase in a number of urine metabolites observed with acute hyperglycaemia. CONCLUSIONS Empagliflozin was associated with increased lipid and TCA cycle metabolites in participants with type 1 diabetes, suggesting a shift in metabolic substrate use and improved mitochondrial function. These effects result in more efficient energy production and may contribute to end-organ protection by alleviating local hypoxia and oxidative stress.
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Affiliation(s)
- Hongyan Liu
- Toronto General Hospital Research Institute, UHN, Toronto, Ontario, Canada
- Department of Medicine, Division of Nephrology, UHN, Toronto, Ontario, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Vikas S Sridhar
- Toronto General Hospital Research Institute, UHN, Toronto, Ontario, Canada
- Department of Medicine, Division of Nephrology, UHN, Toronto, Ontario, Canada
- Department of Medicine, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
- Banting and Best Diabetes Centre, Toronto, Ontario, Canada
| | - Daniel Montemayor
- Center for Renal Precision Medicine, Division of Nephrology, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Leif Erik Lovblom
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Yuliya Lytvyn
- Toronto General Hospital Research Institute, UHN, Toronto, Ontario, Canada
- Department of Medicine, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Hongping Ye
- Center for Renal Precision Medicine, Division of Nephrology, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Jiwan Kim
- Center for Renal Precision Medicine, Division of Nephrology, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Mir Tariq Ali
- Center for Renal Precision Medicine, Division of Nephrology, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Daniel Scarr
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Ted Rogers Centre for Heart Research, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bruce A Perkins
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kumar Sharma
- Center for Renal Precision Medicine, Division of Nephrology, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - David Z I Cherney
- Toronto General Hospital Research Institute, UHN, Toronto, Ontario, Canada
- Department of Medicine, Division of Nephrology, UHN, Toronto, Ontario, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
- Banting and Best Diabetes Centre, Toronto, Ontario, Canada
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
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30
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Jürgens M, Schou M, Hasbak P, Kjær A, Wolsk E, Zerahn B, Wiberg M, Brandt-Jacobsen NH, Gæde P, Rossing P, Faber J, Inzucchi SE, Gustafsson F, Kistorp C. Effects of Empagliflozin on Myocardial Flow Reserve in Patients With Type 2 Diabetes Mellitus: The SIMPLE Trial. J Am Heart Assoc 2021; 10:e020418. [PMID: 34278803 PMCID: PMC8475664 DOI: 10.1161/jaha.120.020418] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background Sodium–glucose cotransporter 2 inhibitors reduce hospitalizations for heart failure and cardiovascular death, although the underlying mechanisms have not been resolved. The SIMPLE trial (The Effects of Empagliflozin on Myocardial Flow Reserve in Patients With Type 2 Diabetes Mellitus) investigated the effects of empagliflozin on myocardial flow reserve (MFR) reflecting microvascular perfusion, in patients with type 2 diabetes mellitus at high cardiovascular disease risk. Methods and Results We randomized 90 patients to either empagliflozin 25 mg once daily or placebo for 13 weeks, as add‐on to standard therapy. The primary outcome was change in MFR at week 13, quantified by Rubidium‐82 positron emission tomography/computed tomography. The secondary key outcomes were changes in resting rate‐pressure product adjusted MFR, changes to myocardial flow during rest and stress, and reversible cardiac ischemia. Mean baseline MFR was 2.21 (95% CI, 2.08–2.35). There was no change from baseline in MFR at week 13 in either the empagliflozin: 0.01 (95% CI, −0.18 to 0.21) or placebo groups: 0.06 (95% CI, −0.15 to 0.27), with no treatment effect −0.05 (95% CI, −0.33 to 0.23). No effects on the secondary outcome parameters by Rubidium‐82 positron emission tomography/computed tomography was observed. Treatment with empagliflozin reduced hemoglobin A1c by 0.76% (95% CI, 1.0–0.5; P<0.001) and increased hematocrit by 1.69% (95% CI, 0.7–2.6; P<0.001). Conclusions Empagliflozin did not improve MFR among patients with type 2 diabetes mellitus and high cardiovascular disease risk. The present study does not support that short‐term improvement in MFR explains the reduction in cardiovascular events observed in the outcome trials. Registration URL: https://clinicaltrialsregister.eu/; Unique identifier: 2016‐003743‐10.
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Affiliation(s)
- Mikkel Jürgens
- Department of Endocrinology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark.,Department of Endocrinology Copenhagen University HospitalHerlev/Gentofte Herlev Denmark
| | - Morten Schou
- Department of Cardiology Copenhagen University Hospitals Herlev/Gentofte Herlev Denmark.,Department of Clinical Medicine Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
| | - Philip Hasbak
- Department of Clinical Physiology Nuclear Medicine & PET and Cluster for Molecular Imaging Department of Biomedical Sciences Rigshospitalet and University of Copenhagen Copenhagen Denmark
| | - Andreas Kjær
- Department of Clinical Physiology Nuclear Medicine & PET and Cluster for Molecular Imaging Department of Biomedical Sciences Rigshospitalet and University of Copenhagen Copenhagen Denmark
| | - Emil Wolsk
- Department of Cardiology The Heart CentreRigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Bo Zerahn
- Department of Clinical Physiology and Nuclear Medicine Copenhagen University Hospitals Herlev/Gentofte Herlev Denmark
| | - Mikkel Wiberg
- Department of Endocrinology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Niels H Brandt-Jacobsen
- Department of Endocrinology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Peter Gæde
- Slagelse Hospital Slagelse Denmark.,University of Southern Denmark Odense Denmark
| | - Peter Rossing
- Department of Clinical Medicine Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark.,Steno Diabetes Center Copenhagen Gentofte Denmark
| | - Jens Faber
- Department of Endocrinology Copenhagen University HospitalHerlev/Gentofte Herlev Denmark.,Department of Clinical Medicine Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
| | - Silvio E Inzucchi
- Yale Section of EndocrinologyYale University School of Medicine New Haven CT
| | - Finn Gustafsson
- Department of Cardiology The Heart CentreRigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Caroline Kistorp
- Department of Endocrinology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark.,Department of Clinical Medicine Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
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31
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Sorice GP, Cinti F, Leccisotti L, D'Amario D, Lorusso M, Guzzardi MA, Mezza T, Cocchi C, Capece U, Ferraro PM, Crea F, Giordano A, Iozzo P, Giaccari A. Effect of Dapagliflozin on Myocardial Insulin Sensitivity and Perfusion: Rationale and Design of The DAPAHEART Trial. Diabetes Ther 2021; 12:2101-2113. [PMID: 34037951 PMCID: PMC8266960 DOI: 10.1007/s13300-021-01083-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/12/2021] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Sodium-glucose co-transporter-2 (SGLT-2) inhibitors have been shown to have beneficial effects on various cardiovascular (CV) outcomes in patients with type 2 diabetes (T2D) in primary prevention and in those with a high CV risk profile. However, the mechanism(s) responsible for these CV benefits remain elusive and unexplained. The aim of the DAPAHEART study will be to demonstrate that treatment with SGLT-2 inhibitors is associated with greater myocardial insulin sensitivity in patients with T2D, and to determine whether this improvement can be attributed to a decrease in whole-body (and tissue-specific) insulin resistance and to increased myocardial perfusion and/or glucose uptake. We will also determine whether there is an appreciable degree of improvement in myocardial-wall conditions subtended by affected and non-affected coronary vessels, and if this relates to changes in left ventricular function. METHODS The DAPAHEART trial will be a phase III, single-center, randomized, two-arm, parallel-group, double-blind, placebo-controlled study. A cohort of 52 T2D patients with stable coronary artery disease (without any previous history of myocardial infarction, with or without previous percutaneous coronary intervention), with suboptimal glycemic control (glycated hemoglobin [HbA1c] 7-8.5%) on their current standard of care anti-hyperglycemic regimen, will be randomized in a 1:1 ratio to dapagliflozin or placebo. The primary outcome is to detect changes in myocardial glucose uptake from baseline to 4 weeks after treatment initiation. The main secondary outcome will be changes in myocardial blood flow, as measured by 13N-ammonia positron emission tomography/computed tomography (PET/CT). Other outcomes include cardiac function, glucose uptake in skeletal muscle, adipose tissue, liver, brain and kidney, as assessed by fluorodeoxyglucose (FDG) PET-CT imaging during hyperinsulinemic-euglycemic clamp; pericardial, subcutaneous and visceral fat, and browning as observed on CT images during FDG PET-CT studies; systemic insulin sensitivity, as assessed by hyperinsulinemic-euglycemic clamp, glycemic control, urinary glucose output; and microbiota modification. DISCUSSION SGLT-2 inhibitors, in addition to their insulin-independent plasma glucose-lowering effect, are able to directly (substrate availability, fuel utilization, insulin sensitivity) as well as indirectly (cardiac after-load reduction, decreased risk factors for heart failure) affect myocardial functions. Our study will provide novel insights into how these drugs exert CV protection in a diabetic population. TRIAL REGISTRATION EudraCT No. 2016-003614-27; ClinicalTrials.gov Identifier: NCT03313752.
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Affiliation(s)
- Gian Pio Sorice
- Dipartimento di Scienze Mediche e Chirurgiche, Centro Malattie Endocrine e Metaboliche, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Emergency and Organ Transplantation, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari, Italy
| | - Francesca Cinti
- Dipartimento di Scienze Mediche e Chirurgiche, Centro Malattie Endocrine e Metaboliche, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Lucia Leccisotti
- Dipartimento di Diagnostica Per Immagini, Radioterapia Oncologica ed Ematologia, UOC di Medicina Nucleare, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Domenico D'Amario
- Dipartimento di Scienze Cardiovascolari, UOC di Cardiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Margherita Lorusso
- Dipartimento di Diagnostica Per Immagini, Radioterapia Oncologica ed Ematologia, UOC di Medicina Nucleare, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Angela Guzzardi
- Istituto di Fisiologia Clinica, Consiglio Nazionale Delle Ricerche (CNR), Pisa, Italy
| | - Teresa Mezza
- Dipartimento di Scienze Mediche e Chirurgiche, Centro Malattie Endocrine e Metaboliche, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Camilla Cocchi
- Dipartimento di Scienze Mediche e Chirurgiche, Centro Malattie Endocrine e Metaboliche, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Umberto Capece
- Dipartimento di Scienze Mediche e Chirurgiche, Centro Malattie Endocrine e Metaboliche, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Pietro Manuel Ferraro
- Dipartimento di Scienze Mediche e Chirurgiche, UOC di Nefrologia, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Filippo Crea
- Dipartimento di Scienze Cardiovascolari, UOC di Cardiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandro Giordano
- Dipartimento di Diagnostica Per Immagini, Radioterapia Oncologica ed Ematologia, UOC di Medicina Nucleare, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Patricia Iozzo
- Istituto di Fisiologia Clinica, Consiglio Nazionale Delle Ricerche (CNR), Pisa, Italy
| | - Andrea Giaccari
- Dipartimento di Scienze Mediche e Chirurgiche, Centro Malattie Endocrine e Metaboliche, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy.
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Pollock C, Neuen BL. Sodium-Glucose Cotransporter 2 Inhibition: Rationale and Mechanisms for Kidney and Cardiovascular Protection in People With and Without Diabetes. Adv Chronic Kidney Dis 2021; 28:298-308. [PMID: 34922686 DOI: 10.1053/j.ackd.2021.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 01/10/2023]
Abstract
Large-scale randomized trials have demonstrated the remarkable capacity of sodium-glucose cotransporter 2 inhibitors to reduce the risk of cardiovascular outcomes and kidney disease progression, irrespective of the presence or absence of type 2 diabetes mellitus. Although the results of these trials have transformed clinical practice guidelines, the mechanisms underpinning the wide-ranging benefits of this class of agents remain incompletely understood and subject to ongoing investigation. Improvements in cardiometabolic risk factors such as glucose, blood pressure, body weight, and albuminuria likely contribute. However, other direct effects on physiological and cellular function, such as restoration of tubuloglomerular feedback, improvements in kidney and cardiac oxygenation and energy efficiency, as well as restoration of normal autophagy are also likely to be important. This review summarizes the rationale and potential mechanisms for cardiorenal protection with sodium-glucose cotransporter 2 inhibitors in people with and without diabetes, their relative importance, and the experimental and clinical lines of evidence supporting these hypotheses.
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Mann PA, Lehrke M. Cardiac substrate utilization in heart failure: Where is the relevance of SGLT2 inhibition? J Thorac Cardiovasc Surg 2021; 164:895-899. [DOI: 10.1016/j.jtcvs.2021.02.092] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 12/14/2022]
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34
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Gaborit B, Ancel P, Abdullah AE, Maurice F, Abdesselam I, Calen A, Soghomonian A, Houssays M, Varlet I, Eisinger M, Lasbleiz A, Peiretti F, Bornet CE, Lefur Y, Pini L, Rapacchi S, Bernard M, Resseguier N, Darmon P, Kober F, Dutour A. Effect of empagliflozin on ectopic fat stores and myocardial energetics in type 2 diabetes: the EMPACEF study. Cardiovasc Diabetol 2021; 20:57. [PMID: 33648515 PMCID: PMC7919089 DOI: 10.1186/s12933-021-01237-2] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 02/01/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Empagliflozin is a sodium-glucose cotransporter 2 (SGLT2) inhibitor that has demonstrated cardiovascular and renal protection in patients with type 2 diabetes (T2D). We hypothesized that empaglifozin (EMPA) could modulate ectopic fat stores and myocardial energetics in high-fat-high-sucrose (HFHS) diet mice and in type 2 diabetics (T2D). METHODS C57BL/6 HFHS mice (n = 24) and T2D subjects (n = 56) were randomly assigned to 12 weeks of treatment with EMPA (30 mg/kg in mice, 10 mg/day in humans) or with placebo. A 4.7 T or 3 T MRI with 1H-MRS evaluation-myocardial fat (primary endpoint) and liver fat content (LFC)-were performed at baseline and at 12 weeks. In humans, standard cardiac MRI was coupled with myocardial energetics (PCr/ATP) measured with 31P-MRS. Subcutaneous (SAT) abdominal, visceral (VAT), epicardial and pancreatic fat were also evaluated. The primary efficacy endpoint was the change in epicardial fat volume between EMPA and placebo from baseline to 12 weeks. Secondary endpoints were the differences in PCr/ATP ratio, myocardial, liver and pancreatic fat content, SAT and VAT between groups at 12 weeks. RESULTS In mice fed HFHS, EMPA significantly improved glucose tolerance and increased blood ketone bodies (KB) and β-hydroxybutyrate levels (p < 0.05) compared to placebo. Mice fed HFHS had increased myocardial and liver fat content compared to standard diet mice. EMPA significantly attenuated liver fat content by 55%, (p < 0.001) but had no effect on myocardial fat. In the human study, all the 56 patients had normal LV function with mean LVEF = 63.4 ± 7.9%. Compared to placebo, T2D patients treated with EMPA significantly lost weight (- 2.6 kg [- 1.2; - 3.7]) and improved their HbA1c by 0.88 ± 0.74%. Hematocrit and EPO levels were significantly increased in the EMPA group compared to placebo (p < 0.0001, p = 0.041). EMPA significantly increased glycosuria and plasma KB levels compared to placebo (p < 0.0001, p = 0.012, respectively), and significantly reduced liver fat content (- 27 ± 23 vs. - 2 ± 24%, p = 0.0005) and visceral fat (- 7.8% [- 15.3; - 5.6] vs. - 0.1% [- 1.1;6.5], p = 0.043), but had no effect on myocardial or epicardial fat. At 12 weeks, no significant change was observed in the myocardial PCr/ATP (p = 0.57 between groups). CONCLUSIONS EMPA effectively reduced liver fat in mice and humans without changing epicardial, myocardial fat or myocardial energetics, rebutting the thrifty substrate hypothesis for cardiovascular protection of SGLT2 inhibitors. Trial registration NCT, NCT03118336. Registered 18 April 2017, https://clinicaltrials.gov/ct2/show/NCT03118336.
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Affiliation(s)
- B Gaborit
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France
- Department of Endocrinology, Metabolic Diseases and Nutrition, Pôle ENDO, APHM, Hôpital Nord, Chemin Des Bourrely, 13915, Marseille cedex 20, France
| | - P Ancel
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France
| | - A E Abdullah
- Department of Endocrinology, Metabolic Diseases and Nutrition, Pôle ENDO, APHM, Hôpital Nord, Chemin Des Bourrely, 13915, Marseille cedex 20, France
| | - F Maurice
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France
| | - I Abdesselam
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France
- Aix Marseille Univ, CNRS, CRMBM, Marseille, France
| | - A Calen
- Aix Marseille Univ, CNRS, CRMBM, Marseille, France
| | - A Soghomonian
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France
- Department of Endocrinology, Metabolic Diseases and Nutrition, Pôle ENDO, APHM, Hôpital Nord, Chemin Des Bourrely, 13915, Marseille cedex 20, France
| | - M Houssays
- Assistance-Publique Hôpitaux de Marseille, Medical Evaluation Department, CIC-CPCET, 13005, Marseille, France
| | - I Varlet
- Aix Marseille Univ, CNRS, CRMBM, Marseille, France
| | - M Eisinger
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France
- Department of Endocrinology, Metabolic Diseases and Nutrition, Pôle ENDO, APHM, Hôpital Nord, Chemin Des Bourrely, 13915, Marseille cedex 20, France
| | - A Lasbleiz
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France
- Aix Marseille Univ, CNRS, CRMBM, Marseille, France
| | - F Peiretti
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France
| | - C E Bornet
- Support Unit for Clinical Research and Economic Evaluation, Assistance Publique-Hôpitaux de Marseille, 13385, Marseille, France
| | - Y Lefur
- Aix Marseille Univ, CNRS, CRMBM, Marseille, France
| | - L Pini
- Aix Marseille Univ, CNRS, CRMBM, Marseille, France
| | - S Rapacchi
- Aix Marseille Univ, CNRS, CRMBM, Marseille, France
| | - M Bernard
- Aix Marseille Univ, CNRS, CRMBM, Marseille, France
| | - N Resseguier
- Support Unit for Clinical Research and Economic Evaluation, Assistance Publique-Hôpitaux de Marseille, 13385, Marseille, France
- Aix-Marseille Univ, EA 3279 CEReSS-Health Service Research and Quality of Life Center, Marseille, France
| | - P Darmon
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France
- Department of Endocrinology, Metabolic Diseases and Nutrition, Pôle ENDO, APHM, Hôpital Nord, Chemin Des Bourrely, 13915, Marseille cedex 20, France
| | - F Kober
- Aix Marseille Univ, CNRS, CRMBM, Marseille, France
| | - A Dutour
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France.
- Department of Endocrinology, Metabolic Diseases and Nutrition, Pôle ENDO, APHM, Hôpital Nord, Chemin Des Bourrely, 13915, Marseille cedex 20, France.
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