Diabetes Mellitus-Related All-Cause and Cardiovascular Mortality in a National Cohort of Adults

Beta Cell Imaging-From Pre-Clinical Validation to First in Man Testing

There are presently no reliable ways to quantify human pancreatic beta cell mass (BCM) in vivo, which prevents an accurate understanding of the progressive beta cell loss in diabetes or following islet transplantation. Furthermore, the lack of beta cell imaging hampers the evaluation of the impact of new drugs aiming to prevent beta cell loss or to restore BCM in diabetes. We presently discuss the potential value of BCM determination as a cornerstone for individualized therapies in diabetes, describe the presently available probes for human BCM evaluation, and discuss our approach for the discovery of novel beta cell biomarkers, based on the determination of specific splice variants present in human beta cells. This has already led to the identification of DPP6 and FXYD2ga as two promising targets for human BCM imaging, and is followed by a discussion of potential safety issues, the role for radiochemistry in the improvement of BCM imaging, and concludes with an overview of the different steps from pre-clinical validation to a first-in-man trial for novel tracers.

No Association Between T-peak to T-end Interval on the Resting ECG and Long-Term Incidence of Ventricular Arrhythmias Triggering ICD Interventions

Background and Objectives

Potential of using the T-peak to T-end (TpTe) interval as an electrocardiographic parameter reflecting the transmural dispersion of ventricular repolarization (TDR) to identify patients (pts.) with higher risk of malignant ventricular arrhythmias (MVA) for better selection of candidates for implantable cardioverter-defibrillator (ICD) in primary prevention (PP) of sudden cardiac death (SCD) remains controversial. The primary objective of this study was to investigate the relationship between the TpTe interval in patient’s preimplantation resting 12-lead electrocardiogram (ECG) and the incidence of MVA resulting in appropriate ICD intervention (AI). The secondary objective was to assess its relationship to overall mortality.

Methods

A total of 243 consecutive pts. with severe left ventricular (LV) systolic dysfunction after myocardial infarction (MI) with a single-chamber ICD for PP of SCD from one implantation center were included. Excluded were all pts. with any other disease that could interfere with the indication of ICD implantation. Primarily investigated intervals were measured manually in accordance with accepted methodology. Data on ICD interventions were acquired from device interrogation during regular outpatient visits. Survival data were collected from the databases of health insurance and regulatory authorities.

Results

We did not find a significant relationship between the duration of the TpTe interval and the incidence of MVA (71.5 ms in pts. with MVA vs. 70 ms in pts. without MVA; p = 0.408). Similar results were obtained for the corrected TpTe interval (TpTec) and the ratio of TpTe to QT interval (76.3 ms vs. 76.5 ms; p = 0.539 and 0.178 vs. 0.181; p = 0.547, respectively). There was also no significant difference between the duration of TpTe, TpTec and TpTe/QT ratio in pts. groups by overall mortality (71.5 ms in the deceased group vs. 70 ms in the survivors group; HR 1.01; 95% CI, 0.99–1.02; p = 0.715, 76.3 ms vs. 76.5 ms; HR 1.01; 95% CI, 0.99–1.02; p = 0.208 and 0.178 vs. 0.186; p = 0.116, respectively).

Conclusion

This study suggests no significant association of overall or MVA-free survival with ECG parameters reflecting TDR (TpTe, TpTec) in patients with systolic dysfunction after MI and ICD implanted for primary prevention.

Impact of Diabetes Mellitus on Stroke and Survival in Patients With Atrial Fibrillation

Although diabetes mellitus (DM) has been established as a risk factor for developing atrial fibrillation (AF) and is a known risk factor for stroke, it is unclear whether the presence or duration of DM is the primary adverse influence on the clinical course of AF. We retrospectively analyzed patients diagnosed with incident AF to examine the impact of DM on ischemic stroke and all-cause mortality. The diagnosis of DM was established by ICD-9 codes and review of medical records. To account for the significant differences in baseline characteristics of patients with and without diabetes, we matched 909 AF patients with DM with 909 AF patients without DM using propensity score matching based on 26 baseline variables. Cox regression analysis was used to identify independent factors associated with ischemic stroke and mortality. The mean age of the propensity matched cohort was 74 ± 11.5 years and 55.4% were male. Over a median follow-up period of 5.4 years (maximum 23.9 years), cumulative survival was significantly lower for patients with DM than those without DM; Log-rank p <0.001. In the propensity-matched comparison, the risk of mortality was significantly higher in the DM group compared with the non-DM group (hazard ratio 1.25; 95% confidence interval 1.12 to 1.69; p <0.001). Likewise, patients with DM had a higher risk of stroke (hazard ratio 1.32; 95% confidence interval 1.02 to 1.69; p = 0.03). Duration of DM was not associated with increased risk for stroke or mortality. In conclusion, the co-morbidity of DM represents an independent predictor of reduced survival and further highlights the excess risk of thromboembolism in patients with AF.

Association between Serum Zinc and Calcification Propensity (T50) in Patients with Type 2 Diabetes Mellitus and In Vitro Effect of Exogenous Zinc on T50

Zinc inhibits vascular calcification in vivo and in vitro. Patients with type 2 diabetes mellitus show hypozincemia and are at an elevated risk of cardiovascular events. Recently, an in vitro test (T₅₀-test) was developed for determination of serum calcification propensity and a shorter T₅₀ means a higher calcification propensity. This cross-sectional study investigated the association between serum zinc and T₅₀ in 132 type 2 diabetes mellitus patients with various kidney functions. Furthermore, the effect of exogenous zinc on T₅₀ was also investigated in vitro using separately pooled serum samples obtained from healthy volunteers and patients with hemodialysis. We measured T₅₀ levels using the established nephelometric method. The median (interquartile range) levels of T₅₀ and serum zinc were 306 (269 to 332) min, and 80.0 (70.1 to 89.8) µg/dL, respectively. Serum zinc level showed a weak, but positive correlation with T₅₀ (r_s = 0.219, p = 0.012). This association remained significant in multivariable-adjusted analysis, and was independent of known factors including phosphate, calcium, and magnesium. Kidney function and glycemic control were not significantly associated with T₅₀. Finally, in vitro experiments showed that addition of a physiological concentration of exogenous zinc chloride significantly increased serum T₅₀. Our results indicate that serum zinc is an independent factor with a potential role in suppressing calcification propensity in serum.

Cardiovascular Benefit of Empagliflozin Across the Spectrum of Cardiovascular Risk Factor Control in the EMPA-REG OUTCOME Trial

CONTEXT

Control of multiple cardiovascular (CV) risk factors reduces CV events in individuals with type 2 diabetes.

OBJECTIVE

To investigate this association in a contemporary clinical trial population, including how CV risk factor control affects the CV benefits of empagliflozin, a sodium-glucose cotransporter-2 inhibitor.

DESIGN

Post hoc analysis.

SETTING

Randomized CV outcome trial (EMPA-REG OUTCOME).

PARTICIPANTS

Type 2 diabetes patients with established CV disease.

INTERVENTION

Empagliflozin or placebo.

MAIN OUTCOME MEASURES

Risk of CV outcomes-including the treatment effect of empagliflozin-by achieving 7 goals for CV risk factor control at baseline: (1) glycated hemoglobin <7.5%, (2) low-density lipoprotein cholesterol <100 mg/dL or statin use, (3) systolic blood pressure <140 mmHg and diastolic blood pressure <90 mmHg, (4) pharmacological renin-angiotensin-aldosterone system blockade, (5) normoalbuminuria, (6) aspirin use, (7) nonsmoking.

RESULTS

In the placebo group, the hazard ratio (HR) for CV death was 4.00 (95% CI, 2.26-7.11) and 2.48 (95% CI, 1.52-4.06) for patients achieving only 0-3 or 4-5 risk factor goals at baseline, respectively, compared with those achieving 6-7 goals. Participants achieving 0-3 or 4-5 goals also had increased risk for the composite outcome of hospitalization for heart failure or CV death (excluding fatal stroke) (HR 2.89 [1.82-4.57] and 1.90 [1.31-2.78], respectively) and 3-point major adverse CV events (HR 2.21 [1.53-3.19] and 1.42 [1.06-1.89]). Empagliflozin significantly reduced these outcomes across all risk factor control categories (P > 0.05 for treatment-by-subgroup interactions).

CONCLUSIONS

Cardiovascular risk in EMPA-REG OUTCOME was inversely associated with baseline CV risk factor control. Empagliflozin's cardioprotective effect was consistent regardless of multiple baseline risk factor control.

Optimizing Atherosclerotic Cardiovascular Disease Risk Estimation for Veterans With Diabetes Mellitus

BACKGROUND

Estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk in diabetes mellitus patients is used to guide primary prevention, but the performance of risk estimators (2013 Pooled Cohort Equations [PCE] and Risk Equations for Complications of Diabetes [RECODe]) varies across populations. Data from electronic health records could be used to improve risk estimation for a health system's patients. We aimed to evaluate risk equations for initial ASCVD events in US veterans with diabetes mellitus and improve model performance in this population.

METHODS AND RESULTS

We studied 183 096 adults with diabetes mellitus and without prior ASCVD who received care in the Veterans Affairs Healthcare System (VA) from 2002 to 2016 with mean follow-up of 4.6 years. We evaluated model discrimination, using Harrell's C statistic, and calibration, using the reclassification χ2 test, of the PCE and RECODe equations to predict fatal or nonfatal myocardial infarction or stroke and cardiovascular mortality. We then tested whether model performance was affected by deriving VA-specific β-coefficients. Discrimination of ASCVD events by the PCE was improved by deriving VA-specific β-coefficients (C statistic increased from 0.560 to 0.597) and improved further by including measures of glycemia, renal function, and diabetes mellitus treatment (C statistic, 0.632). Discrimination by the RECODe equations was improved by substituting VA-specific coefficients (C statistic increased from 0.604 to 0.621). Absolute risk estimation by PCE and RECODe equations also improved with VA-specific coefficients; the calibration P increased from <0.001 to 0.08 for PCE and from <0.001 to 0.005 for RECODe, where higher P indicates better calibration. Approximately two-thirds of veterans would meet a guideline indication for high-intensity statin therapy based on the PCE versus only 10% to 15% using VA-fitted models.

CONCLUSIONS

Existing ASCVD risk equations overestimate risk in veterans with diabetes mellitus, potentially impacting guideline-indicated statin therapy. Prediction model performance can be improved for a health system's patients using readily available electronic health record data.

A systematic review of trends in all-cause mortality among people with diabetes

AIMS/HYPOTHESIS

We examined all-cause mortality trends in people with diabetes and compared them with trends among people without diabetes.

METHODS

MEDLINE, EMBASE and CINAHL databases were searched for observational studies published from 1980 to 2019 reporting all-cause mortality rates across ≥2 time periods in people with diabetes. Mortality trends were examined by ethnicity, age and sex within comparable calendar periods.

RESULTS

Of 30,295 abstracts screened, 35 studies were included, providing data on 69 separate ethnic-specific or sex-specific populations with diabetes since 1970. Overall, 43% (3/7), 53% (10/19) and 74% (32/43) of the populations studied had decreasing trends in all-cause mortality rates in people with diabetes in 1970-1989, 1990-1999 and 2000-2016, respectively. In 1990-1999 and 2000-2016, mortality rates declined in 75% (9/12) and 78% (28/36) of predominantly Europid populations, and in 14% (1/7) and 57% (4/7) of non-Europid populations, respectively. In 2000-2016, mortality rates declined in 33% (4/12), 65% (11/17), 88% (7/8) and 76% (16/21) of populations aged <40, 40-54, 55-69 and ≥70 years, respectively. Among the 33 populations with separate mortality data for those with and without diabetes, 60% (6/10) of the populations with diabetes in 1990-1999 and 58% (11/19) in 2000-2016 had an annual reduction in mortality rates that was similar to or greater than in those without diabetes.

CONCLUSIONS/INTERPRETATION

All-cause mortality has declined in the majority of predominantly Europid populations with diabetes since 2000, and the magnitude of annual mortality reduction matched or exceeded that observed in people without diabetes in nearly 60% of populations. Patterns of diabetes mortality remain uncertain in younger age groups and non-Europid populations.

REGISTRATION

PROSPERO registration ID CRD42019095974. Graphical abstract.

Associated Targets of the Antioxidant Cardioprotection of Ganoderma lucidum in Diabetic Cardiomyopathy by Using Open Targets Platform: A Systematic Review

Even with substantial advances in cardiovascular therapy, the morbidity and mortality rates of diabetic cardiomyopathy (DCM) continually increase. Hence, a feasible therapeutic approach is urgently needed. Objectives. This work is aimed at systemically reviewing literature and addressing cell targets in DCM through the possible cardioprotection of G. lucidum through its antioxidant effects by using the Open Targets Platform (OTP) website. Methods. The OTP website version of 19.11 was accessed in December 2019 to identify the studies in DCM involving G. lucidum. Results. Among the 157 cell targets associated with DCM, the mammalian target of rapamycin (mTOR) was shared by all evidence, drug, and text mining data with 0.08 score association. mTOR also had the highest score association 0.1 with autophagy in DCM. Among the 1731 studies of indexed PubMed articles on G. lucidum published between 1985 and 2019, 33 addressed the antioxidant effects of G. lucidum and its molecular signal pathways involving oxidative stress and therefore were included in the current work. Conclusion. mTOR is one of the targets by DCM and can be inhibited by the antioxidative properties of G. lucidum directly via scavenging radicals and indirectly via modulating mTOR signal pathways such as Wnt signaling pathway, Erk1/2 signaling, and NF-κB pathways.

Estimation of Atherosclerotic Cardiovascular Disease Risk Among Patients in the Veterans Affairs Health Care System

IMPORTANCE

Current guidelines recommend statin therapy for millions of US residents for the primary prevention of atherosclerotic cardiovascular disease (ASCVD). It is unclear whether traditional prediction models that do not account for current widespread statin use are sufficient for risk assessment.

OBJECTIVES

To examine the performance of the Pooled Cohort Equations (PCE) for 5-year ASCVD risk estimation in a contemporary cohort and to test the hypothesis that inclusion of statin therapy improves model performance.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included adult patients in the Veterans Affairs health care system without baseline ASCVD. Using national electronic health record data, 3 Cox proportional hazards models were developed to estimate 5-year ASCVD risk, as follows: the variables and published β coefficients from the PCE (model 1), the PCE variables with cohort-derived β coefficients (model 2), and model 2 plus baseline statin use (model 3). Data were collected from January 2002 to December 2012 and analyzed from June 2016 to March 2020.

EXPOSURES

Traditional ASCVD risk factors from the PCE plus baseline statin use.

MAIN OUTCOMES AND MEASURES

Incident ASCVD and ASCVD mortality.

RESULTS

Of 1 672 336 patients in the cohort (mean [SD] baseline age 58.0 [13.8] years, 1 575 163 [94.2%] men, 1 383 993 [82.8%] white), 312 155 (18.7%) were receiving statin therapy at baseline. During 5 years of follow-up, 66 605 (4.0%) experienced an ASCVD event, and 31 878 (1.9%) experienced ASCVD death. Compared with the original PCE, the cohort-derived model did not improve model discrimination in any of the 4 age-sex strata but did improve model calibration. The PCE overestimated ASCVD risk compared with the cohort-derived model; 211 237 of 1 136 161 white men (18.6%), 29 634 of 218 463 black men (13.6%), 1741 of 44 399 white women (3.9%), and 836 of 16 034 black women (5.2%) would be potentially eligible for statin therapy under the PCE but not the cohort-derived model. When added to the cohort-derived model, baseline statin therapy was associated with a 7% (95% CI, 5%-9%) lower relative risk of ASCVD and a 25% (95% CI, 23%-28%) lower relative risk for ASCVD death.

CONCLUSIONS AND RELEVANCE

In this study, lower than expected rates of incident ASCVD events in a contemporary national cohort were observed. The PCE overestimated ASCVD risk, and more than 15% of patients would be potentially eligible for statin therapy based on the PCE but not on a cohort-derived model. In the statin era, health care professionals and systems should base ASCVD risk assessment on models calibrated to their patient populations.

Epidemiology and Risk of Amputation in Patients With Diabetes Mellitus and Peripheral Artery Disease

Peripheral artery disease (PAD) stems from atherosclerosis of lower extremity arteries with resultant arterial narrowing or occlusion. The most severe form of PAD is termed chronic limb-threatening ischemia and carries a significant risk of limb loss and cardiovascular mortality. Diabetes mellitus is known to increase the incidence of PAD, accelerate disease progression, and increase disease severity. Patients with concomitant diabetes mellitus and PAD are at high risk for major complications, such as amputation. Despite a decrease in the overall number of amputations performed annually in the United States, amputation rates among those with both diabetes mellitus and PAD have remained stable or even increased in high-risk subgroups. Within this cohort, there is significant regional, racial/ethnic, and socioeconomic variation in amputation risk. Specifically, residents of rural areas, African-American and Native American patients, and those of low socioeconomic status carry the highest risk of amputation. The burden of amputation is severe, with 5-year mortality rates exceeding those of many malignancies. Furthermore, caring for patients with PAD and diabetes mellitus imposes a significant cost to the healthcare system-estimated to range from $84 billion to $380 billion annually. Efforts to improve the quality of care for those with PAD and diabetes mellitus must focus on the subgroups at high risk for amputation and the disparities they face in the receipt of both preventive and interventional cardiovascular care. Better understanding of these social, economic, and structural barriers will prove to be crucial for cardiovascular physicians striving to better care for patients facing this challenging combination of chronic diseases.

Indirect comparison of glucagon like peptide-1 receptor agonists regarding cardiovascular safety and mortality in patients with type 2 diabetes mellitus: network meta-analysis

Background

The cardiovascular outcome trials (CVOTs) have shown that glucagon like peptide-1 receptor agonists (GLP1RAs) have varying degrees of cardiovascular (CV) safety in patients with type 2 diabetes mellitus (T2DM.) The lack of any head-to-head comparative trials among GLP1RAs urged the need for an indirect comparison of these agents. Therefore, this study was conducted to indirectly compare the CV safety and mortality effects among different GLP1RAs in patients with T2DM using network meta-analysis (NMA).

Methods

Medline was searched to identify GLP1RA CVOTs to date. The outcomes of interest were CV death, myocardial infarction (IM), stroke, and death from any cause. An NMA with binomial likelihood logit link model was used for the binary outcomes. We conducted both fixed effects and random effects models for each outcome, and selected the best model based on the deviance information and the average posterior residual deviance. This NMA was reported in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA-NMA).

Results

A total of seven GLP1RA CVOTs were included having 56,004 patients. The NMA results showed that oral semaglutide was statistically better than exenatide (OR 0.47, 95% CI 0.21–0.99), dulaglutide (OR 0.46, 95% CI 0.20–0.97), albiglutide (OR 0.45, 95% CI 0.19–0.97), lixisenatide (OR 0.43, 95% CI 0.19–0.92) in reducing CV death events. No significant differences were detected between most of the treatments regarding reducing death from any cause, MI and stroke events. The ranking results showed that oral semaglutide had the highest probability to be ranked first (> 90%) in reducing CV death and death from any cause. Moreover, once weekly semaglutide had the highest probability to be ranked first in reducing MI and stroke events.

Conclusion

The GLP1RAs have shown significant benefits in terms of CV safety. The indirect comparison and ranking probability results have shown that one weekly semaglutide and oral semaglutide seems to be the preferred option in patients with T2DM and established or at high risk of CVD. This result can aid health care providers, pharmacy and therapeutics committees in hospitals, and insurance companies when deciding which GLP1RA to start or add to their formulary.

Apolipoprotein B and non-high-density lipoprotein cholesterol reveal a high atherogenicity in individuals with type 2 diabetes and controlled low-density lipoprotein-cholesterol

Background

Lipid-lowering therapy is guided by Low-density-lipoprotein cholesterol (LDL-c) levels, although the cardiovascular disease (CVD) risk could be better reflected by other lipid parameters. This study aimed at comparing a comprehensive lipid profile between patients with type 2 diabetes mellitus (T2DM) with LDL-c concentration within and above target.

Methods

A comprehensive lipid profile was characterized in 96 T2DM patients. The European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) 2016 and 2019 Guidelines for the Management of Dyslipidemias were used to define LDL-c targets.

Results

In this population, only 28.1 and 16.7% of patients had mean LDL-c levels within target, as defined by the 2016 and 2019 guidelines, respectively. Applying the 2016 guidelines criteria, in patients with LDL-c within target, 22, 25 and 44% presented non-high-density lipoprotein cholesterol (non-HDL-c), Apolipoprotein B (ApoB) and oxidized LDL-c levels above the recommended range, respectively, whereas according to the 2019 guidelines criteria, 50, 39 and 44% of the patients with LDL-c within target had elevated high-density lipoprotein cholesterol (HDL-c), ApoB and oxidized LDL-c levels, respectively. LDL-c was strongly correlated with non-HDL-c (r = 0.850), ApoB (r = 0.656) and oxidized LDL-c (r = 0.508). Similarly, there was a strong correlation between non-HDL-c with both ApoB (r = 0.808) and oxidized LDL-c (r = 0.588).

Conclusions

These findings emphasize the limitations of only considering LDL-c concentration for cardiovascular (CV) risk assessment. Targeting only LDL-c could result in missed opportunities for CV risk reduction in T2DM patients. These data suggest that non-HDL-c, ApoB and oxidized LDL-c levels could be considered as an important part of these patients’ evaluation allowing for a more accurate estimation of CV risk and hopefully better management of these high-risk patients.

Hypoglycaemia and cardiac arrhythmias in diabetes

Hypoglycaemia remains an inevitable risk in insulin-treated type 1 diabetes and type 2 diabetes and has been associated with multiple adverse outcomes. Whether hypoglycaemia is a cause of fatal cardiac arrhythmias in diabetes, or merely a marker of vulnerability, is still unknown. Since a pivotal report in 1991, hypoglycaemia has been suspected to induce cardiac arrhythmias in patients with type 1 diabetes, the so-called 'dead-in-bed syndrome'. This suspicion has subsequently been supported by the coexistence of an increased mortality and a three-fold increase in severe hypoglycaemia in patients with type 2 diabetes receiving intensive glucose-lowering treatment in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Studies have investigated the association between hypoglycaemia-induced cardiac arrhythmias. In a rat-model, severe hypoglycaemia resulted in a specific pattern of cardiac arrhythmias including QT-prolongation, ventricular tachycardia, second- and third-degree AV block and ultimately cardiorespiratory arrest. In clinical studies of experimentally induced hypoglycaemia, QTc-prolongation, a risk factor of ventricular arrhythmias, is an almost consistent finding. The extent of QT-prolongation seems to be modified by several factors, including antecedent hypoglycaemia, diabetes duration and cardiac autonomic neuropathy. Observational studies indicate diurnal differences in the pattern of electrocardiographic alterations during hypoglycaemia with larger QTc-prolongations during daytime, whereas the risk of bradyarrhythmias may be increased during sleep. Daytime periods of hypoglycaemia are characterized by shorter duration, increased awareness and a larger increase in catecholamines. The counterregulatory response is reduced during nightly episodes of hypoglycaemia, resulting in prolonged periods of hypoglycaemia with multiple nadirs. An initial sympathetic activity at plasma glucose nadir is replaced by increased vagal activity, which results in bradycardia. Here, we provide an overview of the existing literature exploring potential mechanisms for hypoglycaemia-induced cardiac arrhythmias and studies linking hypoglycaemia to cardiac arrhythmias in patients with diabetes.

Changes in mortality rates and ratios in people with pharmacologically treated type 2 diabetes mellitus between 2001 and 2016 in Hungary

AIMS

Type 2 diabetes mellitus (T2DM) is associated with a higher risk of all-cause mortality; however, detailed analyses of subgroups are rare. In this study we analyzed the changes of age- and gender-specific all-cause mortality rates and ratios in T2DM subjects (aged > 40 years) in Hungary between 2001 and 2016.

METHODS

We used the central database of the National Institute of Health Insurance Fund. All-cause mortality rates in patients with T2DM and ratios (T2DM/non-T2DM) were determined in males/females and in different age-groups. Age-adjusted values were used for standardized mortality rates.

RESULTS

Among pharmacologically treated T2DM subjects we found 117,700 and 329,845 males, 232,143 and 391,382 females in 2001 and 2016, respectively. Standardized all-cause mortality rate was higher in males than in females in 2001 (4540/100,000 vs. 3365/100,000) which decreased to 4125/100,000 in males (total change: -11.8%, p < 0.0001) and to 2977/100,000 in females (total change: -9.2%; p = 0.0558) in 2016. We found a significant increase (8.35%; p = 0.0272) in standardized all-cause mortality ratios between 2001 and 2016 which was higher in males (11.44%; p = 0.0096) than in females (2.78%; p = 0.3288). We observed the most pronounced increase in younger age-groups (age 41-60 years) in both genders (change varied from 54.2% to 101.8%; p < 0.05) which was due to distinct tendencies in changes of mortality curves.

CONCLUSIONS

Pharmacologically treated T2DM subjects in lower age-groups (41-60 years) had the highest increase in all-cause mortality ratios between 2001 and 2016 in Hungary. These data indicate that relatively younger patients with T2DM need special attention for improving long-term outcomes.

Use of Troponin as a predictor for cardiovascular diseases in patients with type 2 Diabetes Mellitus

People with type 2 diabetes mellitus (T2DM) have two- to four-fold increased cardiovascular mortality in comparison to the general population. With the identification of new therapeutic targets and hypoglycemic drugs for T2DM, the need for a better stratification of CVD risk has emerged to select patients who may need intensive or specific treatment. At present, risk stratification is based on clinical, demographic, and biochemical factors. High sensitivity cardiac troponin (hs-cTn) increases after several ischemic and non-ischemic insults and it is considered a marker of myocardial injury. This review summarizes the main findings about hs-cTn utilization for risk stratification in people with T2DM and no clinical CVD. Several large observational studies have documented the association between hs-cTn and adverse cardiovascular outcomes in both the general population and in patients with T2DM. Lifestyle interventions, and particularly promotion of physical activity and adoption of healthy nutritional habits, have been associated to a significant benefit on hs-cTn release in the general population. Randomized controlled trials suggested that hypoglycemic, anti-hypertensive and lipid-lowering therapy may influence the degree of T2DM-induced cardiac injury. Besides these promising findings, the efficacy of an hs-cTn-based approach for CVD prevention in T2DM patients still requires more investigations.

Clinical outcomes after cardiac rehabilitation in elderly patients with and without diabetes mellitus: The EU-CaRE multicenter cohort study

Background

The prevalence of patients with concomitant cardiovascular disease and diabetes mellitus (DM) is increasing rapidly. We aimed to compare the effectiveness of current cardiac rehabilitation (CR) programs across seven European countries between elderly cardiac patients with and without DM.

Methods

1633 acute and chronic coronary artery disease (CAD) patients and patients after valve intervention with an age 65 or above who participated in comprehensive CR (3 weeks to 3 months, depending on centre) were included. Peak oxygen uptake (VO₂ peak), body mass index, resting systolic blood pressure, low-density lipoprotein-cholesterol (LDL-C), and glycated haemoglobin (HbA1c) were assessed before start of CR, at termination of CR (variable time point), and 12 months after start of CR, with no intervention after CR. Baseline values and changes from baseline to 12-month follow-up were compared between patients with and without DM using mixed models, and mortality and hospitalisation rates using logistic regression.

Results

430 (26.3%) patients had DM. Patients with DM had more body fat, lower educational level, more comorbidities, cardiovascular risk factors, and more advanced CAD. Both groups increased their VO₂ peak over the study period but with a significantly lower improvement from baseline to follow-up in patients with DM. In the DM group, change in HbA1c was associated with weight change but not with change in absolute VO₂ peak. 12-month cardiac mortality was higher in patients with DM.

Conclusions

While immediate improvements in VO₂ peak after CR in elderly patients with and without DM were similar, 12-month maintenance of this improvement was inferior in patients with DM, possibly related to disease progression. Glycemic control was less favourable in diabetic patients needing insulin in the short- and long-term. Since glycemic control was only related to weight loss but not to increase in exercise capacity, this highlights the importance of weight loss in obese DM patients during CR.

Trial registration NTR5306 at trialregister.nl; trial registered 07/16/2015; https://www.trialregister.nl/trial/5166

Metformin and heart failure-related outcomes in patients with or without diabetes: a systematic review of randomized controlled trials

Metformin is considered a safe anti-hyperglycemic drug for patients with type 2 diabetes (T2D); however, information on its impact on heart failure-related outcomes remains inconclusive. The current systematic review explored evidence from randomized clinical trials (RCTs) reporting on the impact of metformin in modulating heart failure-related markers in patients with or without T2D. Electronic databases such as MEDLINE, Cochrane Library, and EMBASE were searched for eligible studies. Included studies were those assessing the use of metformin as an intervention, and also containing the comparison group on placebo, and all articles had to report on measurable heart failure-related indices in individuals with or without T2D. The modified Downs and Black checklist was used to evaluate the risk of bias. Overall, nine studies met the inclusion criteria, enrolling a total of 2486 patients. Although summarized evidence showed that metformin did not affect left ventricular function, this antidiabetic drug could improve myocardial oxygen consumption concomitant to reducing prominent markers of heart failure such as n-terminal pro-brain natriuretic peptide and low-density lipoprotein levels, inconsistently between diabetic and nondiabetic patients. Effective modulation of some heart failure-related outcomes with metformin treatment was related to its beneficial effects in ameliorating insulin resistance and blocking pro-inflammatory markers such as the aging-associated cytokine CCL11 (C-C motif chemokine ligand 11). Overall, although such beneficial effects were observed with metformin treatment, additional RCTs are necessary to improve our understanding on its modulatory effects on heart failure-related outcomes especially in diabetic patients.

Diabetes Mellitus-Related All-Cause and Cardiovascular Mortality in a National Cohort of Adults

Background Diabetes mellitus is a risk factor for cardiovascular disease ( CVD ) and has been associated with 2- to 4-fold higher mortality. Diabetes mellitus-related mortality has not been reassessed in individuals receiving routine care in the United States in the contemporary era of CVD risk reduction. Methods and Results We retrospectively studied 963 648 adults receiving care in the US Veterans Affairs Healthcare System from 2002 to 2014; mean follow-up was 8 years. We estimated associations of diabetes mellitus status and hemoglobin A1c (HbA1c) with all-cause and CVD mortality using covariate-adjusted incidence rates and multivariable Cox proportional hazards regression. Of participants, 34% had diabetes mellitus. Compared with nondiabetic individuals, patients with diabetes mellitus had 7.0 (95% CI , 6.7-7.4) and 3.5 (95% CI, 3.3-3.7) deaths/1000-person-years higher all-cause and CVD mortality, respectively. The age-, sex-, race-, and ethnicity-adjusted hazard ratio for diabetes mellitus-related mortality was 1.29 (95% CI, 1.28-1.31), and declined with adjustment for CVD risk factors (hazard ratio, 1.18 [95% CI, 1.16-1.19]) and glycemia (hazard ratio, 1.03 [95% CI, 1.02-1.05]). Among individuals with diabetes mellitus, CVD mortality increased as HbA1c exceeded 7% (hazard ratios, 1.11 [95% CI, 1.08-1.14], 1.25 [95% CI, 1.22-1.29], and 1.52 [95% CI, 1.48-1.56] for HbA1c 7%-7.9%, 8%-8.9%, and ≥9%, respectively, relative to HbA1c 6%-6.9%). HbA1c 6% to 6.9% was associated with the lowest mortality risk irrespective of CVD history or age. Conclusions Diabetes mellitus remains significantly associated with all-cause and CVD mortality, although diabetes mellitus-related excess mortality is lower in the contemporary era than previously. We observed a gradient of mortality risk with increasing HbA1c >6% to 6.9%, suggesting HbA1c remains an informative predictor of outcomes even if causality cannot be inferred.

Association between Dietary Quality and Prediabetes based on the Diet Balance Index

Dietary quality is an important factor influencing prediabetes, but few studies have applied the Chinese Diet Balance Index (DBI-16) to evaluate the dietary quality of individuals with prediabetes and explore the associations between dietary quality and prediabetes. In our study, the lower-bound score, higher-bound score and diet quality distance, were respectively calculated to assess dietary quality based on each food group. Logistic regression was used to calculate the odds ratio (OR) and 95% confidence interval (95%CI) of unfavorable dietary quality leading to prediabetes in every subgroup. The results were shown that individuals with prediabetes had excessive intake in the categories of cereals, salt and inadequate intake in vegetables, fish and diet variety than participants without prediabetes (all P < 0.01). Unfavourable dietary quality was significantly associated with an increased risk of prediabetes (OR: 1.45, 95%CI: 1.29-1.63), especially among the subjects who lived in rural areas (OR: 1.63, 95%CI: 1.25-1.76), those who had abdominal obesity (OR: 1.58, 95%CI: 1.36-1.85), those who smoked (OR: 1.58, 95%CI: 1.30-1.93), those who consumed alcohol (OR: 1.57, 95%CI: 1.28-1.93) and those who did not drink tea (OR: 1.64, 95%CI: 1.42-1.88). In Conclusion, unfavourable dietary quality was significantly associated with an increased risk of prediabetes.

Real-World Adherence and Discontinuation of Glucagon-Like Peptide-1 Receptor Agonists Therapy in Type 2 Diabetes Mellitus Patients in the United States

AIM

To assess adherence and discontinuation of injectable glucagon-like peptide-1 receptor agonists (GLP-1 RA) at 12 and 24 months among adult type 2 diabetes mellitus (T2DM) patients in the United States initiating GLP-1 RA using the administrative claims-based database, Optum Clinformatics^® Data Mart 7.1.

METHODS

A retrospective study was conducted from 01/2009 to 12/2017. Patients were required to be continuously enrolled for 12 months prior to their first GLP-1 RA prescription. Proportion of days covered (PDC) from prescription claims ≥0.80 defined adherence. Discontinuation was defined as a ≥90-day gap from the last date of GLP-1 RA supply to the first date of subsequent prescription claim.

RESULTS

A total of 4791 T2DM patients had ≥1 and 3907 had ≥2 GLP-1 RA prescription claims. 50.9% and 47.4% of patients were adherent at 12 and 24 months, respectively. Adherence was significantly higher among patients on weekly vs daily doses (p<0.001). Median time to discontinuation was 13 months. The discontinuation rate was 47.7% and 70.1% at 12 and 24 months, respectively, with differences at 24 months for age and dosing frequency (p<0.001 for both).

CONCLUSION

Over half of T2DM patients initiating GLP-1 RA were non-adherent and the majority (70.1%) discontinued therapy by 24 months. Reasons for non-adherence and discontinuation merit further research.

The Changing Landscape of Pharmacotherapy for Diabetes Mellitus: A Review of Cardiovascular Outcomes

The prevention of cardiovascular morbidity and mortality has always been a primary concern in patients with type 2 diabetes. Modern trials of glucose-lowering therapies now assess major adverse cardiac events as an endpoint in addition to the effects on glycaemic control. Whilst the data on the efficacy of intensive glucose lowering on reducing cardiovascular risk are limited, there are now increasing numbers of glucose-lowering therapies that have proven cardiovascular benefit independent of glucose lowering. This review will summarise the available literature on cardiovascular outcomes in relation to metformin, sulphonylureas, di-peptidyl peptidase-4 inhibitors, glucagon-like peptide receptor agonists, sodium-glucose co-transporter 2 inhibitors, thiazolidinediones, acarbose and insulin. In addition, new paradigms in diabetes management and the importance of treatment selection based on considerations including but not limited to glycaemic control will be discussed.

Heme oxygenase-1 contributes to the protective effect of resveratrol against endothelial dysfunction in STZ-induced diabetes in rats

Endothelial dysfunction is a common complication of diabetes that mainly stems from increased reactive oxygen species, which makes antioxidants of great benefit. Resveratrol (RSV) is an antioxidant that shows protective effects in a variety of disease models where the ameliorative effect appears to be mediated, in part, via heme oxygenase-1 (HO-1) induction. However, the pathophysiological relevance of HO-1 in the ameliorative response of RSV in endothelial dysfunction is not clearly defined. The present study was conducted to investigate whether HO-1 plays a role in diabetes-induced vascular dysfunction. Streptozotocin-diabetic rats were treated with RSV (10 mg/kg) in presence or absence of an HO-1 blocker, Zinc protoporphyrin (ZnPP) to assess vascular function and indicators of disease status. We found that RSV treatment significantly abrogated diabetes induced vascular dysfunction. This improvement was associated with the ability of RSV to decrease oxidative stress markers alongside a reduction in the aortic TGF-β expression, elevation of NOS3 expression and aortic nitrite concentration as well as HO activity. These ameliorative effects were diminished when ZnPP was administered prior to RSV. Our results clearly demonstrate the protective effects of RSV in diabetes-associated endothelial dysfunction and verified a causal role of HO-1 in this setting.

Decreasing incidence of pharmacologically treated Type 2 diabetes in Hungary from 2001 to 2016: A nationwide cohort study

AIMS

Incidence and prevalence of Type 2 diabetes mellitus (T2DM) vary in different regions. Long-term nationwide epidemiological data are useful to assess trends over time. The aim of the study was to analyze the epidemiological changes of pharmacologically treated T2DM among people aged over 18 years in Hungary between 2001 and 2016.

METHODS

Annual incidence, prevalence and all-cause mortality rate of pharmacologically treated T2DM patients were evaluated from 2001 to 2016 using the central database of the National Institute of Health Insurance Fund Management. Data were adjusted to age using the 2013 European Standard Population.

RESULTS

Incident rate of pharmacologically treated T2DM decreased from 931.6 cases/100,000 person-years to 350.7 cases/100,000 person-years resulting in a -62.4% change (annual average change: -6.46% [95% CI: -7.64%; -5.67%]) between 2001 and 2016. The prevalence rate continuously increased from 4949.9 cases/100,000 persons in 2001 to the highest rate (8135.0 cases/100,000 persons) in 2011, which plateaued during the next 3 years and slightly decreased thereafter. Standardized all-cause mortality rate in people with T2DM decreased between 2001 and 2016 by 11.9% (annual average change: -0.84% [95% CI: -1.22%; -0.39%]).

CONCLUSIONS

Despite a clearly decreasing incidence of pharmacologically treated T2DM in patients aged over 18 years, the prevalence rate increased from 2001 to 2011 followed by a 3-year-long plateau and a slight decrease thereafter. These long-term trends with the reduced mortality rate may indicate favorable effects of health promotional activities for preventing and treating T2DM.

Predictors of cardiomyopathy in patients with type-2 diabetes mellitus with and without cardiovascular complications: A cross-sectional study

AIM

This study was aimed to evaluate the cardiomyopathy in patients with type 2 diabetes mellitus (T2DM) who live with or without cardiovascular complications by estimating different cardiac biomarkers.

METHODS

This cross-sectional study enrolled 125 participants including 25 healthy volunteers and 100 T2DM patients. After meeting all inclusion criteria, the participants were categorized into five groups (N = 25 in each) as; healthy volunteers (I), T2DM (II), T2DM with hypertension (III), T2DM with dyslipidemia (IV), T2DM with hypertension and dyslipidemia (V). Pearson's correlation analysis was performed to assess the significant association between cardiac biomarkers other biochemical parameters. P-values <0.05 were considered statistically significant.

RESULTS

The average age of the participants was found to be 55.04 ± 7.51 years. The positive correlation was found between HbA1c and calcium or BNP levels however, a negative association was observed with zinc level. Group V showed higher mean of BNP (pg/mL) as 86.73 ± 64.49 followed by Group III (61.02 ± 53.69), IV (33.88 ± 33.71), II (13.49 ± 11.67) and I (5.54 ± 1.49) which predicts the subclinical cardiomyopathies in the respective groups. Serum zinc (µg/dL) level were significantly lower in Group V (52.72 ± 12.16) followed by III (56.15 ± 9.64), IV (58.10 ± 10.05), II (59.49 ± 11.33) and I (73.96 ± 21.91).

CONCLUSIONS

In summary, BNP and calcium levels were significantly elevated while zinc was significantly reduced in T2DM patients with cardiovascular complication. Results from the study also shown positive correlation between BNP, calcium, Troponin-I levels and blood pressure. However, further longitudinal studies required to confirm these findings.

Impact of serum 1,5-anhydro-D-glucitol level on the prediction of severe coronary artery calcification: an intravascular ultrasound study

BACKGROUND

A low 1,5-anhydro-D-glucitol (AG) blood level is considered a clinical marker of postprandial hyperglycemia. Previous studies reported that 1,5-AG levels were associated with vascular endothelial dysfunction and coronary artery disease (CAD). However, the association between 1,5-AG levels and coronary artery plaque in patients with CAD is unclear.

METHODS

This study included 161 patients who underwent percutaneous coronary intervention for CAD. The culprit plaque characteristics and the extent of coronary calcification, which was measured by the angle of its arc, were assessed by preintervention intravascular ultrasound (IVUS). Patients with chronic kidney disease or glycosylated hemoglobin ≥ 7.0 were excluded. Patients were divided into 2 groups according to serum 1,5-AG levels (< 14.0 μg/mL vs. ≥ 14 μg/mL).

RESULTS

The total atheroma volume and the presence of IVUS-attenuated plaque in the culprit lesions were similar between groups. Calcified plaques were frequently observed in the low 1,5-AG group (p = 0.06). Compared with the high 1,5-AG group, the low 1,5-AG group had significantly higher median maximum calcification (144° vs. 107°, p = 0.03) and more frequent calcified plaques with a maximum calcification angle of ≥ 180° (34.0% vs. 13.2%, p = 0.003). Multivariate logistic regression analysis showed that a low 1,5-AG level was a significant predictor of a greater calcification angle (> 180°) (OR 2.64, 95% CI 1.10-6.29, p = 0.03).

CONCLUSIONS

Low 1,5-AG level, which indicated postprandial hyperglycemia, was associated with the severity of coronary artery calcification. Further studies are needed to clarify the effects of postprandial hyperglycemia on coronary artery calcification.

Improving Outcomes in Patients With Diabetes Mellitus

See Article by Raghavan et al.