(8) Cardiovascular disease and risk management

Navigating Cardiovascular Risk in Type 1 Diabetes: A Comprehensive Review of Strategies for Prevention and Management

Type 1 diabetes mellitus (T1DM) poses a significant cardiovascular risk, necessitating comprehensive prevention and management strategies. This review provides insights into the cardiovascular risk landscape in T1DM, emphasizing the importance of glycemic control, lipid management, blood pressure regulation, and lifestyle modifications. Pharmacological interventions, including insulin therapy and lipid-lowering medications, are discussed alongside lifestyle interventions such as diet, exercise, and smoking cessation. Early detection and management of cardiovascular complications are essential, highlighting the need for regular screening and multidisciplinary care. Patient-centered approaches, including shared decision-making and psychosocial support, are vital to effective care delivery. The review concludes with a call to action for healthcare providers and policymakers to prioritize cardiovascular risk management in T1DM. It explores future directions, including emerging therapies and technological innovations. By implementing evidence-based strategies and fostering collaboration across disciplines, we can mitigate cardiovascular risk and improve outcomes for individuals with T1DM.

The Diabetes-Heart Disease Connection: Recent Discoveries and Implications

Diabetes and heart disease are 2 prevalent and interconnected conditions with a significant global burden. Understanding the relationship between diabetes and heart disease is crucial for effective management and prevention strategies. This article provides an overview of the 2 conditions, highlighting their types, risk factors, and global prevalence. Recent research findings establish a strong correlation between diabetes and various aspects of cardiovascular health, including coronary artery disease, heart failure, and stroke. Mechanisms such as insulin resistance, inflammation, and oxidative stress contribute to the interplay between diabetes and heart disease. The implications for clinical practice underscore the importance of early detection, risk assessment, and comprehensive management of both conditions. Lifestyle modifications, such as diet, exercise, and weight management, are essential interventions. Pharmacological interventions, including antidiabetic drugs and cardiovascular medications, play a crucial role in treatment. Managing diabetes and heart disease simultaneously poses challenges that require interdisciplinary collaboration among endocrinologists, cardiologists, and primary care physicians. Ongoing research explores personalized medicine and targeted therapies as potential future directions. Continued research and awareness are paramount to mitigate the impact of the diabetes-heart disease connection and improve patient outcomes.

Trends in obesity prevalence and cardiometabolic risk factor control in US adults with diabetes, 1999-2020

OBJECTIVE

Trends in obesity prevalence and trends in control of cardiometabolic risk factors among National Health and Nutrition Examination Survey participants with diabetes from 1999 through 2020 were analyzed.

METHODS

Adults who were 20 years or older and who reported having received a diagnosis of diabetes from a physician were included.

RESULTS

The prevalence of overall obesity, obesity class II, and obesity class III increased from 46.9%, 14.1%, and 10.3% in 1999 to 2002 to 58.1%, 16.6%, and 14.8% in 2015 to 2020, respectively. The prevalence of participants who achieved glycemic control (HbA1c <7%) increased from 42.5% in 1999 to 2002 to 51.8% in 2007 to 2010, then decreased to 48.0% in 2015 to 2020. The prevalence of participants who achieved blood pressure control (<140/90 mmHg) or achieved non-high-density lipoprotein cholesterol control (<130 mg/dL) increased throughout the study periods. The prevalence of participants who met all three risk factor goals increased from 8.3% in 1999 to 2002 to 21.2% in 2011 to 2014 and then decreased to 18.5 in 2015 to 2020. Participants with obesity showed worsening glycemic control and lipid control than participants with normal weight.

CONCLUSIONS

There were increasing trends in prevalence of obesity, blood pressure control, and lipid control from 1999 to 2002 to 2015 to 2020. Participants with obesity showed worsening glycemic control and lipid control than normal-weight participants.

Trained immunity in monocyte/macrophage: Novel mechanism of phytochemicals in the treatment of atherosclerotic cardiovascular disease

Atherosclerosis (AS) is the pathology of atherosclerotic cardiovascular diseases (ASCVD), characterized by persistent chronic inflammation in the vessel wall, in which monocytes/macrophages play a key role. It has been reported that innate immune system cells can assume a persistent proinflammatory state after short stimulation with endogenous atherogenic stimuli. The pathogenesis of AS can be influenced by this persistent hyperactivation of the innate immune system, which is termed trained immunity. Trained immunity has also been implicated as a key pathological mechanism, leading to persistent chronic inflammation in AS. Trained immunity is mediated via epigenetic and metabolic reprogramming and occurs in mature innate immune cells and their bone marrow progenitors. Natural products are promising candidates for novel pharmacological agents that can be used to prevent or treat cardiovascular diseases (CVD). A variety of natural products and agents exhibiting antiatherosclerotic abilities have been reported to potentially interfere with the pharmacological targets of trained immunity. This review describes in as much detail as possible the mechanisms involved in trained immunity and how phytochemicals of this process inhibit AS by affecting trained monocytes/macrophages.

Optimize PLA/EVA Polymers Blend Compositional Coating for Next Generation Biodegradable Drug-Eluting Stents

In this research work, polymer blends of poly-lactic acid (PLA)/ethylene vinyl acetate (EVA) were prepared as the drug carrier materials for a bi-layer drug-loaded coating film for coronary stents. Different optimum compositions of blends were prepared by using an intense mixer. Then, the blends were hot-pressed and later cold-pressed to prepare for films of different thickness. The changes in weight, surface analysis and biodegradability with increasing time were studied using Scanning electron microscopy (SEM), weight loss and biodegradability tests. The mechanical and thermal properties of drug-loaded films were studied through universal testing machine (UTM) and thermo-gravimetric analysis (TGA). The effects of PLA, EVA and drug contents on in-vitro drug contents were investigated through the Ultraviolet-Visible Spectroscopy (UV-VIS) chemical analysis technique. The results obtained clearly showed that the addition of PLA promoted the unleashing of the drug whereas the addition of EVA nearly did not have the same affect. The mechanical properties of these various films can be tuned by adjusting the contents of blend parts. The factors affecting the unleashing of the drug became a serious matter of concern in evaluating the performance of bio-resorbable drug eluting stents. As a result, today’s chemical blends may be useful drug carrier materials for drug-loaded tube coatings capable delivering purgative drug in an incredibly tunable and regulated manner.

Cardiovascular risk management in people with type 1 diabetes: performance using three guidelines

INTRODUCTION

Cardiovascular disease (CVD) is the leading cause of mortality in individuals with type 1 diabetes mellitus (T1DM). Cardiovascular risk management is therefore essential in the management of individuals with T1DM. This study describes the performance of lipid and blood pressure management in individuals with T1DM using three guidelines.

RESEARCH DESIGN AND METHODS

Individuals ≥18 years with T1DM, treated with insulin for ≥1 year, visiting Diabeter or the University Medical Center Groningen between January 1, 2018 and December 31, 2018, were included. Lipid and blood pressure management were examined using the Dutch, American Diabetes Association (ADA) and National Institute for Health and Care Excellence (NICE) guidelines. Concordance of recommended and prescribed lipid-lowering (LLM) or antihypertensive medication (AHM) was assessed per guideline and 10-year age groups. Achievement of treatment targets was assessed for those prescribed medication.

RESULTS

A total of 1855 individuals with T1DM were included. LLM and AHM was prescribed in 19% and 17%, respectively. In individuals recommended LLM, this was prescribed in 22%-46% according to Dutch, ADA or NICE guideline recommendations. For individuals recommended AHM, this was prescribed in 52%-75%. Recommended and actual prescription of LLM and AHM increased over age for all three guidelines. However, discordance between treatment recommendation and medication prescribed was higher in younger, compared with older, age groups. Low-density lipoprotein-cholesterol targets were achieved by 50% (without CVD) and 31% (with CVD) of those prescribed LLM. The blood pressure target was achieved by 46% of those prescribed AHM.

CONCLUSION

This study suggests that there is undertreatment of lipid and blood pressure according to guideline recommendations, particularly in younger age groups. Treatment targets are not met by most individuals prescribed medication, while guidelines recommendations differ considerably. We recommend to investigate the factors influencing undertreatment of lipid and blood pressure management in individuals with T1DM.

Nutraceutic Potential of Bioactive Compounds of Eugenia dysenterica DC in Metabolic Alterations

The fruit and leaves of Eugenia dysenterica DC., locally known as cagaita, are rich in antioxidant glycosylated quercetin derivatives and phenolic compounds that have beneficial effects on diabetes mellitus, hypertension and general inflammation. We conducted a literature search to investigate the nutraceutical potentials of these phenolic compounds for treating obesity, diabetes mellitus and intestinal inflammatory disease. The phenolic compounds in E. dysenterica have demonstrated effects on carbohydrate metabolism, which can prevent the development of these chronic diseases and reduce LDL (low-density lipoprotein) cholesterol and hypertension. E. dysenterica also improves intestinal motility and microbiota and protects gastric mucosa, thereby preventing inflammation. However, studies are necessary to identify the mechanism by which E. dysenterica nutraceutical compounds act on such pathological processes to support future research.

Vitamin D Deficiency Is Significantly Associated with Retinopathy in Type 2 Diabetes Mellitus: A Case-Control Study

AIM

Results from meta-analyses point to an association between vitamin D deficiency and the onset of diabetic retinopathy (DR). The objectives of the present study were to evaluate the association of vitamin D for the development of DR and to determine the levels of vitamin D associated with a greater risk of DR.

METHODS

Between November 2013 and February 2015, we performed a case-control study based on a sample of patients with diabetes in Spain. The study population comprised all patients who had at least one evaluable electroretinogram and recorded levels of 25(OH)D. We collected a series of analytical data: 25(OH)D, 1,25(OH)2D, iPTH, calcium, albumin, and HbA1c. Glycemic control was evaluated on the basis of the mean HbA1c values for the period 2009-2014. A logistic regression analysis was performed to identify the variables associated with DR.

RESULTS

The final study sample comprised 385 patients, of which 30 (7.8%) had DR. Significant differences were found between patients with and without DR for age (69.54 vs. 73.43), HbA1c (6.68% vs. 7.29%), years since diagnosis of diabetes (10.9 vs. 14.17), level of 25(OH)D (20.80 vs. 15.50 ng/mL), level of 1,25(OH)2D (35.0 vs. 24.5 pg/mL), treatment with insulin (14.9% vs. 56.7%), hypertension (77.7% vs. 100%), cardiovascular events (33.2% vs. 53.3%), and kidney failure (22.0% vs. 43.3%). In the multivariate analysis, the factors identified as independent risk factors for DR were treatment of diabetes (p = 0.001) and 25(OH)D (p = 0.025). The high risk of DR in patients receiving insulin (OR 17.01) was also noteworthy.

CONCLUSIONS

Levels of 25(OH)D and treatment of diabetes were significantly associated with DR after adjusting for other risk factors. Combined levels of 25(OH)D < 16 ng/mL and levels of 1,25(OH)2D < 29 pg/mL are the variables that best predict the risk of having DR with respect to vitamin D deficiency. The risk factor with the strongest association was the treatment of type 2 diabetes mellitus. This was particularly true for patients receiving insulin, who had a greater risk of DR than those receiving insulin analogues. However, further studies are necessary before a causal relationship can be established.

Placing a Well-Designed Vegan Diet for Slovenes

Interest in vegan diets has increased globally as well as in Slovenia. The quantity of new scientific data requires a thorough synthesis of new findings and considerations about the current reserved position of the vegan diet in Slovenia. There is frequently confusion about the benefits of vegetarian diets that are often uncritically passed on to vegan diets and vice versa. This narrative review aims to serve as a framework for a well-designed vegan diet. We present advice on how to maximize the benefits and minimize the risks associated with the vegan diet and lifestyle. We highlight the proper terminology, present the health effects of a vegan diet and emphasize the nutrients of concern. In addition, we provide guidance for implementing a well-designed vegan diet in daily life. We conducted a PubMed search, up to November 2021, for studies on key nutrients (proteins, vitamin B12, vitamin D, omega-3 long chain polyunsaturated fatty acids (eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)), calcium, iron, zinc, iodine and selenium) in vegan diets. Given the limited amount of scientific evidence, we focus primarily on the general adult population. A well-designed vegan diet that includes a wide variety of plant foods and supplementation of vitamin B12, vitamin D in the winter months and potentially EPA/DHA is safe and nutritionally adequate. It has the potential to maintain and/or to improve health. For physically active adult populations, athletes or individuals with fast-paced lifestyles, there is room for further appropriate supplementation of a conventional vegan diet according to individuals' health status, needs and goals without compromising their health. A healthy vegan lifestyle, as included in government guidelines for a healthy lifestyle, includes regular physical activity, avoidance of smoking, restriction of alcohol and appropriate sleep hygiene.

Effect of exercise and diet intervention in NAFLD and NASH via GAB2 methylation

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is a disorder that extends from simple hepatic steatosis to nonalcoholic steatohepatitis (NASH), which is effectively alleviated by lifestyle intervention. Nevertheless, DNA methylation mechanism underling the effect of environmental factors on NAFLD and NASH is still obscure. The aim of this study was to investigate the effect of exercise and diet intervention in NAFLD and NASH via DNA methylation of GAB2.

METHODS

Methylation of genomic DNA in human NAFLD was quantified using Infinium Methylation EPIC BeadChip assay after exercise (Ex), low carbohydrate diet (LCD) and exercise plus low carbohydrate diet (ELCD) intervention. The output Idat files were processed using ChAMP package. False discovery rate on genome-wide analysis of DNA methylation (q < 0.05), and cytosine-guanine dinucleotides (CpGs) which are located in promoters were used for subsequent analysis (|Δβ|≥ 0.1). K-means clustering was used to cluster differentially methylated genes according to 3D genome information from Human embryonic stem cell. To quantify DNA methylation and mRNA expression of GRB2 associated binding protein 2 (GAB2) in NASH mice after Ex, low fat diet (LFD) and exercise plus low fat diet (ELFD), MassARRAY EpiTYPER and quantitative reverse transcription polymerase chain reaction were used.

RESULTS

Both LCD and ELCD intervention on human NAFLD can induce same DNA methylation alterations at critical genes in blood, e.g., GAB2, which was also validated in liver and adipose of NASH mice after LFD and ELFD intervention. Moreover, methylation of CpG units (i.e., CpG_10.11.12) inversely correlated with mRNA expression GAB2 in adipose tissue of NASH mice after ELFD intervention.

CONCLUSIONS

We highlighted the susceptibility of DNA methylation in GAB2 to ELFD intervention, through which exercise and diet can protect against the progression of NAFLD and NASH on the genome level, and demonstrated that the DNA methylation variation in blood could mirror epigenetic signatures in target tissues of important biological function, i.e., liver and adipose tissue. Trial registration International Standard Randomized Controlled Trial Number Register (ISRCTN 42622771).

Hyperglycemia Induces Trained Immunity in Macrophages and Their Precursors and Promotes Atherosclerosis

BACKGROUND

Cardiovascular risk in diabetes remains elevated despite glucose-lowering therapies. We hypothesized that hyperglycemia induces trained immunity in macrophages, promoting persistent proatherogenic characteristics.

METHODS

Bone marrow-derived macrophages from control mice and mice with diabetes were grown in physiological glucose (5 mmol/L) and subjected to RNA sequencing (n=6), assay for transposase accessible chromatin sequencing (n=6), and chromatin immunoprecipitation sequencing (n=6) for determination of hyperglycemia-induced trained immunity. Bone marrow transplantation from mice with (n=9) or without (n=6) diabetes into (normoglycemic) Ldlr-/- mice was used to assess its functional significance in vivo. Evidence of hyperglycemia-induced trained immunity was sought in human peripheral blood mononuclear cells from patients with diabetes (n=8) compared with control subjects (n=16) and in human atherosclerotic plaque macrophages excised by laser capture microdissection.

RESULTS

In macrophages, high extracellular glucose promoted proinflammatory gene expression and proatherogenic functional characteristics through glycolysis-dependent mechanisms. Bone marrow-derived macrophages from diabetic mice retained these characteristics, even when cultured in physiological glucose, indicating hyperglycemia-induced trained immunity. Bone marrow transplantation from diabetic mice into (normoglycemic) Ldlr-/- mice increased aortic root atherosclerosis, confirming a disease-relevant and persistent form of trained innate immunity. Integrated assay for transposase accessible chromatin, chromatin immunoprecipitation, and RNA sequencing analyses of hematopoietic stem cells and bone marrow-derived macrophages revealed a proinflammatory priming effect in diabetes. The pattern of open chromatin implicated transcription factor Runt-related transcription factor 1 (Runx1). Similarly, transcriptomes of atherosclerotic plaque macrophages and peripheral leukocytes in patients with type 2 diabetes were enriched for Runx1 targets, consistent with a potential role in human disease. Pharmacological inhibition of Runx1 in vitro inhibited the trained phenotype.

CONCLUSIONS

Hyperglycemia-induced trained immunity may explain why targeting elevated glucose is ineffective in reducing macrovascular risk in diabetes and suggests new targets for disease prevention and therapy.

Sex Differences of the Diabetic Heart

Type 2 diabetes is a chronic disease associated with micro- and macro-vascular complications, including myocardial ischemia, and also with a specific and intrinsic cardiac dysfunction called diabetic cardiomyopathy (DCM). Both clinical and animal studies demonstrate significant sex differences in prevalence, pathophysiology, and outcomes of cardiovascular diseases (CVDs), including those associated with diabetes. The increased risk of CVDs with diabetes is higher in women compared to men with 50% higher risk of coronary artery diseases and increased mortality when exposed to acute myocardial infarction. Clinical studies also reveal a sexual dimorphism in the incidence and outcomes of DCM. Based on these clinical findings, growing experimental research was initiated to understand the impact of sex on CVDs associated with diabetes and to identify the molecular mechanisms involved. Endothelial dysfunction, atherosclerosis, coagulation, and fibrosis are mechanisms found to be sex-differentially modulated in the diabetic cardiovascular system. Recently, impairment of energy metabolism also emerged as a determinant of multiple CVDs associated with diabetes. Therefore, future studies should thoroughly analyze the sex-specific metabolic determinants to propose new therapeutic targets. With current medicine tending toward more personalized care of patients, we finally propose to discuss the importance of sex as determinant in the treatment of diabetes-associated cardiac diseases to promote a more systemic inclusion of both males and females in clinical and preclinical studies.

External validity of type 2 diabetes clinical trials on cardiovascular outcomes for a multimorbid population

AIM

To investigate the external validity of recent antihyperglycaemic trials evaluating cardiovascular outcomes in a multimorbid population.

MATERIALS AND METHODS

Selection criteria of 15 randomized controlled trials from the 2020 American Diabetes Association Standard of Care statement were applied in a stepwise manner to tertiary care patients with type 2 diabetes. Primary outcomes were the number of patients eligible per individual trial and for the aggregate of trials. Secondary outcomes included patient predictors of trial eligibility.

RESULTS

Of 1059 patients, the mean (SD) age was 66 (10.74) years, the median (IQR) Charlson index was 2 (2, 3) and 458 (43%) had documented cardiovascular disease. The median (IQR) number of patients included in individual trials was 263 (174.25-308.75) and 795 (75.1%) of them were eligible for at least one trial. Among those 264 ineligible, 127 (48.1%) had an HbA1c level of 7% or less and no cardiovascular disease; 53.5% and 34.4% of the patients were eligible for two and three different classes of drugs, respectively. The strongest predictor of trial eligibility was cardiovascular disease (risk ratio 2.17, 95% CI 2.01-2.35).

CONCLUSIONS

A considerable proportion of multimorbid patients would be eligible for recent antihyperglycaemic trials. This positive finding can be attributed to development guidance in diabetes trials and the different approach we took, in which we evaluated inclusion by trials as an aggregate.

Independent effects of 2hPG, FPG and HbA1c on cardiovascular risk: Analysis of a nationally representative sample from China

AIMS

To evaluate the independence of the effect of 2-hour post-load plasma glucose (2hPG), fasting plasma glucose (FPG) and glycated hemoglobin (HbA1c) on cardiovascular disease (CVD) after adjusting for each other and non-glycemic factors.

METHODS

We analyzed data from a nationally representative sample of 174,329 Chinese adults from a survey conducted in 2013-2014. The associations of glycemic measures with the risk of CVD were examined and compared by using logistic regression analyses.

RESULTS

After adjusting for non-glycemic factors, the odds ratio for one standard-deviation increase of 2hPG, FPG and HbA1c was 1.08 (95% confidence interval [CI]: 1.05-1.11), 1.02 (95% CI: 0.99-1.06) and 1.05 (95% CI: 1.02-1.07), respectively. The odds ratio for 2hPG (1.10, 95% CI: 1.05-1.16) remained statistically significant after FPG and HbA1c were added to the models, whereas the odds ratios for FPG and HbA1c became statistically insignificant after 2hPG was adjusted for. The results remained consistent across various scenarios.

CONCLUSIONS

2hPG showed an effect on cardiovascular risk which was independent from FPG and HbA1c, whereas whether the effects of FPG and HbA1c were independent from 2hPG was open to question. This finding calls for more research on how to better use FPG and HbA1c in diagnosing diabetes.

Prevalence of and Factors Associated with Diabetic Retinopathy in Patients with Diabetes Mellitus at Siriraj Hospital - Thailand's Largest National Tertiary Referral Center

PURPOSE

We aimed to determine the prevalence of and factors associated with diabetic retinopathy (DR) in patients with diabetes mellitus (DM) and to evaluate the relationship between significant factors and severity of DR.

PATIENTS AND METHODS

A retrospective cross-sectional study of 1130 diabetic patients (mean age: 60 years, 62.7% female, 91% type 2 diabetes) was conducted in the diabetes clinic of Siriraj Hospital (Bangkok, Thailand) during January 2012 to June 2015. DR was graded as absent, mild, moderate, or severe non-proliferative DR, or proliferative DR. Multivariate logistic regression analysis was used to identify independent risk factors for DR in DM patients.

RESULTS

The overall prevalence of DR was 34.78%. Multivariate analysis revealed duration of diabetes, glycated hemoglobin level (HbA_1c), presence of albuminuria, and abnormal protective sensation to be independent risk factors for DR. The prevalence of DR increased with longer duration of diabetes (p < 0.001), deterioration of glucose control (p = 0.006 for HbA_1c), presence of significant albuminuria (p = 0.010), and loss of protective sensation (p = 0.001).

CONCLUSION

In this study, one-third of DM were found to have DR. The independent predictors of DR were duration of diabetes, HbA_1c level, presence of significant albuminuria, and impaired protective sensation. Heightened awareness of these risk factors will decrease the prevalence and severity of DR, and will improve early diagnosis and treatment of DR.

Effect of Low Diastolic Blood Pressure to Cardiovascular Risk in Patients With Ischemic Stroke or Transient Ischemic Attacks Under Different Systolic Blood Pressure Levels

Background: In the context of recently updated strategies of pressure management, there is a paucity of evidence on the effect of diastolic blood pressure (DBP) level on adverse events among stroke patients. This study aimed to examine the effect of low DBP (<60 mmHg) under different levels of systolic blood pressure (SBP) on the risk of composite events and stroke recurrence among patients with ischemic stroke (IS) or transient ischemic attack (TIA).

Material and Methods: This study was conducted in 2,325 patients with IS or TIA. DBP values were categorized into <60, 60–70, 70–80 (reference), 80–90, and ≥90 mmHg in the main sample and were further categorized as <60 and ≥60 mmHg (reference) when patients were stratified according to SBP levels (<140, <130, and <120 mmHg). The outcomes were defined as recurrent stroke and cumulative composite events (defined as the combination of nonfatal myocardial infarction, nonfatal congestive heart failure, and death) at 1 year.

Results: During 1 year of follow-up, a total of 95 composite events and 138 stroke recurrences were identified. The patients with low DBP showed a significantly higher risk of composite events [hazard ratio (HR) = 4.86, 95% confidence interval (CI) = 2.54–8.52], especially the elderly patients (≥60 years); however, this result was not observed for stroke recurrence (HR = 0.90, 95% CI = 0.46–1.74). With the reduction of the SBP levels, the proportion of patients with low DBP increased (6.87, 12.67, and 34.46%), and the risk for composite events persisted.

Conclusions: Along with the new target levels of SBP suggested by updated criteria, there is a trend for DBP to be reduced to a harmfully low level, which was associated with an increased risk of composite events among patients with IS or TIA.

Impact of blood pressure early after allogeneic hematopoietic cell transplantation on clinical outcomes

Allogeneic hematopoietic transplantation (allo-HCT) is still associated with significant morbidity and mortality, and risk stratification is critical. In this study, we analyzed the relationship between blood pressure control early after allo-HCT and survival outcomes. All patients who survived longer than 28 days after allo-HCT at our center between June 2007 and June 2018 (n = 353) were included, and the average systolic blood pressure (asBP) from 1 to 28 days after allo-HCT was calculated. According to the results of a ROC curve analysis, an asBP of 131 mmHg was defined as a cut-off value between high and low asBP groups. Non-relapse mortality (NRM) and OS were significantly inferior in the high asBP group (2-year-NRM 28.0% vs 11.1%, P < 0.001; 2-year-OS 46.7% vs 65.7%, P = 0.001). In addition, baseline asBP before commencement of the conditioning regimen and elevation of asBP (asBP - baseline asBP) were both associated with inferior NRM. While these results were also observed in the younger patients (≤ 50 years), no relationship was observed in the older patients (> 50 years). High blood pressure within 28 days after allo-HCT was associated with inferior survival outcomes, especially in patients younger than 50 years.

The atherogenic index of plasma plays an important role in predicting the prognosis of type 2 diabetic subjects undergoing percutaneous coronary intervention: results from an observational cohort study in China

Background

Many studies have reported the predictive value of the atherogenic index of plasma (AIP) in the progression of atherosclerosis and the prognosis of percutaneous coronary intervention (PCI). However, the utility of the AIP for prediction is unknown after PCI among type 2 diabetes mellitus (T2DM).

Methods

2356 patients with T2DM who underwent PCI were enrolled and followed up for 4 years. The primary outcome was major cardiovascular and cerebrovascular adverse events (MACCEs), considered to be a combination of cardiogenic death, myocardial infarction, repeated revascularization, and stroke. Secondary endpoints included all-cause mortality, target vessel revascularization (TVR), and non-target vessel revascularization (non-TVR). Multivariate Cox proportional hazards regression modelling found that the AIP was correlated with prognosis and verified by multiple models. According to the optimal cut-off point of the ROC curve, the population was divided into high/low-AIP groups. A total of 821 pairs were successfully matched using propensity score matching. Then, survival analysis was performed on both groups.

Results

The overall incidence of MACCEs was 20.50% during a median of 47.50 months of follow-up. The multivariate Cox proportional hazards regression analysis before matching suggested that the AIP was an independent risk factor for the prognosis of T2DM after PCI (hazard ratio [HR] 1.528, 95% CI 1.100–2.123, P = 0.011). According to the survival analysis of the matched population, the prognosis of the high AIP group was significantly worse than that of the low AIP group (HR (95% CI) 1.614 (1.303–2.001), P < 0.001), and the difference was mainly caused by repeat revascularization. The low-density lipoprotein-cholesterol (LDL-C) level did not affect the prognosis of patients with T2DM (P = 0.169), and the effect of the AIP on prognosis was also not affected by LDL-C level (P < 0.001).

Conclusions

The AIP, a comprehensive index of lipid management in patients with T2DM, affects prognosis after PCI. The prognosis of diabetic patients with high levels of the AIP included more MACCEs and was not affected by LDL-C levels. It is recommended to monitor the AIP for lipid management in diabetic patients after PCI and ensure that the AIP is not higher than 0.318.

Trial registration This is an observational cohort study that does not involve interventions. So we didn’t register. We guarantee that the research is authentic and reliable, and hope that your journal can give us a chance.

LDL-C plays a causal role on T2DM: a Mendelian randomization analysis

Diabetic dyslipidemia is a common condition in patients with Type 2 diabetes mellitus (T2DM). However, with the increasing application of statins which mainly decrease low-density lipoprotein cholesterol (LDL-C) levels, clinical trials and meta-analysis showed a clearly increase of the incidence of new-onset DMs, partly due to genetic factors. To determine whether a causal relationship exists between LDL-C and T2DM, we conducted a two-sample Mendelian Randomization (MR) analysis using genetic variations as instrumental variables (IVs). Initially, 29 SNPs significantly related to LDL-C (P≤ 5.0×10^-8) were selected as based on results from the study of Henry et al, which processed loci data influencing lipids identified by the Global Lipids Genetics Consortium (GLGC) from 188,577 individuals of European ancestry. While 6 SNPs related to T2DM (P value < 5×10^-2) were deleted, with the remaining 23 SNPs without LD eventually being deemed as IVs. The combined effect of all these 23 SNPs on T2DM, as generated with use of the penalized robust inverse-variance weighted (IVW) method (Beta value 0.24, 95%CI 0.087~0.393, P-value=0.002) demonstrated that elevated LDL-C levels significantly increased the risk of T2DM. The relationship between LDL-C and Type 1 diabetes mellitus (T1DM) with this analysis producing negative pooled results (Beta value -0.202, 95%CI -2.888~2.484, P-value=0.883).

Financial Burdens and Barriers to Care Among Nonelderly Adults With Heart Disease: 2010-2015

Background We examined the prevalence of high burdens and barriers to care among adults with heart disease treatment. Methods and Results The participants were aged 18 to 64 years from the Medical Expenditure Panel Survey-Household Component (MEPS-HC) for 2010-2015. High burden is out-of-pocket spending on care and insurance premiums >20% of income. Barriers to care are forgoing and delaying care for financial reasons. Logistic regressions were used to estimate the odds of having high burdens and barriers. Adults treated for heart disease have odds ratios (ORs) of 2.18 (95% CI, 1.91-2.50) for having high burden, 2.51 (95% CI, 2.23-2.83) for forgoing care, and 3.57 (95% CI, 3.8-4.13) for delaying care compared with adults without any chronic condition. Among adults treated for heart disease compared with adults with private group coverage, ORs for having high burdens were significantly lower among those with public insurance (OR: 0.17; 95% CI, 0.10-0.26) or the uninsured (OR: 0.58; 95% CI, 0.36-0.92) and higher among those with private nongroup insurance (OR: 5.30; 95% CI, 3.26-8.61). Compared with adults with private group coverage, ORs for delaying care were 2.07 (95% CI, 1.37-3.12) for those with public insurance, 2.64; 95% CI, 1.70-4.10) for those without insurance, and 2.16 (95% CI, 1.24-3.76) for those with private nongroup insurance. Conclusions Public insurance provides protection against high burdens but not against forgoing or delaying care. Future research should investigate whether and to what extent barriers to care are associated with worse health outcomes and higher costs in the long term.

Evidence for and Against ACC/AHA 2017 Guideline for Target Systolic Blood Pressure of < 130 mmHg in Persons with Type 2 Diabetes

PURPOSE OF REVIEW

We summarize the evidence for and against a target systolic blood pressure (SBP) < 130 mmHg in individuals with type 2 diabetes mellitus (T2DM).

RECENT FINDINGS

The primary ACCORD trial pooled data from patients with more- and less-intense glycemic control and found no benefit to lowering SBP < 140 mmHg, findings consistent with multiple meta-analyses. However, a re-analysis of the ACCORD trial found that participants randomized to less-intense glycemic control (HbA1c 7.0-7.9%) benefited from targeting SBP < 120 vs. 140 mmHg. The SPRINT trial also found benefit for targeting SBP < 120 vs. 140 mmHg in participants at risk for cardiovascular events but excluded persons with T2DM. There is no consensus as to the optimal SBP target for patients with T2DM, though data suggest a benefit to targeting SBP < 130 mmHg in patients with less-intensive glucose control. Further research is also needed on BP control in the setting of newer anti-diabetic agents.

The medical treatment with pasireotide in Cushing's disease: an Italian multicentre experience based on "real-world evidence"

A phase III study has demonstrated that 6-month pasireotide treatment induced disease control with good safety in 15-26% of patients with Cushing's disease (CD). The aim of the current study was to evaluate the 6-month efficacy and safety of pasireotide treatment according to the real-world evidence. Thirty-two CD patients started pasireotide at the dose of 600 µg twice a day (bid) and with the chance of up-titration to 900 µg bid, or down-titration to 450 or 300 µg bid, on the basis of urinary cortisol (UC) levels or safety. Hormonal, clinical and metabolic parameters were measured at baseline and at 3-month and 6-month follow-up, whereas tumour size was evaluated at baseline and at 6-month follow-up. At baseline, 31 patients had very mild to moderate disease and 1 patient had very severe disease. Five (15.6%) patients discontinued treatment for adverse events; the remaining 27 patients (26 with very mild to moderate disease and 1 with very severe disease), reached 6-month follow-up. Considering the group of patients with very mild to moderate disease, responsiveness, defined by the normalization (<1 the upper limit of normal range, ULN) or near normalization (>1 and ≤1.1 ULN) of UC levels, was registered in 21 patients (full control in 19 and near control in 2), corresponding to 67.7% and 80.8% according to an "intention-to-treat" or "per-protocol" methodological approach, respectively. Weight, body mass index, waist circumference, as well as total and LDL-cholesterol significantly decreased, whereas fasting plasma glucose and glycated haemoglobin significantly increased. Hyperglycaemia was documented in 81.2%, whereas gastrointestinal disturbances in 40.6% of patients. In conclusion, in the real-life clinical practice, pasireotide treatment normalizes or nearly normalizes UC in at least 68% of patients with very mild to moderate disease, with consequent improvement in weight, visceral adiposity and lipid profile, despite the occurrence or deterioration of diabetes in the majority of cases, confirming the usefulness of this treatment in patients with milder disease and without uncontrolled diabetes.

Biochemical Urine Testing of Adherence to Cardiovascular Medications Reveals High Rates of Nonadherence in People Attending Their Annual Review for Type 2 Diabetes

OBJECTIVE

Liquid chromatography-tandem mass spectrometry (LC-MS/MS) is a new method to objectively and robustly detect nonadherence. We applied this technique to study nonadherence to cardiovascular medications in people with type 2 diabetes (T2DM).

RESEARCH DESIGN AND METHODS

Routine urine samples, received at the time of the annual diabetes review from 228 people with T2DM in primary care, were assessed for adherence by LC-MS/MS.

RESULTS

A total of 28.1% patients (N = 64) were nonadherent to antidiabetic, antihypertensive, and/or lipid-lowering medications. Nonadherence to statins was the highest at 23.7%, and nonadherence to oral hypoglycemic agents was 9.3%. HbA_1c, albumin-to-creatinine ratio, and lipid profiles were significantly higher in the patients who were nonadherent compared with those who were adherent to treatment.

CONCLUSIONS

This unique study shows that routine urine samples can be used for adherence testing screening by LC-MS/MS and has demonstrated high nonadherence rates especially to statins in people with T2DM. Future intervention studies using LC-MS/MS as a diagnostic/therapeutic tool may help to improve clinical outcomes.

Long-term statin adherence in patients after hospital discharge for new onset of atherosclerotic cardiovascular disease: a population-based study of real world prescriptions in Taiwan

Background

Despite the recommendations of statins treatment for secondary prevention of atherosclerotic cardiovascular disease (ASCVD), treatment adherence and persistence are still a concern. This study examined the real world practice of long-term adherence and persistence to statins treatment initiated after hospital discharge for ASCVD, and their associated factors in a nationwide cohort.

Methods

Post discharge statin prescriptions between 2006 and 2012 were extracted from the Taiwan National Health Insurance claims database. Good adherence, defined as proportion of days covered (PDC) ≥0.8 and mean medication possession ratio (MPR), was measured every 180-day period. Non-persistence was defined on the date patients failed to refill statin for 90 days after the end of the last prescription. Their associations with influential factors were analyzed using a generalized estimating equation and Cox’s proportional hazard model.

Results

There was a total of 185,252 post-discharge statin initiations (from 169,624 patients) and followed for 467,398 patient-years in the study cohort. Percentage of good adherence (mean MPR) was 71% (0.87) at 6-months; declined to 54% (0.68), 47% (0.59), and 42% (0.50) at end of year 1, 2, and 7, respectively. Persistence in statin treatment was 86, 67, 50, and 25% at 6-month, 1-, 2-, and 7-year, respectively. Comparing the statin-cohort initiated from year 2006 to 2012, 1-year persistence increased from 58 to 73%, and 1-year good adherence improved from 45 to 61%. Factors associated with sub-optimal adherence and non-persistence included: prescription by primary care clinics or non-cardiology specialties; patients’ age > 75 years; no history of previous statin use; ASCVD events with ischemic stroke diagnosis; comorbidities of renal disease, liver disease, depression, and chronic obstructive pulmonary disease.

Conclusions

Despite the improving trends, long-term adherence and persistence of statin treatment were suboptimal in Taiwan. Strategies to maintain statin treatment adherence and persistence need to be implemented to further enhance the positive trend.

A prescription support-tool for chronic management of oral antithrombotic combinations in adults based on a systematic review of international guidelines

BACKGROUND

Oral antithrombotic (AT) drugs, which include antiplatelet and anticoagulant therapies, are widely implicated in serious preventable bleeding events. Avoiding inappropriate oral AT combinations is a major concern. Numerous practical guidelines have been released; a document to enhance prescriptions of oral AT combinations for adults would be of great help.

OBJECTIVE

To synthesize guidelines on the prescription of oral AT combinations in adults and to create a prescription support-tool for clinicians about chronic management (≥ one month) of oral AT combinations.

METHODS

A systematic review of guidelines published between January 2012 and April 2017, in English or in French, from Trip database, Guideline International Network and PubMed, dealing with the prescription of oral ATs in adults was conducted. In-hospital management of ATs, bridging therapy and switches of ATs were not considered. Some specific topics requiring specialized follow-up (cancer, auto-immune disease, haemophilia, HIV, paediatrics and pregnancy) were excluded. Last update was made in November 2018.

RESULTS

A total of 885 guidelines were identified and 70 met the eligibility criteria. A prescription support-tool summarizing medical conditions requiring chronic management of oral AT combinations in adults with drug types, dosage and duration, on a double-sided page, was provided and tested by an external committee of physicians. The lack of specific guidelines for old people (age 75 years and older) is questioned considering the specific vulnerability of this age group to serious bleedings.

CONCLUSIONS

Recommendations on prescriptions about chronic management of oral AT combinations in adults were mainly consensual but dispersed in numerous guidelines according to the medical indication. We provide a prescription support-tool for clinicians. Further studies are needed to assess the impact of this tool on appropriate prescribing and the prevention of serious adverse drug events.

Intercellular adhesion molecule-1 (ICAM-1) associates with 24-hour ambulatory blood pressure variability in type 2 diabetes and controls

BACKGROUND AND AIM

Endothelial dysfunction is a common feature in hypertension and type 2 diabetes. Whether blood pressure (BP) variability is influencing serum intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) remains to be clarified. We aimed to assess the association between the circulating adhesion molecules and ambulatory blood pressure variability in patients with type 2 diabetes and controls.

PATIENTS AND METHODS

The study included data from type 2 diabetes with controlled BP (n = 55), type 2 diabetes with uncontrolled BP (n = 55) and control subjects (n = 28). ICAM-1 and VCAM-1 were measured with specific enzyme-linked immunosorbent assay method. BP variability was assessed using standard deviation of mean systolic and diastolic BP evaluated during 24-hour ambulatory BP monitoring.

RESULTS

The uncontrolled BP type 2 diabetes group had significantly higher serum ICAM-1 and VCAM-1 levels compared to controlled BP type 2 diabetes and control groups. In linear regression analysis, after adjustment, higher ICAM-1 was consistently associated with higher daytime and 24-hour diastolic BP variability, and daytime systolic BP variability in the study population. VCAM-1 was associated only with daytime systolic BP variability.

CONCLUSIONS

Our study evaluating the association of serum ICAM-1 and VCAM-1 with 24-hour ambulatory BP variability in patients with type 2 diabetes and controls might offer better understanding of the mechanisms generating endothelial dysfunction. Elevated 24-hour ambulatory BP variability might induce endothelial activation by increasing circulating adhesion molecules levels.

Novel ABCA1 peptide agonists with antidiabetic action

Previously, apoE-derived ABCA1 agonist peptides have been shown to possess anti-atherosclerotic and possibly antidiabetic properties. Here we assessed the in vitro and in vivo actions of a second generation of ABCA1 peptide agonists, CS6253 and T6991-2, on glucose homeostasis. The results show that these two peptides improve glucose tolerance in a prediabetic diet-induced obesity mouse model by enhancing insulin secretion. It was further demonstrated that T6991-2 also improved glucose tolerance in leptin-deficient (ob/ob) mice. CS6253 increased insulin secretion both under basal conditions and in response to high glucose stimulation in pancreatic INS-1 β-cells rendered leptin receptor deficient with specific siRNA. Additional in vitro cell studies suggest that the CS6253 agonist attenuates hepatic gluconeogenesis and glucose transport. It also potentiates insulin-stimulated glucose uptake and utilization. These observed anti-diabetic actions suggest additional benefits of the CS6253 and T6991-2 ABCA1 peptide agonists for cardiovascular disease beyond their direct anti-atherosclerosis properties previously described.

Is Atorvastatin Associated with New Onset Diabetes or Deterioration of Glycemic Control? Systematic Review Using Data from 1.9 Million Patients

BACKGROUND

Current evidence indicates that statins increase the risk of new onset diabetes mellitus (NOD) and also deteriorate the glycemic control in patients with known diabetes mellitus (DM) after high-dose statin therapy.

AIMS

The aim of this review was to explore the effect of atorvastatin in causing NOD or deteriorating glycemic control in patients with DM.

METHODS

Two independent reviewers conducted the literature search, through PubMed database searching for articles published in English until April 2015, and only primary studies were included.

RESULTS

Of the 919 articles identified in our original search, 33 met the criteria for this review encompassing 1,951,113 participants. Twenty articles examined dysregulation of DM due to atorvastatin. Half of them showed that there was no significant change in glycemic control in patients treated with atorvastatin. Other studies showed that fasting plasma glucose and HbA1c levels were increased by atorvastatin. Thirteen articles examined if atorvastatin causes NOD. The majority of these articles showed that patients who used atorvastatin had a higher dose-dependent risk of developing NOD.

CONCLUSION

This systematic review suggests that there is an association between atorvastatin treatment and NOD. Moreover, it showed that atorvastatin in high dose causes worsening of the glycemic control in patients with DM.

Performance of Cardiovascular Disease Risk Scores in People Diagnosed With Type 2 Diabetes: External Validation Using Data From the National Scottish Diabetes Register

OBJECTIVE

To evaluate the performance of five cardiovascular disease (CVD) risk scores developed in diabetes populations and compare their performance to QRISK2.

RESEARCH DESIGN AND METHODS

A cohort of people diagnosed with type 2 diabetes between 2004 and 2016 was identified from the Scottish national diabetes register. CVD events were identified using linked hospital and death records. Five-year risk of CVD was estimated using each of QRISK2, ADVANCE (Action in Diabetes and Vascular disease: preterAx and diamicroN-MR Controlled Evaluation), Cardiovascular Health Study (CHS), New Zealand Diabetes Cohort Study (NZ DCS), Fremantle Diabetes Study, and Swedish National Diabetes Register (NDR) risk scores. Discrimination and calibration were assessed using the Harrell C statistic and calibration plots, respectively.

RESULTS

The external validation cohort consisted of 181,399 people with type 2 diabetes and no history of CVD. There were 14,081 incident CVD events within 5 years of follow-up. The 5-year observed risk of CVD was 9.7% (95% CI 9.6, 9.9). C statistics varied between 0.66 and 0.67 for all risk scores. QRISK2 overestimated risk, classifying 87% to be at high risk for developing CVD within 5 years; ADVANCE underestimated risk, and the Swedish NDR risk score calibrated well to observed risk.

CONCLUSIONS

None of the risk scores performed well among people with newly diagnosed type 2 diabetes. Using these risk scores to predict 5-year CVD risk in this population may not be appropriate.

Prevention of Cardiovascular Disease

Cardiovascular disease remains the leading cause of death in the United States and worldwide. Prevention of cardiovascular disease is an achievable goal. A rigorous 2010 analysis by the World Health Organization suggests that reducing risk factors in young adults and maintaining an optimum risk profile through age 50 could prevent 90% of atherosclerotic cardiovascular disease events. Misinformation and poor implementation of proven preventive strategies, misplaced fears of medications, or incorrect understanding of ideal dietary and lifestyle choices all contribute to poor risk profiles. Every patient deserves an individualized prescription for cardiovascular disease prevention incorporating strategies to control modifiable cardiovascular risk factors.

Blood pressure and cardiovascular outcomes in patients with diabetes and high cardiovascular risk

Aims

Optimal blood pressure for prevention of cardiovascular (CV) events in patients with Type 2 diabetes mellitus (T2DM) remains uncertain and there is concern for increased risk with low diastolic blood pressure (DBP). This study analysed the association between blood pressure and CV outcomes in high-risk patients with T2DM.

Methods and results

Patients with T2DM and elevated CV risk were enrolled in the Saxagliptin Assessment of Vascular Outcomes Recorded in patients with diabetes mellitus-Thrombolysis in Myocardial Infarction 53 trial. Cardiovascular outcomes were compared in the biomarker subgroup (n = 12 175) after stratification by baseline systolic blood pressure (SBP) and DBP. Adjusted risk was calculated by blood pressure stratum using clinical covariates plus N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity troponin-T (hsTnT). Trends were tested using linear and quadratic models. Adjusted risk of the composite endpoint of CV death, myocardial infarction (MI), or ischaemic stroke showed U-shaped relationships with baseline SBP and DBP (Pquadratic ≤ 0.01) with nadirs at SBP 130-140 or DBP 80-90 mmHg. Diastolic blood pressure <60 mmHg was associated with increased risk of MI (adjusted hazard ratio 2.30; 95% confidence interval 1.50-3.53) relative to DBP 80-90 mmHg. Adjusted odds of hsTnT concentration ≥14 ng/L showed U-shaped relationships with SBP and DBP (Pquadratic ≤ 0.01). The relationships between low DBP, elevated hsTnT, and increased MI remained after exclusion of patients with prior heart failure or NT-proBNP >median, suggesting that the relationship was not due to confounding from diagnosed or undiagnosed heart failure.

Conclusions

In patients with diabetes and elevated CV risk, even after extensive adjustment for underlying disease burden, there was a persistent association for low DBP with subclinical myocardial injury and risk of MI.

Blood pressure targets for hypertension in patients with type 2 diabetes

BACKGROUND

Clinical guidelines vary in determining optimal blood pressure targets in adults with diabetes mellitus.

METHODS

We systematically searched PubMed, EMBASE, Cochrane Library, and clinicaltrials.gov in March 2018; conducted random effects frequentist meta-analyses of direct aggregate data; and appraised the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

RESULTS

From eligible 14 meta-analyses and 95 publications of randomized controlled trials (RCT), only 6 RCTs directly compared lower versus higher blood pressure targets; remaining RCTs aimed at comparative effectiveness of hypotensive drugs. In adults with diabetes mellitus and elevated systolic blood pressure (SBP), direct evidence (2 RCTs) suggests that intensive target SBP <120-140 mmHg decreases the risk of diabetes-related mortality [relative risk (RR) =0.68; 95% confidence interval (CI), 0.50-0.92], fatal (RR =0.41; 95% CI, 0.20-0.84) or nonfatal stroke (RR =0.60; 95% CI, 0.43-0.83), prevalence of left ventricular hypertrophy and electrocardiogram (ECG) abnormalities, macroalbuminuria, and non-spine bone fractures, with no differences in all-cause or cardiovascular mortality or falls. In adults with diabetes mellitus and elevated diastolic blood pressure (DBP) ≥90 mmHg, direct evidence (2 RCTs) suggests that intensive DBP target ≤80 versus 80-90 mmHg decreases the risk of major cardiovascular events. Published meta-analyses of aggregate data suggested a significant association between lower baseline and attained blood pressure and increased cardiovascular mortality.

CONCLUSIONS

We concluded that in adults with diabetes mellitus and arterial hypertension, in order to reduce the risk of stroke, clinicians should target blood pressure at 120-130/80 mmHg, with close monitoring for all drug-related harms.

Legacy benefits of blood glucose, blood pressure and lipid control in individuals with diabetes and cardiovascular disease: Time to overcome multifactorial therapeutic inertia?

Cardiovascular disease is a major cause of morbidity and mortality globally and the largest contributor to healthcare costs. There is good evidence that management of risk factors such as blood pressure, dyslipidaemia and glucose can lead to improved microvascular and macrovascular complications in individuals with type 2 diabetes mellitus. Legacy effect is a phenomenon used to describe the prolonged benefits of glucose, blood pressure or lipid control in individuals with cardiovascular disease, diabetes or in primary prevention of cardiovascular disease by early risk factor control. There is now also good quality evidence on the legacy benefits of multifactorial risk factor interventions on renal, cardiovascular and mortality outcomes. Despite this robust evidence, therapeutic inertia is widespread in the management of these risk factors in clinical practice.

Awareness of Cardiovascular Risk Factors in U.S. Young Adults Aged 18-39 Years

INTRODUCTION

Young adults with hyperlipidemia, hypertension, and diabetes are at increased risk of developing heart disease later in life. Despite emphasis on early screening, little is known about awareness of these risk factors in young adulthood.

METHODS

Data from the nationally representative cross-sectional National Health and Nutrition Examination Survey 2011-2014 were analyzed in 2017 to estimate the prevalence of self-reported awareness of hypercholesterolemia, hypertension, and diabetes in U.S. young adults aged 18-39 years (n=11,083). Prevalence estimates were weighted to population estimates using survey procedures, and predictors of awareness were identified using weighted logistic regression.

RESULTS

Among U.S. young adults, the prevalence of hypercholesterolemia, hypertension, and diabetes was 8.8% (SE=0.4%); 7.3% (SE=0.3%); and 2.6% (SE=0.2%), respectively. The prevalence of borderline high cholesterol, blood pressure, and blood glucose were substantially higher (21.6% [SE= 0.6%]; 26.9% [SE=0.7%]; and 18.9% [SE=0.6%], respectively). Awareness was low for hypercholesterolemia (56.9% [SE=2.4%]) and moderate for hypertension and diabetes (62.7% [SE=2.4%] and 70.0% [SE=2.7%]); <25% of young adults with borderline levels of these risk factors were aware of their risk. Correlates of risk factor awareness included older age, insurance status, family income above the poverty line, U.S. origin, having a usual source of health care, and the presence of comorbid conditions.

CONCLUSIONS

Despite the high prevalence of cardiovascular risk factors in U.S. young adults, awareness remains less than ideal. Interventions that target access may increase awareness and facilitate achieving treatment goals in young adults.

Geographic assessment of access to health care in patients with cardiovascular disease in South Africa

Background

Noncommunicable diseases (NCDs) including cardiovascular diseases (CVDs), diabetes, cancer and chronic lung disease are increasingly emerging as major contributors to morbidity and mortality in developing countries. For example, in South Africa, 195 people died per day between 1997 and 2004 from CVDs related causes. Access to efficient and effective health facility and care is an important contributing factor to overall population health and addressing prognosis, care and management CVD disease burden. This study aimed to spatially evaluate geographic health care access of people diagnosed with CVD to health facilities and to evaluate the density of the existing health facility network in South Africa.

Methods

Data was obtained from the National Income Dynamics Study (NIDS) conducted in 4 waves (phases) between 2008 and 2014. The participants who responded as having heart problems that were diagnosed by a health practitioner were extracted for use in this study. Network analyst in ArcGIS ® was used to generate a least-cost path, which refers to the best path that one can travel. The residential locations of participants diagnosed with heart problems were put into the network analysis model as origins and the location of health facilities were destinations. District averages were used to protect the identity of studied participants.

Results

There were a total of 51, 42, 43, 43 health districts out the 52 that had recorded subjects with a heart condition in the 2008, 2010–2011, 2012 and 2014–2015 waves, respectively. The mean distance from a case household to a health facility per wave was 2, 2.3, 2.1 and 2.1 km in 2008, 2010–2011 and 2014–2015 respectively. The maximum individual distances travelled per wave were 41.4 km, 40,5 km, 44,2 km and 39.6 km for the 2008, 2010–2011, 2012 and 2014–2015 waves respectively. For district level analysis, participants with CVD residing in the districts found to be among the poorest in the country travelled the longest distances. These were located in the provinces of Limpopo and KwaZulu Natal. It was also found that districts with large proportions of their population living in rural settings had among the lowest densities of health facilities. Significant percentages of study participants were exposed to numerous CVD risk factors, the commonly reported one being high blood pressure. A lack of regular exercise was also commonly reported in each of the waves.

Conclusion

A lack of accessible healthcare in already impoverished municipalities could result in an increase lack of timely diagnosis, CVD case management. This could result in increased CVD-related morbidity and mortality. GIS methods have the potential to assist national health programs to develop policies that target issues such as areas or populations being underserved by health facilities and populations that must travel long distances to receive healthcare. These policies will be key in preventing and controlling the emerging CVD burden through an accessible primary healthcare system for early detection and case management.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3006-0) contains supplementary material, which is available to authorized users.

Long term (4 years) improved insulin sensitivity following islet cell transplant in type 1 diabetes

BACKGROUND

Impaired insulin sensitivity (IS) predicts complications and mortality in type 1 diabetes (T1D). Insulin sensitivity improves shortly after islet cell transplant for T1D, yet long-term changes in IS and associated factors such as patient characteristics, transplant factors, clinical management, and IS-related biomarkers are unknown.

METHODS

Up to 9 years (mean 4) of longitudinal data were available on 22 adults (18 female) with T1D who received 1 to 3 transplants in Phase 1/2 or 3 clinical trials (2004-2014). Metabolic testing posttransplant estimated IS by the Homeostasis Model Assessment for Insulin Resistance (HOMA-IR; 111 observations) and the Simple Index of Insulin Sensitivity (SIis ; 95 observations).

RESULTS

Simple Index of Insulin Sensitivity significantly increased the first year posttransplant (P = .02), then stabilized (P = .39); HOMA-IR remained stable posttransplant (P = .92). Adjusting for age and BMI, higher SIis was associated with lower HbA1c following transplant (P = .03). Greater IS as measured by lower HOMA-IR and higher SIis was associated with lower fasting C-peptide (both P ≤ .04) and also with higher exenatide dose (both P ≤ .01). More islets transplanted were associated with higher SIis (P < .0001). Lower leptin at transplant predicted lower HOMA-IR and higher SIis after transplant, and lower bone marker receptor activator of nuclear factor kappa-B ligand predicted lower HOMA-IR (all P ≤ .01).

CONCLUSIONS

Insulin sensitivity measured by SIis was improved several years following transplant, while IS measured by HOMA-IR did not worsen. Higher exenatide dose, more islets transplanted, and diet and exercise (lowering leptin and receptor activator of nuclear factor kappa-B ligand) may improve IS, which may enhance glycaemic control and lower metabolic demand on transplanted islets. Long-term clamp studies are needed to confirm these results.

Diabetes and lipid metabolism

The authors review the association between diabetes mellitus (DM) and aberrations of lipid metabolism related to DM, diabetic dyslipidemia (DD). DM is considered as a major health burden worldwide and one of the most important modifiable cardiovascular disease (CVD) risk factors. This applies to both the developed and the developing countries, especially the latter. While patients with type 1 DM, 10% of all DM cases, usually do not have dyslipidemia, DD is frequent among patients with type 2 DM (T2DM) (prevalence > 75%) and is mainly a mixed dyslipidemia [increase in triglycerides (TGs), low high-density lipoprotein cholesterol (HDL-C), and small-dense (atherogenic), low-density lipoprotein cholesterol (LDL-C) particles]. The components of DD, which is characterized by quantitative (mentioned above), qualitative, and kinetic abnormalities all contributing to CVD risk, are mostly related to insulin resistance. Statins, ezetimibe, and PCSK9 inhibitors can be used in monotherapy or consecutively in combinations if needed. Statins compose the main drug. For the residual CVD risk after statin treatment, the use of statin-fibrate combinations is indicated only in patients with mixed dyslipidemia. In conclusion, DD is a major health problem worldwide. It is a significant CVD risk factor and should be treated according to current guidelines. The means today exist to normalize all quantitative, qualitative, and kinetic aberrations of DD, thereby reducing CVD risk.

Effects of Pravastatin on Type 1 Diabetic Rat Heart with or without Blood Glycemic Control

Although statins have been suggested to attenuate the progression of diabetic cardiomyopathy, its effect without glycemic control remains unclear. Therefore, we evaluated the effect of pravastatin on diabetic rat hearts according to glycemic control. Rats were randomly divided into five groups: control (C), diabetes (D), diabetes with insulin (I), diabetes with pravastatin (P), and diabetes with insulin and pravastatin (IP). Eight weeks after allocated treatments, the heart was extracted and analyzed following echocardiography. Cardiac fibrosis was measured using Masson's trichrome stain. Cardiac expression of collagen I/III, matrix metalloproteinase (MMP)-2, MMP-9, and angiotensin-converting enzyme (ACE)/ACE2 was evaluated by immunohistochemistry and/or Western blot. Enzyme-linked immunosorbent assay was used for measuring reactive oxygen species (ROS). Diabetic groups without glycemic control (D and P) showed significantly impaired diastolic function and increased levels of cardiac fibrosis, collagen I/III, MMP-2, MMP-9, and ROS production. However, there were little significant differences in the outcomes among the control and two glucose-controlled diabetic groups (I and IP). Groups C and IP showed more preserved ACE2 and lower ACE expressions than the other groups did (D, I, and P). Our study suggested glycemic control would be more important to attenuate the progression of diabetic cardiomyopathy than pravastatin medication.

Aggressive systolic blood pressure control in older subjects: benefits and risks

Systolic hypertension, especially isolated systolic hypertension (ISH) is very common in older subjects aged ≥ 65 years and is a major risk factor for cardiovascular disease (CVD), strokes, heart failure (HF) and chronic kidney disease (CKD). It is also, directly and linearly related with these complications irrespective of sex, or ethnicity, but it is worse with the advancement of age. Effective control of systolic blood pressure (SBP), is associated with significant reduction in the incidence of these complications. Currently, there is a debate about the optimal SBP control in view of the Systolic Blood Pressure Intervention Trial (SPRINT) showing beneficial cardiovascular (CV) effects of intensive SBP of < 120 mmHg in older patients. Also, the recently released blood pressure (BP) guidelines by the American College of Cardiology, the American Heart Association and the American Society of Hypertension (ACC/AHA/ASH) recommend a SBP reduction of < 130 mmHg. These SBP treatment recommendations are in contrast with the current (JNC VIII) committee of BP treatment guidelines, which recommend a SBP reduction < 150 mmHg for the same age of patients. All these different recommendations have created a debate regarding the optimal treatment targets for the systolic hypertension of the elderly patients. To gain more information a focused Medline search was conducted from 2010 to 2017 using the terms, systolic blood pressure, aggressive control, older subjects, treatment guidelines, and 37 pertinent papers were retrieved. The findings from these studies suggest a SBP reduction of < 140 mm Hg for persons aged ≥ 60 years, with an attempt for SBP reduction to ≤130 mm Hg in healthier subjects and hose with CVD, DM, and CKD. Care should be taken not to further reduce the SBP in older subjects if their DBP is ≤60 mmHg for the fear of J-curve effect.

Diabetes Care in Iran: Where We Stand and Where We Are Headed

BACKGROUND

The prevalence of diabetes has steadily increased in Iran from the time of the first published nationally representative survey in 1999 and despite efforts and strategies to reduce disease burden.

OBJECTIVES

The aim of the present review was to describe the current status of diabetes care in Iran.

METHODS

A selective review of the relevant literature, focusing on properly conducted studies, describing past and present diabetes care strategies, policies, and outcomes in Iran was performed.

FINDINGS

The quality of diabetes care has gradually improved as suggested by a reduction in the proportion of undiagnosed patients and an increase in affordability of diabetes medications. The National Program for Prevention and Control of Diabetes has proven successful at identifying high-risk individuals, particularly in rural and remote-access areas. Unfortunately, the rising tide of diabetes is outpacing these efforts by a considerable margin.

CONCLUSIONS

Substantial opportunities and challenges in the areas of prevention, diagnosis, and management of diabetes exist in Iran that need to be addressed to further improve the quality of care and clinical outcomes.

Blood Pressure-Lowering Targets in Patients With Diabetes Mellitus

Diabetes is a highly prevalent medical condition that commonly coexists with hypertension. The presence of diabetes and hypertension significantly increases the risk of adverse cardiovascular events. Although compelling evidence exists from randomized controlled trials demonstrating that blood pressure (BP) reduction effectively prevents cardiovascular complications, optimal BP targets remain uncertain and continue to be the subject of ongoing controversy. Until recently, most major clinical practice guidelines recommended a BP target of < 130/80 mm Hg, but some expert panels have raised their recommended treatment targets in recent years. The primary benefit of more intensive BP reduction appears to be prevention of stroke, but this is balanced against an increase in treatment burden, side effects, and cost. The purpose of this review is to summarize the global body of evidence evaluating BP targets as well as to compare the recommendations from different clinical practice guidelines, which inform the treatment of patients with hypertension and diabetes.

Contemporary Primary Prevention Aspirin Use by Cardiovascular Disease Risk: Impact of US Preventive Services Task Force Recommendations, 2007-2015: A Serial, Cross-sectional Study

BACKGROUND

No previous study has evaluated the impact of past US Preventive Services Task Force statements on primary prevention (PP) aspirin use in a primary care setting. The aim of this study was to evaluate temporal changes in PP aspirin use in a primary care population, stratifying patients by their 10-year global cardiovascular disease risk, in response to the 2009 statement.

METHODS AND RESULTS

This study estimated biannual aspirin use prevalence using electronic health record data from primary care clinics within the Fairview Health System (Minnesota) from 2007 to 2015. A total of 94 270 patient encounters had complete data to estimate a 10-year cardiovascular disease risk score using the 2013 American College of Cardiology/American Heart Association global risk estimator. Patients were stratified into low- (<10%), intermediate- (10-20%), and high- (≥20%) risk groups. Over the 9-year period, PP aspirin use averaged 43%. When stratified by low, intermediate and high risk, average PP aspirin use was 41%, 63%, and 73%, respectively. Average PP aspirin use decreased after the publication of the 2009 US Preventive Services Task Force recommendation statement: from 45% to 40% in the low-risk group; from 66% to 62% in the intermediate-risk group; and from 76% to 73% in the high-risk group, before and after the guideline.

CONCLUSIONS

Publication of the 2009 US Preventive Services Task Force recommendation was not associated with an increase in aspirin use. High risk PP patients utilized aspirin at high rates. Patients at intermediate risk were less intensively treated, and patients at low risk used aspirin at relatively high rates. These data may inform future aspirin guideline dissemination.