A propensity-matched study of the association of diabetes mellitus with incident heart failure and mortality among community-dwelling older adults

Nonprescription Magnesium Supplement Use and Risk of Heart Failure in Patients With Diabetes: A Target Trial Emulation

BACKGROUND

Both diabetes and low magnesium-containing food intake may increase the risk of heart failure (HF). However, the effect of nonprescription magnesium supplements on the risk of HF or major adverse cardiac events in patients with diabetes is unknown.

METHODS AND RESULTS

Using a target-trial-emulation approach, we assembled a national cohort of 94 239 veterans ≥40 years with diabetes, without prior HF or magnesium use, who received ambulatory care in the US veterans-health care system documented by electronic clinic notes between January 1, 2006 and December 31, 2020. A natural language processing approach was used to detect self-reported magnesium-supplement use from clinic notes, n=17 619 were identified as users versus n=76 620 as nonusers. Using inverse probability treatment weighting, we constructed a cohort balanced in 88 baseline characteristics between users and nonusers. The primary outcome was incident HF. Secondary outcomes were major adverse cardiac events (myocardial infarction, stroke, HF hospitalization, or death). Hazard ratios (HRs) associated with magnesium-supplement use and outcomes were estimated in the inverse probability treatment weighting weighted cohort using Cox regression. The inverse probability treatment weighting weighted cohort had a mean age of 67.4±10.3 years; 18.4% were Black, and 5.1% were women. The mean duration of magnesium-supplement use was 3.5±3.1 (interquartile range, 1.1-5.1) years. Incident HF occurred in 8.0% of users and 9.7% of nonusers of magnesium supplements (HR, 0.94 [95% CI, 0.89-0.99]). Magnesium-supplement use was also associated with a reduced risk of major adverse cardiac events (HR, 0.94 [95% CI, 0.90-0.97]).

CONCLUSIONS

Long-term nonprescription magnesium supplement use was associated with a lower risk of incident HF and major adverse cardiac events in patients with diabetes. These findings should be replicated in randomized controlled trials.

Admission Blood Glucose Associated with In-Hospital Mortality in Critically III Non-Diabetic Patients with Heart Failure: A Retrospective Study

Background

Heart failure (HF) is a primary public health issue associated with a high mortality rate. However, effective treatments still need to be developed. The optimal level of glycemic control in non-diabetic critically ill patients suffering from HF is uncertain. Therefore, this study examined the relationship between initial glucose levels and in-hospital mortality in critically ill non-diabetic patients with HF.

Methods

A total of 1159 critically ill patients with HF were selected from the Medical Information Mart for Intensive Care-III (MIMIC-III) data resource and included in this study. The association between initial glucose levels and hospital mortality in seriously ill non-diabetic patients with HF was analyzed using smooth curve fittings and multivariable Cox regression. Stratified analyses were performed for age, gender, hypertension, atrial fibrillation, CHD with no MI (coronary heart disease with no myocardial infarction), renal failure, chronic obstructive pulmonary disease (COPD), estimated glomerular filtration rate (eGFR), and blood glucose concentrations.

Results

The hospital mortality was identified as 14.9%. A multivariate Cox regression model, along with smooth curve fitting data, showed that the initial blood glucose demonstrated a U-shape relationship with hospitalized deaths in non-diabetic critically ill patients with HF. The turning point on the left side of the inflection point was HR 0.69, 95% CI 0.47-1.02, p = 0.068, and on the right side, HR 1.24, 95% CI 1.07-1.43, p = 0.003. Significant interactions existed for blood glucose concentrations (7-11 mmol/L) (p-value for interaction: 0.009). No other significant interactions were detected.

Conclusions

This study demonstrated a U-shape correlation between initial blood glucose and hospital mortality in critically ill non-diabetic patients with HF. The optimal level of initial blood glucose for non-diabetic critically ill patients with HF was around 7 mmol/L.

Diabetes and risk of heart failure in people with and without cardiovascular disease: systematic review and meta-analysis

BACKGROUND

People with diabetes have an increased risk of heart failure (HF), compared to those without diabetes. However, no comprehensive systematic review and meta-analysis has explored whether these associations could differ in relation to prevalent cardiovascular disease (CVD).

AIMS

To estimate the association between diabetes and incident heart failure (HF), compared to without diabetes, in individuals with and without CVD.

METHODS

PubMed, Scopus, and Web of Science were searched for observational cohort studies from the earliest dates to 22nd March 2023. A random-effects model calculated the pooled relative risk (RR).

RESULTS

Of 11,609 articles, 31 and 6 studies reported data in people with type 2 diabetes (T2D) and type 1 diabetes (T1D) respectively. Individuals with T2D had an increased risk of HF irrespective of CVD prevalence: 1.61 (95% CI: 1.35-1.92) in those with CVD; 1.78 (1.60-1.99) without CVD; and 2.02 (1.75-2.33) with unspecified CVD prevalence. Meta-regression did not identify a significant difference comparing HF risk in T2D individuals with vs. without CVD (p = 0.232).

CONCLUSION

Peoplewith T2D, compared to those without diabetes, have similar increased risk of HF, regardless of CVD prevalence. Strategiesproven to lower HF risk in T2D individuals should be prioritized for those with and without CVD.

Diabetes mellitus and risk of new-onset and recurrent heart failure: a systematic review and meta-analysis

Despite mounting evidence of the positive relationship between diabetes mellitus (DM) and heart failure (HF), the entire context of the magnitude of risk for HF in relation to DM remains insufficiently understood. The principal reason is because new‐onset HF (HF occurring in participants without a history of HF) and recurrent HF (HF re‐occurring in patients with a history of HF) are not discriminated. This meta‐analysis aims to comprehensively and separately assess the risk of new‐onset and recurrent HF depending on the presence or absence of DM. We systematically searched cohort studies that examined the relationship between DM and new‐onset or recurrent HF using EMBASE and MEDLINE (from 1 Jan 1950 to 28 Jul 2019). The risk ratio (RR) for HF in individuals with DM compared with those without DM was pooled with a random‐effects model. Seventy‐four and 38 eligible studies presented data on RRs for new‐onset and recurrent HF, respectively. For new‐onset HF, the pooled RR [95% confidence interval (CI)] of 69 studies that examined HF as a whole [i.e. combining HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF)] was 2.14 (1.96–2.34). The large between‐study heterogeneity (I² = 99.7%, P < 0.001) was significantly explained by mean age [pooled RR (95% CI) 2.60 (2.38–2.84) for mean age < 60 years vs. pooled RR (95% CI) 1.95 (1.79–2.13) for mean age ≥ 60 years] (P < 0.001). Pooled RRs (95% CI) of seven and eight studies, respectively, that separately examined HFpEF and HFrEF risk were 2.22 (2.02–2.43) for HFpEF and 2.73 (2.71–2.75) for HFrEF. The risk magnitudes between HFpEF and HFrEF were not significantly different in studies that examined both HFpEF and HFrEF risks (P = 0.86). For recurrent HF, pooled RR (95% CI) of the 38 studies was 1.39 (1.33–1.45). The large between‐study heterogeneity (I² = 80.1%, P < 0.001) was significantly explained by the proportion of men [pooled RR (95% CI) 1.53 (1.40–1.68) for < 65% men vs. 1.32 (1.25–1.39) for ≥65% men (P = 0.01)] or the large pooled RR for studies of only participants with HFpEF [pooled RR (95% CI), 1.73 (1.32–2.26) (P = 0.002)]. Results indicate that DM is a significant risk factor for both new‐onset and recurrent HF. It is suggested that the risk magnitude is large for new‐onset HF especially in young populations and for recurrent HF especially in women or individuals with HFpEF. DM is associated with future HFpEF and HFrEF to the same extent.

Higher risk for incident heart failure and cardiovascular mortality among community-dwelling octogenarians without pneumococcal vaccination

AIMS

Octogenarians have the highest incidence of heart failure (HF) that is not fully explained by traditional risk factors. We explored whether lack of pneumococcal vaccination is associated with higher risk of incident HF among octogenarians.

METHODS AND RESULTS

In the Cardiovascular Health Study (CHS), 5290 community-dwelling adults, ≥65 years of age, were free of baseline HF and had data on pneumococcal vaccination. Of these, 851 were octogenarians, of whom, 593 did not receive pneumococcal vaccination. Multivariable-adjusted hazard ratios (aHR) and 95% confidence intervals (CI) for associations of lack of pneumococcal vaccination with incident HF and other outcomes during 13 years of follow-up were estimated using Cox regression models, adjusting for demographics and other HF risk factors including influenza vaccination. Octogenarians had a mean (±SD) age of 83 (±3) years; 52% were women and 17% African American. Overall, 258 participants developed HF and 662 died. Lack of pneumococcal vaccination was associated with higher relative risk of incident HF (aHR, 1.37; 95% CI, 1.01-1.85; P = 0.044). There was also higher risk for all-cause mortality (aHR, 1.23; 95% CI, 1.02-1.49; P = 0.028), which was mostly driven by cardiovascular mortality (aHR, 1.45; 95% CI, 1.06-1.98; P = 0.019). Octogenarians without pneumococcal vaccination had a trend toward higher risk of hospitalization due to pneumonia (aHR, 1.34; 95% CI, 0.99-1.81; P = 0.059). These associations were not observed among those 65-79 years of age.

CONCLUSIONS

Among community-dwelling octogenarians, lack of pneumococcal vaccination was associated with a significantly higher independent risk of incident HF and mortality, and trend for higher pneumonia hospitalization.

Heart failure as a risk factor for diabetes mellitus

BACKGROUND

Diabetes mellitus (DM) is a well-recognized risk factor for heart failure (HF). We hypothesized that HF also increases the risk for DM.

OBJECTIVE

We explored the hypothesis that HF is a risk factor for DM.

METHODS

The Cardiovascular Health Study was a prospective cohort study of cardiovascular risk in ambulatory older adults. We used a limited-access dataset provided by the National Heart, Lung and Blood Institute. The impact of HF at baseline on DM after 3 or 4 years was examined in a cohort of 3,748 nondiabetic participants aged ≥65 years. The magnitude and significance of the association were evaluated using logistic regression models. Analyses were performed with and without adjustment for confounders and separately among subjects with normal and impaired fasting glucose at baseline.

RESULTS

Among subjects with normal fasting glucose at baseline, HF significantly increased the odds of developing impaired fasting glucose after 3 or 4 years [odds ratio (OR) 2.18, 95% confidence interval (CI) 1.03-4.61, p = 0.043] or overt DM (OR 4.78, 95% CI 1.84-12.4, p < 0.001). After adjusting for demographic and biomedical factors, HF remained significantly associated with a worsening DM status (OR 2.43, 95% CI 1.38-4.29, p = 0.002).

CONCLUSIONS

In the elderly population, the presence of HF more than doubles the incidence of DM within a few years. This association remains significant when adjusting for age, gender and cardiovascular comorbidities.

Prevalence and associations of diabetic retinopathy in a large cohort of prediabetic subjects: the Gutenberg Health Study

AIMS

To evaluate the prevalence of diabetic retinopathy/maculopathy (DR/DMac) and its associations with cardiovascular risk factors (CRF) in participants with prediabetes (PwPD) in a large European cohort within the population-based Gutenberg Health Study (GHS).

METHODS

The study was based on a sub-cohort of the GHS (n=5,000, age: 35-74 y). Prediabetes was diagnosed according to HbA1c levels (5.7-6.4%). DR/DMac was graded from fundus photographs. Blood samples and comprehensive questionnaires served for evaluation of laboratory results and CRF.

RESULTS

The prevalence of prediabetes was 22.4%, and of DR/DMac 8.1%/0.2%, respectively. The majority of participants had mild DR (7.2%). A percentage of 0.5 of PwPD presented with moderate and 0.3% with severe non-proliferative disease. None of the subjects had proliferative DR. No independent association was found between any of the analyzed CRF [hypertension, smoking, (family) history of myocardial infarction, congestive heart failure, coronary heart disease, stroke, obesity, dyslipidemia, chronic obstructive pulmonary disease, peripheral artery disease and chronic kidney disease] and DR.

CONCLUSIONS

Although prevalences of prediabetes and DR in this Caucasian cohort are considerable, retinopathy findings are mainly mild, and no association was found for DR/DMac and CRF.

Infection hospitalization increases risk of dementia in the elderly

OBJECTIVES

Severe infections, often requiring ICU admission, have been associated with persistent cognitive dysfunction. Less severe infections are more common and whether they are associated with an increased risk of dementia is unclear. We determined the association of pneumonia hospitalization with risk of dementia in well-functioning older adults.

DESIGN

Secondary analysis of a randomized multicenter trial to determine the effect of Gingko biloba on incident dementia.

SETTING

Five academic medical centers in the United States.

SUBJECTS

Healthy community volunteers (n = 3,069) with a median follow-up of 6.1 years.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

We identified pneumonia hospitalizations using International Classification of Diseases, 9th Edition-Coding Manual codes and validated them in a subset. Less than 3% of pneumonia cases necessitated ICU admission, mechanical ventilation, or vasopressor support. Dementia was adjudicated based on neuropsychological evaluation, neurological examination, and MRI. Two hundred twenty-one participants (7.2%) incurred at least one hospitalization with pneumonia (mean time to pneumonia = 3.5 yr). Of these, dementia was developed in 38 (17%) after pneumonia, with half of these cases occurring 2 years after the pneumonia hospitalization. Hospitalization with pneumonia was associated with increased risk of time to dementia diagnosis (unadjusted hazard ratio = 2.3; CI, 1.6-3.2; p < 0.0001). The association remained significant when adjusted for age, sex, race, study site, education, and baseline mini-mental status examination (hazard ratio = 1.9; CI, 1.4-2.8; p < 0.0001). Results were unchanged when additionally adjusted for smoking, hypertension, diabetes, heart disease, and preinfection functional status. Results were similar using propensity analysis where participants with pneumonia were matched to those without pneumonia based on age, probability of developing pneumonia, and similar trajectories of cognitive and physical function prior to pneumonia (adjusted prevalence rates, 91.7 vs 65 cases per 1,000 person-years; adjusted prevalence rate ratio = 1.6; CI, 1.06-2.7; p = 0.03). Sensitivity analyses showed that the higher risk also occurred among those hospitalized with other infections.

CONCLUSION

Hospitalization with pneumonia is associated with increased risk of dementia.

Prediabetes is not an independent risk factor for incident heart failure, other cardiovascular events or mortality in older adults: findings from a population-based cohort study

BACKGROUND

Whether prediabetes is an independent risk factor for incident heart failure (HF) in non-diabetic older adults remains unclear.

METHODS

Of the 4602 Cardiovascular Health Study participants, age≥65 years, without baseline HF and diabetes, 2157 had prediabetes, defined as fasting plasma glucose (FPG) 100-125 mg/dL. Propensity scores for prediabetes, estimated for each of the 4602 participants, were used to assemble a cohort of 1421 pairs of individuals with and without prediabetes, balanced on 44 baseline characteristics.

RESULTS

Participants had a mean age of 73 years, 57% were women, and 13% African American. Incident HF occurred in 18% and 20% of matched participants with and without prediabetes, respectively (hazard ratio {HR} associated with prediabetes, 0.90; 95% confidence interval {CI}, 0.76-1.07; p=0.239). Unadjusted and multivariable-adjusted HRs (95% CIs) for incident HF associated with prediabetes among 4602 pre-match participants were 1.22 (95% CI, 1.07-1.40; p=0.003) and 0.98 (95% CI, 0.85-1.14; p=0.826), respectively. Among matched individuals, prediabetes had no independent association with incident acute myocardial infarction (HR, 1.02; 95% CI, 0.81-1.28; p=0.875), angina pectoris (HR, 0.93; 95% CI, 0.77-1.12; p=0.451), stroke (HR, 0.86; 95% CI, 0.70-1.06; p=0.151) or all-cause mortality (HR, 0.99; 95% CI, 0.88-1.11; p=0.840).

CONCLUSIONS

We found no evidence that prediabetes is an independent risk factor for incident HF, other cardiovascular events or mortality in community-dwelling older adults. These findings question the wisdom of routine screening for prediabetes in older adults and targeted interventions to prevent adverse outcomes in older adults with prediabetes.

A new scoring system for evaluating the risk of heart failure events in Japanese patients with atrial fibrillation

Risk stratification for heart failure (HF) in patients with atrial fibrillation (AF) has not been well established. The aim of this study was to identify the predictors of HF events in patients with AF, consequently developing a new risk-scoring system that stratifies the risk for HF events. In this prospective, single hospital-based cohort, all patients who presented from July 2004 to March 2010 were registered (Shinken Database 2004-2009). Follow-up was maintained by being linked to the medical records or by sending study documents of prognosis. Of the 13,228 patients in the Shinken Database 2004-2009, 1,942 patients with AF were identified. Of the patients with AF, HF events (hospitalization or death from HF) occurred in 147 patients (7.6%) during a mean follow-up period of 776 ± 623 days. After identifying the parameters that were independently associated with the incidence of HF events (coexistence of organic heart diseases, anemia [hemoglobin level <11 g/dl], renal dysfunction [estimated glomerular filtration rate <60 ml/min/m(2)], diabetes mellitus, and the use of diuretics), a new scoring system was developed, the H(2)ARDD score (heart diseases = 2 points, anemia = 1 point, renal dysfunction = 1 point, diabetes = 1 point, and diuretic use = 1 point; range 0 to 6 points). This scoring system discriminated the low- and high-risk populations well (incidence in patients scoring 0 and 6 points of 0.2% and 40.8% per patient-year, respectively) and showed high predictive ability (area under the curve 0.840, 95% confidence interval 0.803 to 0.876). In conclusion, the new H(2)ARDD score may help identify the population of patients with AF at high risk for HF events.

Glycemic variability and glycemic control in the acutely ill cardiac patient

The mechanisms for hyperglycemia-mediated harm in the hospitalized cardiac patient are poorly understood. Potential obstacles in the inpatient management of hyperglycemia in cardiac patients include rapidly changing clinical status, frequent procedures and interruptions in carbohydrate exposure, and short hospital length of stay. A patient's preadmission regimen is rarely suitable for inpatient glycemic control. Instead, an approach to a flexible, physiologic insulin regimen is described, which is intended to minimize glycemic excursions. When diabetes or hyperglycemia is addressed early and consistently, the hospital stay can serve as a potential window of opportunity for reinforcing self-care behaviors that reduce long-term complications.