Effect of sodium-glucose co-transporter 2 inhibitors on left ventricular mass and left atrial volume indices assessed either by cardiovascular magnetic resonance or transthoracic echocardiography

Background

Sodium-glucose co-transporter 2 (SGLT-2) inhibitors are a novel class of antidiabetic regimens linked with a significant reduction in the risk for surrogate cardiovascular and renal outcomes. Specific patient populations, for example subjects with heart failure with reduced ejection fraction (HFrEF), also benefit from this drug class, regardless the presence of T2DM. Left ventricular (LV) hypertrophy is a strong, independent predictor of cardiovascular morbidity and mortality; left atrial volume index (LAVI), an indicator of severity of LV diastolic dysfunction and filling properties, has been shown to predict “hard” cardiovascular outcomes among patients with T2DM, while it might predict the recovery of left ventricular ejection fraction in patients with HFrEF.

Purpose

We sought to determine the effect of SGLT-2 inhibitors on the above indices, in order to evaluate additional cardioprotective mechanisms of this drug class.

Methods

We searched 2 major electronic databases (PubMed and Cochrane/CENTRAL) along with grey literature sources for parallel-group RCTs investigating the effect of SGLT-2 inhibitors compared to placebo or active control on LV mass, LV mass index (LVMI) and LAVI, evaluated either by TTE or CMR, on adult patients regardless the presence of T2DM or HF.

Results

After screening the potentially eligible records, 9 studies were included in our analysis with a total of 843 patients. Treatment with SGLT-2 inhibitors compared to placebo or active control leads to a statistically significant decrease in LV mass by 6.01 g (95% CI −11.33 to −0.69, I2=76%) (Figure 1a). A significant decrease in LVMI by 2.61 g/m2 was observed (MD=−2.61, 95% CI −4.94 to −0.29, I2=65%) (Figure 1b). Of note, the effect on LAVI was marginally non-significant (MD=−1.51 ml/m2, 95% CI −3.05 to 0.03, I2=0%) (Figure 1c). Subgroup analysis for patients with HFrEF demonstrated a non-significant reduction in LV mass (MD=−11.72 g, 95% CI −30.61 to 7.16, I2=90%) and in LVMI (MD=−6.28 g/m2, 95% CI −30.61 to 0.25, I2=80%) (Figure 2a and 2b).

Conclusions

SGLT-2 inhibitors demonstrate a clear benefit on LV mass and LVMI, regardless of diabetes status, while a marginally non-significant effect is observed on LAVI. These results provide further insights into the cardioprotective mechanisms mediated by this drug class, besides those already established.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Risk of death with sodium-glucose co-transporter-2 inhibitors across the hallmark cardiovascular and renal outcome trials: an updated meta-analysis

Background

Patients with type 2 diabetes mellitus (T2DM) experience a 15% increase in the risk for death compared to the general population, with age less than 55 years, insufficient glycemic control and albuminuria representing the major risk factors for all-cause and cardiovascular mortality. Despite progression in diagnosis and treatment, mortality remains elevated among affected individuals. Sodium-glucose co-transporter 2 (SGLT-2) inhibitors are considered as the optimal treatment option for patients with T2DM and concomitant cardiovascular or renal disease, while these regimens demonstrated a clear benefit in all-cause and cardiovascular mortality compared to placebo.

Purpose

As we recently welcomed the publication of large-scale randomized controlled trials (RCTs) with SGLT-2 inhibitors addressing surrogate, hard endpoints, we sought to perform an updated meta-analysis, investigating the effect of SGLT-2 inhibitors on all-cause, cardiovascular and renal death among the high- or very-high risk patients enrolled in those trials.

Methods

We pooled data from the relevant, recent hallmark RCTs; 10 trials were included in our analysis encompassing a total of 71,533 enrolled participants, assigned either to SGLT-2 inhibitor treatment or placebo. We set cardiovascular death as the primary efficacy outcome, while we assessed all-cause death and renal death as secondary efficacy outcomes.

Results

Treatment with SGLT-2 inhibitors resulted in a significant decrease in the risk of cardiovascular death, equal to 14% (RR = 0.86, 95% CI; 0.80 to 0.93, I2=22%). Only canagliflozin produced a significant result, while dapagliflozin led to a marginally non-significant reduction in cardiovascular mortality (Figure 1). Notably, SGLT-2 inhibitors led to a significant decrease in the risk for all-cause death, equal to 14% (RR=0.86, 95% CI; 0.81 to 0.92, I2=34%) the result was significant only for canagliflozin and dapagliflozin, while none of the rest SGLT-2 inhibitors resulted in a significant decrease in the risk for all-cause death (Figure 1). SGLT-2 inhibitors also produced a non-significant decrease in the risk for renal death (RR=0.36, 95% CI; 0.12 to 1.14, I2=0%). Neither canagliflozin nor dapagliflozin had a significant impact on risk reduction for renal death, while no cases of renal death were reported in VERTIS CV trial. No subgroup differences were identified for any of the three comparisons (Figure 2).

Conclusions

Antidiabetic treatment with SGLT-2 inhibitors provides a clear benefit in terms of cardiovascular and all-cause mortality for the very high-risk patients enrolled in the cardiovascular and renal outcome trials. Canagliflozin seems to be associated with the greatest impact on risk reduction for all-cause and cardiovascular death, followed by dapagliflozin.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

The effect of glucagon-like peptide-1 receptor agonists on 24-hour ambulatory blood pressure: a meta-analysis

Background

Hypertension augments overall cardiovascular risk in patients with type 2 diabetes mellitus (T2DM), constituting a major additional burden for diabetic subjects; however, control rates of hypertension remain suboptimal. Glucagon-like peptide-1 receptor agonists (GLP-1RAs), second-line treatment option for diabetics, have revolutionized the field of T2DM therapeutic management due to their pleiotropic effects, while they seem to hold multiple cardiovascular benefits. A few randomized controlled trials (RCTs) evaluated the effect of GLP-1RAs on ambulatory blood pressure (ABP). Ambulatory blood pressure monitoring (ABPM) provides a better method to predict long-term cardiovascular outcomes than office blood pressure.

Purpose

We sought to determine the effect of GLP-1RAs on ABPM, pooling data from relevant randomized controlled trials (RCTs).

Methods

We searched 2 major electronic databases, namely PubMed and Cochrane/CENTRAL, along with grey literature sources, for RCTs assessing the effect of various GLP-1RAs on ABP in patients with T2DM.

Results

After screening of the potentially eligible records, 7 RCTs were finally included in our meta-analysis (4 parallel-group and 3 cross-over). GLP-1RA treatment compared to placebo or active control resulted in a nonsignificant decrease in 24-h systolic blood pressure (MD=−1.57 mm Hg, 95% CI: −4.12 to 0.98, I2=63%) (Figure 1) and in 24-h diastolic blood pressure (MD=1.28 mmHg, 95% CI: −0.31 to 2.87, I2=49%) (Figure 2). No subgroup differences between the various GLP-1RAs were identified. More specifically, it was demonstrated that liraglutide once daily produced a non-significant decrease in 24-h systolic blood pressure (MD=−1.43 mm Hg, 95% CI: −5.24 to 2.38, I2=72%) and a non-significant increase in 24-h diastolic blood pressure (MD=1.47 mm Hg, 95% CI: −1.12 to 4.05, I2=61%), while data concerning the effect of once weekly dulaglutide and twice daily exenatide on ABPM were pooled from one RCT respectively (Figures 1, 2).

Conclusions

Antidiabetic treatment with GLP-1RAs does not influence either systolic or diastolic ABP in patients with T2DM.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Meta-analysis assessing cardiovascular outcomes with febuxostat versus allopurinol for patients with gout

Background

Gout, the most common inflammatory arthritis in the USA, represents an established risk factor for cardiovascular disease and coronary artery disease mortality. In addition, patients with gout experience an increased risk for non-fatal myocardial infarction, while they might also feature increased risk for stroke. Recent real-world data also highlight the association between gout and atrial fibrillation, which inevitably augments cardiovascular burden. Allopurinol, a xanthine oxidase inhibitor, remains the uric acid-lowering treatment option of first choice, while febuxostat is prescribed, when allopurinol is contraindicated or not tolerated. Unfortunately, medication adherence among gout patients is poor, associated with age and related co-morbidities.

Purpose

We sought to determine the comparative efficacy of febuxostat versus allopurinol across surrogate cardiovascular outcomes of interest, by pooling data from the 2 dedicated cardiovascular outcome trials available so far. The motive for this analysis was the U.S. Food and Drug Administration (FDA) warning raised after the publication of the CARES trial, regarding the increased risk for cardiovascular and all-cause death with febuxostat compared to allopurinol.

Methods

We pooled data from the 2 dedicated cardiovascular outcome trials (CARES and FAST) and we assessed the following cardiovascular outcomes of interest: cardiovascular death, all-cause death, non-fatal myocardial infarction (MI), non-fatal stroke, fatal MI, fatal stroke, transient ischemic attack, hospitalization for heart failure, coronary revascularization, cerebrovascular revascularization and atrial fibrillation. Risk of bias was low across the included studies.

Results

Our analysis in a total of 12,318 patients with gout showed that febuxostat compared to allopurinol treatment does not confer significant risk reduction for any of the assessed, prespecified surrogate outcomes in a study population with significant cardiovascular co-morbidities (Figure 1). One third of patients enrolled in the FAST trial and 40% of the patients enrolled in the CARES trial had pre-existing cardiovascular disease, as depicted in Figure 2. Heterogeneity was low for the vast majority of the assessed outcomes, except for cardiovascular and all-cause death and fatal MI.

Conclusions

There is no significant difference across surrogate cardiovascular outcomes of interest between febuxostat and allopurinol in patients with gout and cardiovascular co-morbidities. Febuxostat seems to be a safe treatment alternative to allopurinol, despite initial concerns in terms of its cardiovascular safety.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Meta-analysis of cardiovascular outcome trials assessing the cardiovascular efficacy and safety of dipeptidyl peptidase-4 inhibitors in patients with type 2 diabetes mellitus

Background

Type 2 diabetes mellitus (T2DM) represents an independent risk factor for the development of cardiovascular disease, which accounts for half of deaths among the affected patients. Patients with T2DM experience higher incidence of vascular interventions compared to high-risk patients without T2DM or cardiovascular disease at baseline, underscoring the necessity for targeted therapeutic interventions. Dipeptidyl peptidase-4 (DPP-4) inhibitors constitute a safe treatment option with fair glycemic efficacy in T2DM whose cardiovascular efficacy has been doubted over recent years. A series of randomized controlled trials (RCTs) addressing cardiovascular outcomes with DPP-4 inhibitors have been recently published, while previous meta-analyses failed to show any cardiovascular benefit with their use in patients with T2DM.

Purpose

The purpose of our analysis was to report the impact of antidiabetic treatment with DPP-4 inhibitors on different cardiovascular efficacy outcomes.

Methods

We searched PubMed for all published RCTs assessing cardiovascular outcomes after antidiabetic treatment with DPP-4 inhibitors. We extracted data related to the following efficacy outcomes: fatal and non-fatal myocardial infarction, fatal and non-fatal stroke, hospitalization for heart failure, hospitalization for unstable angina, hospitalization for coronary revascularization and cardiovascular death.

Results

We pooled data from a total of 6 trials in a total of 52,520 patients. Antidiabetic treatment with DPP-4 inhibitors did not significantly affect any of the prespecified cardiovascular efficacy outcomes. More specifically, DPP-4 inhibitors compared to control led to a non-significant increase in the risk for fatal and non-fatal myocardial infarction (RR=1.02, 95% CI: 0.94–1.11, I2=0%), hospitalization for heart failure (RR=1.09, 95% CI: 0.92–1.29, I2=65%) and cardiovascular death (RR=1.02, 95% CI: 0.93–1.11, I2=0%), as shown in figures 1a, 1c and 1f. In addition, DPP-4 inhibitors produced a non-significant decrease in the risk for fatal and non-fatal stroke (RR=0.96, 95% CI: 0.85–1.08, I2=0%) and coronary revascularization (RR=0.99, 95% CI: 0.90–1.09, I2=0%), as depicted in figures 1b and 1e. Finally, DPP-4 inhibitors demonstrated a neutral effect on the risk for hospitalization due to unstable angina (RR=1.00, 95% CI: 0.85–1.18, I2=0%), as shown in figure 1d.

Conclusions

Antidiabetic treatment with DPP-4 inhibitors does not seem to confer any significant cardiovascular benefit for patients with T2DM.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Risk of developing metabolic syndrome after gestational diabetes mellitus - a systematic review and meta-analysis

PURPOSE

A systematic review and meta-analysis were conducted to quantitatively synthesize the current evidence regarding the risk of developing metabolic syndrome (MetS) in women with a personal history of gestational diabetes mellitus (GDM), without pre-existing diabetes, compared with those without a history of GDM.

METHODS

Four electronic databases [MEDLINE (via PubMed), Scopus, Cochrane Library, PROSPERO] were searched for relevant literature until July 29th 2020. Cochran's Q test was applied for the assessment of heterogeneity. The random-effects model was applied by calculating the odds ratio (OR) and 95% confidence interval (CI) for each study. Publication bias was estimated with Egger's linear regression test.

RESULTS

The results from 23 studies (10,230 pregnant women; 5169 cases, 5061 controls), indicated that women with a history of GDM had a higher risk of developing MetS compared with those without such a history (OR 3.45; 95% CI 2.80-4.25, p < 0.0001). This risk remained higher, independently of maternal age and ethnicity (although the risk was not as high in Asians; OR 2.11; 95% CI 1.27-3.52). The risk of developing MetS was even higher in studies where women with GDM had increased body mass index (BMI) compared with the controls (OR 4.14; 95% CI 3.18-5.38).

CONCLUSIONS

The risk for developing MetS following delivery is higher in women with a history of GDM compared with women without such a history. Timely recognition and appropriate intervention are critical to halt progression to MetS and its associated morbidity.