Congestive heart failure in type 2 diabetes: prevalence, incidence, and risk factors

Predictors of intra-hospital mortality in patients with diabetic foot ulcers in Nigeria: data from the MEDFUN study

BACKGROUND

Diabetic foot ulcers (DFU) are associated with high morbidity and mortality globally. Mortality in patients hospitalized for DFU in Nigeria is unacceptably high. This study was undertaken to determine factors that predict mortality in patients hospitalized for DFU in Nigeria.

METHODS

The current study was part of Multi-centre Evaluation of Diabetic Foot Ulcer in Nigeria (MEDFUN), an observational study conducted in six tertiary healthcare institutions across the 6 geopolitical zones of Nigeria. Consecutive type 1 or 2 diabetic patients hospitalized for DFU who consented to participate were recruited and subjected to relevant clinical, biochemical, and radiological assessments and multidisciplinary care until discharge or death. Data for type 1 diabetes mellitus (DM) patients were expunged from current mortality analysis due to their small number.

RESULTS

Three hundred and twenty-three type 2 DM subjects with mean age and mean duration of DM of 57.2 ± 11.4 years and 8.7 ± 5.8 years respectively participated in this study. The median duration of ulcers was 39 days with a range of 28 to 54 days and the majority (79.9%) presented with advanced ulcers of at least Wagner grade 3. Mortality of 21.4% was recorded in the study, with the highest mortality observed among subjects with Wagner grade 5. Variables significantly associated with mortality with their respective p values were DM duration more than 120 months (p 0.005), ulcer duration > 1 month (p 0.020), ulcer severity of Wagner grade 3 and above (p 0.001), peripheral arterial disease (p 0.005), proteinuria (p < 0.001), positive blood cultures (p < 0.001), low HDL (p < 0.001), shock at presentation (p < 0.001), cardiac failure (p 0.027), and renal impairment (p < 0.001). On Multivariate regression analysis, presence of bacteraemia (OR 5.053; 95% CI 2.572-9.428) and renal impairment (OR 2.838; 95% CI 1.349-5.971) were significantly predictive of mortality independent of other variables.

CONCLUSIONS

This study showed high intra-hospital mortality among patients with DFU, with the majority of deaths occurring among those with advanced ulcers, bacteraemia, cardiac failure, and renal impairment. Prompt attention to these factors might help improve survival from DFU in Nigeria.

Neue Antidiabetika

Diabetes steigert das Risiko für Herz-Kreislauf-Erkrankungen und hat eine zunehmende Prävalenz. Die Therapie des Diabetes stellte bisher ein Dilemma dar, da viele Therapien zwar den Blutzucker, aber nicht kardiovaskuläre Ereignisse reduzierten. Erst Glukagon-like Peptid-1-Rezeptor-Agonisten (GLP1) und Natrium/Glukose-Cotransporter-2(SGLT2)-Inhibitoren senkten deutlich kardiovaskuläre Endpunkte, und SGLT2-Inhibitoren beugten darüber hinaus der Entwicklung einer Herzinsuffizienz vor. Die Glukosesenkung an sich ist daher nicht entscheidend für den Schutz vor Herz-Kreislauf-Erkrankungen. Die neuen Leitlinien der Europäischen Gesellschaft für Kardiologie stellen daher bei Patienten mit Diabetes und hohem kardiovaskulären Risiko die Verwendung von GLP1-Rezeptor-Agonisten und SGLT2-Inhibitoren der Behandlung mit Metformin voran. Die neuen Studiendaten eröffnen zudem neue metabolische Ansatzpunkte für die Behandlung von Herz-Kreislauf-Erkrankungen auch unabhängig vom Vorliegen eines Diabetes.

Association of Long-term Change and Variability in Glycemia With Risk of Incident Heart Failure Among Patients With Type 2 Diabetes: A Secondary Analysis of the ACCORD Trial

OBJECTIVE

To evaluate the associations between long-term change and variability in glycemia with risk of heart failure (HF) among patients with type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

Among participants with T2DM enrolled in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, variability in HbA_1c was assessed from stabilization of HbA_1c following enrollment (8 months) to 3 years of follow-up as follows: average successive variability (ASV) (average absolute difference between successive values), coefficient of variation (SD/mean), and SD. Participants with HF at baseline or within 3 years of enrollment were excluded. Adjusted Cox models were used to evaluate the association of percent change (from baseline to 3 years of follow-up) and variability in HbA_1c over the first 3 years of enrollment and subsequent risk of HF.

RESULTS

The study included 8,576 patients. Over a median follow-up of 6.4 years from the end of variability measurements at year 3, 388 patients had an incident HF hospitalization. Substantial changes in HbA_1c were significantly associated with higher risk of HF (hazard ratio [HR] for ≥10% decrease 1.32 [95% CI 1.08-1.75] and for ≥10% increase 1.55 [1.19-2.04]; reference <10% change in HbA_1c). Greater long-term variability in HbA_1c was significantly associated with higher risk of HF (HR per 1 SD of ASV 1.34 [95% CI 1.17-1.54]) independent of baseline risk factors and interval changes in cardiometabolic parameters. Consistent patterns of association were observed with use of alternative measures of glycemic variability.

CONCLUSIONS

Substantial long-term changes and variability in HbA_1c were independently associated with risk of HF among patients with T2DM.

Risk stratification tools for heart failure in the diabetes clinic

The advent of Sodium Glucose Transporter 2-inhibitors (SGLT2-i) in recent years gave endocrinologists the opportunity to actively treat and prevent heart failure (HF) in patients with type 2 diabetes (T2DM). While the relationship between T2DM and HF has been extensively reviewed, previous works focused mostly on epidemiology, pathophysiology and treatment of HF in T2DM. The aim of our work was to aid health care professionals in identifying individuals at high risk for this dreadful complication. Recent guidelines recommend to use drugs with proven cardiovascular benefits (Glucagon-like peptide-1 receptor agonists (GLP1-RA) and SGLT2-i) in patients with previous cardiovascular disease (CVD) and to prefer SGLT2-i in patients with known HF. In everyday clinical practice, the choice between these two drug classes in patients without known HF or atherosclerotic CVD is mostly arbitrary and based on the side effect profile. Recently, risk stratification tools to estimate HF incidence have been developed in order to guide treatment with a view to bring precision medicine into diabetes care. With this purpose, we provide a review of the tools able to predict HF incidence for patients in primary CVD prevention as well as risk of future hospitalizations for patients with known HF.

Comparison of heart failure risk and medical costs between patients with type 2 diabetes mellitus treated with dapagliflozin and dipeptidyl peptidase-4 inhibitors: a nationwide population-based cohort study

Background

Dapagliflozin is one of the novel glucose-lowering agents, which has recently been reported to reduce the risk of hospitalization for heart failure (hHF). The present study aimed to compare the differences between the risk of hHF after using dapagliflozin and dipeptidyl peptidase-4 inhibitors (DPP-4i) as second-line drugs for the treatment of type 2 diabetes mellitus using the latest nationwide population data in Korea. Additionally, we aimed to examine the impact of clinical outcomes on direct medical costs in the two groups.

Methods

The present population-based, retrospective cohort study was conducted using the nationwide claims data between September 01, 2014 and June 30, 2018. New users of dapagliflozin and DPP-4i were identified from the database and the differences in patients’ characteristics between the two groups were analyzed using propensity score-weighted analysis. Cox proportional hazards regression analysis was used to estimate the risk of hHF. A simple model was used for the estimation of direct medical costs for 3 years.

Results

In total, 23,147 patients in the dapagliflozin group and 237,187 patients in the DPP-4i group were selected for the analysis. The incidence rates of hHF were 3.86 and 6.79 per 1000 person-years in the dapagliflozin and DPP-4i groups, respectively. In the entire study population, the hazard ratio for hHF in the dapagliflozin group compared to the DPP-4i group was 0.58 (95% confidence interval 0.46–0.74), with 0.55 (95% confidence interval 0.41–0.74) among patients with underlying cardiovascular disease and 0.66 (95% confidence interval 0.46–0.95) among patients without underlying cardiovascular disease. The direct medical costs were $57,787 lower in the dapagliflozin group than in the DPP-4i group for 3 years.

Conclusions

This study showed that dapagliflozin lowers the risk for hHF and subsequently reduces direct medical costs compared to DPP-4i. The protective effect against hHF was more evident among patients with underlying cardiovascular disease.

[Clinical characteristics and quality assessment of the treatment of patients with chronic heart failure with diabetes mellitus]

AIM

A study of the clinical and instrumental characteristics and quality of treatment of patients with chronic heart failure (CHF) with diabetes mellitus.

MATERIALS AND METHODS

The study was conducted by using the CHF register method, which is a computer program with remote access, which allows on-line data collection on patients who have been examined and treated in primary care and in hospitals. The study included 8272 patients with CHF IIIV FC (functional class) (New York Heart Association NYHA); among them 62% of patients were treated in hospital.

RESULTS

The study showed that the frequency of diabetes was 21%. The main causes of CHF in diabetic patients are coronary artery disease, myocardial infarction (in anamnesis) and hypertension. These patients are more often diagnosed with III and IV CHF FC according to (NYHA) and retained LV (left ventricular) ejection fraction. The reduced ejection fraction was observed in 6.8% of cases, and the frequency of the intermediate LV was significantly higher than among patients with CHF and with diabetes and accounted for 18.9%. At patients with CHF with diabetes in comparison with patients with CHF without diabetes, atherosclerosis of the peripheral arteries, stroke (in anamnesis) and chronic kidney disease of stage III and IV were significantly more common.

CONCLUSION

Under the treatment, patients with CHF with diabetes have higher levels of SBP (systolic blood pressure), lipids and glucose in the blood plasma, indicating a lack of quality of treatment and, accordingly, the doctors are not optimally performing the clinical guidelines on treating this category of patients.

Second revolution in cardiovascular prevention

Type 2 diabetes has become a major disease burden in twenty-first century. Both incidence and prevalence of type 2 diabetes have quadrupled between 1980 and 2004 in the whole world. Atherosclerotic cardiovascular disease (ASCVD) is the major complication of type 2 diabetes. The introduction of statins in clinical settings is the first revolution in our battle against ASCVD. Most ASCVDs could be prevented or treated with statins. However, statin failed to reduce chronic kidney diseases (CKD) and heart failure (HF). Owing to a mandate from US Food and Drug Administration in 2008 that every new antidiabetic drug should be tested in clinical trials to demonstrate its safety, we now have a good opportunity to look for better antidiabetic drugs not only to decrease blood sugar but also to decrease CVD or renal disease. Among them, glucagon-like peptide-1 receptor agonists and sodium-glucose transport protein 2 inhibitors (SGLT-2 i) are two most extensively studied ones. SGLT-2 i, in particular, prevent CKD and end-stage renal disease, and prevent HF. In the recent CREDENCE trial, canagliflozin reduced renal endpoints by 34% and end-stage renal disease by 32%. Furthermore, in the recent DAPA-HF trial, dapagliflozin decreased hospitalization for HF/cardiovascular death by 26%, and total death by 17%, in patients with HF with reduced ejection fraction, irrespective of diabetes or nondiabetes. The beneficial effects of SGLT-2 i in CKD and HF are complementary to the effects of statins. The introduction of SGLT-2 i in clinical practice is the second revolution in cardiovascular prevention.

Diabetic cardiomyopathy

The relationship between diabetes and heart failure is complex and bidirectional. Nevertheless, the existence of a cardiomyopathy attributable exclusively to diabetes has been and is still the subject of controversy, due, among other reasons, to a lack of a consensus definition. There is also no unanimous agreement in terms of the physiopathogenic findings that need to be present in the definition of diabetic cardiomyopathy or on its classification, which, added to the lack of diagnostic methods and treatments specific for this disease, limits its general understanding. Studies conducted on diabetic cardiomyopathy, however, suggest a unique physiopathogenesis different from that of other diseases. Similarly, new treatments have been shown to play a potential role in this disease. The following review provides an update on diabetic cardiomyopathy.

A Framework to Understand the Progression of Cardiovascular Disease for Type 2 Diabetes Mellitus Patients Using a Network Approach

The prevalence of chronic disease comorbidity has increased worldwide. Comorbidity-i.e., the presence of multiple chronic diseases-is associated with adverse health outcomes in terms of mobility and quality of life as well as financial burden. Understanding the progression of comorbidities can provide valuable insights towards the prevention and better management of chronic diseases. Administrative data can be used in this regard as they contain semantic information on patients' health conditions. Most studies in this field are focused on understanding the progression of one chronic disease rather than multiple diseases. This study aims to understand the progression of two chronic diseases in the Australian health context. It specifically focuses on the comorbidity progression of cardiovascular disease (CVD) in patients with type 2 diabetes mellitus (T2DM), as the prevalence of these chronic diseases in Australians is high. A research framework is proposed to understand and represent the progression of CVD in patients with T2DM using graph theory and social network analysis techniques. Two study cohorts (i.e., patients with both T2DM and CVD and patients with only T2DM) were selected from an administrative dataset obtained from an Australian health insurance company. Two baseline disease networks were constructed from these two selected cohorts. A final disease network from two baseline disease networks was then generated by weight adjustments in a normalized way. The prevalence of renal failure, fluid and electrolyte disorders, hypertension and obesity was significantly higher in patients with both CVD and T2DM than patients with only T2DM. This showed that these chronic diseases occurred frequently during the progression of CVD in patients with T2DM. The proposed network-based model may potentially help the healthcare provider to understand high-risk diseases and the progression patterns between the recurrence of T2DM and CVD. Also, the framework could be useful for stakeholders including governments and private health insurers to adopt appropriate preventive health management programs for patients at a high risk of developing multiple chronic diseases.

Exercise enhances cardiac function by improving mitochondrial dysfunction and maintaining energy homoeostasis in the development of diabetic cardiomyopathy

Diabetic cardiomyopathy (DCM) is a major cause of morbidity and mortality in diabetic patients. Reactive oxygen species (ROS) produced by oxidative stress play an important role in the development of DCM. DCM involves abnormal energy metabolism, thereby reducing energy production. Exercise has been reported to be effective in protecting the heart against ROS accumulation during the development of DCM. We hypothesize that the AMPK/PGC-1α axis may play a crucial role in exercise-induced bioenergetic metabolism and aerobic respiration on oxidative stress parameters in the development of diabetic cardiomyopathy. Using a streptozotocin/high-fat diet mouse to generate a diabetic model, our aim was to evaluate the effects of exercise on the cardiac function, mitochondrial oxidative capacity, mitochondrial function, and cardiac expression of PGC-1α. Mice fed a high-fat diet were given MO-siPGC-1α or treated with AMPK inhibitor. Mitochondrial structure and effects of switching between the Warburg effect and aerobic respiration were analysed. Exercise improved blood pressure and systolic dysfunction in diabetic mouse hearts. The beneficial effects of exercise were also observed in a mitochondrial function study, as reflected by an enhanced oxidative phosphorylation level, increased membrane potential, and decreased ROS level and oxygen consumption. On the other hand, depletion of PGC-1α attenuated the effects of exercise on the enhancement of mitochondrial function. In addition, PGC-1α may be responsible for reversing the Warburg effect to aerobic respiration, thus enhancing mitochondrial metabolism and energy homoeostasis. In this study, we demonstrate the protective effects of exercise on shifting energy metabolism from fatty acid oxidation to glucose oxidation in an established diabetic stage. These data suggest that exercise is effective at ameliorating diabetic cardiomyopathy by improving mitochondrial function and reducing metabolic disturbances.

Diabetes Mellitus Is an Independent Predictor for the Development of Heart Failure: A Population Study

OBJECTIVES

To delineate the impact of diabetes mellitus (DM) on the development of cardiovascular diseases in a community population.

PATIENTS & METHODS

Cross-sectional survey of residents randomly selected through the Rochester Epidemiology Project, 45 years or older, of Olmsted County as of June 1, 1997, through September 30, 2000. Responders (2042) underwent assessment of systolic and diastolic function using echocardiography. The current analyses included all participants with DM and were compared with a group of participants without DM matched 1:2 for age, sex, hypertension, and coronary artery disease. Baseline characteristics and laboratory and echocardiography findings between groups were compared along with rates of mortality due to various cardiovascular conditions.

RESULTS

We identified 116 participants with DM and 232 matched participants without DM. Those with DM had a higher body mass index and plasma insulin and serum glucose levels. Although left ventricular ejection fractions were similar, E/e' ratio (9.7 vs 8.5; P=.001) was higher in DM vs non-DM. During a follow-up of 10.8 (interquartile range, 7.8-11.7) years, participants with DM had a higher incidence of heart failure (HF); hazard ratio, 2.1; 95% confidence limits, 1.2-3.6; P=.01) and 10-year Kaplan-Meier rate of 21% (22 of 116) vs 12% (24 of 232) compared with those without DM. We also examined the subgroup of participants without diastolic dysfunction. In this subgroup, those with DM had an increased risk for HF; hazard ratio, 2.5; 95% confidence limits, 1.0-6.3; P=.04).

CONCLUSION

In this cohort, participants with DM have an increased incidence of HF over a 10-year follow-up period even in the absence of underlying diastolic dysfunction. These findings suggest that DM is an independent risk factor for the development of HF and supports the concept of DM cardiomyopathy.

ANGPTL8 Gene Polymorphism rs2278426 Is Related to Carotid Intima-Media Thickness in T2DM

AIM

ANGPTL8 is a cytokine expressed and secreted by liver and adipose tissue, and is involved in glucose, lipid, and energy metabolism. Although studies have shown that ANGPTL8 is elevated in type 2 diabetes mellitus (T2DM) and cardiovascular disease, few have examined the association between ANGPTL8 single-nucleotide polymorphisms and the risk of macrovascular complications in T2DM patients. This study aimed to explore the relationship between rs2278426 and carotid intima-media thickening (cIMT) in T2DM.

METHODS

A total of 217 T2DM patients and 201 healthy control subjects with normal glucose tolerance were recruited in the study. T2DM patients were divided into two groups: T2DM patients without cIM thickening (cIMT <1 mm, 109 cases) and T2DM patients with cIM thickening (cIMT ≥1 mm, 108 cases). rs2278426 genotypes in all 418 subjects were determined and the risk of T2DM and T2DM with cIM thickening analyzed.

RESULTS

CT+TT-genotype frequency in T2DM was higher than in controls with normal glucose tolerance, and the proportion of the CT+TT genotype in the group with cIMT was higher than in the group (P<0.05). In addition, T alleles were associated with waist:hip ratio, triglycerides, high density-lipoprotein cholesterol, plasma glucose at 2 hours' oral glucose tolerance, and homeostatic model assessment of insulin resistance (P<0.05).

CONCLUSION

Generally, carriers of the T allele at rs2278426 are more likely to develop T2DM, and the risk of cIM thickening is significantly increased for T-allele carriers with T2DM, which indicates an increased risk of macroangiopathy.

Prevalence of diabetes mellitus as well as cardiac and other main comorbidities in a representative sample of the adult Greek population in comparison with the general population

BACKGROUND

Diabetes mellitus (DM) is the most common metabolic disorder that increases the risk of cardiovascular disease by two to four times compared with the general population. There are limited data on the prevalence of heart diseases in subjects with DM in Greece. In this study, we examined the prevalence of self-reported DM as well as cardiac and other main comorbidities in a representative sample of the adult Greek population.

METHODS

The target study population included 30,843 participants stratified by gender, age, and district, and this was a representative sample of the adult Greek population in 2010. A structured questionnaire was built to report the prevalence of self-reported DM and the main comorbidities in participants with and without DM. Collection of data was performed through telephone interviews.

RESULTS

The prevalence of self-reported DM was 6.6%. The prevalence of the main comorbidities in participants with DM vs. those without DM was as follows: heart diseases 24.0% vs. 8.9%, p<0.001; lung diseases 11.3% vs. 5.3%, p<0.001; kidney diseases 3.4% vs. 1.2%, p=0.001; liver diseases 1.4% vs. 0.7%, p=0.001; benign blood diseases 1.6% vs. 0.9%, p=0.005; and solid organ and/or blood malignancies 2.9% vs. 1.5%, p<0.001.

CONCLUSIONS

The prevalence of self-reported DM in a representative sample of the adult Greek population in 2010 was 6.6%. The prevalence of heart diseases in subjects with DM was 2.7-fold higher than the prevalence in those without DM. Diseases of the lung, kidney, liver, and blood as well as malignancies were significantly more common among participants with DM.

Heart Failure and Diabetes Mellitus: Defining the Problem and Exploring the Interrelationship

Type 2 diabetes mellitus and congestive heart failure are highly prevalent diseases with significant morbidity and mortality. These 2 diseases often occur concurrently because of shared risk factors such as coronary artery disease, and also because type 2 diabetes mellitus has direct cardiotoxic effects. Type 2 diabetes mellitus likely has a causative role in the development and prognosis of patients with heart failure. Optimal prevention and treatment of type 2 diabetes mellitus and heart failure likely involves identifying and treating their shared pathophysiologic features. Novel drug therapies, such as sodium-glucose co-transporter 2 inhibitors, offer an exciting potential to better understand the relationship between type 2 diabetes mellitus and heart failure, and may prove to have beneficial effects on cardiovascular outcomes in patients affected by these diseases.

Novel Insights into the Role of HDL-Associated Sphingosine-1-Phosphate in Cardiometabolic Diseases

Sphingolipids are key signaling molecules involved in the regulation of cell physiology. These species are found in tissues and in circulation. Although they only constitute a small fraction in lipid composition of circulating lipoproteins, their concentration in plasma and distribution among plasma lipoproteins appears distorted under adverse cardiometabolic conditions such as diabetes mellitus. Sphingosine-1-phosphate (S1P), one of their main representatives, is involved in regulating cardiomyocyte homeostasis in different models of experimental cardiomyopathy. Cardiomyopathy is a common complication of diabetes mellitus and represents a main risk factor for heart failure. Notably, plasma concentration of S1P, particularly high-density lipoprotein (HDL)-bound S1P, may be decreased in patients with diabetes mellitus, and hence, inversely related to cardiac alterations. Despite this, little attention has been given to the circulating levels of either total S1P or HDL-bound S1P as potential biomarkers of diabetic cardiomyopathy. Thus, this review will focus on the potential role of HDL-bound S1P as a circulating biomarker in the diagnosis of main cardiometabolic complications frequently associated with systemic metabolic syndromes with impaired insulin signaling. Given the bioactive nature of these molecules, we also evaluated its potential of HDL-bound S1P-raising strategies for the treatment of cardiometabolic disease.

Impact of diabetes on mortality and rehospitalization in acute heart failure patients stratified by ejection fraction

Aims

The aim of this study is to determine the impact of diabetes mellitus on all‐cause mortality and rehospitalization rates at 3 months and at 1 year in patients admitted with acute heart failure (AHF) stratified by left ventricular ejection fraction (EF).

Methods and results

We analysed consecutive patients admitted to 47 hospitals in seven Middle Eastern countries (Saudi Arabia, Oman, Yemen, Kuwait, United Arab Emirates, Qatar, and Bahrain) with AHF from February to November 2012 with AHF who were enrolled in Gulf CARE, a multinational registry of patients with heart failure (HF). AHF patients were stratified into three groups: HF patients with reduced (EF) (HFrEF) (<40%), HF with mid‐range EF (HFmrEF) (40–49%), and HF patients with preserved EF (HFpEF) (≥50%). Analyses were performed using univariate and multivariate statistical techniques. The mean age of the cohort was 59 ± 15 years (ranging from 18 to 99 years), and 63% (n = 2887) of the patients were males. A total of 2258 (49%) AHF patients had diabetes mellitus. The mean EF was 37 ± 14%. A reduced EF was observed in 2683 patients (59%), whereas 962 patients (21%) had mid‐range and 932 patients (20%) had preserved EF. Multivariable analyses demonstrated no significant differences in all‐cause mortality between diabetics and non‐diabetics in all the three types of HF; at 3 months follow‐up: HFrEF [adjusted odds ratio (aOR), 1.30; 95% confidence interval (CI): 0.94–1.80; P = 0.119], HFmrEF (aOR, 0.98; 95% CI: 0.51–1.87; P = 0.952), and HFpEF (aOR, 0.69; 95% CI: 0.38–1.26; P = 0.225); and at 12‐months follow‐up: HFrEF (aOR, 1.25; 95% CI: 0.97–1.62; P = 0.080), HFmrEF (aOR, 1.07; 95% CI: 0.68–1.68; P = 0.783), and HFpEF (aOR, 1.07; 95% CI: 0.67–1.72; P = 0.779). There were also no significant differences in rehospitalization rates between diabetics and non‐diabetics in all the three types of HF; at 3 months follow‐up: HFrEF (aOR, 0.94; 95% CI: 0.74–1.19; P = 0.581), HFmrEF (aOR, 0.82; 95% CI: 0.53–1.26; P = 0.369), and HFpEF (aOR, 1.06; 95% CI: 0.64–1.78; P = 0.812); and at 12‐months follow‐up: HFrEF (aOR, 0.93; 95% CI: 0.73–1.17; P = 0.524), HFmrEF (aOR, 0.81; 95% CI: 0.56–1.17; P = 0.257), and HFpEF (aOR, 1.29; 95% CI: 0.82–2.05; P = 0.271).

Conclusions

There were no significant differences in 3 and 12 months all‐cause mortality as well as rehospitalization rates between diabetics and non‐diabetic patients in all the three types of AHF patients stratified by left ventricular ejection fraction.

Myocardial Function Assessed by Multi-Layered Two-Dimensional Speckle Tracking Analysis in Asymptomatic Young Subjects with Diabetes Mellitus Type 1

BACKGROUND

Diabetes mellitus type 1 (DM1) is associated with a high risk for cardiovascular disease, and early detection of myocardial dysfunction is crucial for the prevention of cardiac complications.

OBJECTIVES

The aim of this study was to evaluate left ventricular (LV) and right ventricular (RV) function by using both conventional echocardiography as well as multi-layered speckle tracking echocardiography (STE) in young adults with DM1.

METHODS

We included 50 young asymptomatic adults diagnosed with DM1 (mean interval from diagnosis 9 ± 6 years) and 80 healthy controls. STE was acquired using the GE Vivid S60 equipment. The LV longitudinal strain (LS), layer-specific strains of the endocardium, myocardium, and epicardium (global longitudinal strain [GLS]endo, GLSmyo, GLSepi) as well as RV strain were obtained using the EchoPAC BT13 workstation.

RESULTS

No significant intergroup differences in LV ejection fraction were noted. GLSendo and GLSmyo were reduced in the DM1 group (-20.6 ± 2.7 vs. -22.0 ± 2.3 and -18.0 ± 2.4 vs. -19.1 ± 1.9, respectively, p < 0.05) compared to controls. Mechanical dispersion was higher in the diabetes group (34 ± 11 vs. 29 ± 7, p < 0.05). RV strain measurements showed no significant difference between the groups.

CONCLUSIONS

Young adults with DM1 and without known heart disease have subclinical myocardial dysfunction with lower LV endocardium and myocardium LS and higher mechanical dispersion demonstrated by multi-layered STE.

Heart failure and its complications in patients with diabetes: Mounting evidence for a growing burden

Heart failure (HF) is one of the major challenges in the management of diabetes patients. Among subjects with diabetes, up to 20% could have HF. Conversely, diabetes prevalence in HF patients varies greatly from more than 10% up to 50%. When it is present, the risk of mortality and rehospitalization increases substantially. In addition, current evidence points to an increased risk of atrial fibrillation and sudden cardiac death in patients with diabetes. The inter-relation between diabetes cardiomyopathy, left ventricular hypertrophy, coronary artery disease and renal dysfunction indicates complex and intricate pathways. Despite the great value of clinical assessment and echocardiography, there is insufficient data to suggest systematic screening for HF in asymptomatic patients with diabetes. There is little evidence to indicate that improved glycaemic control improves HF outcome in this population. In the case of established HF, the general guidelines apply in diabetes patients. However, recent advances concerning glucose-lowering treatment in patients with cardiovascular disease suggest that the choice of glucose-lowering agent is of crucial interest and should be based on the patient’s phenotype. New drug classes, such as SGLT2 inhibitors, seem to be of particular benefit in these patients. In the future, new personalized strategies should aim at not only good control of the glycaemic level but also the reduction and possibly the prevention of HF onset.

Heart failure with insulin degludec versus glargine U100 in patients with type 2 diabetes at high risk of cardiovascular disease: DEVOTE 14

Background

Heart failure (HF) is a common cardiovascular complication of type 2 diabetes (T2D). This secondary analysis investigated baseline factors and treatment differences associated with risk of hospitalization for HF (hHF), and the possible association between severe hypoglycemia and hHF.

Methods

DEVOTE was a treat-to-target, double-blind cardiovascular outcomes trial in patients (n = 7637) with T2D and high cardiovascular risk randomized to insulin degludec (degludec) or insulin glargine 100 units/mL (glargine U100). The main endpoint of this secondary analysis was time to first hHF (standardized MedDRA Query definition). Severe hypoglycemia was adjudicated (American Diabetes Association definition). The main endpoint and the temporal association between severe hypoglycemia and hHF were analyzed with a Cox proportional hazards regression model. Predictors of time to first hHF were identified using baseline variables.

Results

Overall, 372 (4.9%) patients experienced hHF (550 events). There was no significant difference in the risk of hHF between treatments (hazard ratio [HR] 0.88 [0.72;1.08]_{95% CI}, p = 0.227). Prior HF (HR 4.89 [3.90;6.14]_{95% CI}, p ≤ 0.0001) was the strongest predictor of future hHF events. The risk of hHF significantly increased after (HR 2.2), and within a week after (HR 11.1), experiencing a severe hypoglycemic episode compared with before an episode.

Conclusions

In patients with T2D and high cardiovascular risk there were no treatment differences in terms of hHF. Prior HF was the strongest predictor of future hHF events, and there was an association between severe hypoglycemia and subsequent hHF. Further research should evaluate whether the risk of hHF can be modified by treatments aimed at reducing hypoglycemia.

Trial Registration NCT01959529

Glucose-lowering drugs and heart failure: implications of recent cardiovascular outcome trials in type 2 diabetes

Heart failure (HF) is common in Type-2 diabetes mellitus (T2DM), and viceversa, leading to a mutual impact on prognosis. Knowledge about this complex interplay has dramatically changed recently, due to development of new glucose-lowering drugs, and to specific FDA and EMA Guidance mandating to perform cardiovascular outcome trials (CVOTs), aimed at establishing cardiovascular safety, for new anti-diabetic treatments before they enter the market. Such CVOTs have demonstrated that the effects of the new antidiabetic drugs on the mutual interactions between T2DM and HF may develop across different phases:Results of such trials can be summarized as: (a) all different classes of novel glucose-lowering drugs have good cardiovascular safety profile; (b) with respect to HF, DPP4 inhibitors might tend to increase risk; (c) sodium-glucose co-transporter 2 inhibitors (SGTLi), significantly reduce it; (d) glucagon-like peptide 1 receptor agonists (GLP1) tend to be neutral. These CVOTs data have led to guideline recommendations indicating appropriate therapy to T2DM patients with HF not at glycemic control target with metformin therapy.

Heart Failure in Type 2 Diabetes Mellitus

Patients with diabetes mellitus have >2× the risk for developing heart failure (HF; HF with reduced ejection fraction and HF with preserved ejection fraction). Cardiovascular outcomes, hospitalization, and prognosis are worse for patients with diabetes mellitus relative to those without. Beyond the structural and functional changes that characterize diabetic cardiomyopathy, a complex underlying, and interrelated pathophysiology exists. Despite the success of many commonly used antihyperglycemic therapies to lower hyperglycemia in type 2 diabetes mellitus the high prevalence of HF persists. This, therefore, raises the possibility that additional factors beyond glycemia might contribute to the increased HF risk in diabetes mellitus. This review summarizes the state of knowledge about the impact of existing antihyperglycemic therapies on HF and discusses potential mechanisms for beneficial or deleterious effects. Second, we review currently approved pharmacological therapies for HF and review evidence that addresses their efficacy in the context of diabetes mellitus. Dysregulation of many cellular mechanisms in multiple models of diabetic cardiomyopathy and in human hearts have been described. These include oxidative stress, inflammation, endoplasmic reticulum stress, aberrant insulin signaling, accumulation of advanced glycated end-products, altered autophagy, changes in myocardial substrate metabolism and mitochondrial bioenergetics, lipotoxicity, and altered signal transduction such as GRK (g-protein receptor kinase) signaling, renin angiotensin aldosterone signaling and β-2 adrenergic receptor signaling. These pathophysiological pathways might be amenable to pharmacological therapy to reduce the risk of HF in the context of type 2 diabetes mellitus. Successful targeting of these pathways could alter the prognosis and risk of HF beyond what is currently achieved using existing antihyperglycemic and HF therapeutics.

Consensus recommendations for management of patients with type 2 diabetes mellitus and cardiovascular diseases

The recent American Diabetes Association and the European Association for the Study of Diabetes guideline mentioned glycaemia management in type 2 diabetes mellitus (T2DM) patients with cardiovascular diseases (CVDs); however, it did not cover the treatment approaches for patients with T2DM having a high risk of CVD, and treatment and screening approaches for CVDs in patients with concomitant T2DM. This consensus guideline undertakes the data obtained from all the cardiovascular outcome trials (CVOTs) to propose approaches for the T2DM management in presence of CV comorbidities. For patients at high risk of CVD, metformin is the drug of choice to manage the T2DM to achieve a patient specific HbA1c target. In case of established CVD, a combination of glucagon-like peptide-1 receptor agonist with proven CV benefits is recommended along with metformin, while for chronic kidney disease or heart failure, a sodium-glucose transporter proteins-2 inhibitor with proven benefit is advised. This document also summarises various screening and investigational approaches for the major CV events with their accuracy and specificity along with the treatment guidance to assist the healthcare professionals in selecting the best management strategies for every individual. Since lifestyle modification and management plays an important role in maintaining the effectiveness of the pharmacological therapies, authors of this consensus recommendation have also briefed on the patient-centric non-pharmacological management of T2DM and CVD.

Cardiac Insulin Resistance in Heart Failure: The Role of Mitochondrial Dynamics

Heart failure (HF) frequently coexists with conditions associated with glucose insufficiency, such as insulin resistance and type 2 diabetes mellitus (T2DM), and patients with T2DM have a significantly high incidence of HF. These two closely related diseases cannot be separated on the basis of their treatment. Some antidiabetic drugs failed to improve cardiac outcomes in T2DM patients, despite lowering glucose levels sufficiently. This may be, at least in part, due to a lack of understanding of cardiac insulin resistance. Basic investigations have revealed the significant contribution of cardiac insulin resistance to the pathogenesis and progression of HF; however, there is no clinical evidence of the definition or treatment of cardiac insulin resistance. Mitochondrial dynamics play an important role in cardiac insulin resistance and HF because they maintain cellular homeostasis through energy production, cell survival, and cell proliferation. The innovation of diagnostic tools and/or treatment targeting mitochondrial dynamics is assumed to improve not only the insulin sensitivity of the myocardium and cardiac metabolism, but also the cardiac contraction function. In this review, we summarized the current knowledge on the correlation between cardiac insulin resistance and progression of HF, and discussed the role of mitochondrial dynamics on the pathogenesis of cardiac insulin resistance and HF. We further discuss the possibility of mitochondria-targeted intervention to improve cardiac metabolism and HF.

miR‑132 inhibits high glucose‑induced vascular smooth muscle cell proliferation and migration by targeting E2F5

The dysregulated behavior of vascular smooth muscle cells (VSMCs) serves an important role in the pathogenesis of cardiovascular diseases in diabetes. The present study aimed to investigate the effects of microRNA (miR)‑132 on the proliferation and migration of VSMCs under high glucose conditions to mimic diabetes. We observed that the expression of miR‑132 was significantly decreased and that of E2F transcription factor 5 (E2F5) was upregulated in high glucose (HG)‑treated VSMCs or those obtained from diabetic rats. A dual luciferase reporter gene assay revealed that miR‑132 could specifically bind to the 3'‑untranslated region of E2F5 and significantly suppress the luciferase activity. The proliferation and migration of diabetic rat or HG‑treated VSMCs were increased compared with non‑diabetic rat VSMCs and those under normal glucose conditions. Upregulation of miR‑132 significantly inhibited the proliferation and migration of diabetic rat VSMCs; similar effects were observed following E2F5 downregulation. The inhibitory effects of miR‑132 on the proliferation and migration of HG‑treated VSMCs could be reversed by E2F5 overexpression. In conclusion, miR‑132 was proposed to inhibit the proliferation and migration of diabetic rat or high‑glucose‑treated VSMCs by targeting E2F5. The findings of the present study suggested that increasing the expression of miR‑132 may serve as a novel therapeutic approach to inhibit the progression of cardiovascular disease in diabetes.

Molecular Dysfunction and Phenotypic Derangement in Diabetic Cardiomyopathy

The high incidence and poor prognosis of heart failure (HF) patients affected with diabetes (DM) is in part related to a specific cardiac remodeling currently recognized as diabetic cardiomyopathy (DCM). This cardiac frame occurs regardless of the presence of coronary artery diseases (CAD) and it can account for 15–20% of the total diabetic population. The pathogenesis of DCM remains controversial, and several molecular and cellular alterations including myocardial hypertrophy, interstitial fibrosis, oxidative stress and vascular inflammation, have been postulated. The main cardio-vascular alterations associated with hyperglycemia comprise endothelial dysfunction, adverse effects of circulating free fatty acids (FFA) and increased systemic inflammation. High glucose concentrations lead to a loss of mitochondrial networks, increased reactive oxygen species (ROS), endothelial nitric oxide synthase (eNOS) activation and a reduction in cGMP production related to protein kinase G (PKG) activity. Current mechanisms enhance the collagen deposition with subsequent increased myocardial stiffness. Several concerns regarding the exact role of DCM in HF development such as having an appearance as either dilated or as a concentric phenotype and whether diabetes could be considered a causal factor or a comorbidity in HF, remain to be clarified. In this review, we sought to explain the different DCM subtypes and the underlying pathophysiological mechanisms. Therefore, the traditional and new molecular and signal alterations and their relationship with macroscopic structural abnormalities are described.

The role of sodium glucose cotransporter-2 (SGLT-2) inhibitors in heart failure and chronic kidney disease in type 2 diabetes

Background: Heart failure (HF) and chronic kidney disease (CKD) are responsible for substantial morbidity and mortality in individuals with type 2 diabetes (T2D). Methods: This review discusses the significance of these comorbidities of T2D and current options for managing them, with a focus on sodium-glucose cotransporter-2 (SGLT-2) inhibitors. Based on a focused literature search of cardiovascular outcomes trials (CVOTs), this review assessed the effects of SGLT-2 inhibitors in individuals with T2D with or without established cardiovascular disease (CVD). Results: In addition to effective glycemic control and weight loss, SGLT-2 inhibitor treatment of T2D prevents adverse cardiovascular and renal outcomes in individuals with and without these comorbidities. Reduced rate of hospitalization due to HF (HHF) and improved renal outcomes appear to be class effects of SGLT-2 inhibitors. Reduction in CV events may be more significant in individuals with established cardiovascular disease. Conclusions: CVOTs and other studies confirm that the SGLT-2 inhibitors, mostly used in combination with other glucose-lowering drugs, offer several clinical benefits beyond improved glycemic control. These include reducing HHF risk and improving renal outcomes. HF and renal benefits are observed in individuals with and without established CVD, which may simplify therapeutic selection. Ongoing SGLT-2 inhibitor CVOTs will help clarify the potential of these drugs to treat T2D comorbid with different forms of HF (HF with preserved vs reduced ejection fraction) and different degrees of renal dysfunction, and in individuals with T2D vs pre-diabetes or normal glucose metabolism.

Challenges to hemoglobin A1c as a therapeutic target for type 2 diabetes mellitus

Glycated hemoglobin (HbA1c) is widely accepted as the most reliable measure of long-term glycemia. However, there is disagreement among professional medical societies on a proper glycemic target for long-term benefits in type 2 diabetes (T2D). The use of some glucose-lowering drugs was associated with heart failure despite substantial lowering of HbA1c. The failure of intensive glycemic control to reduce cardiovascular risk in some trials again brought into question the usefulness of HbA1c as a therapeutic target in T2D. In large cardiovascular outcome trials, some newer glucose-lowering drugs were associated with higher risks of heart failure or amputation despite comparable glycemic control between the test and placebo groups. Here, we provide evidence that variation in hemoglobin glycation between individuals is responsible for these inconsistencies. We suggest that further research be conducted in this area and that the findings be applied to clinical trials and practice.

O-GlcNAcylation of Histone Deacetylase 4 Protects the Diabetic Heart From Failure

BACKGROUND

Worldwide, diabetes mellitus and heart failure represent frequent comorbidities with high socioeconomic impact and steadily growing incidence, calling for a better understanding of how diabetic metabolism promotes cardiac dysfunction. Paradoxically, some glucose-lowering drugs have been shown to worsen heart failure, raising the question of how glucose mediates protective versus detrimental cardiac signaling. Here, we identified a histone deacetylase 4 (HDAC4) subdomain as a molecular checkpoint of adaptive and maladaptive signaling in the diabetic heart.

METHODS

A conditional HDAC4 allele was used to delete HDAC4 specifically in cardiomyocytes (HDAC4-knockout). Mice were subjected to diabetes mellitus either by streptozotocin injections (type 1 diabetes mellitus model) or by crossing into mice carrying a leptin receptor mutation (db/db; type 2 diabetes mellitus model) and monitored for remodeling and cardiac function. Effects of glucose and the posttranslational modification by β-linked N-acetylglucosamine (O-GlcNAc) on HDAC4 were investigated in vivo and in vitro by biochemical and cellular assays.

RESULTS

We show that the cardio-protective N-terminal proteolytic fragment of HDAC4 is enhanced in vivo in patients with diabetes mellitus and mouse models, as well as in vitro under high-glucose and high-O-GlcNAc conditions. HDAC4-knockout mice develop heart failure in models of type 1 and type 2 diabetes mellitus, whereas wild-type mice do not develop clear signs of heart failure, indicating that HDAC4 protects the diabetic heart. Reexpression of the N-terminal fragment of HDAC4 prevents HDAC4-dependent diabetic cardiomyopathy. Mechanistically, the posttranslational modification of HDAC4 at serine (Ser)-642 by O-GlcNAcylation is an essential step for production of the N-terminal fragment of HDAC4, which was attenuated by Ca²⁺/calmodulin-dependent protein kinase II-mediated phosphorylation at Ser-632. Preventing O-GlcNAcylation at Ser-642 not only entirely precluded production of the N-terminal fragment of HDAC4 but also promoted Ca²⁺/calmodulin-dependent protein kinase II-mediated phosphorylation at Ser-632, pointing to a mutual posttranslational modification cross talk of (cardio-detrimental) phosphorylation at Ser-632 and (cardio-protective) O-GlcNAcylation at Ser-642.

CONCLUSIONS

In this study, we found that O-GlcNAcylation of HDAC4 at Ser-642 is cardio-protective in diabetes mellitus and counteracts pathological Ca²⁺/calmodulin-dependent protein kinase II signaling. We introduce a molecular model explaining how diabetic metabolism possesses important cardio-protective features besides its known detrimental effects. A deeper understanding of the here-described posttranslational modification cross talk may lay the groundwork for the development of specific therapeutic concepts to treat heart failure in the context of diabetes mellitus.

Bayesian adaptive lasso for additive hazard regression with current status data

Variable selection is a crucial issue in model building and it has received considerable attention in the literature of survival analysis. However, available approaches in this direction have mainly focused on time-to-event data with right censoring. Moreover, a majority of existing variable selection procedures for survival models are developed in a frequentist framework. In this article, we consider additive hazards model in the presence of current status data. We propose a Bayesian adaptive least absolute shrinkage and selection operator procedure to conduct a simultaneous variable selection and parameter estimation. Efficient Markov chain Monte Carlo methods are developed to implement posterior sampling and inference. The empirical performance of the proposed method is demonstrated by simulation studies. An application to a study on the risk factors of heart failure disease for type 2 diabetes patients is presented.

Heart failure risk in systemic lupus erythematosus compared to diabetes mellitus and general medicaid patients

BACKGROUND

Patients with systemic lupus erythematosus (SLE) have a similar risk of myocardial infarction as those with diabetes mellitus (DM). Whether the risk of heart failure (HF) in SLE is similar to the elevated risk in DM is unknown. We sought to estimate the rates and risks for HF hospitalization among US Medicaid patients with SLE and to compare them to those for DM and the general Medicaid population.

METHODS

Using U.S. Medicaid data from 2007-2010, we identified patients with SLE or DM, and a matched cohort from the general Medicaid population and calculated incidence rates (IR), incidence rate ratios (IRR) and adjusted hazard ratios (HR) of a first HF hospitalization.

RESULTS

We identified 37,902 SLE (93% female, mean age 40.1 ± 12.1), 76,657 DM (93% female, mean age 40.0 ± 12.1), and 158,695 general Medicaid patients (93% female, mean age 40.2 ± 12.1). The IR per 1000-person years was 6.9 (95% CI 6.3-7.5) for SLE, 6.6 (95% CI 6.2-7.0) for DM, and 1.6 (95% CI 1.5-1.8) for general Medicaid patients. The highest IRR compared to general Medicaid was seen among SLE patients in age group 18-39 (14.7, 95% CI 13.9-15.5). Multivariable-adjusted HRs for HF compared to general Medicaid population were similar for SLE (2.7, 95% CI 2.3-3.1) and DM (3.0, 95% CI 2.6-3.4).

CONCLUSION

The incidence of HF among SLE patients was 2.7-fold higher than general Medicaid patients, and similar to DM. Further investigation into the biologic mechanism of HF among SLE compared to non-SLE and DM patients may shed light on the findings of this study.

Heart failure in the patient with diabetes: Epidemiology, aetiology, prognosis, therapy and the effect of glucose-lowering medications

In people with type 2 diabetes the frequency of heart failure (HF) is increased and mortality from HF is higher than with non-diabetic HF. The increased frequency of HF is attributable to the cardiotoxic tetrad of ischaemic heart disease, left ventricular hypertrophy, diabetic cardiomyopathy and an extracellular volume expansion resistant to atrial natriuretic peptides. Activation of the renin-angiotensin-aldosterone system and sympathetic nervous systems results in cardiac remodelling, which worsens cardiac function. Reversal of remodelling can be achieved, and cardiac function improved in people with HF with reduced ejection fraction (HFrEF) by treatment with angiotensin-converting enzyme inhibitors and β-blockers. However, with HF with preserved ejection fraction (HFpEF), only therapy for the underlying risk factors helps. Blockers of mineralocorticoid receptors may be beneficial in both HFrEF and HFpEF. Glucose-lowering drugs can have a negative effect (insulin, sulphonylureas, dipeptidyl peptidase-4 inhibitors and thiazolidinediones), a neutral effect (α-glucosidase inhibitors and glucagon-like peptide-1 receptor agonists) or a positive effect (sodium-glucose co-transporter-2 inhibitors and metformin).

High brain natriuretic peptide is associated with sarcopenia in patients with type 2 diabetes: a cross-sectional study of KAMOGAWA-DM cohort study

Association between heart failure and sarcopenia has been reported, however, the association between sarcopenia and brain natriuretic peptide (BNP) is unclear. Thus, we investigated the association between sarcopenia and BNP in type 2 diabetic patients without heart failure. In this cross-sectional study, skeletal muscle mass index (SMI, kg/m²) was calculated as appendicular muscle mass, measured by bioimpedance analyzer, by the square of the height. Sarcopenia was defined as having both handgrip strength of <26 kg for men and <18 kg for women, and SMI of <7.0 kg/m² for men and <5.7 kg/m² for women. To investigate the impact of BNP levels on the presence of sarcopenia, propensity-score matching analysis was used to remove the bias of confounding variables, including age, sex, duration of diabetes, body mass index, exercise, systolic blood pressure, smoking status, hemoglobin A1c, creatinine, energy and protein intake. The area under the curve (AUC) of BNP levels for the presence of sarcopenia was calculated by the receiver operating characteristic curve (ROC). Among 433 patients (236 men and 65.4 (11.1) years), 32 patients (7.4%) were diagnosed as sarcopenia. In the propensity-matched 58 patients, BNP levels (Δ10 pg/mL incremental) were associated with the presence of sarcopenia by logistic regression analysis, (odds ratio: 1.56, 95% confidence interval: 1.14-2.13, p = 0.002). The optimal cut-off point of BNP levels for sarcopenia is 27.3 pg/mL (AUC 0.777, 95%CI, 0.691-0.863, sensitivity = 0.813, specificity = 0.736, p < 0.001). In conclusion, BNP levels were associated with sarcopenia in type 2 diabetic patients without heart failure.

Diabetic Cardiomyopathy: Definition, Diagnosis, and Therapeutic Implications

A strict bidirectional relationship exists between diabetes mellitus and heart failure. Diabetic cardiomyopathy is a specific cardiac manifestation of patients with diabetes characterized by left ventricular hypertrophy and diastolic dysfunction in the early phase up to overt heart failure with reduced systolic function in the advanced stages. The pathogenesis of this condition is multifactorial and recognizes as main promoting factors the presence of insulin resistance and hyperglycemia. Diabetic cardiomyopathy exerts a negative prognostic impact in affected patients and no target treatments are currently available. More efforts are needed to better define the diagnostic and therapeutic approach in this specific setting.

Opportunities for microRNAs in the Crowded Field of Cardiovascular Biomarkers

Cardiovascular diseases exist across all developed countries. Biomarkers that can predict or diagnose diseases early in their pathogeneses can reduce their morbidity and mortality in afflicted individuals. microRNAs are small regulatory RNAs that modulate translation and have been identified as potential fluid-based biomarkers across numerous maladies. We describe the current state of cardiovascular disease biomarkers across a range of diseases, including myocardial infarction, acute coronary syndrome, myocarditis, hypertension, heart failure, heart transplantation, aortic stenosis, diabetic cardiomyopathy, atrial fibrillation, and sepsis. We present the current understanding of microRNAs as possible biomarkers in these categories and where their best opportunities exist to enter clinical practice.

Risk of heart failure in a population with type 2 diabetes versus a population without diabetes with and without coronary heart disease

AIMS

To conduct a population-based study comparing age- and sex-specific risk estimates of heart failure (HF) between people with type 2 diabetes and people without diabetes, and to investigate the risks of HF in association with type 2 diabetes in people with various coronary heart diseases (CHDs).

MATERIALS AND METHODS

We used a nationally representative sample (one million people) selected from Taiwan's National Health Insurance (NHI) system. A total of 34 291 patients with type 2 diabetes were identified from ambulatory care claims in 2000, and the same number of age- and sex-matched controls were randomly selected from the registry of NHI beneficiaries in the same year. All study subjects were linked to inpatient claims (2000-2013) to identify the possible admissions for HF. Using a Cox proportional hazard regression model, we compared the relative hazards of HF in relation to type 2 diabetes according to various age and sex stratifications. We also compared the relative hazard of HF between type 2 diabetes and controls, with and without histories of various CHDs and coronary revascularization procedures.

RESULTS

Compared with absence of diabetes (control group), type 2 diabetes was significantly associated with an increased hazard of HF (adjusted hazard ratio [aHR] 1.47, 95% confidence interval [CI] 1.40-1.54]. In both sexes, those with type 2 diabetes aged <45 years had the highest increased hazard of HF, with an aHR of 2.54 (95% CI 1.62-3.98) and 4.12 (95% CI 2.35-7.23) for men and women, respectively. Compared with the control subjects without any CHD, people with type 2 diabetes without prior CHD had increased hazards of HF (aHR 1.54, 95% CI 1.41-1.68, in men and aHR 1.56, 95% CI 1.43-1.71, in women), which were similar to the aHRs for people without diabetes who had histories of heart diseases (aHR 1.60 and 1.55 for men and women, respectively).

CONCLUSIONS

Diabetes mellitus may increase the risk of HF in both men and women, as well as in all age groups, especially in young people. People with type 2 diabetes without CHD had a similarly increased risk of HF to that of control subjects with CHD. Certain coronary revascularization procedures and CHDs, including percutaneous transluminal coronary angiography, coronary artery bypass surgery and acute myocardial infarction, were found to greatly increase risk of HF in people with type 2 diabetes.

Type 2 diabetes increases the risk of hospital admission for heart failure and reduces the risk of in hospital mortality in Spain (2001-2015)

BACKGROUND

To compare trends in incidence, clinical characteristics and outcomes of heart failure (HF) hospitalizations among patients with or without type 2 diabetes (T2DM) in Spain (2001-2015).

METHODS

We used national hospital discharge data to select hospital admissions for HF as primary diagnosis. Incidence, comorbidities, diagnostic and therapeutic procedures, and in hospital mortality (IHM) were analyzed.

RESULTS

We identified a total of 1,501,811 admissions for HF (36.87% with T2DM). Incidences were higher among those with T2DM than those without diabetes. The adjusted incidence of HF among T2DM patients was 4.93 higher than for non-diabetic subjects (IRR 4.93;95%CI 4.91-4.95). Jointpoint analysis showed that sex-age-adjusted admissions in T2DM patients with HF increased by 7.12% per year from 2001 to 2007 and stabilized afterwards. For non-diabetic patients a constant increase overtime of around 1% was found. Patients with T2DM were significantly younger than patients without diabetes (77.22 vs. 79.36 years) and had more coexisting medical conditions according to the Charlson Comorbidity Index (mean CCI 1.99 ± 0.88 vs. 1.90 ± 0.86). For the total time period, crude IHM was lower for T2DM patients than for non-diabetic people (8.35% vs, 10.57%; p < 0.05) and the association remained significant after multivariable adjustment ((OR, 0.84; 95%CI 0.83-0.86).). Female sex, older age and multiple comorbidities were significant risk factors for IHM.

CONCLUSIONS

T2DM increases the risk of admission for HF by five-fold. Our study demonstrates an increase in hospitalization for HF in diabetic patients from 2001 to 2007 and stabilization afterwards. T2DM was associated with a lower IHM after hospitalization for HF.

The E/e' ratio difference between subjects with type 2 diabetes and controls. A meta-analysis of clinical studies

Type 2 diabetes is associated with an increased risk of heart failure. Left ventricular diastolic dysfunction and type 2 diabetes are frequently associated. Using echocardiography, we know that tissue Doppler imaging E/e’ ratio is a reliable predictor of left ventricular filling pressure. We performed a systematic review and meta-analysis to investigate the averaged E/e’ ratio value in patients with type 2 diabetes compared to non-diabetic controls. In the analysis we included cross-sectional studies providing the averaged E/e’ ratio. Subgroup/sensitivity analyses were conducted according to variables known to influence E/e’ ratio measurements. The analysis included 15 cross sectional studies with 877 type 2 diabetes patients and 1193 controls. The weighted mean difference showed higher values in diabetes (WMD 2.02; 95% CI 1.35, 2.70; p<0.001). The result was consistent in the subgroup/sensitivity analyses. Visual inspection of the funnel plot did not identify substantial asymmetry and the Egger test for funnel plot asymmetry showed a p value of 0.36. In conclusion, our assessment suggests that averaged E/e’ ratio is consistently increased in patients with type 2 diabetes compared to non-diabetic controls in the absence of cardiovascular diseases and complicated hypertension. This alteration may be a precocious diastolic alteration in the diabetic cardiomyopathy.

Clinical Impact of Diabetes Mellitus on Short-Term Outcomes andIn-Hospital Mortality of Cardiac Mechanical Support with Left Ventricular Assist Device (LVAD): A Retrospective Study from a National Database

BACKGROUND

Cardiac support with left ventricular assist devices (LVAD) is a growing field. LVAD are increasingly used for patients with advanced congestive heart failure. Multiple studies have evaluated the outcomes of cardiac support with LVAD in patients with and without diabetes mellitus (DM), yet we still have conflicting results. This study aimed to assess the clinical impact of diabetes mellitus on patients undergoing cardiac support with LVAD.

METHODS

Diabetic patients who underwent mechanical support with LVAD between 2011 and 2014 were identified in the National Inpatient Sample (NIS) database using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). The primary outcome was the effect of diabetes mellitus on inpatient mortality. Secondary outcomes were the impact of diabetes on other immediate post-LVAD complications and the cost of hospitalization. Multivariable logistic regression models analysis was performed to address potential confounding.

RESULTS

After adjusting for patient-level and hospital-level characteristics, diabetic patients who underwent cardiac support with LVAD have no significant increase in in-hospital mortality (OR: 0.79, 95% CI (0.57-1.10), p = 0.166), post-LVAD short-term complications and cost of hospitalization (OR: 0.97, 95% CI (0.93-1.01), p = 0.102).

CONCLUSION

Cardiac mechanical support with LVAD implantation is feasible and relatively safe in patients with diabetes and stage-D heart failure as a bridge for transplantation or as destination therapy for patients who are not candidates for transplantation. However, further trials and studies using bigger study sample and more comprehensive databases, need to be conducted for a stronger and more valid evidence.

Impact of diabetes and sex in heart failure with reduced ejection fraction patients from the ASIAN-HF registry

AIMS

To examine sex differences in clinical characteristics, echocardiographic features, quality of life and 1-year death or heart failure (HF) hospitalization outcomes in patients with/without diabetes mellitus (DM).

METHODS AND RESULTS

Utilizing the Asian Sudden Cardiac Death in HF (ASIAN-HF) registry, 5255 patients (mean age 59.6 ± 13.1, 78% men) with symptomatic HF with reduced ejection fraction (HFrEF) were stratified by DM status to address the research aims. Despite similar prevalence of DM between Asian men (43%) and women (42%), the odds of DM increased at lower body mass index in women vs. men (≥ 23 vs. ≥ 27.5 kg/m² , P_interaction  = 0.014). DM was more strongly related to chronic kidney disease in women vs. men [adjusted odds ratio (OR) 1.85, 95% confidence interval (CI) 1.33-2.57 vs. OR 1.32, 95% CI 1.11-1.56, P_interaction  = 0.009]. Sex also modified the relationship between DM and left ventricular geometry (P_interaction  = 0.003), whereby DM was associated with a more concentric left ventricular geometry in women than men. Women had lower quality of life than men (P < 0.001), in both DM and non-DM groups. DM was associated with worse composite outcomes at 1 year in women vs. men [hazard ratio (HR) 1.79, 95% CI 1.24-2.60 vs. HR 1.32, 95% CI 1.12-1.56; P_interaction  = 0.005).

CONCLUSIONS

Asian women with HFrEF were more likely to have DM despite a lean body mass index, a greater burden of chronic kidney disease and more concentric left ventricular geometry, compared to men. Furthermore, DM confers worse quality of life, irrespective of sex, and a greater risk of adverse outcomes in women than men. These data underscore the need for sex-specific approaches to diabetes in patients with HF.

The metabolic model of heart failure: the role of sodium glucose co-transporter-2 (SGLT-2) inhibition

Heart failure (HF) is one of the leading causes of hospital readmissions and health care expenditures. With a vast degree of advancements in the clinical approach and diagnosis, its management protocol is limited in terms of enhancing quality of life and prognosis. Type 2 diabetes mellitus (T2DM) is considered as one of the commonly associated comorbid conditions in the HF population. The understanding of the molecular and metabolic models of HF has led to the utilization of therapeutic goals of T2DM in improving HF-related complications. In the recent era, SGLT-2 inhibitors have shown success in decreasing cardiovascular mortality in the T2DM population. This article will help the reviewer to comprehend the pathophysiology of HF and the potential role of SGLT-2 inhibitors in the management algorithm of HF and its associated risk factors in T2DM.

The prevalence of left ventricular diastolic dysfunction and heart failure with preserved ejection fraction in men and women with type 2 diabetes: A systematic review and meta-analysis

OBJECTIVE

Type 2 diabetes is a risk factor for the development of left ventricular diastolic dysfunction and heart failure with preserved ejection fraction. Our aim was to provide a summary estimate of the prevalence of left ventricular diastolic dysfunction and heart failure with preserved ejection fraction in type 2 diabetes patients and to investigate sex disparities.

METHODS AND RESULTS

A systematic search of the databases Medline and Embase was conducted for studies reporting the prevalence of left ventricular diastolic dysfunction or heart failure with preserved ejection fraction among type 2 diabetes patients. Studies were only included if echocardiography was performed. Prevalence estimates were pooled using random-effects meta-analysis. A total of 28 studies were included. Data on the prevalence of left ventricular diastolic dysfunction were available in 27 studies. The pooled prevalence for left ventricular diastolic dysfunction in the hospital population (2959 type 2 diabetes participants) and in the general population (2813 type 2 diabetes participants) was 48% [95% confidence interval: 38%-59%] and 35% (95% confidence interval: 24%-46%), respectively. Heterogeneity was high in both populations, with estimates ranging from 19% to 81% in the hospital population and from 23% to 54% in the general population. For women and men, the pooled prevalence estimates of left ventricular diastolic dysfunction were 47% (95% confidence interval: 37%-58%) and 46% (95% confidence interval: 37%-55%), respectively. Only two studies presented the prevalence of heart failure with preserved ejection fraction; 8% (95% confidence interval: 5%-14%) in a hospital population and 25% (95% confidence interval: 21%-28%) in the general population [18% in men (mean age: 73.8; standard deviation: 8.6) and 28% in women (mean age: 74.9; standard deviation: 6.9)].

CONCLUSION

The prevalence of left ventricular diastolic dysfunction among type 2 diabetes patients is similarly high in men and women, while heart failure with preserved ejection fraction seems to be more common in women than men, at least in community people with type 2 diabetes.

Excess risk of hospitalisation for heart failure among people with type 2 diabetes

AIMS/HYPOTHESIS

Type 2 diabetes is an established risk factor for heart failure, but age-specific data are sparse. We aimed to determine excess risk of heart failure, based on age, glycaemic control and kidney function in comparison with age- and sex-matched control individuals from the general population.

METHODS

Individuals with type 2 diabetes registered in the Swedish National Diabetes Registry 1998-2012 (n = 266,305) were compared with age-, sex- and county-matched control individuals without diabetes (n = 1,323,504), and followed over a median of 5.6 years until 31 December 2013.

RESULTS

We identified 266,305 individuals with type 2 diabetes (mean age 62.0 years, 45.3% women) and 1,323,504 control individuals. Of the individuals with type 2 diabetes and control individuals, 18,715 (7.0%) and 50,157 (3.8%) were hospitalised with a diagnosis of heart failure, respectively. Comparing individuals with diabetes with those in the control group, men and women with type 2 diabetes who were younger than 55 years of age had HRs for hospitalisation for heart failure of 2.07 (95% CI 1.73, 2.48) and 4.59 (95% CI 3.50, 6.02), respectively, using analyses adjusted for socioeconomic variables and associated conditions. Younger age, poorer glycaemic control and deteriorating renal function were all associated with increased excess risk of heart failure in those with type 2 diabetes compared with the control group. However, people with diabetes who were ≥75 years and without albuminuria or with good glycaemic control (HbA_1c ≤52 mmol/mol [≤6.9%]) had a similar risk of hospitalisation for heart failure as control individuals in the same age group.

CONCLUSIONS/INTERPRETATION

Men and women aged <55 years with type 2 diabetes are at markedly elevated excess risk of heart failure. The excess risk declined with age, but persisted even with good glycaemic control. However, among those who were 75 years and older, diabetic individuals with well controlled glucose levels or without albuminuria had a risk of heart failure that was on a par with individuals without diabetes.

Revisiting the Diabetes-Heart Failure Connection

PURPOSE OF THE REVIEW

To summarize current clinical data investigating the link between diabetes and heart failure pathophysiology, the association of glucose control with heart failure, and the impact of current antihyperglycemic drugs on heart failure.

RECENT FINDINGS

Although heart failure is one of the most prevalent outcomes occurring in real life and cardiovascular outcome trials, insufficient attention was given to this condition in diabetes research over the last decades. With both beneficial and detrimental findings for heart failure hospitalization in the health authority-mandated outcome trials for new antihyperglycemic agents, research on heart failure and its interplay with diabetes mellitus gained momentum. Diabetes mellitus and heart failure are both prevalent and intertwined conditions. While currently available heart failure therapies have a similar degree of effectiveness in patients with and without diabetes, the choice of glucose-lowering agents can substantially affect heart failure-related outcome.