Comprehensive Management of Cardiovascular Risk Factors for Adults With Type 2 Diabetes: A Scientific Statement From the American Heart Association

Encouraging the prescribing of SGLT2i and GLP-1RA medications to reduce cardiovascular and renal risk in patients with type 2 diabetes: Rationale and design of a randomized controlled trial

BACKGROUND

Sodium-glucose cotransporter-2 inhibitor (SGLT2i) and glucagon-like peptide-1 receptor agonist (GLP-1RA) medications reduce the risk of cardiovascular and renal complications among patients with type 2 diabetes but are underutilized. There are numerous barriers to prescribing including insurance coverage, medication availability, comfort with prescribing, and diffusion of responsibility of prescribing across specialists. Methods are needed to support prescribing in primary care.

METHODS

This was a pragmatic, randomized controlled trial testing interventions to increase appropriate SGLT2i and GLP-1RA prescribing. Primary care providers (PCPs) were randomized to 1 of 3 arms: (1) peer champion support (2) peer champion support and information on insurance coverage, or (3) usual care (no intervention). PCPs in both intervention arms received a welcome email and electronic health record (EHR) messages before visits with patients who had sub-optimally controlled diabetes and an indication for 1 of these medications. In the peer champion support only arm the EHR messages included prescribing tips. In the arm that provided peer champion support and information on insurance coverage, EHR messages contained information on medications in each class that would be most affordable for the patient based on their insurance coverage and offered support for prior authorizations if needed. The primary outcome was prescriptions for an SGLT2i or GLP-1RA medication, beginning 3 days before the targeted visit and continuing through 28 days, in each intervention arm compared to control.

RESULTS

191 primary care providers were included in the study. 1,389 patients had at least 1 visit scheduled with their PCP during the 6-month intervention period; of these 1,079 patients attended at least 1 of these visits and will be included in the primary outcome analysis. 66 providers (484 patients) received the peer champion intervention alone, 63 providers (446 patients) received the peer champion intervention and information on insurance coverage, and 62 providers (459 patients) received usual care. On average, patients were 66 years old, 46% were female, 61% were white, and 16% were Hispanic. There were small differences between groups with regards to patient sex, race, ethnicity, partner status, and percent with Medicare insurance.

CONCLUSIONS

These medication classes have the potential to reduce cardiovascular and kidney disease among patients with type 2 diabetes. This study tests interventions to support prescribing of these medications in primary care.

CLINICAL TRIAL

Clinicaltrials.gov. Unique identifier: (NCT, Registered: NCT05463705).

Reminders embedded in PCI reports to optimize discharge diabetes mellitus care (REMIND-DM): Rationale, design, and baseline characteristics

BACKGROUND

Despite the robust clinical evidence base supporting their role for high-risk patients with type 2 diabetes (T2DM) and concomitant cardiovascular disease, prescription of sodium-glucose co-transporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1RA) remains suboptimal. Clinical encounters occurring in the period post angiography may present a key opportunity to improve implementation in high-risk patients with T2DM.

METHODS

Reminders EMbedded IN PCI Reports to Optimize Discharge Diabetes Mellitus Care (REMIND-DM) is a pragmatic, prospective, cluster randomized quality improvement study in patients with type 2 diabetes undergoing angiography and was run as a quality improvement initiative. Following a 6 month "baseline period", REMIND-DM randomized 23 participating percutaneous coronary intervention (PCI) sites (caring for 7,045 patients over the study period) within the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) quality improvement collaborative to either usual care or a quality improvement intervention consisting of a templated PCI report "reminder" of medication eligibility linked to a decision support tool. Sites were followed for a 6 month "evaluation period." The primary outcome is the new prescription of SGLT2 inhibitor or GLP-1RA among eligible patients at discharge after PCI. To examine the effectiveness of the intervention, primary analyses will be conducted using a difference-in-difference design examining changes in new cardioprotective therapy prescription from baseline to the evaluation periods in both arms.

CONCLUSIONS

The REMIND-DM implementation trial has enrolled a large, high-risk population of patients with T2DM and will determine the effectiveness of a low touch QI intervention within BMC2 implemented in the post-PCI period to improve timely prescription of risk lowering therapies in high-risk patients with T2DM.

Cardiovascular risk in newly diagnosed patients with type 2 diabetes mellitus: a nationwide, facility-based, cross-sectional study in Bangladesh

Aims

Evidence on cardiovascular (CV) risk stratification in Bangladeshi patients with type 2 diabetes mellitus (T2DM) who are asymptomatic for cardiovascular disease (CVD) is limited. This study aimed to assess the 10-year CV risk in newly diagnosed patients with T2DM.

Methods

In 2023, a cross-sectional study was carried out at endocrinology clinics in tertiary hospitals throughout Bangladesh, involving newly diagnosed patients with T2DM aged 25 to 84 who had no prior history of CVD and were asymptomatic for the condition. CV risk was assessed and classified using QRISK3.

Results

1617 newly diagnosed patients with T2DM (age 44.92 ± 11.84 years, male 49.5 %) were analyzed. Their median QRISK3 score was 11.0 %, with 46.5 % at low, 25.7 % at moderate, and 27.8 % at high 10-year CV risk, respectively. The QRISK3 score increased with age for both men and women, with men consistently scoring higher than women in every age group. Among the age groups 25-39, 40-64, and 65-84, the percentages of patients with high 10-year CV risk were 3.3 %, 34.0 %, and 94.5 %, respectively. The median relative risk (RR) of CVD was 4.3. RR decreased with age for both sexes, and men had a lower RR than women across all age groups. A sleep duration of 6-9 h was associated with a lower 10-year CV risk.

Conclusions

Many newly diagnosed Bangladeshi patients with T2DM have substantial CV risk. QRISK3 can assist clinicians in predicting 10-year CV risk and choosing appropriate treatments to prevent CVD.

Psychosocial factors and associations with preventive cardiovascular screening among U.S adults: Findings from the National Health Interview Survey, 2023

OBJECTIVE

Structural and COVID-related factors have been linked with the decline in preventive health screenings among adults. However, associations between psychosocial factors and undergoing preventive cardiovascular screening are not fully known. The current study examined associations between psychosocial factors and preventive cardiovascular screening among U.S. adults.

METHODS

We used data from the 2023 National Health Interview Survey (N = 23,428). Data were collected from January to December from adults living in U.S. Preventive cardiovascular (CV) screening (i.e., blood pressure, cholesterol, or blood sugar level) was defined as no screening, and undergoing screening for any CV risk within the past year. Psychosocial factors were defined as discrimination, life satisfaction, and depression. Multivariable logistic regression models examined the associations between psychosocial factors and preventive cardiovascular screening, adjusted for sociodemographic characteristics.

RESULTS

Adults with diagnosis of depression (OR: 1.93, 95 % CI: 1.65-2.25) had higher odds of undergoing screening for any CV risk. Adults who experienced discrimination had lower odds of undergoing screening for cholesterol (OR: 0.77, 95 % CI: 0.71-0.84) and blood sugar level specifically (OR: 0.78, 95 % CI: 0.72-0.85), while life dissatisfaction was associated with lower odds of screening for blood pressure (OR: 0.76, 95 % CI: 0.58-0.99) and blood sugar level specifically (OR: 0.80, 95 % CI: 0.65-0.97).

CONCLUSIONS

Discrimination and life dissatisfaction were associated with decreased odds of undergoing specific preventive cardiovascular screening, and depression is associated with increased odds of undergoing any preventive cardiovascular screening. Equitable health care policies focused on addressing psychosocial factors are needed to increase preventive cardiovascular screening among U.S. adults.

Prevalence of atherosclerotic cardiovascular disease in people with type 2 diabetes in the Gulf Region: Results from the PACT-MEA study

OBJECTIVES

This study aimed to determine the prevalence and risk for atherosclerotic cardiovascular disease (ASCVD) in patients with type 2 diabetes (T2D) in Bahrain, Kuwait, and Qatar. The study will help to inform the country's health systems in identifying opportunities and challenges for optimal management of T2D and ASCVD.

STUDY DESIGN

The study was a sub-analysis within the PACT-MEA study, a noninterventional, cross-sectional, observational study, which included 1062 adults from Bahrain, Kuwait, and Qatar diagnosed with T2D.

METHODS

The presence and the risk of ASCVD were determined from patient medical records. Statistical analyses included prevalence estimates stratified by sex, age and ASCVD type.

RESULTS

Among the three countries included in this study, Bahrain had the highest prevalence at 36.6 %, followed by Qatar and Kuwait at 23.4 % and 19.4 %, respectively. The unweighted prevalence was significantly higher in men and increased with age. Coronary artery disease was the most common type of ASCVD, followed by cerebrovascular and peripheral artery disease. Furthermore, participants in all three countries were classified as having a high or very high ASCVD risk based on the European Society of Cardiology 2021 guidelines.

CONCLUSION

Based on the prevalence in this study, one in five participants had established ASCVD across Bahrain, Kuwait, and Qatar, and all the participants investigated were at high or very high risk. Study results indicate an immediate need to implement policy measures that include preventative strategies on the common risk factors to reduce the high CVD mortality and morbidity in the Gulf Region.

Effects of insulin-induced hypoglycaemia on cardiac function in people with type 1 and type 2 diabetes and people without diabetes

AIMS

Cardiovascular disease is the most common complication and cause of death in people with diabetes. Hypoglycaemia is independently associated with the development of cardiovascular complications, including death. The aim of this study was to assess changes in cardiac function and workload during acute hypoglycaemia in people with and without diabetes and to explore the role of diabetes type, magnitude of the adrenaline response, and other phenotypic traits.

MATERIALS AND METHOD

We enrolled people with type 1 diabetes (n = 24), people with insulin-treated type 2 diabetes (n = 15) and controls without diabetes (n = 24). All participants underwent a hyperinsulinaemic-normoglycaemic-(5.3 ± 0.3 mmol/L)-hypoglycaemic (2.8 ± 0.1 mmol/L)-glucose clamp. Cardiac function was assessed by echocardiography, with left ventricular ejection fraction (LVEF) as the primary endpoint.

RESULTS

During hypoglycaemia, LVEF increased significantly in all groups compared to baseline (6.2 ± 5.2%, p < 0.05), but the increase was significantly lower in type 1 diabetes compared to controls without diabetes (5.8 ± 3.4% vs. 9.4 ± 5.0%, p = 0.03, 95% CI difference: -5.0, -0.3). In people with type 1 diabetes, ΔLVEF was inversely associated with diabetes duration (β: -0.16, 95% CI: -0.24, -0.53, p = 0.001) and recent exposure to hypoglycaemia (β: -0.30, 95% CI: -0.53, -0.07, p = 0.015). Hypoglycaemia also increased global longitudinal strain (GLS) in controls without diabetes (p < 0.05), but this did not occur in the two diabetes subgroups (p > 0.10).

CONCLUSIONS

Hypoglycaemia increased LVEF in all groups, but the increase diminished with longer disease duration and prior exposure to hypoglycaemia in type 1 diabetes, suggesting adaptation to recurrent hypoglycaemia. The increment in GLS observed in controls was blunted in people with diabetes. More research is needed to determine the clinical relevance of these findings.

The Prevalence of Atherosclerotic Cardiovascular Disease in Patients with Type 2 Diabetes in Jordan: The PACT-MEA Study

INTRODUCTION

This study investigated the prevalence and clinical management of atherosclerotic cardiovascular disease (ASCVD) and ASCVD risk in patients with type 2 diabetes (T2D) in Jordan.

METHODS

PACT-MEA (NCT05317845) was a non-interventional, cross-sectional, observational study of adults with T2D recruited in seven countries across the Middle East and Africa. In Jordan, assessments were conducted at ten sites, three in primary care and seven in secondary care settings.

RESULTS

The Jordan cohort included 576 individuals (27.8% primary care, 72.2% secondary care settings), similarly represented by male and female patients, with a mean age of 59.7 ± 11.7 years and a median duration of diabetes of 10.0 years. The prevalence of established ASCVD (eASCVD) was 26.2% overall (95% CI: 22.8-30.0) and 21.9% and 27.9% in primary care and secondary care settings, respectively (95% CI: 16.1-28.9, 23.8-32.4), higher than that observed in the regional PACT-MEA analysis. By the European Society of Cardiology 2021 criteria, 66.0% of patients were classified as high risk and 33.3% as very high risk (which included eASCVD). Use of renin-angiotensin system inhibitors, statins, and cardioprotective antidiabetic medication was higher in secondary care settings. None of the participants achieved all guideline recommendations with respect to risk factor control, body mass index, exercise, and pharmacotherapy.

CONCLUSIONS

More than one-quarter of patients with T2D in Jordan had ASCVD, and nearly all were at high/very high ASCVD risk. These findings suggest a need for multifactorial approaches to risk reduction in this population within Jordan in both primary and secondary care settings.

TRIAL REGISTRATION

URL: https://www.

CLINICALTRIALS

gov ; Unique identifier: NCT05317845.

The management of cardiovascular risk in people with diabetes: Insights from an audit of health services providing diabetes care

AIMS

To assess cardiovascular risk management among Australians with diabetes.

METHODS

Retrospective analysis of clinical audit data collected from diabetes centres participating in the Australian National Diabetes Audit in 2022. Adults (≥18 years) with type 1 or type 2 were included. Clinical performance was assessed by comparing modifiable cardiovascular risk factors against evidence-based clinical targets at the national and diabetes centre level for the total cohort, with sub-analyses by diabetes type, and by cardiovascular disease (CVD) status.

RESULTS

There were 4341 people included; 32.4 % with type 1 and 67.6 % with type 2 diabetes. Of the total cohort, 25.9 % met the HbA1c target (≤7% or 53 mmol/mol), 45.5 % met the low-density lipoprotein cholesterol target (<2 mmol/L), 43.4 % met the systolic blood pressure target (<130 mmHg), 19.8 % met the body mass index target (<25 kg/m2), 30.2 % met the physical activity target (≥150 mins/week of moderate-to-vigorous intensity), and 85.0 % were non-smokers. Compared to patients with type 1 diabetes, patients with type 2 diabetes were less likely to meet targets. Compared to patients without existing CVD, patients with CVD were less likely to meet targets.

CONCLUSIONS

Management of cardiovascular risk in adults with diabetes is sub-optimal, increasing the risk of preventable adverse health outcomes.

Prediction of cardiac autonomic dysfunction using heart rate response to deep breathing test among type 2 diabetes mellitus

BACKGROUND

Cardiac autonomic neuropathy (CAN) is an underdiagnosed complication of type 2 diabetes mellitus (T2DM) and a predictor of mortality and cardiovascular morbidity. Hence, CAN screening is essential. The objective of the study was to examine whether cardiac autonomic dysfunction can be predicted using the heart rate response to deep breathing test of cardiac autonomic reflex tests (CARTs) among type 2 diabetes mellitus.

METHODS

The study was a cross-sectional study of T2DM individuals between 40 and 65 years. Each participant underwent a heart rate (HR) response to deep breathing test (CARTs) as per standard guidelines. ANOVA F-test was used to check the difference between the CAN severity and the heart rate response to deep breathing parameters. A post-hoc (Tukey's) test was used to check which groups showed the difference.

RESULTS

Eighty-four participants were screened, of which forty-one were included in the present study. The mean age of the participants was 58.8 ± 4.0 years. The Fisher's test showed a statistically significant difference between groups for the average deep breathing difference (F(3,27) = 16.09, p < 0.001) and the respiratory sinus arrhythmia index (F(3,27) = 7.35, p < 0.001).

CONCLUSION

HR response to deep breathing can be used as a preliminary tool to screen CAN in T2DM to differentiate between normal and the other stages of CAN, which can then be followed by the gold standard tests. Further studies are required to establish HR response to deep breathing as a singular tool using regression analysis.

CLINICAL TRIALS REGISTRATION

The study was registered prospectively in the Clinical Trials Registry- India (CTRI/2023/11/060077) on 21st November 2023.

Metformin-mediated protection against Immunosenescence in diabetic cardiomyopathy: The potential roles of GDF-15 and klotho proteins

Diabetic cardiomyopathy (DCM) is a global health concern. However, studies examining the effect of metformin on diabetes-induced cardiac myocyte aging are lacking. This study aimed to investigate the protective effect of metformin against DCM involving modulation of macrophage phenotypes, growth differentiation factor-15 (GDF-15), and the anti-aging protein Klotho. Diabetes was induced in male Wistar rats using streptozotocin. Diabetic and nondiabetic rats were treated with metformin (200 mg/kg/day) and saline (control). DCM, inflammation, adhesion molecules, immunometabolic, and GDF-15 biomarkers were assessed using immunoassays. Western blotting was used to analyze Klotho expression. Macrophage phenotypes, senescence-associated-galactosidase (SA-β-gal), and p16INK4a were examined using immunohistochemistry, whereas the heart sections were histologically examined. The untreated diabetic rats showed increased serum troponin I and creatine kinase-MB levels, reflecting cardiac damage, which was confirmed via morphological changes and senescence. Klotho expression was decreased, indicating cardiac aging. Treatment with metformin reduced the heart weight-body weight ratio and lowered cardiac injury, inflammation, and adhesion molecule biomarker levels. It also reversed the histopathological changes induced by diabetes. It shifted macrophage polarization toward the M2 phenotype, decreased p16INK4a and SA-β-gal expression, and enhanced Klotho and GDF-15 expression. These findings revealed that diabetes induces cardiac aging by increasing senescence markers and decreasing the expression of Klotho. Metformin treatment protects against DCM by modulating macrophage phenotypes, attenuating immunosenescence-related dysregulation, and enhancing GDF-15 and Klotho expressions. Thus, metformin has potential clinical implications in alleviating DCM.

Hypertension and cardiometabolic disorders appear 5-10 years earlier in women with pre-eclampsia

AIMS

Despite increased cardiovascular (CV) disease risks after pre-eclampsia, guidelines remain indefinite on the necessity, timing, and frequency of CV risk assessment in these women. We aimed to provide prevalence-based recommendations on systematic follow-up after pre-eclampsia by evaluating the age-related prevalence of CV risk factors in former pre-eclamptic women compared to women with a history of normotensive gestation.

METHODS AND RESULTS

A retrospective cohort study was performed amongst parous women, up to 30 years postpartum. Prevalence of CV risk constituents was assessed based on standardized clinical measurements and medical history, including hypertension, diabetes mellitus, hypercholesterolaemia, obesity, insulin resistance, chronic kidney disease, and micro-albuminuria We included 1040 women after pre-eclampsia and 518 normotensive gestated controls. Higher development rates of either/combined hypertension, diabetes mellitus, or hypercholesterolaemia were observed after pre-eclampsia than normotensive gestation (aHR 2.6 (95% CI 2.1-3.2)). These factors occurred on average 8 years earlier after pre-eclampsia (39 ± 9 years) than normotensive gestation (47 ± 8 years). With ageing, hypertension prevalence increased more steeply after pre-eclampsia (P-value interaction = 0.044). Cumulative proportion of hypertension exceeded the 10% cut-off for CV risk assessment initiation from 35 years onwards in women after pre-eclampsia, with an increase above the 5% cut-off for re-assessment every five years.

CONCLUSION

Cardiovascular risk factors occur almost a decade earlier in former pre-eclamptic women compared to women after normotensive gestation, predominantly, but not exclusively, due to the early and accelerated development of hypertension. Systematic CV risk (re-)assessment is recommended at least five yearly in former pre-eclamptic women from 35 years of age onwards.

Association between diabetes phenotypes with hypertension and cardiovascular diseases, using single-sample confirmatory testing: a national study

AIM

To investigate, for the first time, the association between undiagnosed diabetes-using a single-sample confirmatory definition-and prevalent hypertension and cardiovascular diseases (CVD) in an Iranian national population. A few studies on this topic have been limited to Western populations.

METHODS

The study included 16328 adults aged ≥ 30 years. Diabetes phenotypes were classified as: 1-no diabetes: fasting plasma glucose (FPG) < 7 mmol/L (126 mg/dL) and glycated hemoglobin (HbA1c) < 6.5% (48 mmol/mol), as reference; 2-unconfirmed undiagnosed diabetes: having elevated levels of either FPG or HbA1c; 3-confirmed undiagnosed diabetes: having elevated levels of both tests; 4-known diabetes: self-reported history of glucose-lowering medications. Hypertension was defined using American Heart Association criteria. Self-reported history of CVD is defined as prevalent CVD. Multivariable logistic regression models were applied to estimate the odds ratio (OR) and 95% confidence interval (CI) of the association between diabetes phenotypes with hypertension and CVD.

RESULTS

Prevalence of unconfirmed undiagnosed-, confirmed undiagnosed-, and known -diabetes was calculated as 2.70, 3.10, and 5.64%, respectively. Unconfirmed undiagnosed-, confirmed undiagnosed-, and known -diabetes were associated with hypertension with corresponding OR were, 1.30, 1.37, and 1.62; the related values for CVD were 1.80, 1.61, and 2.38; and for the coexistence of CVD and hypertension were 1.86, 1.79, and 2.80, respectively (all P values < 0.05). Furthermore, isolated HbA1c elevation was significantly associated with prevalent CVD [2.04 (1.20-3.45)], and coexistence of hypertension and CVD [1.89 (1.00-3.55)].

CONCLUSIONS

Both unconfirmed- and confirmed- undiagnosed -diabetes were significantly associated with hypertension and CVD, the issue that was mainly attributable to high HbA1c.

Comparative efficacy of various mind-body exercise types on cardiometabolic health in patients with type 2 diabetes: a network meta-analysis of randomized controlled trials

OBJECTIVE

This study aims to compare the efficacy of different mind-body exercises (MBEs) on cardiometabolic risk factors in patients with type 2 diabetes mellitus (T2DM) using a network meta-analysis of randomized controlled trials (RCTs).

METHODS

This study followed PRISMA guidelines and was registered in PROSPERO (CRD42025630741). A systematic search of PubMed, Cochrane Library, Web of Science, and Embase was conducted up to December 15, 2024, using MeSH terms related to mind-body therapies and cardiometabolic risk in type 2 diabetes. Randomized controlled trials (RCTs) evaluating mind-body exercises (MBEs) on glucose metabolism, body composition, cardiovascular physiology, and lipid metabolism were included. Data extraction and risk of bias assessment (RoB 2 tool) were performed independently by two reviewers. Network meta-analysis was conducted using R (gemtc package) and Stata 17.0, with effect sizes reported as mean difference (MD) or standardized mean difference (SMD). Evidence quality was assessed using CINeMA.

RESULTS

This network meta-analysis compared the effects of various mind-body exercise interventions on ten cardiometabolic risk factors. Meditative Exercise (ME) was most effective in reducing fasting plasma glucose (SUCRA = 97.9%, SMD = -7.23, 95% CI: -8.27 to -6.20), while Mindfulness Intervention Training (MIT) showed the greatest benefit for glycated hemoglobin (SUCRA = 92.2%, MD = -0.78, 95% CI: -1.12 to -0.44) and blood pressure reduction (SBP: SUCRA = 86.1%, MD = -13.00, 95% CI: -17.22 to -8.78; DBP: SUCRA = 99.8%, MD = -6.00, 95% CI: -7.64 to -4.36), significantly outperforming conventional exercise. Yoga with Meditation (YWM) was most effective in lowering body mass index (SUCRA = 99.4%, MD = -2.90, 95% CI: -4.05 to -1.75). CINeMA assessments rated most comparisons as very low certainty due to within-study bias and between-study heterogeneity. Nevertheless, consistency was supported by node-splitting analysis, and no significant publication bias was detected, indicating robust and reliable findings.

CONCLUSION

Compared with conventional exercise intervention, MBE exerts unique and superior effects on various cardiometabolic risk factors in T2DM, underscoring their potential as effective and integrative interventions for personalized diabetes management. Clinicians should consider incorporating MBEs, such as MIT, ME, and YWM, into treatment plans based on individual patient needs, particularly for glycemic control, weight management, and cardiovascular health. Further research is warranted to explore the long-term benefits and optimal implementation strategies, especially given the heterogeneity in intervention protocols and the relatively short duration of the included trials.

Application of an interpretable machine learning method to predict the risk of death during hospitalization in patients with acute myocardial infarction combined with diabetes mellitus

BACKGROUND

Predicting the prognosis of patients with acute myocardial infarction (AMI) combined with diabetes mellitus (DM) is crucial due to high in-hospital mortality rates. This study aims to develop and validate a mortality risk prediction model for these patients by interpretable machine learning (ML) methods.

METHODS

Data were sourced from the Medical Information Mart for Intensive Care IV (MIMIC-IV, version 2.2). Predictors were selected by Least absolute shrinkage and selection operator (LASSO) regression and checked for multicollinearity with Spearman's correlation. Patients were randomly assigned to training and validation sets in an 8:2 ratio. Seven ML algorithms were used to construct models in the training set. Model performance was evaluated in the validation set using metrics such as area under the curve (AUC) with 95% confidence interval (CI), calibration curves, precision, recall, F1 score, accuracy, negative predictive value (NPV), and positive predictive value (PPV). The significance of differences in predictive performance among models was assessed utilising the permutation test, and 10-fold cross-validation further validated the model's performance. SHapley Additive exPlanations (SHAP) and Local Interpretable Model-agnostic Explanations (LIME) were applied to interpret the models.

RESULTS

The study included 2,828 patients with AMI combined with DM. Nineteen predictors were identified through LASSO regression and Spearman's correlation. The Random Forest (RF) model was demonstrated the best performance, with an AUC of 0.823 (95% CI: 0.774-0.872), high precision (0.867), accuracy (0.873), and PPV (0.867). The RF model showed significant differences (p < 0.05) compared to the K-Nearest Neighbours and Decision Tree models. Calibration curves indicated that the RF model's predicted risk aligned well with actual outcomes. 10-fold cross-validation confirmed the superior performance of RF model, with an average AUC of 0.828 (95% CI: 0.800-0.842). Significant Variables in RF model indicated that the top eight significant predictors were urine output, maximum anion gap, maximum urea nitrogen, age, minimum pH, maximum international normalised ratio (INR), mean respiratory rate, and mean systolic blood pressure.

CONCLUSION

This study demonstrates the potential of ML methods, particularly the RF model, in predicting in-hospital mortality risk for AMI patients with DM. The SHAP and LIME methods enhance the interpretability of ML models.

Comparative effects of different macronutrient compositions for type 2 diabetes management: a systematic review and network meta-analysis of randomized trials

BACKGROUND

To assess and rank the comparative effects of different exact macronutrient compositions for type 2 diabetes management rather than examining single macronutrients or as a dietary pattern.

METHODS

PubMed, Scopus, and Cochrane Library Central Register of Controlled Trials were searched. Randomized controlled trials were included. A random-effects network meta-analysis with a Bayesian framework was performed to calculate the mean difference (MD) and 95% credible intervals (CrIs). The certainty of evidence was rated using the GRADE approach.

RESULTS

80 trials with 9232 patients with type 2 diabetes were included in the network meta-analysis. A very low-carbohydrate, high-protein, and calorie-restricted diet had the greatest effect on reducing HbA1c (range of mean difference: - 1.0% to - 1.79%), weight (range of mean difference: -5.83 kg to -10.96 kg), and FPG (range of mean difference: - 2.20 mmol/L to - 2.88 mmol/L) at 6-month follow-up, but at 12-month follow-up, the effect remained only for HbA1c (range of mean difference: - 1.25% to - 1.30%) and FPG (range of mean difference: - 1.21 mmol/L to - 1.27 mmol/L). For weight loss in 12-month follow-up, the low-carbohydrate, high-protein diet was probably the most effective approach (range of mean difference: - 10.05 kg to - 14.52 kg). The best dietary approach to reduce LDL at 6-month follow-up was a low carbohydrate, high protein, calorie-restricted diet (range of mean difference: - 0.49 mmol/L to - 0.59 mmol/L) and at 12-month follow-up, a moderate carbohydrate, standard protein, calorie-restricted diet was effective in reducing LDL (mean difference: - 0.87 mmol/L, 95%CrI - 1.55 to - 0.16).

CONCLUSIONS

A very low carbohydrate, high protein, calorie-restricted diet can be an effective dietary composition in managing diabetes, but milder dietary carbohydrate restriction for weight loss in the long-term, and improving lipid profiles is needed.

Efficacy and Safety of Policosanol (Sugarcane Wax Alcohols) 20 mg/Day in Cuban Prehypertensive Patients: A Randomized, Double-Blind, Multicentre Study

Hypertension is the most common modifiable cardiovascular risk factor. Policosanol exhibits lipid-modifying and beneficial vascular pleiotropic effects. Some previous Cuban trials found that policosanol lowered blood pressure in hypercholesterolemic patients. Similar results were found recently in prehypertensive Asian subjects. The aim of this study was to report the effects of 20 mg/day of policosanol on blood pressure in Cuban patients with prehypertension. A double-blind multicenter trial randomized 400 eligible patients into two strata of 200 patients each (prehypertension and Grade 1 hypertension), treated with placebo or 20 mg/day of policosanol (100 patients/group/stratum) for 12 weeks. The primary outcome was to determine whether policosanol could achieve significant systolic blood pressure (SBP) reductions ≥10 mmHg versus placebo. Changes in diastolic blood pressure (DBP) and lipid profile were secondary outcomes. Safety indicators and adverse events (AE) were assessed. Statistical analyses were conducted by intention-to-treat (ITT). Here we report the results of the prehypertension stratum (SBP 120-139 mmHg, DBP 80-89 mmHg). Both groups were similar at randomization. At study completion, policosanol significantly lowered (p < 0.001) SBP and DBP values versus baseline and placebo. Also, more (p < 0.0001) policosanol patients (44%) reached SBP reductions ≥10 mmHg and DBP reductions ≥5 mmHg versus baseline (44% and 61%, respectively) than placebo patients (7% and 22%, respectively). Policosanol significantly lowered low-density lipoprotein cholesterol (LDL-C) and total cholesterol (TC) and increased low-density lipoprotein cholesterol (HDL-C). Policosanol was well tolerated. Nine patients (4.5%) discontinued the trial, none because of AE. Four patients (3 placebo, 1 policosanol) reported AE. It is concluded that policosanol 20 mg/day given for 12 weeks to Cuban patients with prehypertension lowered SBP and DBP and produced beneficial changes in the lipid profile, being well tolerated.

Body Mass Index, Comorbidities, and Ambulatory Care Visits: The REGARDS Study

BACKGROUND

Individuals with obesity have more ambulatory care usage than individuals with normal weight and overweight. There is limited information on whether this is consistent across provider specialties and whether comorbidities explain the associations.

METHODS AND RESULTS

Among REGARDS (Reasons for Geographic and Racial Differences in Stroke) cohort study participants with Medicare fee-for-service coverage (n=9648), we identified ambulatory visits over 5 years. We used marginalized zero-inflated Poisson models to calculate ratios of means by body mass index (BMI), adjusted for demographics and health behaviors, and inverse odds weighting to evaluate mediation by diabetes, hypertension, dyslipidemia, stroke, coronary heart disease, atrial fibrillation, heart failure, chronic kidney disease, depressive symptoms, cancer, arthritis, and sleep apnea. The mean age of participants was 71.7±7.3 years, 35.1% were Black individuals and 64.9% White individuals, and 51.1% were women. Participants had a mean of 37.8 total, 16.0 primary care, 3.4 cardiology, 1.9 orthopedics, 0.9 pulmonology, and 0.4 endocrinology visits. Compared with individuals with BMI 18.5 to <25 kg/m2 (n=2613), participants with BMI ≥35 kg/m2 (n=1259) had 23% (95% CI, 21%-24%) more ambulatory visits. Participants with BMI ≥35 kg/m2 had 26% more primary care, 20% more cardiology, 74% more orthopedics, 62% more pulmonology, and 85% more endocrinology visits. Comorbidities partly explained associations with overall, primary care, and orthopedics visits (39%, 38%, and 15%, respectively) and largely explained associations with cardiology, pulmonology, and endocrinology visits.

CONCLUSIONS

Understanding which specialty visits are associated with higher BMI can help with workforce planning and allocation of resources.

Myths and Facts Regarding Low-Carbohydrate Diets

As the prevalence of chronic diseases persists at epidemic proportions, health practitioners face ongoing challenges in providing effective lifestyle treatments for their patients. Even for those patients on GLP-1 agonists, nutrition counseling remains a crucial strategy for managing these conditions over the long term. This paper aims to address the concerns of patients and practitioners who are interested in a low-carbohydrate or ketogenic diet, but who have concerns about its efficacy, safety, and long-term viability. The authors of this paper are practitioners who have used this approach and researchers engaged in its study. The paper reflects our opinion and is not meant to review low-carbohydrate diets systematically. In addressing common concerns, we hope to show that this approach has been well researched and can no longer be seen as a "fad diet" with adverse health effects such as impaired renal function or increased risk of heart disease. We also address persistent questions about patient adherence, affordability, and environmental sustainability. This paper reflects our perspective as clinicians and researchers engaged in the study and application of low-carbohydrate dietary interventions. While the paper is not a systematic review, all factual claims are substantiated with citations from the peer-reviewed literature and the most rigorous and recent science. To our knowledge, this paper is the first to address potential misconceptions about low-carbohydrate and ketogenic diets comprehensively.

Managing Heart Disease in Persons with Diabetes

There are an estimated 38 million people in the United States who have diabetes mellitus, both diagnosed and undiagnosed. Chronic complications are generally due to insulin deficiency or insulin resistance, with persistent hyperglycemia, dyslipidemia, and other metabolic pathways disorders. They have 2 to 8 times greater risk of cardiovascular (CV) disease including complications from ischemic heart disease, peripheral artery disease, heart failure, and stroke, which can result in death for more than 50% of persons with type 2 diabetes. This article will discuss the latest CV risk reduction guideline recommended for persons with diabetes.

Use of SGLT2i Versus DPP-4i as an Add-on Therapy and the Risk of PAD-Related Surgical Events (Amputation, Stent Placement, or Vascular Surgery): A Cohort Study in Veterans With Diabetes

OBJECTIVE

To compare the risk of composite peripheral artery disease (PAD) surgical outcome, including peripheral revascularization and amputation procedures, between new users of sodium-glucose cotransporter 2 inhibitors (SGLT2is) and dipeptidyl peptidase 4 inhibitors (DPP-4is).

RESEARCH DESIGN AND METHODS

This retrospective cohort study of U.S. veterans age ≥18 years with diabetes who received care from the Veterans Health Administration was performed from 1 October 2000 to 31 December 2021. Data were linked to Medicare, Medicaid, and the National Death Index. New use of SGLT2i or DPP-4i medications as an add-on to metformin, sulfonylurea, or insulin treatment alone or in combination was evaluated for an association with PAD surgical procedure for peripheral revascularization and amputation. A Cox proportional hazards model for time-to-PAD event analysis compared the risk of a PAD event between SGLT2is and DPP-4is in a propensity score-weighted cohort with a competing risk of death and allowance for events to occur up to 90 days or 360 days after stopping SGLT2is.

RESULTS

The weighted cohort included 76,072 SGLT2i vs. 75,833 DPP-4i use episodes. The median age was 69 years, HbA1c was 8.4% (interquartile range [IQR] 7.5-9.4%), and the median diabetes duration was 10.1 (IQR 6.6-14.6) years. There were 874 and 780 PAD events among SGLT2i and DPP-4i users, respectively, for an event rate of 11.2 (95% CI 10.5-11.9) and 10.0 (9.4-10.6) per 1,000 person-years (adjusted hazard ratio [aHR] 1.18 [95% CI 1.08-1.29]). When PAD events were allowed for 360 days after SGLT2i use ended, the aHR was 1.16 (95% CI 1.06-1.26).

CONCLUSIONS

SGLT2i as an add-on diabetes therapy was associated with an increased cause-specific hazard of PAD surgeries compared with DPP-4i.

Composite cardiovascular risk factor control in US adults with diabetes and relation to social determinants of health: The All of Us research program

Background

Data are limited on composite cardiovascular risk factor control in patients with type 2 diabetes mellitus (T2DM). This study aims to identify disparities in cardiovascular risk factor control based on most recent recommendations and relationships to social determinants of health in a large-scale real-world cohort of US adults.

Methods

We analyzed data from 88,416 participants with T2DM in the NIH Precision Medicine Initiative All of Us Research Program 2018-2022. We investigated the management of five key cardiovascular risk factors-glycated hemoglobin (HbA1c), LDL cholesterol (LDL-C), body mass index (BMI), blood pressure (BP), and smoking status. Statistical methods included Chi-square tests for categorical comparisons, t-tests for mean differences, and multiple logistic regression to assess the impact of demographic and socioeconomic factors on risk factor control.

Results

The study revealed low risk factor control with only 27.7 % of participants achieving recommended levels for three or more risk factors (RFs) and 4.9 % for four or more RFs. Overall, while 81.0% were at target for HbA1c, only 37.9% were at target for BP and 10.4% for LDL-C. Notably, only 1.9 % and 6.9 % were at target for HbA1c, LDL-C, and BP together, based on current and prior recommendations, respectively. Significant disparities were observed across race/ethnicity, sex, and socioeconomic lines with 43.1 % of Asian participants at control for ≥3 RFs compared to 21.1 % of non-Hispanic black participants. In logistic regression analysis, factors such as higher income, higher educational attainment, and health insurance were associated with better RF control, while higher polysocial risk scores linked to poorer control.

Conclusions

Despite some progress in managing individual CVD risk factors in T2DM, overall composite risk factor control remains poor, especially among underrepresented and socioeconomically disadvantaged groups. The findings highlight the necessity for integrated healthcare strategies that address both medical and social needs to improve control of CVD risk factors and outcomes in T2DM.

The effect of HbA1c variability on the efficacy of intensive blood pressure control in patients with type 2 diabetes

AIMS

The efficacy of intensive blood pressure (BP) control remains controversial, and the variability of HbA1c was a risk factor for macrovascular events in patients with type 2 diabetes. We investigated whether the HbA1c variability modifies the efficacy of intensive BP control.

METHODS

Data from the Action to Control Cardiovascular Risk in Diabetes Blood Pressure (ACCORD-BP) trial was utilized. K-means clustering was used to cluster patients into three groups based on the HbA1c variability score and baseline HbA1c values. Cox proportional hazard models and generalized linear models were used to measure the subgroup differences in intensive BP control treatment effects. The primary outcome was a composite of nonfatal myocardial infarction (MI), stroke, or death from cardiovascular causes.

RESULTS

In patients with low HbA1c variability rather than medium or high HbA1c variability, intensive BP control reduced the risk of the primary outcome on a relative scale (HR 0.60, 95%CI 0.40-0.90, p interaction was 0.03), non-fatal MI (HR 0.61, 95% CI 0.37-1.00, p interaction was 0.04) and stroke (HR 0.19, 95%CI 0.05-0.64, p interaction was 0.02) or absolute scale. Regardless of the variability group, intensive BP control did not reduce the risk of cardiovascular or all-cause mortality (p interaction >0.05) both on relative and absolute risk scales.

CONCLUSION

HbA1c variability had effect on the efficacy of intensive BP control and intensive BP control brought a significant macrovascular benefit in patients with type 2 diabetes and low HbA1c variability.

Association between elevated fibrosis-4 index of liver fibrosis and risk of hemorrhagic stroke

BACKGROUND

Cirrhosis is associated with an increased risk of hemorrhagic stroke. Liver fibrosis, typically a silent condition, is antecedent to cirrhosis. The objective of this study was to test the hypothesis that elevated Fibrosis-4 (FIB-4) index, indicating a high probability of liver fibrosis, is associated with an increased risk of hemorrhagic stroke.

METHODS

We performed a cohort analysis of the prospective United Kingdom Biobank cohort study. Participants 40-69 years old were enrolled between 2007 and 2010 and had available follow-up data until March 1, 2018. We excluded participants with prevalent hemorrhagic stroke or thrombocytopenia. High probability of liver fibrosis was defined as having a value >2.67 of the validated FIB-4 index. The primary outcome was hemorrhagic stroke (intracerebral or subarachnoid hemorrhage), defined based on hospitalization and death registry data. Secondary outcomes were intracerebral and subarachnoid hemorrhage, separately. We used Cox proportional hazards models to evaluate the association of FIB-4 index >2.67 with hemorrhagic stroke while adjusting for potential confounders including hypertension, alcohol use, and antithrombotic use.

RESULTS

Among 452,994 participants (mean age, 57 years; 54% women), approximately 2% had FIB-4 index >2.67, and 1241 developed hemorrhagic stroke. In adjusted models, FIB-4 index >2.67 was associated with an increased risk of hemorrhagic stroke (HR, 2.0; 95% CI, 1.6-2.6). Results were similar for intracerebral hemorrhage (HR, 2.0; 95% CI, 1.5-2.7) and subarachnoid hemorrhage (HR, 2.2; 95% CI, 1.5-3.5) individually.

CONCLUSIONS

Elevated FIB-4 index was associated with an increased risk of hemorrhagic stroke.

Prevalence and Control of Diabetes Among US Adults, 2013 to 2023

This study uses data from the National Health and Nutrition Examination Survey to evaluate trends in the prevalence and control of diabetes among US adults overall and by age and sex between 2013 and 2023.

Effects of Sodium-Glucose Cotransporter 2 Inhibitors on Nervous System Disorders: A Systematic Review and Meta-Analysis

BACKGROUND

Adults with type 2 diabetes mellitus (T2DM) are at an increased risk for certain brain or psychiatric disorders, as are those with or without chronic kidney disease or heart failure. Whether sodium-glucose cotransporter 2 (SGLT2) inhibitors are associated with these diseases is unclear.

OBJECTIVE

This systematic review and meta-analysis aimed to investigate the effects of SGLT2 inhibitors on nervous system disorders.

METHODS

We searched PubMed, ClinicalTrials.gov, and Web of Science for randomized, double-blind placebo-controlled trials of at least ≥24 weeks. We used Mantel-Haenszel statistical method, risk ratio (RR), and 95% confidence interval (CI) to dichotomous variables.

RESULTS

We included 52 publications/trials covering 111 376 participants (SGLT2 inhibitors 62 192; Placebo 49 184). Sodium-glucose cotransporter 2 inhibitors had no significant effect on ischaemic stroke (RR = 0.97; 95% CI = 0.87-1.09; P = 0.64), cerebrovascular accident (RR = 1.05; 95% CI = 0.91-1.22; P = 0.50), dementia (RR = 1.29; 95% CI = 0.78-2.12; P = 0.32), carotid artery occlusion/carotid artery stenosis (RR = 1.18; 95% CI: 0.92-1.53; P = 0.20), haemorrhagic stroke (RR = 0.84; 95% CI = 0.62-1.12; P = 0.23), and transient ischaemic attack (RR = 0.97; 95% CI = 0.82-1.15; P = 0.73) compared to placebo. No significant heterogeneity was observed. However, SGLT2 inhibitors showed slight effects to reduce the risk of Parkinson's disease (major heart failure subgroup). Empagliflozin and dapagliflozin significantly increased the risk of syncope (RR = 1.65; 95% CI = 1.15-2.38; P < 0.01) and carotid artery occlusion/carotid artery stenosis (RR = 1.65; 95% CI = 1.04-2.61; P = 0.03), respectively.

CONCLUSION AND RELEVANCE

No significant effect of SGLT2 inhibitors on nervous system disorders was observed. There was reduced risk for Parkinson's Disease observed in some specific populations. In addition, the risks of empagliflozin and dapagliflozin concerning syncope and carotid artery occlusion/carotid artery stenosis are worth attention.

Metformin's Effects on Cognitive Function from a Biovariance Perspective: A Narrative Review

This study examines the effects of metformin on brain functions focusing on the variability of the results reported in the literature. While some studies suggest that metformin may have neuroprotective effects in diabetic patients, others report an insignificant impact of metformin on cognitive function, or even a negative effect. We propose that this inconsistency may be due to intrinsic cellular-level variability among individuals, which we term "biovariance". Biovariance persists even in demographically homogeneous samples due to complex and stochastic biological processes. Additionally, the complex metabolic actions of metformin, including its influence on neuroenergetics and neuronal survival, may produce different effects depending on individual metabolic characteristics.

TOWARD, a metabolic health intervention, demonstrates robust 1-year weight loss and cost-savings through deprescription

Background

Cost, scalability, and durability represent major challenges to the implementation of intensive lifestyle treatments for obesity and diabetes. We previously reported pilot data from a 6-month intervention in which a self-insured manufacturing company partnered with a metabolic health clinic that utilizes therapeutic carbohydrate reduction (TCR), asynchronous monitoring, and a community-based approach to treat employees with metabolic disease. This manuscript presents weight loss and cost-savings from deprescription at the 12-month time point.

Methods

50 employees, mean BMI 43.2 ± 8.7 kg/m2, 64% with prediabetes or type 2 diabetes, were enrolled in the multimodal TOWARD telemedicine intervention, which includes: Text-based communications, Online interactions, Wellness coaching, Asynchronous education, Real-time biofeedback and remote monitoring, and Dietary modifications that emphasizes TCR.

Results

41 completed the one-year intervention. Mean weight loss for the 50 subjects in the intention-to-treat analysis was 19.5 ± 11.4 kg, corresponding to 15.5% total body weight loss with concomitant deprescription of 96 medications, while starting only 8 medications. In patients who discontinued GLP-1 receptor agonists, weight loss continued or was maintained. Annualized cost savings from the TOWARD approach were approximately -$1700 per patient, as compared to an annualized cost burden of roughly +$13000 per patient for a GLP-1 receptor agonist.

Conclusion

The TOWARD approach represents a scalable metabolic health intervention that demonstrates robust improvements in weight while simultaneously allowing for deprescription leading to substantial cost savings. TOWARD could serve as a scalable tool to facilitate intensive lifestyle intervention with efficacy on par with GLP-1 receptor agonists.

Clonal hematopoiesis of indeterminate potential, health indicators, and risk of cardiovascular diseases among patients with diabetes: a prospective cohort study

BACKGROUND

Clonal hematopoiesis of indeterminate potential (CHIP) was associated with diabetes and cardiovascular diseases (CVD). However, the effect of CHIP on CVD have not been evaluated among patients with diabetes, and whether maintaining the healthy indictors could mitigate the adverse influence was also unclear.

METHODS

A total of 22,239 adults from the UK Biobank with diabetes and available whole-exome sequence data, and free of CVD were included. Multivariable-adjusted Cox regressions were used to explore the associations of any CHIP (variant allele fraction ≥ 2%), large CHIP (variant allele fraction ≥ 10%), and the top 10 commonly mutated driver genes for CHIP and with risk of CVD. The joint associations between health indicators (body mass index [BMI], HbA1c, blood pressure [BP], and low-density lipoprotein cholesterol [LDL]) and CHIP were further investigated.

RESULTS

Over a median follow-up of 13.2 years, 5366 participants with diabetes developed CVD events. The hazard ratios (HRs) (95% confidence intervals [CIs]) of any CHIP and large CHIP were (1.21, 1.08-1.36) and (1.25, 1.09-1.43) for incident CVD, respectively. Significant associations between any CHIP and coronary heart disease (HR, 95%CI: 1.18, 1.03-1.36) and heart failure (1.73, 1.46-2.06) were observed, but not for stroke (1.14, 0.89-1.48). Gene-specific analyses suggested that the greatest association were for SF3B1 (HR, 95%CI: 2.50, 1.25-5.01) and TET2 (HR, 95%CI: 1.36, 1.07-1.77) with risk of CVD. There was no significant interaction between the four health indicators and CHIP in relation to incident CVD. Compared to patients without CHIP, those with any CHIP and ideal health indicators still exhibited significantly or nonsignificantly higher HRs (BMI: 1.18, 0.82-1.68; HbA1c: 1.12, 0.96-1.30; BP: 1.24, 1.03-1.49; LDL: 1.29, 1.09-1.53). Similar results were demonstrated using large CHIP.

CONCLUSIONS

CHIP is independently associated with an increased risk of CVD in patients with diabetes, regardless of health indicator levels. Diabetic patients with CHIP but ideal health indicators still exhibited higher CVD risk compared with diabetic patients without CHIP.

The protective effect of sodium-glucose cotransporter-2 inhibitor on left ventricular global longitudinal strain in patients with type 2 diabetes mellitus according to disease duration

Our study aimed to elucidate the impact of sodium-glucose cotransporter-2 inhibitor on left ventricular systolic function using global longitudinal strain in type 2 diabetes mellitus patients and to assess its protective effect depending on disease duration. Type 2 diabetes mellitus patients treated at our institute were included. According to whether sodium-glucose cotransporter-2 inhibitor was used in drug treatment, the patients were divided into SGLT2i group and control group, and propensity score matching was performed. For subgroup analysis, patients were further classified based on disease duration (1-5 years, 5-10 years, and 10-20 years). A total of 256 patients with type 2 diabetes mellitus were enrolled. Significantly better global longitudinal strain results were observed at the 6-month follow-up in the SGLT2i group than those of the control group and its baseline (p < 0.001). A significantly lower proportion of subclinical cardiac dysfunction was observed in the SGLT2i group (p < 0.001). Significantly greater global longitudinal strains were observed in the SGLT2i subgroups compared with control subgroups (p all < 0.05). Furthermore, sodium-glucose cotransporter-2 inhibitor use and epicardial adipose tissue thickness change were independently associated with global longitudinal strain change according to multivariate analysis. Sodium-glucose cotransporter-2 inhibitor significantly improved left ventricular function in type 2 diabetes mellitus patients without cardiovascular complications, regardless of disease duration, with more prominent outcomes observed in patients with early-stage disease.

The comorbidity burden of diabetes and stroke: a retrospective study in Beijing, China

BACKGROUND

The high costs associated with diabetes management, coupled with the increasing prevalence of comorbidities, present a significant challenge to China's healthcare system, with cardiovascular complications being particularly prominent. The purpose of this study was to evaluate the comorbidities of diabetic patients with stroke in Beijing from 2016 to 2018 and the impact on treatment options and associated costs.

METHODS

This retrospective cohort study included diabetic patients enrolled in Beijing's medical insurance with outpatient medical records. We compared comorbidities, medications, and related treatment costs between stroke and non-stroke patients.

RESULTS

A representative sample of 2,853,036 patients with diabetes was identified from the data collected from 2016 to 2018, of which an average of 21.18% of patients reported stroke. A higher percentage of diabetic patients with stroke reported other comorbidities including hypertension, coronary artery disease, dyslipidemia, chronic respiratory disease, and osteoporosis as compared to those without stroke(all p's < 0.0001). The costs increased dramatically if diabetic patients developed comorbidities, including hypertension, CAD, dyslipidemia, CRD, and osteoporosis. Annual costs of medications were higher for diabetic patients with stroke and any types of comorbidity compared to diabetic patients without stroke (p <.0001, respectively). More types of drugs were used for diabetic patients with stroke and any types of comorbidity.

CONCLUSIONS

The needs of individuals with diabetes and stroke, including their comorbidity patterns and medical burdens, must be carefully taken into account. Health systems will need to address the increasing demand for diagnosing and managing comorbidities in individuals with diabetes and stroke.

Ferroptosis: mechanism and role in diabetes-related cardiovascular diseases

Cardiovascular diseases represent the principal cause of death and comorbidity among people with diabetes. Ferroptosis, an iron-dependent non-apoptotic regulated cellular death characterized by lipid peroxidation, is involved in the pathogenesis of diabetic cardiovascular diseases. The susceptibility to ferroptosis in diabetic hearts is possibly related to myocardial iron accumulation, abnormal lipid metabolism and excess oxidative stress under hyperglycemia conditions. Accumulating evidence suggests ferroptosis can be the therapeutic target for diabetic cardiovascular diseases. This review summarizes ferroptosis-related mechanisms in the pathogenesis of diabetic cardiovascular diseases and novel therapeutic choices targeting ferroptosis-related pathways. Further study on ferroptosis-mediated cardiac injury can enhance our understanding of the pathophysiology of diabetic cardiovascular diseases and provide more potential therapeutic choices.

Type 2 Diabetes Mellitus: A Comprehensive Review of Pathophysiology, Comorbidities, and Emerging Therapies

Humans are perhaps evolutionarily engineered to get deeply addicted to sugar, as it not only provides energy but also helps in storing fats, which helps in survival during starvation. Additionally, sugars (glucose and fructose) stimulate the feel-good factor, as they trigger the secretion of serotonin and dopamine in the brain, associated with the reward sensation, uplifting the mood in general. However, when consumed in excess, it contributes to energy imbalance, weight gain, and obesity, leading to the onset of a complex metabolic disorder, generally referred to as diabetes. Type 2 diabetes mellitus (T2DM) is one of the most prevalent forms of diabetes, nearly affecting all age groups. T2DM is clinically diagnosed with a cardinal sign of chronic hyperglycemia (excessive sugar in the blood). Chronic hyperglycemia, coupled with dysfunctions of pancreatic β-cells, insulin resistance, and immune inflammation, further exacerbate the pathology of T2DM. Uncontrolled T2DM, a major public health concern, also contributes significantly toward the onset and progression of several micro- and macrovascular diseases, such as diabetic retinopathy, nephropathy, neuropathy, atherosclerosis, and cardiovascular diseases, including cancer. The current review discusses the epidemiology, causative factors, pathophysiology, and associated comorbidities, including the existing and emerging therapies related to T2DM. It also provides a future roadmap for alternative drug discovery for the management of T2DM.

Systematic Mendelian Randomization Exploring Druggable Genes for Hemorrhagic Strokes

Patients with hemorrhagic stroke have high rates of morbidity and mortality, and drugs for prevention are very limited. Mendelian randomization (MR) analysis can increase the success rate of drug development by providing genetic evidence. Previous MR analyses only analyzed the role of individual drug target genes in hemorrhagic stroke; therefore, we used MR analysis to systematically explore the druggable genes for hemorrhagic stroke. We sequentially performed summary-data-based MR analysis and two-sample MR analysis to assess the associations of all genes within the database with intracranial aneurysm, intracerebral hemorrhage, and their subtypes. Validated genes were further analyzed by colocalization. Only genes that were positive in all three analyses and were druggable were considered desirable genes. We also explored the mediators of genes affecting hemorrhagic stroke incidence. Finally, the associations of druggable genes with other cardiovascular diseases were analyzed to assess potential side effects. We identified 56 genes that significantly affected hemorrhagic stroke incidence. Moreover, TNFSF12, SLC22A4, SPARC, KL, RELT, and ADORA3 were found to be druggable. The inhibition of TNFSF12, SLC22A4, and SPARC can reduce the risk of intracranial aneurysm, subarachnoid hemorrhage, and intracerebral hemorrhage. Gene-induced hypertension may be a potential mechanism by which these genes cause hemorrhagic stroke. We also found that blocking these genes may cause side effects, such as ischemic stroke and its subtypes. Our study revealed that six druggable genes were associated with hemorrhagic stroke, and the inhibition of TNFSF12, SLC22A4, and SPARC had preventive effects against hemorrhagic strokes.

Analyzing the impact of glycemic metabolic status on cardiovascular mortality and all-cause mortality related to the estimated glucose disposal rate: a nationwide cohort study

Objective

The Estimated Glucose Disposal Rate (eGDR) serves as a surrogate marker for insulin resistance, with numerous studies highlighting its significant prognostic value. This paper aims to analyze the impact of eGDR on cardiovascular and all-cause mortality across different glycemic metabolic statuses, including normal fasting glucose (NFG), prediabetes, and diabetes.

Methods

This study included 46,016 American adults who underwent health examinations as part of the National Health and Nutrition Examination Survey from 1999 to 2018. Multivariable Cox regression was employed to explore the relationships between eGDR and mortality rates under varying glycemic states. Additionally, Kaplan-Meier curves were used to compare the cumulative incidence of cardiovascular and all-cause mortality across different metabolic statuses. Finally, the predictive value of eGDR for mortality was assessed using receiver operating characteristic curves.

Results

During an average follow-up of 115 months, a total of 6,906 (15.01%) participants experienced all-cause mortality, with 1,798 (3.91%) deaths attributed to cardiovascular causes. Kaplan-Meier analysis revealed that higher eGDR levels were associated with gradually reduced mortality rates. After adjusting for confounders, elevated eGDR levels were protective against both cardiovascular and all-cause mortality; the protective effect was notably stronger for cardiovascular mortality [Cardiovascular mortality hazard ratio: 0.92; All-cause mortality hazard ratio: 0.94]. Further interaction tests indicated that glycemic status significantly modified the protective effect of eGDR (P-interaction<0.0001); specifically, high eGDR conferred stronger protection against cardiovascular and all-cause mortality in individuals with NFG and prediabetes compared to those with diabetes. Receiver operating characteristic analysis suggested that eGDR had superior predictive value for mortality in the NFG and prediabetic populations compared to the diabetic group.

Conclusion

eGDR is a straightforward surrogate for insulin resistance, acting as a protective factor against cardiovascular and all-cause mortality in American adults, with glycemic status modifying this protective effect. Specifically, high eGDR levels offer stronger protection in individuals with NFG and prediabetes compared to those with diabetes; moreover, eGDR appears to be more suitable for predicting mortality events in the NFG and prediabetic populations.

Cohort profile: the prospective cohort study on the incidence of metabolic diseases and risk factors in Shunde, China (Speed-Shunde cohort)

AIMS

The objective of this prospective cohort study on the incidence of metabolic diseases and risk factors in Shunde (Speed-Shunde cohort) was to evaluate the incidence of cardiovascular-kidney-metabolic (CKM) syndrome and metabolic-associated multimorbidity, such as diabetes, hypertension, dyslipidaemia, and metabolic dysfunction-associated steatotic liver disease in Shunde, Foshan, Guangdong, China. Additionally, the study sought to identify the potential determinants that may impact the development of these conditions and the potential consequences that may result.

METHODS AND RESULTS

In the Speed-Shunde cohort, data were gathered via questionnaires, physical measurements, and laboratory analyses encompassing demographic data, behavioural tendencies, anthropometric assessments, controlled attenuation parameters, and liver stiffness measurement utilizing vibration-controlled transient elastography, as well as serum and urine detection (such as oral 75 g glucose tolerance tests, haemoglobin A1c levels, lipid profiles, liver and renal function tests, urinary microalbumin, and creatinine levels). The baseline data were gathered from October 2021 to September 2022 from over 10 000 Chinese community-based adults and the follow-up surveys would be conducted every 2 or 3 years. Blood and urine samples were obtained and stored for future omics data acquisition. Initial analyses revealed the prevalence and risk factors associated with metabolic-associated multimorbidity.

CONCLUSIONS

The Speed-Shunde cohort study is a longitudinal community-based cohort with comprehensive CKM health and metabolic-associated multimorbidity assessment. It will provide valuable insights into these conditions' development, progression, and interrelationships, potentially informing future prevention and treatment strategies.

Visit-to-visit lipid variability on long-term major adverse cardiovascular events: a prospective multicentre cohort from the CORE-Thailand registry

Lipid variability (LV) has been studied and proposed as a potential predictor for cardiovascular disease (CVD), and increased LV may contribute to adverse clinical outcomes. This study aimed to investigate the association of various LV parameters with the risk of long-term major adverse cardiovascular events (MACE) among the Thai population. The study used data from the CORE-Thailand Registry, a prospective multicentre study of adults with high cardiovascular risk or established CVD. The primary outcome was 4-point MACE, including non-fatal myocardial infarction, non-fatal stroke, heart failure hospitalisation, and all-cause mortality. LV was defined as visit-to-visit variability in individual and combined lipid parameters using the coefficient of variation (CV), and patients were stratified into four groups according to CV quartiles. The hazard ratio (HR) and 95% confidence interval (CI), adjusted for potential confounders, were calculated using the Cox proportional hazards model. In a total of 9,390 patients, 6,041 patients with data of intra-individual LV were included. After adjusting covariates in the Cox proportional hazards model, higher LV was independently associated with an increased risk of 4-point MACE (HR for quartiles 2, 3, and 4 of the CV of total cholesterol, compared to first quartile, were 3.63 (95% CI 3.20-4.06, P < 0.001), 6.85 (95% CI 6.23-7.47, P < 0.001), and 8.91 (95% CI 8.18-9.64, P < 0.001), respectively). The present study demonstrated that higher visit-to-visit LV, particularly in the higher quartiles, was independently associated with MACE, MI, and all-cause mortality in the Thai population at high cardiovascular risk or established atherosclerotic CVD, indicating that LV might be useful as a potential risk indicator.

Fasting-mimicking diet in type 2 diabetes reduces myocardial triglyceride content: A 12-month randomised controlled trial

BACKGROUND AND AIMS

Type 2 diabetes is associated with a heightened risk of cardiovascular complications, including myocardial steatosis. Fasting-mimicking diets (FMDs) may mimic the metabolic benefits of fasting, while being less intensive than fasting. This study aims to investigate the effect of following an FMD program on myocardial triglyceride content (MTGC), as assessed by Magnetic Resonance Spectroscopy (MRS), in patients with type 2 diabetes.

METHODS AND RESULTS

100 patients with type 2 diabetes, who used metformin as the only glucose-lowering drug or no medication were randomly assigned to either an FMD group or a control group. The FMD group received the FMD program for 5 consecutive days a month alongside usual care, while the control group received usual care only. Both groups underwent baseline, 6-months and 12-months examinations, including single voxel cardiac 1H-MRS to assess MTGC. N = 13 participants of the FMD and n = 13 of the control group had complete data at baseline and twelve month follow-up. The FMD group exhibited a significant reduction in MTGC over the twelve month period (-0.235 % MTGC, p = 0.027), while the control group saw no significant change (0.143 % MTGC, p = 0.236). The decrease of MTGC in the FMD group was statistically different (p = 0.018) from control.

CONCLUSION

Following an FMD program reduces MTGC, which indicates a favorable effect on cardiac metabolism and thereby may be an effective strategy to reduce the cardiovascular risk in patients with type 2 diabetes.

CLINICAL TRIALS REGISTRATION NUMBER

NCT03811587.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT03811587, submitted January 13th, 2019.

Emirates consensus recommendations on cardiovascular risk management in type 2 diabetes

Background

The combination of cardiovascular disease and diabetes is a highly prevalent condition in the United Arab Emirates. Development and dissemination of evidence-based regional recommendations for optimal screening, treatment and referrals of people with diabetes and high cardiovascular risk is an important priority.

Consensus panel

An expert panel of diabetologists, endocrinologists and cardiologists from the Emirates Cardiac Society and Emirates Diabetes and Endocrine Society as well as different entities in the UAE, discussed and reviewed evidence and also a consensus report from the American Diabetes Association to formulate contextualized recommendations that could be applied for optimal management of cardiovascular risk in people with diabetes in the UAE.

Consensus findings

The combination of heart failure and other cardiovascular risks is a highly prevalent finding among people with diabetes in the United Arab Emirates. The causal inter-relationships between diabetes and heart failure are multifactorial and regular assessments of symptoms and steps for mitigation of risk factors are an important priority. The universal definition and classification of heart failure provides a useful framework for recommending optimal screening, treatment, and referral strategies to diabetic individuals at various stages of the cardiovascular continuum. Routine measurement (at least yearly) of natriuretic peptides and high-sensitivity troponins can help identify patients requiring cardiac imaging referrals. However, recommending routine measurements of natriuretic peptides and/or high-sensitivity troponins to all diabetic individuals must balance clinical judgment and cost implications. While SGLT2i must be an important part of the standard of care, insulin, GLP1 receptor agonists and/or metformin can be useful for additional glycemic control.

Conclusion

The consensus panel hopes that the recommendations presented herein can offer guidance for optimal screening, treatment and referral of people with a concomitance of diabetes and high cardiovascular risk in the United Arab Emirates.

NLRP3 inflammasome-modulated angiogenic function of EPC via PI3K/ Akt/mTOR pathway in diabetic myocardial infarction

BACKGROUND

Inflammatory diseases impair the reparative properties of endothelial progenitor cells (EPC); however, the involvement of diabetes in EPC dysfunction associated with myocardial infarction (MI) remains unknown.

METHODS

A model was established combining high-fat diet (HFD)/streptozotocin (STZ)-induced diabetic mice with myocardial infarction. The therapeutic effects of transplanted wild-type EPC, Nlrp3 knockout EPC, and Nlrp3 overexpression EPC were evaluated. Chip and Luciferase assay revealed CEBPB regulated the transcriptional expression of Nlrp3 as a transcription factor in EPC stimulated by high glucose (HG) or advanced glycation end products (AGEs). CO-IP results suggested that USP14 selectively suppressed NLRP3 degradation. KEGG enrichment revealed PI3K/ Akt/mTOR signaling showed striking significance in the entire pathway.

RESULTS

In our study, wild-type, Nlrp3 knockout and Nlrp3 overexpressed EPC, intracardiac injections effectively improved cardiac function, increased angiogenesis, and reduced infarct size in mice with myocardial infarction. However, in the HFD/STZ-induced diabetic mice model combined with myocardial infarction, Nlrp3 knockout EPC significantly restored angiogenic capacity. Mechanically, CEBPB regulated the transcriptional level of Nlrp3 as a transcription factor in EPC. Meanwhile, we found that USP14 selectively suppressed NLRP3 protein degradation through the USP motif on the NACHT domain in mediating inflammasome activation. Cardiac functional outcomes in recipient mice after intramyocardial injection of shNlrp3 EPC overexpressing CEBPB or USP14 validated the modulation of EPC function by regulating Nlrp3 transcription or post-translational modification. Furthermore, KEGG enrichment and validation at the protein levels revealed PI3K/ Akt/mTOR cascade might be a downstream signal for NLRP3 inflammasome.

CONCLUSION

Our study provides a new understanding of how diabetes affected progenitor cell-mediated cardiac repair and identifies NLRP3 as a new therapeutic target for improving myocardial infarction repair in inflammatory diseases.

Real-world Evidence on Oral Semaglutide for the Management of Type 2 Diabetes. A Narrative Review for Clinical Practice

PURPOSE

Oral semaglutide is the first oral glucagon-like peptide-1 receptor agonist (GLP-1RA) available for type 2 diabetes mellitus (T2DM) management, whose effectiveness and tolerability have extensively been demonstrated in the PIONEER clinical trial program. Nevertheless, data from real-world are crucial to evaluate treatment performance under routine care. The aim of this narrative review is to summarize available evidence regarding real-world utilization patterns of oral semaglutide, and discuss efficacy, safety, and dosing regimen data in routine scenarios.

METHODS

We searched PubMed for real-world studies evaluating oral semaglutide up to August 2024, and specific search terms were: "oral semaglutide," and "real-world studies" or "observational studies" or "retrospective studies".

FINDINGS

19 real-world studies were included in the narrative review. In real-world settings, oral semaglutide provided significant glycemic (median HbA1c reduction at 6 months of 1%) and weight (median body weight reduction of 2 to 3 kg) benefits across the spectrum of T2DM, aligning with pre-clinical evidence from the PIONEER program. No new tolerability and safety issue has emerged from oral semaglutide administration in routine clinical practice.

IMPLICATIONS

Oral semaglutide constitutes an effective and safe option for T2DM management, and its increased acceptance has the potential to favor the early introduction of GLP-1RAs along the disease course. Nevertheless, continuous evaluation of real-world data is critical to better define the optimal positioning of oral semaglutide along T2DM trajectory and fully exploit its potential in everyday clinical practice.

The CNIC polypill (Acetylsalicylic acid + Atorvastatin + Rampril) in secondary prevention of cardiovascular disease in patients with type 2 diabetes: A comparative analysis with alternative therapeutic approaches

BACKGROUND

Patients with type 2 DM (T2DM) and established cardiovascular disease (CVD) are at high risk of recurrent CV events. We analysed the use of the CNIC-polypill (acetylsalicylic acid, ramipril, and atorvastatin) compared with other therapeutic strategies in patients with T2DM and CVD from the retrospective NEPTUNO study.

METHODS

Patients were stratified into four therapeutic approaches: CNIC-polypill, its monocomponents as loose medications, equipotent medications, and other therapies. Outcomes included the 2-year cumulative incidence and risk of recurrent major adverse CV events (MACE) and CV death, risk factors control, medication persistence, and utilisation of healthcare resources and costs.

RESULTS

After two years, T2DM patients treated with Monocomponents, Equipotent drugs, or Other therapies had increased recurrent MACE risk compared to CNIC-polypill (11 %, 23 %, and 44 %, respectively; P < 0.05) and shorter median time to CV events (305-377 vs. 396 days; P < 0.05). The CNIC-polypill group achieved a significant 11.2 % increase in patients reaching LDL-c targets <70 mg/dL, outperforming other strategies. It also exhibited superior triglyceride control and a higher proportion achieving the <130/80 mmHg blood pressure goal. The CNIC-polypill cohort displayed significantly higher 24-month persistence (71.5 % vs. 54.7 %-58.3 %, p < 0.05) and lower mean adjusted costs per patient (€5083 vs. €6000-€6523; p < 0.05). In a comparative analysis, T2DM patients had lower baseline LDL-c and total cholesterol levels than non-T2DM counterparts yet experienced a higher incidence of recurrent MACE over two years.

CONCLUSION

The CNIC-polypill (ASA, atorvastatin and ramipril) emerged as a promising treatment for patients with CVD, particularly those with T2DM, offering improved clinical outcomes and economic efficiency.

Cardiovascular Therapy Benefits of Novel Antidiabetic Drugs in Patients With Type 2 Diabetes Mellitus Complicated With Cardiovascular Disease: A Network Meta-Analysis

OBJECTIVE

Provide an evidence-based basis for the selection of cardiovascular benefit drugs in Type 2 diabetes mellitus (T2DM) patients with cardiovascular disease (CVD).

METHODS

Conduct a comprehensive search of all relevant literature from PubMed, Embase, Web of Science, Cochrane Library, and Clinical Trials.gov from their establishment until December 13, 2023, and select randomized controlled trials (RCTs) that meet the pre-established inclusion and exclusion criteria. Use the Cochrane bias risk assessment tool to evaluate the quality of the included literature. Use R 4.3.2 software to conduct network meta-analysis for drug category comparison.

RESULTS

A total of 24 large-scale randomized controlled trials (RCTs) were included, including 19 intervention measures, and 172 803 patients participated in the study. The results of the network meta-analysis show that: GLP1RA (OR 0.89, 95% CI 0.81-0.97) and SGLT2i (OR 0.91, 95% CI 0.83-0.99) can reduce the occurrence of major adverse cardiovascular events (MACE), GLP1RA (OR 0.88, 95% CI 0.79-0.97) and SGLT2i (OR 0.89, 95% CI 0.81-0.99) reduced the risk of cardiovascular death. SGLT2i (OR 0.68, 95% CI 0.62-0.75) reduced the occurrence of hospitalization for heart failure, GLP1RA (OR 0.88, 95% CI 0.81-0.97) and SGLT2i (OR 0.89, 95% CI 0.80-0.97) reduced the occurrence of all-cause death.

CONCLUSION

In the comparison of new hypoglycemic drug classes, GLP1RA and SGLT2i reduced MACE, cardiovascular mortality and all-cause mortality in T2DM patients with CVD, with no significant difference in efficacy, and DPP4i was noninferior to placebo. Only GLP1RA reduced the risk of nonfatal stroke, and only SGLT2i reduced the risk of HHF.

Overcoming Missing Data: Accurately Predicting Cardiovascular Risk in Type 2 Diabetes, A Systematic Review

Understanding is limited regarding strategies for addressing missing value when developing and validating models to predict cardiovascular disease (CVD) in type 2 diabetes mellitus (T2DM). This study aimed to investigate the presence of and approaches to missing data in these prediction models. The MEDLINE electronic database was systematically searched for English-language studies from inception to June 30, 2024. The percentages of missing values, missingness mechanisms, and missing data handling strategies in the included studies were extracted and summarized. This study included 51 articles published between 2001 and 2024, involving 19 studies that focused solely on prediction model development, and 16 and 16 studies that incorporated internal and external validation, respectively. Most articles reported missing data in the development (n = 40/51) and external validation (n = 12/16) stages. Furthermore, the missing data were addressed in 74.5% of development studies and 68.8% of validation studies. Imputation emerged as the predominant method employed for both development (27/40) and validation (7/12) purposes, followed by deletion (17/40 and 4/12, respectively). During the model development phase, the number of studies reported missing data increased from 9 out of 15 before 2016 to 31 out of 36 in 2016 and subsequent years. Although missing values have received much attention in CVD risk prediction models in patients with T2DM, most studies lack adequate reporting on the methodologies used for addressing the missing data. Enhancing the quality assurance of prediction models necessitates heightened clarity and the utilization of suitable methodologies to handle missing data effectively.

Exosomes Derived from Astragaloside IV-pretreated Endothelial Progenitor Cells (AS-IV-Exos) Alleviated Endothelial Oxidative Stress and Dysfunction via the miR-210/ Nox2/ROS Pathway

BACKGROUND

Chronic hyperglycemia in diabetes induces oxidative stress, leading to damage to the vascular system. In this study, we aimed to evaluate the effects and mechanisms of AS-IV-Exos in alleviating endothelial oxidative stress and dysfunction caused by high glucose (HG).

METHODS

Histopathological changes were observed using HE staining, and CD31 expression was assessed through immunohistochemistry (IHC). Cell proliferation was evaluated through CCK8 and EDU assays. The levels of ROS, SOD, and GSH-Px in the skin tissues of each group were measured using ELISA. Cell adhesion, migration, and tube formation abilities were assessed using adhesion, Transwell, and tube formation experiments. ROS levels in HUVEC cells were measured using flow cytometry. The levels of miR-210 and Nox2 were determined through quantitative reverse transcription-polymerase chain reaction (qRT-PCR). The expression of Nox2, SOD, GSH-Px, CD63, and CD81 was confirmed using WB.

RESULTS

The level of miR-210 was reduced in diabetes-induced skin damage, while the levels of Nox2 and ROS increased. Treatment with AS-IV increased the level of miR-210 in EPC-Exos. Compared to Exos, AS-IV-Exos significantly reduced the proliferation rate, adhesion number, migration speed, and tube-forming ability of HGdamaged HUVEC cells. AS-IV-Exos also significantly decreased the levels of SOD and GSH-Px in HG-treated HUVEC cells and reduced the levels of Nox2 and GSH-Px. However, ROS levels and Nox2 could reverse this effect.

CONCLUSION

AS-IV-Exos effectively alleviated endothelial oxidative stress and dysfunction induced by HG through the miR-210/Nox2/ROS pathway.

Clinical features and prognostic factors of cardiorenal anemia syndrome in China: a retrospective single-center study

BACKGROUND

There is little research on cardiorenal anemia syndrome (CRAS) in China. This study was to describe the characteristics of patients with CRAS and to explore risk factors of all-cause death.

METHODS

A total of 81,795 patients were hospitalized from August 2012 to August 2021 in the nephrology department and cardiology department, of which 820 patients with CRAS were recruited into this study. The 820 patients were divided into three groups based on New York Heart Association (NYHA) functional class: a NYHA Class II group (n = 124), a NYHA Class III group (n = 492), and a NYHA Class IV group (n = 204). Demographics and laboratory tests were collected and risk factors of all-cause death were analyzed. The primary endpoint of the study was all-cause death.

RESULTS

820 patients were included, with a median age of 65.00 (51.00-75.00) years and 61.2% were men. The median follow-up was 27.0 (13.0-51.0) months. 416 (50.7%) patients died during follow-up. Age, smoking history, cerebral infarction, NYHA functional class, albumin, serum creatinine (SCr), left ventricular end-diastolic diameter (LVEDD), and left ventricular ejection fraction (LVEF) remained independent predictors of all-cause mortality risk in patients with CRAS (P < 0.05) after adjusting to the potential confounders.

CONCLUSIONS

In patients with CRAS, older age, smoking history, and more advanced systolic heart failure and renal failure correlated with worse clinical outcomes at follow-up.

Assessment of myocardial infarctions knowledge, attitudes and beliefs among adults living in Riyadh Saudi Arabia - insights from cross-sectional study

Globally, the prevalence of coronary artery disease (CAD) is increasing, accounting for a third of all deaths worldwide including myocardial infarctions (MIs) which represent the most severe clinical manifestation of CAD and are among the most dangerous coronary events. Therefore, this study aims to assess the knowledge of symptoms and risk factors of MIs, as well as attitudes and beliefs regarding MIs and confidence in recognizing CAD symptoms in Riyadh, Saudi Arabia. A cross-sectional study was conducted among individuals living in Riyadh, Saudi Arabia between November 2023 and April 2024 to assess their knowledge and beliefs about CAD and MIs. Data collection was done using convenience sampling with pretested and validated questionnaire. Furthermore, recruiting more sample was achieved by distributing the questionnaires using the snowball technique. ANOVA and Student's t-test were used to determine the association between variables, with a p-value of < 0.05 considered statistically significant. Among respondents, approximately 65.5% were male, 27.3%, fell between the ages of 26 and 30 and 59.1% held a master's degree. In terms of marital status, the majority, 76.2%, were married. The majority (90%) stated that jaw pain was a symptom of a heart attack, followed by chest pain/pressure (85.9%), weakness/fatigue (85.8%), palpitations/rapid heart rate, and chest discomfort (83.4%). Most respondents (91.6%) were aware that smoking and obesity could increase the risk of MIs, while 85.3% believed that a family history of coronary heart disease could affect the risk of MIs. Additionally, 92.3% said they would seek medical care if they experienced chest pain within 15 min. The respondents' gender (p = 0.001), age (p = 0.004), education (p = 0.001), and marital status (p = 0.004) were significantly associated with levels of knowledge of MI. The findings showed that half of the study population had good knowledge and were well-informed about jaw and chest pain as the main symptoms of MI. Despite understanding the clinical potential of MI, the majority expressed low confidence in their ability to identify heart attack symptoms and recommended health education about the illness to provide prompt assistance.

Clinical practice guideline for the management of hypertension in China

In China, hypertension is the most common chronic non-communicable disease and the most significant risk factor for cardiovascular mortality among urban and rural residents. To standardize the clinical diagnosis and treatment of hypertension and to improve the prevention and control level of hypertension in China, Chinese Society of Cardiology, Chinese Medical Association; Hypertension Committee of Cross-Straits Medicine Exchange Association; Cardiovascular Disease Prevention and Rehabilitation Committee, Chinese Association of Rehabilitation Medicine, jointly collaborated to formulate the Clinical Practice Guideline for Hypertension Management in China. The Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach was used to rate the quality of evidence and strength of recommendations, and the reporting items for practice guidelines in healthcare (RIGHT) were followed to establish the guideline. Detailed evidence-based recommendations for the diagnosis, evaluation, and treatment of 44 clinical questions in the field of hypertension, including essential and secondary hypertension, have been provided to guide clinical practice.

REGISTRATION

International Practice Guidelines Registry Platform, http://www.guidelines-registry.cn/ , No. IPGRP-2021CN346.

Addiction to Smartphone Use in Smokers Diagnosed with Type 2 Diabetes in Jordan: Are Their Medications Involved?

BACKGROUND/OBJECTIVES

The prevalence of type 2 diabetes and smoking is increasing in developing countries and is associated with deteriorated health outcomes. Also, addiction to smartphone use is an alarming behavior that can be associated with clinical factors. This study aimed to determine the prevalence and clinical correlates of smartphone addiction in smokers with T2DM in Jordan, with a particular focus on the role of medications.

METHODS

This cross-sectional study recruited patients from Prince Hamza Hospital, Jordan, according to pre-defined criteria. Besides demographics and clinical information, this study used the validated Arabic version of the Smartphone Addiction Scale to assess addiction to smartphones and a multivariable regression analysis to identify the correlates of smartphone addiction.

RESULTS

Data analyzed from 346 patients revealed that 117 (33.8%) of these participants reported addiction to smartphones. Patients who had been diagnosed with T2DM for less than five years (aOR = 3.30; 95% CI = 1.43-7.60), who were "employed" (aOR = 8.85; 95% CI = 2.20-35.64), and who were "retired" (aOR = 11.46; 95% CI = 2.72-48.23) all reported a significantly (p < 0.05) higher odds of smartphone addiction. In contrast, patients on "sulfonylurea" (aOR = 0.18; 95% CI = 0.06-0.53); "metformin" (aOR = 0.19; 95% CI = 0.06-0.66), and "gabapentin" (aOR = 0.16; 95% CI = 0.04-0.67) and those with "comorbid hypertension" (aOR = 0.15; 95% CI = 0.06-0.38) had a significantly (p < 0.05) lower odds of smartphone addiction.

CONCLUSION

These alarming results require adequate action from the health authorities to raise awareness of adopting positive behaviors that could improve the well-being of this high-risk population.

Hemoglobin A1c and abdominal obesity as predictors of diabetes and ASCVD in individuals with prediabetes in UK Biobank: a prospective observational study

OBJECTIVES

Whether "prediabetes" merits particular clinical attention beyond the management of associated risk factors is controversial, particularly given the expansion of the definition of prediabetes from HbA1c 6.0-6.4% to 5.7-6.4%. Accordingly, we compared the risk of atherosclerotic cardiovascular disease (ASCVD) and type II diabetes mellitus (DM) risk in male and female participants with prediabetes and HbA1c 5.7-6.0% (low) versus 6.1-6.4% (high) to examine whether preventive recommendations should prioritize treating blood sugar or obesity, the major determinants of risk of DM versus other causes of ASCVD, such as lipids and blood pressure.

RESEARCH DESIGN AND METHODS

10-year risks of ASCVD and DM risk were determined separately in 296,470 women and men, age 40-73, from UK Biobank, free of ASCVD and DM at baseline. Cox proportional hazards regression with adjustment for conventional risk factors and Kaplan-Meier estimators were used with low (HbA1c 5.7-6.0%) and high prediabetes (HbA1c 6.1-6.4%) as primary exposuress with further stratification and adjustment for waist circumference.

RESULTS

In multivariate-adjusted models, low and high prediabetes was associated with increased risk of ASCVD versus normal HbA1c in both women (HR = 1.08, 95% CI 1.01,1.15 in low prediabetes and 1.25, 95% CI 1.14,1.38 in high prediabetes) and men (HR = 1.18, 95%CI 1.11,1.24 in low prediabetes and 1.27, 95% CI 1.17,1.38 in high prediabetes). The associations with new onset DM were substantially more potent, achieving HR of 4.05, 95%CI 3.73,4.40 in low prediabetic women versus 14.22, 95% CI 13.06,15.49 in high pre-diabetic women and 4.45, 95% CI 4.12,4.80 in low prediabetic men versus 15.59, 95% CI 14.43,16.85 in high pre-diabetic men. Furthermore, increasing waist circumference in low prediabetic men and all prediabetic women was associated with meaningful increase in DM risk.

CONCLUSIONS

The risks of progression to both new onset DM and ASCVD are significantly greater in the prediabetic population. This underscores the importance of preventing the development of DM and efforts to reduce cardiometabolic risk through optimizing multiple risk factors in both categories of prediabetes. Risk modification by waist circumference suggests weight and glucose lowering therapies should be targeted at those with highest risks.

Unravelling the cardio-renal-metabolic-foot connection in people with diabetes-related foot ulceration: a narrative review

Diabetes-related foot ulceration (DFU), a serious but preventable complication of diabetes, is a leading cause of hospitalisation, lower extremity amputation and disability worldwide. People with DFU have a greater burden of cardiovascular risk factors, heart failure and chronic kidney disease, resulting in over two-fold higher risk of cardiovascular death compared with people with diabetes without DFU. Here, we propose a "cardio-renal-metabolic-foot" connection in people with diabetes based on shared pathophysiological mechanisms linking DFU with cardiovascular and renal disease. Whilst these mechanistic links remain to be fully elucidated, systemic inflammation and infection in the context of DFU are postulated as key mediators in the development, and progression of, cardiovascular and renal disease. However, cardiovascular and renal disease are also implicated in the pathogenesis of DFU, highlighting the multi-directional interplay between conditions. The impact of screening, prevention, and early management of cardiovascular complications associated with DFU requires further research. Multi-modality cardiac imaging could play a role in unravelling disease mechanisms leading to novel therapeutic strategies, as well as facilitating personalised risk assessment and management. Recent clinical trials have transformed the therapeutic landscape for people with type 2 diabetes, by demonstrating that sodium glucose co-transporter 2 inhibitors, glucagon-like peptide-1 agonists and non-steroidal mineralocorticoid receptor antagonists improve cardiovascular and renal outcomes. Although dedicated research in people with DFU is warranted, these therapies could target multiple facets of the "cardio-renal-metabolic-foot" connection. The holistic, person-centred approach to managing DFU should incorporate new multidisciplinary models of care focusing on the prevention and management of cardiovascular and kidney disease.