Diabetes and cardiovascular disease

Ranking age-specific modifiable risk factors for cardiovascular disease and mortality: evidence from a population-based longitudinal study

Background

Cardiovascular disease (CVD) remains a paramount contemporary health challenge. This study examined age-specific effects of 14 risk factors on CVD and mortality in different age groups.

Methods

We analyzed data from 226,759 CVD-free participants aged 40 years and older in the UK Biobank during the period from baseline time (2006-2010) to September 30, 2021. The primary CVD outcome was a composite of incident coronary artery disease, heart failure, and stroke. We calculated age-specific hazard ratios (HRs) and population-attributable fractions (PAF) for CVD and mortality associated with 14 potentially modifiable risk factors.

Findings

During 12.17-year follow-up, 23,838 incident CVD cases and 11,949 deaths occurred. Age-specific disparities were observed in the risk factors contributing to CVD, and the overall PAF declined with age (PAF of 56.53% in middle-age; 49.78% in quinquagenarian; 42.45% in the elderly). Metabolic factors had the highest PAF in each age group, with hypertension (14.04% of the PAF) and abdominal obesity (9.58% of the PAF) being prominent. Behavioral factors had the highest PAF in the middle-aged group (10.68% of the PAF), and smoking was the leading behavioral factor in all age groups. In socioeconomic and psychosocial risk clusters, low income contributed most among middle-aged (3.74% of the PAF) and elderly groups (3.66% of the PAF), while less education accounted more PAF for quinquagenarian group (4.46% of the PAF). Similar age-specific patterns were observed for cardiovascular subtypes and mortality.

Interpretation

A large fraction of CVD cases and deaths were associated with modifiable risk factors in all age groups. Targeted efforts should focus on the most impactful risk factors, as well as age-specific modifiable risk factors. These findings may inform the development of more precise medical strategies to prevent and manage CVD and related mortality.

Funding

The work was supported by the Bill & Melinda Gates Foundation (grant number: INV-016826 to Hualiang Lin) and the National Natural Science Foundation of China (grant number: 82373534 to Hualiang Lin).

Trends in the Association Between Diabetes and Cardiovascular Events, 1994-2019

This study uses administrative health care data from Ontario, Canada, to assess whether changes in diabetes management practices have affected trends in the association between diabetes vs prior cardiovascular disease and risk of cardiovascular events from 1994 to 2019 among adults aged 20 to 84 years.

Relationships between the diabetes awareness and clinical indices/nutrient intakes in Korean adults: Based on the 2012-2013 Korea National Health and Nutrition Examination Survey Data

BACKGROUND/OBJECTIVES

Diabetes is diagnosed after an average of 10-12 years of diabetic development. Strict glycemic control in diabetic patients promotes the normalization of blood glucose and reduces cardiovascular diseases (CVDs) and diabetic complications. Therefore, early diagnosis in non-aware individuals is very important.

SUBJECTS/METHODS

Clinical indices and nutrient intakes in Korean diabetic adults aged 19-64 years were examined according to the awareness of diabetes, using 2012 and 2013 Korea National Health and Nutrition Examination Survey (KNHANES) data. The aware group was defined as individuals who were aware of having diabetes from diagnosis by physician before the survey and the non-aware group as individuals who were not aware of having diabetes.

RESULTS

The average age was higher in the aware group compared to the non-aware group in both men (P = 0.002) and women (P = 0.004). The prevalences of hypertension and dyslipidemia were not different between the two groups, but the diagnosis rate was significantly lower in the non-aware group. In the non-aware group, total and LDL-cholesterol were significantly higher (P < 0.001), the risk for total cholesterol over 240 mg/dL was 3.4 times (95% CI: 1.58-7.52) higher (P = 0.002) and the risk for LDL-cholesterol over 160 mg/dL was 4.59 times (95% CI: 2.07-10.17) higher (P < 0.001). The calorie intake of the female non-aware group was significantly higher compared to the female aware group (P = 0.033).

CONCLUSION

The results suggested that the recommendation of screening test is necessary even for young adults. Studies on the methodology for early diagnosis of diabetes are also needed.

Thymosin β4 promotes glucose-impaired endothelial progenitor cell function via Akt/endothelial nitric oxide synthesis signaling pathway

Circulating endothelial progenitor cells (EPCs) are a subtype of hematopoietic stem cells, which can differentiate into endothelial cells and restore endothelial function. However, high glucose decreases the number and impairs the function of EPCs. A previous study showed that thymosin β4 (Tβ4), a pleiotropic peptide beneficial for multiple functions of various types of cells, could promote EPC migration and dose-dependently upregulate the phosphorylation of Akt and endothelial nitric oxide synthesis signaling (eNOS). In present study, the hypothesis that Tβ4 can improve glucose-suppressed EPC functions via the Akt/eNOS signaling pathway and restores the production of nitric oxide (NO) is investigated. EPCs were isolated from the peripheral blood of healthy volunteers and formed a cobblestone shape after 3–4 weeks of cultivation. Then, EPCs were treated with high concentrations of glucose (25 mM) for 4 days and administrated with Tβ4 for further study. Transwell migration and tube formation assays were performed to access the migratory and angiogenic ability of EPCs. In addition, the quantity of Akt, eNOS and the concentration of nitric oxide (NO) was investigated. Functional studies showed that high concentrations of glucose significantly suppressed EPC function, while this adverse effect was reversed by the administration of Tβ4. In addition, Akt small interfering (si)RNA and eNOS siRNA were demonstrated to reduce the protective effect of Tβ4 against glucose-impaired EPC functions. These findings suggest that Tβ4 improves glucose-impaired EPC functions via the Akt/eNOS signaling pathway.

Transcatheter aortic valve implantation and surgical aortic valve replacement among hospitalized patients with and without type 2 diabetes mellitus in Spain (2014-2015)

Background

Type 2 diabetes mellitus (T2DM) is strongly related to the in-hospital and short-term prognosis in patients with cardiovascular diseases needing surgical or invasive interventions. How T2DM might influence the treatment of aortic stenosis (AS) has not been completely elucidated for surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI). The aims of this study were: (1) to describe the use of aortic valve replacement procedures (TAVI and SAVR) among hospitalized patients with and without T2DM; and (2) to identify factors associated with in hospital mortality (IHM) among patients undergoing these procedures.

Methods

We analyzed data from the Spanish National Hospital Discharge Database between January 1, 2014 and December 31, 2015 for patients aged ≥ 40 years. We selected patients whose medical procedures included TAVI (ICD-9-CM codes 35.05, 35.06) and SAVR (ICD-9-CM codes 35.21, 35.22). We stratified each cohort by diabetes status: T2DM (ICD-9-CM codes 250.x0, 250.x2) and no diabetes. We retrieved data about specific comorbidities, risk factors, procedures, and specific in-hospital postoperative complications. Hospital outcome variables included IHM, and length of hospital stay (LOHS).

Results

We identified a total of 2141 and 16,013 patients who underwent TAVI (n = 715; 33.39% with T2DM) and SAVR (n = 4057; 25.33% with T2DM). In patients who underwent TAVI we found no differences in IHM (3.64% in T2DM vs. 5.12% in non-T2DM, p = 0.603). In the cohort of SAVR, mean LOHS was significantly lower in patients with T2DM than in non-diabetic patients (13.77 vs. 17.27 days). IHM was lower in patients with T2DM (4.36% vs. 6.31%, p < 0.01). After multivariable adjustment for both procedures, patients with T2DM had significantly lower IHM than patients without diabetes (adjusted OR 0.60; IC 95% 0.37–0.99 for TAVI and adjusted OR 0.80; IC 95% 0.66-0-96 for SAVR).

Conclusions

T2DM diabetic patients with AS undergoing a valvular replacement procedure through SAVR or TAVI did not have a worse prognosis compared to non-diabetic patients during hospitalization, showing lower IHM after multivariable adjustment. However, given the limitations of administrative data more prospective studies and clinical trials aimed at evaluating the influence of these procedures in diabetic patients with AS are needed.

Electronic supplementary material

The online version of this article (10.1186/s12933-017-0631-6) contains supplementary material, which is available to authorized users.

Refining Long-Term Prediction of Cardiovascular Risk in Diabetes - The VILDIA Score

Cardiovascular risk assessment in patients with diabetes relies on traditional risk factors. However, numerous novel biomarkers have been found to be independent predictors of cardiovascular disease, which might significantly improve risk prediction in diabetic patients. We aimed to improve prediction of cardiovascular risk in diabetic patients by investigating 135 evolving biomarkers. Based on selected biomarkers a clinically applicable prediction algorithm for long-term cardiovascular mortality was designed. We prospectively enrolled 864 diabetic patients of the LUdwigshafen RIsk and Cardiovascular health (LURIC) study with a median follow-up of 9.6 years. Independent risk factors were selected using bootstrapping based on a Cox regression analysis. The following seven variables were selected for the final multivariate model: NT-proBNP, age, male sex, renin, diabetes duration, Lp-PLA2 and 25-OH vitamin D3. The risk score based on the aforementioned variables demonstrated an excellent discriminatory power for 10-year cardiovascular survival with a C-statistic of 0.76 (P < 0.001), which was significantly better than the established UKPDS risk engine (C-statistic = 0.64, P < 0.001). Net reclassification confirmed a significant improvement of individual risk prediction by 22% (95% confidence interval: 14–30%) compared to the UKPDS risk engine (P < 0.001). The VILDIA score based on traditional cardiovascular risk factors and reinforced with novel biomarkers outperforms previous risk algorithms.

Non-Obese Diabetes and Its Associated Factors in an Underdeveloped Area of South China, Guangxi

Background: Little research has been conducted on the prevalence of diabetes mellitus in underdeveloped areas in China, especially stratified into obesity and non-obese diabetes. The aim of the present study was to investigate the prevalence and associated factors of non-obese diabetes in an underdeveloped area in South China, Guangxi. Methods: Data derived from the Chinese Health and Nutrition Survey 2010–2012 involved a sample of 3874 adults from Guangxi. Questionnaires and oral glucose-tolerance tests were conducted, and fasting and 2-h glucose levels and serum lipids were measured. Logistic regression analysis was performed to assess associated factors for non-obese diabetes. Results: 68.2% and 62.2% of instances of newly detected diabetes were those of non-obese diabetes based on BMI (NODB) and based on WC (NODW), respectively. The male sex, an age older than 50 years, lower education, hypertension, and hypertriglyceridemia were significantly associated with a higher risk of both NODB and NODW, while some associated factors for NODB were found different from those associated with NODW, and an interaction effect was found to increase the risk of NODW. Conclusions: Our study indicated that non-obese diabetes was highly prevalent in an underdeveloped area of South China. Non-obese diabetes should be considered for increased public attention in these areas.

Bioactivities of fish protein hydrolysates from defatted salmon backbones

Bioactivities of bulk fish protein hydrolysates (FPH) from defatted salmon backbones obtained with eight different commercial enzymes and their combinations were tested. All FPH showed antioxidative activity in vitro. DPPH scavenging activity increased, while iron chelating ability decreased with increasing time of hydrolysis. All FPH showed ACE inhibiting effect which depended on type of enzyme and increased with time of hydrolysis. The highest effect was found for FPH produced with Trypsin. Bromelain + Papain hydrolysates reduced the uptake of radiolabelled glucose into CaCo-2 cells, a model of human enterocytes, indicating a potential antidiabetic effect of FPH. FPH obtained by Trypsin, Bromelain + Papain and Protamex showed the highest ACE inhibitory, cellular glucose transporter (GLUT/SGLT) inhibitory and in vitro antioxidative activities, respectively. Correlation was observed between the measured bioactivities, degree of hydrolysis and molecular weight profiles, supporting prolonged hydrolysis to obtain high bioactivities.

Effect of interleukin-2 receptor antagonists on new-onset diabetes after liver transplantation: A retrospective cohort study

BACKGROUND

The aim of the present retrospective observational study was to examine the effect of interleukin-2 receptor antagonists (IL-2Ra) on new-onset diabetes after transplantation (NODAT) in liver transplant recipients.

METHODS

Pre- and postoperative clinical data of 781 patients undergoing liver transplantation between April 2001 and December 2014 at Zhongshan Hospital, Fudan University, were analyzed. Patients were divided into two groups depending on the use of IL-2Ra (IL-2Ra and non-IL-2Ra). The cumulative incidence of NODAT was compared between the IL-2Ra and non-IL-2Ra groups and the effect of IL-2Ra on the incidence of NODAT in liver transplant recipients was evaluated.

RESULTS

Of the 781 patients in the study, 451 received IL-2Ra. During follow-up, 138 (41.8%) and 137 (30.4%) patients in the non-IL-2Ra and IL-2Ra groups, respectively, developed NODAT (P = 0.001). The cumulative incidence of NODAT at 1, 3, 5, and 8 years after transplantation in the IL-2Ra group was 30%, 38%, 45%, and 54%, respectively; these values were substantially lower than corresponding values for the non-IL-2Ra group (P < 0.05). Cox regression analyses showed that IL-2Ra was a protective factor against NODAT development (odds ratio 0.685; 95% confidence interval 0.473-0.991; P = 0.044). This was independent of age, sex, donor type, hepatitis virus infection, body mass index, history of hypertension, preoperative liver function, preoperative fasting plasma glucose, total cholesterol, and total triglyceride levels, severity of liver cirrhosis, acute rejection, initial immunosuppressant regimen type, and postoperative immunosuppressant levels.

CONCLUSION

In conclusion, IL-2Ra reduces the risk of NODAT in liver transplant recipients.

Holter monitoring for the screening of cardiac disease in diabetes mellitus: The non-invasive Holter monitoring observation of new cardiac events in diabetics study

We investigated the usefulness of Holter monitoring to detect cardiac disease and predict future cardiovascular risk in asymptomatic diabetic patients. This is a multi-centre, prospective study in 406 asymptomatic diabetic patients. They were categorized into three groups based on findings of Holter monitoring. A total of 377 met inclusion criteria and were classified as low (n = 172), moderate (n = 136) and high risk (n = 69). In total, 86 in moderate and 53 in high risk receive further evaluation. In total, 29 in moderate and 25 in high risk were diagnosed as cardiac disease and 12 required additional treatment, including coronary intervention. Over 1.8 years of mean follow-up, 11 (16.5 per 1000 person-years) experienced cardiovascular events. The cumulative incidence in moderate and high risk was higher than that in low risk (p = 0.029 and p = 0.014, respectively). Our study suggests that Holter monitoring may be a useful screening tool to detect cardiac disease and predict future cardiovascular risk in asymptomatic diabetic patients.

Cardiovascular disease and diabetes mortality, and their relation to socio-economical, environmental, and health behavioural factors in worldwide view

BACKGROUND

Today, non-communicable diseases, mainly cardiovascular diseases and diabetes, represent a leading threat to human health and development. This study observed mortality trends in all income group countries in relation to a wide variety of related factors like economical and environmental factors, health behaviour and health risk factors.

STUDY DESIGN

Ecological study.

METHOD

Data were analysed for 72 countries using the ecological study method. Data were collected from various sources including WHO, World Bank and previous studies. Cardiovascular disease and diabetes mortality rates for males and females were used as the dependent variables. GDP, GINI, literacy rate, urbanization, health expenditure, the number of physicians and the number of beds, BMI, western diet, blood glucose, blood pressure, serum cholesterol, physical inactivity, alcohol, and smoking were used as the independent variables initially. The final model was decided on the basis of availability of complete data and result of co-linearity test. Correlation test and linear regression were employed to identify the affecting factors for the dependent variables.

RESULT

Analysis showed that cardiovascular disease and diabetes mortality was more concentrated in middle- and low-income countries and was negatively associated with GDP, GINI, and western diet. Countries with high average blood pressure had higher mortality rates showing a positive relationship.

CONCLUSION

Non-communicable disease mortality rate is strongly associated with many economical, social, environmental, and behavioural factors. More comprehensive preventive and diagnostic strategies are needed to decrease mortality especially in low- and middle-income countries.

Prolonged duration of type 2 diabetes is associated with increased thrombin generation, prothrombotic fibrin clot phenotype and impaired fibrinolysis

It has been shown that type 2 diabetes (DM) is associated with enhanced thrombin generation and formation of denser fibrin clots of reduced lysability. We sought to investigate the impact of diabetes duration versus glycaemia control on fibrin clot phenotype and its determinants in type 2 diabetic patients. In 156 consecutive Caucasian patients with type 2 diabetes we investigated ex vivo thrombin generation, fibrinolytic proteins, along with plasma fibrin clot permeation (Ks), compaction, turbidity, and efficiency of tissue plasminogen activator (t-PA)-mediated fibrinolysis. Patients with longer diabetes duration (>5 years, median; n=68) had higher peak thrombin generation (+16.3%, p<0.001), plasminogen activator inhibitor-1 (PAI-1) antigen (+14.8%, p=0.001), t-PA antigen (+13.9%, p=0.002) compared with those with duration ≤5 years (n=88). No such differences were observed between patients with inadequate glycaemic control, defined as glycated haemoglobin (HbA1C) >6.5% (48 mmol/mol) (n=77), versus those with HbA1C≤6.5% (n=79). Fibrinogen, thrombin-activatable fibrinolysis inhibitor antigen, plasminogen and soluble thrombomodulin were unaffected by disease duration or glycaemia control. Lower clot permeability, longer clot lysis, and higher maximum D-dimer levels released from clots (all p<0.05 after adjustment for fibrinogen, age, body mass index, insulin, acetylsalicylic acid treatment, and HbA1c or diabetes duration) were also observed in patients with diabetes duration >5 years and those with HbA1C>6.5%. We conclude that prolonged duration of type 2 diabetes is associated with increased thrombin formation, hypofibrinolysis, and prothrombotic fibrin clot phenotype. The impact of disease duration on coagulation is different and stronger than that observed during inadequate glycaemia control.

Thymosin beta 4 ameliorates hyperglycemia and improves insulin resistance of KK Cg-Ay/J mouse

OBJECT

To evaluate the efficacy of thymosin beta 4 (Tβ(4)) on hyperglycemia and insulin sensitivity in a mouse model of type 2 diabetes mellitus (T2DM).

METHODS

KK mice were divided into the following groups: KK control group, with saline treatment; KK Tβ(4) group, with daily Tβ(4) 100ng/10g body weight intraperitoneal injection for 12 weeks. Non-diabetic C57BL mice were used as normal control. OGTT, plasma insulin, HbA1c, serum adiponectin, Tβ(4), cholesterol, and triglyceride were measured before and after Tβ(4) treatment. The phosphorylated AKT and total AKT protein levels of skeletal muscle from all groups were determined.

RESULTS

After Tβ(4) treatment, repeat OGTT showed a significant decrease in glucose profiles in the KK Tβ(4) group compared with the KK control group. The KK-Tβ(4) group had reduced mean HbA1c and triglyceride levels, and increased adiponectin compared with KK control group. C57BL mice showed normal glucose homeostasis. The phosphorylated AKT levels of skeletal muscle were significantly increased in KK Tβ(4) group compared with KK control group after glucose stimulation. C57BL mice showed no changes in phosphorylated AKT levels after Tβ(4) treatment.

CONCLUSIONS

Tβ(4) improved glucose intolerance and ameliorated insulin resistance in KK mouse. Tβ(4) may be a potential alternative insulin sensitizer for treatment of T2DM.

Variability in the response to antiplatelet treatment in diabetes mellitus

Atherothrombosis is a leading cause of death in patients with diabetes mellitus. Among factors contributing to the diabetic prothrombotic state, platelet activation plays a pivotal role. Numerous studies have investigated the benefits of antiplatelet therapy for primary and secondary cardiovascular prevention in diabetic patients. However, there are limited evidences that low-dose aspirin may be effective in this clinical setting. Several disease-specific factors have been identified as potential determinants of aspirin treatment failure. In this review, the main determinants of interindividual variability in response to antiplatelet agents are discussed, with particular emphasis on the pharmacokinetic and pharmacodynamic mechanisms of clinical efficacy and safety of antiplatelet drugs in patients with diabetes mellitus.

Low Density Lipoprotein Cholesterol Target Goal Attainment Rate and Physician Perceptions about Target Goal Achievement in Korean Patients with Diabetes

BACKGROUND

This study aims to investigate the discrepancy between clinicians' perceptions and actual achievement rates of low density lipoprotein cholesterol (LDL-C) in Korean patients with diabetes according to updated American Diabetes Association (ADA)/American College of Cardiology Foundation (ACC) recommendations.

METHODS

This is a multi-center, retrospective, non-interventional, observational study. Diabetic patients aged 18 years or older were eligible if they had been diagnosed with hypercholesterolemia or were receiving a lipid-lowering therapy between May 2010 and August 2010. The information was obtained by reviewing medical records and using a self-completed questionnaire to examine physician perceptions.

RESULTS

A total of 2,591 subjects who satisfied the inclusion criteria were enrolled. Highest-risk and high-risk patients accounted for 61.9% and 38.1% of the patients, respectively. Although most (96.3%) underwent a statin monotherapy or a statin-based combination therapy, just 47.4% of patients attained the LDL-C target. However, the physicians' perceptions on target achievement rate (70.6%) were different from the actual results (47.4%). Many patients (65.3%) remained on the starting doses of statins, despite evidence of poor achievement of lipid goals.

CONCLUSION

Only less than half of patients with diabetes attained the LDL-C goal. The surveys showed that poor physician performance might be due to the lack of recognition on ADA/ACC consensus causing a low LDL-C target attainment rate. Therefore, changes in doctor perception are needed to attain target LDL-C level and reduce cardiovascular risk in Korean patients with diabetes.