Type 2 Diabetes Mellitus and Heart Failure, A Scientific Statement From the American Heart Association and Heart Failure Society of America

Chitosan hydrochloride coated and nonionic surfactant modified niosomes: a better way for oral administration of semaglutide

Diabetes is now a global chronic disease, with the number of people with diabetes expected to reach 643 million by the end of 2030. Semaglutide, a human glucagon-like peptide-1 (GLP-1) analogue with 94% similarity to human GLP-1, can promote insulin secretion and repress glucagon secretion in a glucose concentration-dependent manner, resulting in substantial improvement of blood glucose levels and reducing the risk of hypoglycemia in patients with type 2 diabetes. To improve the absorption efficiency of semaglutide in oral delivery, we developed chitosan hydrochloride-coated and nonionic surfactant-modified niosomes (CS.HCL-NSPEs-NIO) as a new way to encapsulate it. The results showed that CS.HCL-NSPEs-NIO could efficiently penetrate the cell junctions in the intestinal endothelium and therefore promote drug absorbance. In addition, gastrointestinal distribution studies revealed that CS. HCL-NSPEs-NIO could stay in the intestine for more than 4 h, thus allowing for long-term glucose regulation. Effective reduction of blood glucose levels and weight loss were observed in db/db mice while no toxicity was detected in major organs. On the whole, our recommendation is that CS.HCL-NSPEs-NIO shows promise as an oral delivery tool for enhancing the hypoglycemic effects of semaglutide.

Effect of Hypoglycemic Drugs on Patients with Heart Failure with or without T2DM: A Bayesian Network Meta-analysis

Background

Anti-diabetic drugs have been noted to have a cardioprotective effect in patients with diabetes and heart failure (HF). The purpose of this study was to perform a Bayesian network meta-analysis to evaluate the impact of various anti-diabetic drugs on the prognosis of HF patients with and without diabetes.

Methods

We searched PubMed, Embase, Cochrane, and Web of Science for randomized controlled trials (RCTs) published before November 2024 that investigated the use of anti-diabetic medications in patients with HF. Primary outcomes included re-admission due to HF, all-cause death, cardiovascular death, serum N-terminal pro-brain natriuretic peptide (NTpro-BNP) levels, and left ventricular ejection fraction (LVEF). A Bayesian network meta-analysis was used to compare the effectiveness of different anti-diabetic drugs.

Results

A total of 33 RCTs involving 29,888 patients were included. Sotagliflozin was the most effective in reducing the risk of re-admission due to HF and all-cause death, with a cumulative probability of 0.84 and 0.83, respectively. Liraglutide reduced the risk of cardiovascular death in HF patients with a cumulative probability of 0.97 and had the best efficacy in reducing NTpro-BNP levels with a cumulative probability of 0.69. Empagliflozin was best in improving LVEF in HF patients, with a cumulative probability of 0.69.

Conclusions

This Bayesian network meta-analysis demonstrates that sotagliflozin may be the best option for HF patients with and without diabetes. However, due to the small number of articles in this study, our results must be treated cautiously. Subsequently, there is an urgent need for more high-quality studies to validate our findings.

COVID-19 Prevention and Mitigation Decision-Making Processes While Navigating Chronic Disease Care: Perspectives of Black Adults with Heart Failure and Diabetes

BACKGROUND

Heart failure and diabetes are comorbidities that disproportionately contribute to high morbidity and mortality among Blacks. Further compounding the racial and ethnic disparities in COVID-19 health outcomes, Blacks with cardiometabolic diseases are at high risk of experiencing serious complications or mortality from COVID-19. This study aimed to assess how Blacks with heart failure and diabetes navigated chronic care management during the COVID-19 pandemic.

METHODS

A mixed methods study including in-depth interviews and surveys with adults diagnosed with heart failure and diabetes (n = 17) was conducted in 2021-2022. Verbatim transcripts were analyzed using a thematic analysis approach.

RESULTS

Participants reported that while the pandemic initially caused delays in access to health services, shifts to telemedicine allowed for continued care despite preferences for in-person appointments. Various sources of information were used in different ways to make decisions on how to best reduce health risks due to COVID-19, but individuals and institutions affiliated with science and medicine, or who promoted information from these sources, were considered to be the most trusted sources of information among those who relied on outside guidance when making health-related decisions. Individuals' self-awareness of their own high-risk status and perceived control over their exposure levels to the virus informed what COVID-19 prevention and mitigation strategies people used.

CONCLUSION

Information backed by scientific data was an important health communication tool that alongside other factors, such as fear of mortality due to COVID-19, encouraged individuals to get vaccinated and adopt other COVID-19 prevention and mitigation behaviors.

Heart Failure in Atrial Fibrillation Subtypes in Women and Men in the Tromsø Study

Background

Atrial fibrillation (AF) and heart failure (HF) often coexist and impact morbidity and mortality. There is limited knowledge on the association of AF subtypes with HF according to sex.

Objectives

The purpose of this study was to explore sex-specific associations between AF subtypes and subsequent HF, identifying HF risk factors in participants with AF, and exploring the combined impact on mortality.

Methods

14,790 women and 13,181 men from the Tromsø Study were enrolled between 1994 and 2008 and followed for incident AF and HF through 2016. Cox regression was conducted to provide HRs and 95% CIs.

Results

Those with AF had higher risk of subsequent HF in both sexes compared to those without AF. Women with permanent AF had higher relative risk of HF than men (HR: 10.52; 95% CI: 8.72-12.70, and HR: 7.65; 95% CI: 6.40-9.15, respectively). Risk factors for HF in participants with AF included smoking in all, higher diastolic blood pressure and hypertension in women, underweight, obesity, and low alcohol consumption in men. All-cause mortality was higher in women with both subtypes (paroxysmal/persistent: HR: 2.10; 95% CI: 1.78-2.48, permanent: HR: 1.40, 95% CI: 1.14-1.72) and in men with paroxysmal/persistent AF (HR: 1.66; 95% CI: 1.40-1.96). Subsequent HF increased risk of mortality in both sexes.

Conclusions

All AF subtypes were associated with increased risk of HF. Smoking was a shared risk factor, while diastolic blood pressure and hypertension were specific to women, and underweight, obesity, and low alcohol intake were specific to men. Subsequent HF increased mortality risk in all.

Association between endostatin and mortality in patients with acute dyspnoea, with or without congestive heart failure: a single-centre, prospective, observational study

OBJECTIVE

The aim of this study was to assess associations between endostatin levels and short-term mortality in unsorted acute hospitalised dyspnoea patients with or without congestive heart failure (CHF), adjusted for common cardiovascular risk factors.

DESIGN, SETTING AND PARTICIPANTS

In this prospective observational study, 723 hospitalised patients who visited the emergency department at Skåne University Hospital, Sweden, between 2013 and 2018 were included. Of these, 276 had a history of CHF. The association between endostatin levels and 1 month and 3-month mortality was evaluated, stratified by whether patients had a history of CHF or not.

RESULTS

Patients with prior CHF had higher endostatin levels, higher short-term mortality and were more likely to have CHF as discharge diagnosis. In a fully adjusted model, endostatin was independently associated with 3-month mortality (HR=1.01 per 1 ng/mL increment of endostatin; 95% CI 1.00 to 1.02; p=0.016). No evidence of association was identified with 1-month mortality.

CONCLUSIONS

Endostatins are potential biomarkers for 3 months' mortality in patients hospitalised with CHF seeking emergency care with acute dyspnoea. Further studies are needed in different settings to assess the predictive value of endostatins in patients with CHF.

Long-term outcomes of unselected patients undergoing coronary angiography according to the presence or absence of type II diabetes mellitus

OBJECTIVE

The study investigates long-term outcomes of unselected inpatients undergoing invasive coronary angiography (CA) with and without diabetes mellitus type II (T2DM).

BACKGROUND

Due to continual shifts in demographics and advancements in treating cardiovascular disease, there has been a notable evolution in the types of patients undergoing CA over the past decades. Comprehensive data on the extended outcomes of CA patients, both with and without concurrent T2DM, remains scarce.

METHODS

Consecutive inpatients undergoing invasive CA from 2016 to 2022 were included at one institution. The prognosis of T2DM in patients undergoing CA was investigated with regard to the risk rehospitalization for heart failure (HF), acute myocardial infarction (AMI) and coronary revascularization at 36 months of follow-up. Statistical analyses included Kaplan-Meier uni- and multivariable Cox proportional regression analyses.

RESULTS

From 2016 to 2022, 7150 patients undergoing CA were included with a prevalence of T2DM of 31.2 %. Compared to non-diabetics, patients with T2DM had a higher prevalence (78.0 % vs. 64.3 %; p = 0.001) and extent (3-vessel disease: 36.9 % vs. 23.8 %; p = 0.001) of coronary artery disease (CAD). At 36 months, patients with T2DM had a higher risk rehospitalization for worsening HF (29.0 % vs. 18.2 %; p = 0.001), AMI (9.9 % vs. 6.6 %; p = 0.001), alongside with a higher need for coronary revascularization (10.7 % vs. 7.2 %; p = 0.001) compared to patients without. Even after multivariable adjustment, the risk of rehospitalization for HF (HR = 1.229; 95 % CI 1.099-1.374; p = 0.001), AMI (HR = 1.270; 95 % CI 1.052-1.534; p = 0.013) and coronary revascularization (HR = 1.457; 95 % CI 1.213-1.751; p = 0.001) was higher in patients with T2DM. Especially in patients with left ventricular ejection fraction (LVEF) ≥ 35 %, T2DM was associated with a higher risk of AMI- (HR = 1.395, 95 % CI: 1.104 - 1.763, p = 0.005) and PCI-related rehospitalization (HR = 1.442, 95 % CI: 1.185 - 1.775, p = 0.001).

CONCLUSION

In unselected patients undergoing CA, T2DM represents an independent predictor of HF-related rehospitalization, AMI- and for PCI- at 36 months.

Vericiguat and Cardiovascular Outcomes in Heart Failure by Baseline Diabetes Status: Insights From the VICTORIA Trial

BACKGROUND

Type 2 diabetes mellitus (T2DM) significantly worsens heart failure (HF) prognosis.

OBJECTIVES

This study sought to investigate the impact of T2DM on outcomes in patients enrolled in VICTORIA and assess the efficacy of vericiguat in patients with and without T2DM.

METHODS

Patients with HF with reduced ejection fraction were randomized to receive vericiguat or placebo in addition to standard therapy. The primary outcome was a composite of cardiovascular death or first heart failure hospitalization (HFH). A Cox proportional hazards model was used to calculate HRs and 95% CIs to assess if the effect of vericiguat differed by history of T2DM.

RESULTS

Of 5,050 patients enrolled, 3,683 (72.9%) had glycosylated hemoglobin (HbA1c) measured at baseline. Of these, 2,270 (61.6%) had T2DM, 741 (20.1%) had pre-T2DM, 449 (12.2%) did not have T2DM, and 178 (4.8%) had undiagnosed T2DM. The risks of the primary outcome, HFH, and all-cause and cardiovascular mortality were high across all categories. The efficacy of vericiguat on the primary outcome did not differ in patients stratified by T2DM by history (HR: 0.92; 95% CI: 0.81-1.04), T2DM measured by HbA1c (HR: 0.77; 95% CI: 0.49-1.20), and pre-T2DM measured by HbA1c (HR: 0.88; 95% CI: 0.68-1.13) and in those with normoglycemia (HR: 1.02: 95% CI: 0.75-1.39; P for interaction = 0.752). No significant differences were observed in subgroups with respect to the efficacy of vericiguat on HFH and all-cause or cardiovascular death.

CONCLUSIONS

In this post hoc analysis of VICTORIA, vericiguat compared with placebo significantly reduced the risk of cardiovascular death or HFH in patients with worsening HF with reduced ejection fraction regardless of T2DM status. (A Study of Vericiguat in Participants With Heart Failure With Reduced Ejection Fraction [HFrEF] [Mk-1242-001] [VICTORIA]; NCT02861534).

Evaluation of subclinical left ventricular systolic dysfunction in patients with type 2 diabetes mellitus by combining myocardial work and triglyceride-glucose index

BACKGROUND AND AIM

Type 2 diabetes mellitus (T2DM) frequently presents subclinical left ventricular systolic dysfunction. The TyG index is a surrogate indicator of insulin resistance and is closely related to heart failure (HF). This study aimed to evaluate subclinical systolic dysfunction in T2DM by combining myocardial work (MW) and the TyG index and to investigate the risk factors for MW.

METHODS

This study included 102 diabetic patients and 78 healthy control subjects, and the diabetic group was divided into three subgroups based on the TyG index. LV global longitudinal strain (GLS), global myocardial work index (GWI), global constructive work (GCW), global wasted work (GWW), and global myocardial work efficiency (GWE) were measured in all subjects. GLS and MW were compared between the diabetic and control groups and between subgroups. Regression models were applied to analyze the risk factors for MW in diabetic patients.

RESULTS

GLS, GWI, GCW, and GWE significantly increased, and GWW significantly decreased in the diabetic group (all p < .01). GWI and GCW were significantly lower in the T3 subgroup than in the T1 and T2 subgroups (all p < .05). The TyG index, sex (female), BMI, systolic blood pressure (SBP), and total cholesterol (TC) were independent risk factors for GWI and GCW, and HbA1c was an independent risk factor for GWI.

CONCLUSIONS

MW accurately revealed subtle changes in subclinical LV systolic dysfunction in T2DM patients. An elevated TyG index was strongly associated with decreased GWI and GCW. The TyG index, sex (female), BMI, SBP, and TC were independent risk factors for GWI and GCW, and HbA1c was an independent risk factor for GWI.

Comparative effects of glucagon-like peptide-1 receptor agonists and sodium-glucose co-transporter-2 inhibitors on heart failure with preserved ejection fraction in diabetic patients: a meta-analysis

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) is common in type 2 diabetes mellitus (T2D), leading to high morbidity and mortality. Managing HFpEF in diabetic patients is challenging with limited treatments. Sodium-glucose co-transporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP1-RA) have shown potential cardiovascular benefits. This meta-analysis compares the effects of GLP1-RA and SGLT2 inhibitors on HFpEF in T2D patients.

METHODS

We conducted a meta-analysis of randomized controlled trials (RCTs) and observational studies evaluating GLP1-RA and SGLT2 inhibitors' impact on HFpEF in T2D patients. Databases searched included PubMed, MEDLINE, and Cochrane Library up to July 2024. Primary outcomes were changes in left ventricular ejection fraction (LVEF), myocardial fibrosis (extracellular volume fraction, ECV), and functional capacity (6-minute walk test, 6MWT). Secondary outcomes included HbA1c, body weight, and systolic blood pressure (SBP).  RESULTS: Twelve studies with 3,428 patients (GLP1-RA: 1,654; SGLT2 inhibitors: 1,774) were included. Both GLP1-RA and SGLT2 inhibitors significantly improved LVEF compared to placebo (GLP1-RA: mean difference [MD] 2.8%, 95% confidence interval [CI] 1.5 to 4.1, p < 0.001; SGLT2 inhibitors: MD 3.2%, 95% CI 2.0 to 4.4, p < 0.001). SGLT2 inhibitors significantly reduced myocardial fibrosis (MD -3.5%, 95% CI -4.2 to -2.8, p < 0.001) more than GLP1-RA (MD -2.3%, 95% CI -3.0 to -1.6, p < 0.001). Functional capacity improved significantly with both treatments (GLP1-RA: MD 45 m, 95% CI 30 to 60, p < 0.001; SGLT2 inhibitors: MD 50 m, 95% CI 35 to 65, p < 0.001). Secondary outcomes showed reductions in HbA1c (GLP1-RA: MD -1.1%, 95% CI -1.4 to -0.8, p < 0.001; SGLT2 inhibitors: MD -1.0%, 95% CI -1.3 to -0.7, p < 0.001) and body weight (GLP1-RA: MD -2.5 kg, 95% CI -3.1 to -1.9, p < 0.001; SGLT2 inhibitors: MD -2.0 kg, 95% CI -2.6 to -1.4, p < 0.001). Both treatments significantly lowered SBP (GLP1-RA: MD -5.2 mmHg, 95% CI -6.5 to -3.9, p < 0.001; SGLT2 inhibitors: MD -4.8 mmHg, 95% CI -6.0 to -3.6, p < 0.001).

CONCLUSIONS

GLP1-RA and SGLT2 inhibitors significantly benefit HFpEF management in T2D patients. SGLT2 inhibitors reduce myocardial fibrosis more effectively, while both improve LVEF, functional capacity, and metabolic parameters. These therapies should be integral to HFpEF management in diabetic patients. Further research is needed on long-term outcomes and potential combined therapy effects.

Prevalence and incidence of heart failure in type 2 diabetes patients: results from a nationwide prospective cohort-the DIABET-IC study

BACKGROUND

Type 2 diabetes (T2D) patients have an increased risk of heart failure (HF). There are limited data on the association between HF and T2D in specific healthcare settings. This study sought to analyse the prevalence and incidence of HF in a contemporary cohort of T2D patients attending cardiology and endocrinology outpatient clinics.

METHODS

We conducted an observational multicentre prospective study (DIABET-IC) that enrolled patients with a T2D diagnosis attending cardiology and endocrinology outpatient clinics in 30 centres in Spain between 2018 and 2019. The prevalence at the start of the study and the incidence of HF after a 3 year follow-up were calculated. HF was defined as the presence of typical symptoms and either: a) LVEF < 40%; or b) LVEF ≥ 40% with elevated natriuretic peptides and echocardiographic abnormalities.

RESULTS

A total of 1249 T2D patients were included in the present analysis (67.6 ± 10.1 years, 31.7% female). HF was present in 490 participants at baseline (prevalence 39.2%), 150 (30.6%) of whom had a preserved ejection fraction. The presence of adverse social determinants and chronic conditions such as chronic kidney disease and atherosclerotic cardiovascular disease were more frequent in HF patients. During the study period, there were 58 new diagnoses of HF (incidence 7.6%) among those without baseline HF. The incidence rate was 3.0 per 100 person-years. Independent predictors of incident HF were smoking, left ventricular ejection fraction, NT-ProBNP, history of tachyarrhythmia and treatment with pioglitazone, oral anticoagulants, or diuretics. Despite an average suboptimal glycaemic control, the use of antidiabetic drugs with cardiovascular benefits was low (30.4% for sodium-glucose cotransporter-2 inhibitors and 12.5% for glucagon-like peptide-1 receptor agonists).

CONCLUSIONS

In this contemporary cohort of T2D patients attending cardiology and endocrinology outpatient clinics, the prevalence and incidence of HF were high, comorbidities were frequent, and the use of antidiabetic agents with cardiovascular benefit was low. Outpatient care seems to be a unique opportunity for a comprehensive T2D approach that encompasses HF prevention, diagnosis, and treatment.

Cardio-Renal-Metabolic Outcomes Associated With the Use of GLP-1 Receptor Agonists After Heart Transplantation

BACKGROUND

The use of glucagon-like-peptide 1 receptor agonists (GLP1-RA) has dramatically increased over the past 5 years for diabetes mellitus type 2 (T2DM) and obesity. These comorbidities are prevalent in adult heart transplant (HT) recipients. However, there are limited data evaluating the efficacy of this drug class in this population. The aim of the current study was to describe cardiometabolic changes in HT recipients prescribed GLP1-RA at a large-volume transplant center.

METHODS

We retrospectively reviewed all adult HT recipients who received GLP1-RA after HT for a minimum of 1-month. Cardiometabolic parameters including body mass index (BMI), lipid panel, hemoglobin A1C, estimated glomerular filtration rate (eGFR), and NT-proBNP were compared prior to initiation of the drug and at most recent follow-up. We also evaluated for significant dose adjustments to immunosuppression after drug initiation and adverse effects leading to drug discontinuation.

RESULTS

Seventy-four patients were included (28% female, 53% White, 20% Hispanic) and followed for a median of 383 days [IQR 209, 613] on a GLP1-RA. The majority of patients (n = 56, 76%) were prescribed semaglutide. The most common indication for prescription was T2DM alone (n = 33, 45%), followed by combined T2DM and obesity (n = 26, 35%). At most recent follow-up, mean BMI decreased from 33.3 to 31.5 kg/m2 (p < 0.0001), HbA1C from 7.3% to 6.7% (p = 0.005), LDL from 78.6 to 70.3 mg/dL (p = 0.018) and basal insulin daily dose from 32.6 to 24.8 units (p = 0.0002).

CONCLUSION

HT recipients prescribed GLP1-RA therapy showed improved glycemic control, weight loss, and cholesterol levels during the study follow-up period. GLP1-RA were well tolerated and were rarely associated with changes in immunosuppression dosing.

Continuum of type 2 diabetes mellitus and its comorbidity with other somatic diseases

Type 2 diabetes mellitus (DM) develops in several stages over at least 10—15 years. Along with the progression of DM, the synthesis of endogenous insulin is diminished, while excessive glucagon synthesis and peripheral insulin resistance remain. Chronic hyperglycemia and associated multiple pathogenetic factors are responsible for the development of systemic consequences (chronic diabetic complications) and the formation of associations with other somatic diseases. The literature analyzes data on DM comorbidity with hypertension, chronic obstructive pulmonary disease, bronchial asthma, non-alcoholic fatty liver, erectile dysfunction, hypogonadism, and oncological diseases. Comorbid somatic diseases significantly deteriorate patients’ quality and duration of life. Therefore, they shall be considered in the type 2 DM complications-preventing strategy.

Macrovascular and microvascular complications of type 2 diabetes mellitus

Type 2 diabetes mellitus was declared a pandemic by the World Health Organization in the beginning of XXI century. The global prevalence of diabetes in the 20—79 age group in 2021 was 10.5% (537 million people) and may increase up to 12.2% (784 million people) in 2045. Russia is among the top ten countries in the world with a high prevalence of diabetes. Type 2 diabetes mellitus is known to be an important risk factor for atherosclerotic cardiovascular diseases such as ischemic heart disease, stroke and peripheral arterial disease. Along with this, detection and correction of microvascular complications (retinopathy, cardiac autonomic neuropathy and chronic kidney disease) are relevant tasks of clinical practice.

Comorbidity of patients with noncommunicable diseases in general practice. Eurasian guidelines

Создание руководства поддержано Советом по терапевтическим наукам отделения клинической медицины Российской академии наук.

Obesity, heart failure with preserved ejection fraction, and the role of glucagon-like peptide-1 receptor agonists

Heart failure with preserved ejection fraction (HFpEF) has a high prevalence, affecting more than 50% of patients with heart failure. HFpEF is associated with multiple comorbidities, and obesity is one of the most common. A distinct phenotype has been proposed for obese patients with HFpEF. Recent data show the beneficial role of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) for weight loss in diabetic and non-diabetic patients with obesity or overweight when given as adjunctive therapy to diet and exercise. The mechanisms of action are related to paracrine and endocrine signalling pathways within the gastrointestinal tract, pancreas, and central nervous system that delay gastric emptying, decrease appetite, augment pancreatic beta-cell insulin secretion, and suppress pancreatic glucagon release. These drugs are therefore potentially indicated for treatment of patients with HFpEF and obesity or overweight. Efficacy and safety need to be shown by clinical trials with a first one, Semaglutide Treatment Effect in People with obesity and heart failure with preserved ejection fraction (STEP HFpEF), recently concluded. The aim of the present review is to provide the pathophysiological and pharmacological rationale for GLP-1 RA administration to obese patients with HFpEF.

Diabetes mellitus does not alter mortality or hospitalisation risk in patients with newly diagnosed heart failure with preserved ejection fraction: Time to rethink pathophysiological models of disease progression

INTRODUCTION

Type 2 diabetes is a common and adverse prognostic co-morbidity for patients with heart failure with reduced ejection fraction (HFrEF). The effect of diabetes on long-term outcomes for heart failure with preserved ejection fraction (HFpEF) is less established.

METHODS

Prospective cohort study of patients referred to a regional HF clinic with newly diagnosed with HFrEF and HFpEF according to the 2016 European Society of Cardiology guidelines. The association between diabetes, all-cause mortality and hospitalisation was quantified using Kaplan-Meier or Cox regression analysis.

RESULTS

Between 1st May 2012 and 1st May 2013, of 960 unselected consecutive patients referred with suspected HF, 464 and 314 patients met the criteria for HFpEF and HFrEF respectively. Within HFpEF and HFrEF groups, patients with diabetes were more frequently male and in both groups patients with diabetes were more likely to be treated with β-adrenoceptor antagonists and angiotensin converting enzyme inhibitors. After adjustment for age, sex, medical therapy and co-morbidities, diabetes was associated with increased mortality in individuals with HFrEF (HR 1.46 95% CI: 1.05-2.02; p = .023), but not in those with HFpEF (HR 1.26 95% CI 0.92-1.72; p = .146).

CONCLUSION

In unselected patients with newly diagnosed HF, diabetes is not an adverse prognostic marker in patients with HFpEF, but is in HFrEF.

Changes in Kidney Function After Diagnosis of Advanced Heart Failure

BACKGROUND

Kidney function and its association with outcomes in patients with advanced heart failure (HF) has not been well-defined.

METHODS AND RESULTS

We conducted a retrospective cohort study comprising all adult residents of Olmsted County, Minnesota, with HF who developed advanced HF from 2007 to 2017. Patients were grouped by estimated glomerular filtration rate (eGFR) at advanced HF diagnosis using the 2021 Chronic Kidney Disease Epidemiology Collaboration equation. A linear mixed effects model was fitted to assess the relationship between development of advanced HF and longitudinal eGFR trajectory. A total of 936 patients with advanced HF (mean age 77 years, 55% male, 93.7% White) were included. Twenty-two percent of these patients had an eGFR of <30 at advanced HF diagnosis, 22% had an eGFR of 30-44, 23% had an eGFR of 45-59, and 32% had an eGFR of ≥60 mL/min/1.73 m2. The eGFR decreased faster after advanced HF (7.6% vs 10.9% annual decline before vs after advanced HF), with greater decreases after advanced HF in those with diabetes and preserved ejection fraction. An eGFR of <30 mL/min/1.73 m2 was associated with worse survival after advanced HF compared with an eGFR of ≥60 mL/min/1.73 m2 (adjusted hazard ratio 1.30, 95% confidence interval 1.07-1.57).

CONCLUSIONS

eGFR deteriorated faster after patients developed advanced HF. An eGFR of <30 mL/min/1.73 m2 at advanced HF diagnosis was associated with higher mortality.

Evaluation of the expression levels of lncRNAs H19 and MEG3 in patients with type 2 diabetes mellitus

BACKGROUND

LncRNAs may play a role in either suppressing or exacerbating diabetes-associated vascular complications.

AIMS

This study aimed to assess MEG3 and H19 expression levels in T2DM and pre-diabetes and their roles in diabetes-related microvascular complications.

SUBJECT AND METHODS

(RT-PCR) analysis of the MEG3 and H19 plasma levels was carried out in 180 participants of T2DM, pre-diabetes, and control.

RESULTS

The expression level of lncRNA H19 was significantly down-regulated and lncRNA MEG3 up-regulated in T2DM compared to pre-diabetes and control, also for pre-diabetes versus control. The (ROC) analysis of MEG3 and H19 relative expression levels showed that MEG3 has better sensitivity for distinguishing T2DM from pre-diabetes and control groups.In comparison, H19 offered superior sensitivity to distinguish pre-diabetic from controls. Additionally, H19 was reported as an independent risk factor for T2DM by multivariate analysis. Low expression of H19 and over-expressed MEG3 were significantly associated with retinopathy, nephropathy, and elevated renal indicators (urea, creatinine, and UACR.

CONCLUSION

Our results implicated the potential diagnostic and predictive roles of lncRNA MEG3 and H19 for T2DM and related microvascular complications. Additionally, H19 may serve as a potential biomarker for pre-diabetes prediction.

Cardiorenal syndrome and diabetes: an evil pairing

Cardiorenal syndrome (CRS) is a pathology where the heart and kidney are involved, and the deterioration of one of them leads to the malfunction of the other. Diabetes mellitus (DM) carries a higher risk of HF and a worse prognosis. Furthermore, almost half of people with DM will have chronic kidney disease (CKD), which means that DM is the main cause of kidney failure. The triad of cardiorenal syndrome and diabetes is known to be associated with increased risk of hospitalization and mortality. Cardiorenal units, with a multidisciplinary team (cardiologist, nephrologist, nursing), multiple tools for diagnosis, as well as new treatments that help to better control cardio-renal-metabolic patients, offer holistic management of patients with CRS. In recent years, the appearance of drugs such as sodium-glucose cotransporter type 2 inhibitors, have shown cardiovascular benefits, initially in patients with type 2 DM and later in CKD and heart failure with and without DM2, offering a new therapeutic opportunity, especially for cardiorenal patients. In addition, glucagon-like peptide-1 receptor agonists have shown CV benefits in patients with DM and CV disease in addition to a reduced risk of CKD progression.

High Variability of Body Mass Index Independently Associated with Incident Heart Failure

Background

Heart failure (HF) is a serious condition with increasing prevalence, high morbidity, and increased mortality. Obesity is an established risk factor for cardiovascular diseases, including HF. Fluctuation in body mass index (BMI) has shown a higher risk of cardiovascular outcomes. We investigated the association between BMI variability and incident HF.

Methods

In the UK Biobank, we established a prospective cohort after excluding participants with prevalent HF or cancer at enrollment. A total of 99,368 White (British, Irish, and any other white background) participants with ≥ 3 BMI measures during > 2 years preceding enrollment were included, with a median follow-up of 12.5 years. The within-participant variability of BMI was evaluated using standardized standard deviation (SD) and coefficient of variation (CV). The association of BMI variability with incident HF was assessed using Fine and Gray's competing risk model, and adjusted for age, sex, smoking history, alcohol consumption, diabetes, hypertension, history of heart attack, stroke, atrial fibrillation, lipids, estimated glomerular filtration rate and mean BMI per individual.

Results

In the fully adjusted model, higher BMI variability measured in both SD and CV were significantly associated with higher risk in HF incidence (SD: Hazard Ratio [HR] 1.05, 95% Confidence Interval [CI] 1.02 - 1.07, p = 0.0002; CV: HR 1.06, 95% CI 1.04 - 1.09, p < 0.0001).

Conclusions

Longitudinal health records capture BMI fluctuation, which independently predicts HF incidence. Integration of long-term BMI and other routinely measured health factors may improve risk prediction of HF and other cardiovascular outcomes.

10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Prevalence and treatment of diabetes and pre-diabetes in a real-world heart failure population: a single-centre cross-sectional study

AIMS

The aim of this study was to investigate a real-world heart failure (HF) cohort regarding (1) prevalence of known diabetes mellitus (DM), undiagnosed DM and pre-diabetes, (2) if hf treatment differs depending on glycaemic status and (3) if treatment of DM differs depending on HF phenotype.

METHODS

All patients who had received a diagnosis of HF at Umeå University Hospital between 2010 and 2019 were identified and data were extracted from patient files according to a prespecified protocol containing parameters for clinical characteristics, including echocardiogram results, comorbidities, fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) values. Patients' HF phenotype was determined using the latest available echocardiogram. The number of patients with previous DM diagnosis was assessed. Patients without a previous diagnosis of DM were classified as non-DM, pre-diabetes or probable DM according to FPG and HbA1c levels using WHO criteria.

RESULTS

In total, 2326 patients (59% male, mean age 76±13 years) with HF and at least one echocardiogram were assessed. Of these, 617 (27%) patients had a previous diagnosis of DM. Of the 1709 patients without a previous diagnosis of DM, 1092 (67%) patients had either an FPG or HbA1c recorded, of which 441 (41%) met criteria for pre-diabetes and 97 (9%) met criteria for probable diabetes, corresponding to 19% and 4% of the entire cohort, respectively. Patients with HF and diabetes were more often treated with diuretics and beta blockers compared with non-DM patients (64% vs 42%, p<0.001 and 88% vs 83%, p<0.001, respectively). There was no difference in DM treatment between HF phenotypes.

CONCLUSIONS

DM and pre-diabetes are common in this HF population with 50% of patients having either known DM, probable DM or pre-diabetes. Patients with HF and DM are more often treated with common HF medications. HF phenotype did not affect choice of DM therapy.

Prospective associations of circulating thrombospondin-2 level with heart failure hospitalization, left ventricular remodeling and diastolic function in type 2 diabetes

Background

Circulating thrombospondin-2 (TSP2) levels were associated with the development of heart failure (HF) in recent studies. However, these studies included only a minority of patients with type 2 diabetes, which is associated with an increased HF risk. As hyperglycemia induces TSP2 expression and its tissue expression increases in type 2 diabetes, we investigated the prospective association of circulating TSP2 with incident HF hospitalization (HHF), and its associations with longitudinal changes of echocardiographic parameters in type 2 diabetes.

Methods

Baseline serum TSP2 levels were measured in 4949 patients with type 2 diabetes to determine its association with incident HHF using multivariable Cox regression analysis. In the echocardiographic study, baseline serum TSP2 levels were measured in another 146 patients with type 2 diabetes but without cardiovascular diseases who underwent detailed transthoracic echocardiography at baseline and after 1 year.

Results

Over a median follow-up of 7.8 years, 330 of 4949 patients (6.7%) developed incident HHF. Baseline serum TSP2 levels were independently associated with the development of HHF (HR 1.31, 95%CI 1.06–1.62, p = 0.014) after adjustments for baseline conventional cardiovascular risk factors, atrial fibrillation, estimated glomerular filtration rate, albuminuria and high-sensitivity C-reactive protein level, use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, loop-diuretics, aspirin, insulin, metformin and sodium-glucose co-transporter 2 inhibitors. Moreover, baseline serum TSP2 levels were independently associated with increase in average E/e’ and left atrial volume index (p = 0.04 and < 0.01, respectively).

Conclusion

Serum TSP2 levels were independently associated with both incident HHF and deterioration in diastolic function in type 2 diabetes.

Trial registration

Not Applicable

Supplementary information

The online version contains supplementary material available at 10.1186/s12933-022-01646-x.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

The potential of glucagon-like peptide-1 receptor agonists in heart failure

Heart failure (HF) remains one of the cardiovascular diseases (CVDs) associated with a high unmet medical need due to high morbidity and mortality rates and lack of efficacious interventions. HF is closely related to cardiometabolic diseases such as diabetes, obesity and chronic kidney disease, and strategies that address most or all these intertwined conditions are desirable. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are approved for type 2 diabetes (T2D), and some are also indicated for reduction of the risk of atherosclerotic CVD in T2D and for weight management. As we summarise in this concise review, preliminary evidence suggests that the cardioprotective benefits of GLP-1 RAs may also extend to HF. The most robust clinical evidence arguably originates from the large cardiovascular outcomes trials (CVOTs) completed for most GLP-1 RAs, of which the latest showed a significant relative risk reduction (RRR) of 39% (HR) with once-weekly efpeglenatide on HF requiring hospitalisation, corroborating a meta-analysis which found a significant RRR across eight GLP-1 RA CVOTs of 11%. Further, although incompletely described, multiple studies are available to provide insights into the mechanistic underpinnings, which appear to be associated mostly with indirect cardioprotective benefits owing to the ability of GLP-1 RAs to address hyperglycaemia, and reduce body weight, and, amongst others, inflammation. In sum, current evidence positions GLP-1 RAs as a potential cardioprotective strategy in HF, with HF with preserved ejection fraction emerging as the clinically most relevant phenotype for the drug class, especially when occurring in people with obesity with and without diabetes.

Adherence to the Dietary Approaches to Stop Hypertension (DASH) diet is associated with low levels of insulin resistance among heart failure patients

BACKGROUND AND AIMS

Heart failure (HF) patients are at risk of developing type 2 diabetes. This study examined the association between adherence to the Dietary Approaches to Stop Hypertension (DASH) diet and insulin resistance among U.S. adults with HF.

METHODS AND RESULTS

Using data from National Health and Nutrition Examination Survey 1999-2016 cycles, we included 348 individuals aged 20+ years with HF and no history of diabetes. DASH diet adherence index quartile 1 indicated the lowest and quartile 4 indicated the highest adherence. The highest level of insulin resistance was defined by the upper tertile of the Homeostatic Model Assessment of Insulin Resistance (HOMA-IR). Associations between level of insulin resistance and DASH diet adherence and its linear trends were examined using logistic regressions. Trend analyses showed that participants in upper DASH diet adherence index quartiles were more likely older, female, non-Hispanic White, of normal weight, and had lower levels of fasting insulin than those in lower quartiles. Median values of HOMA-IR from lowest to highest DASH diet adherence index quartiles were 3.1 (interquartile range, 1.8-5.5), 2.9 (1.7-5.6), 2.1 (1.1-3.7), and 2.1 (1.3-3.5). Multivariable logistic analyses indicated that participants with the highest compared to the lowest DASH adherence showed 77.1% lower odds of having the highest level of insulin resistance (0.229, 95% confidence interval: 0.073-0.716; p = 0.017 for linear trend).

CONCLUSION

Good adherence to the DASH diet was associated with lower insulin resistance among community-dwelling HF patients. Heart healthy dietary patterns likely protect HF patients from developing type 2 diabetes.

Epidemiology of the diabetes-cardio-renal spectrum: a cross-sectional report of 1.4 million adults

Background

Type-2 diabetes (T2D), chronic kidney disease, and heart failure (HF) share epidemiological and pathophysiological features. Although their prevalence was described, there is limited contemporary, high-resolution, epidemiological data regarding the overlap among them. We aimed to describe the epidemiological intersections between T2D, HF, and kidney dysfunction in an entire database, overall and by age and sex.

Methods

This is a cross-sectional analysis of adults ≥ 25 years, registered in 2019 at Maccabi Healthcare Services, a large healthcare maintenance organization in Israel. Collected data included sex, age, presence of T2D or HF, and last estimated glomerular filtration rate (eGFR) in the past two years. Subjects with T2D, HF, or eGFR < 60 mL/min/1.73 m² were defined as within the diabetes-cardio-renal (DCR) spectrum.

Results

Overall, 1,389,604 subjects (52.2% females) were included; 445,477 (32.1%) were 25– < 40 years, 468,273 (33.7%) were 40– < 55 years, and 475,854 (34.2%) were ≥ 55 years old. eGFR measurements were available in 74.7% of the participants and in over 97% of those with T2D or HF. eGFR availability increased in older age groups. There were 140,636 (10.1%) patients with T2D, 54,187 (3.9%) with eGFR < 60 mL/min/1.73m², and 11,605 (0.84%) with HF. Overall, 12.6% had at least one condition within the DCR spectrum, 2.0% had at least two, and 0.23% had all three. Cardiorenal syndrome (both HF and eGFR < 60 mL/min/1.73m²) was prevalent in 0.40% of the entire population and in 2.3% of those with T2D. In patients with both HF and T2D, 55.2% had eGFR < 60 mL/min/1.73m² and 15.8% had eGFR < 30 mL/min/1.73m². Amongst those within the DCR spectrum, T2D was prominent in younger participants, but was gradually replaced by HF and eGFR < 60 mL/min/1.73m² with increasing age. The congruence between all three conditions increased with age.

Conclusions

This large, broad-based study provides a contemporary, high-resolution prevalence of the DCR spectrum and its components. The results highlight differences in dominance and degree of congruence between T2D, HF, and kidney dysfunction across ages.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01521-9.

Expert consensus on personalized initiation of glucose-lowering therapy in adults with newly diagnosed type 2 diabetes without clinical cardiovascular disease or chronic kidney disease

Since it is difficult for clinicians to make a decision among the various types of antidiabetic medications due to their great discrepancy in mechanisms, pharmacological properties, and cardiovascular/renal protection, a relatively "precision" or personalized hypoglycemic treatment suggestion is practical for type 2 diabetes (T2D) management in adults. This expert consensus makes some recommendations based on the characteristics of adult T2D patients without clinical cardiovascular disease (CVD) or chronic kidney disease (CKD) by evidence from large-scale clinical trials. The main consideration for initiating antidiabetic medications is the safety and benefits for prevention of target organ damage, such as CVD and CKD. The choice of personalized glucose-lowering therapy regarding target organ protection is based on the various effects of antidiabetic medications, patients' clinical characteristics and their key risks, as well as the sociological factors. According to the effects on glucose reduction, cardiovascular protection, renal benefit, body weight change, hypoglycemic risk, and liver function impact, the antidiabetic medications are recategorized in this consensus. Combined with the glucose control target and the different effects of hypoglycemic agents, a significant body of recommendations have been developed for optimal T2D management according to the risk factors for atherosclerotic CVD, heart failure, CKD, primary fatty liver, and hypoglycemia. This consensus gives detailed guidance on personalized antidiabetic therapy initiation in newly diagnosed T2D adults, which attaches great importance to both glucose control and target organ protection.

Recurrent heart failure hospitalizations increase the risk of mortality in heart failure patients with atrial fibrillation and type 2 diabetes mellitus in the United Kingdom: a retrospective analysis of Clinical Practice Research Datalink database

BACKGROUND

Heart failure (HF) is a global illness and is a leading cause of hospitalizations. Recurrent HF hospitalization (HFH) is associated with increased risk of cardiovascular (CV) and all-cause mortality, thereby burdening the health system. Type 2 diabetes mellitus (T2DM) and atrial fibrillation (AF) are two important comorbidities in patients living with HF. This study aims to assess the association between recurrent HFHs with CV and all-cause mortality in patients living with HF and having AF and/or T2DM.

METHODS

This study was conducted using primary care data from the Clinical Practice Research Datalink database with linkage to hospital data and mortality data. Adults living with HF and with at least 1 HFH were identified from January 2010 to December 2014. Patients were grouped based on the number of recurrent HFHs. During follow-up, all-cause mortality or CV mortality for the HF population with AF and T2DM was recorded.

RESULTS

Overall, 32.9% of 2344 T2DM patients and 28.2% of 4585 AF patients had at least 1 recurrent HFH. The patients were relatively elderly and were predominantly male. The mean number of all-cause hospitalizations in HF patients having T2DM and AF, with ≥ 1 recurrent HFH were significantly higher than patients without recurrent HFH. The annualized mortality rates in CV mortality as the primary cause and for all-cause mortality and increased with recurrent HFHs, in T2DM and AF patients. The risk of CV mortality as primary cause and all cause morality were 5.39 and 3.19 times higher in T2DM patients with 3 recurrent HFHs versus no recurrent HFH. Similarly, the risk of CV mortality as primary cause and all cause morality was 5.98 and 4.3 times higher in AF patients with 3 recurrent HFHs versus those with no recurrent HFH.

CONCLUSIONS

Recurrent HFHs are strongly associated with CV mortality and all-cause mortality in HF patients with TD2M or AF. The hospitalization rate highlights the need for treatment and disease management, which will improve the course of the disease and help patients stay out of hospital.

Premature Mortality in Type 2 Diabetes Mellitus Associated with Heart Failure and Chronic Kidney Disease: 20 Years of Real-World Data

INTRODUCTION

Type 2 diabetes mellitus (T2D) increases the risk of heart failure (HF) and chronic kidney disease (CKD). Nonetheless, evidence of cardiovascular (CV) prognosis is relatively scarce in young T2D patients.

PURPOSE

To estimate the risk of all-cause death, CV death, and non-fatal major CV events (MACEs) in T2D patients younger than 65 years old.

METHODS

We designed a retrospective cohort study using incident cases of either T2D, HF, or CKD in the population aged 40-65 years, from 1st January 2000 to 31st December 2019. Each individual was followed for up to one year. The primary analysis consisted of survival analysis with Cox proportional hazards to compare one-year risk of all-cause death, CV death, and MACEs between T2D without HF or CKD (T2D), T2D with HF (T2D-HF), and T2D with CKD (T2D-CKD) groups.

RESULTS

A total of 14,986 incident adult diabetic patients from the last two decades in our institution were included with an average age at cohort inclusion of 55-58 years old. Glycemic control was similar among groups. The adjusted hazard ratio (HR) of one-year all-cause death was 2.77 (95% CI: 2.26-3.40) for T2D-HF and 3.09 (2.77-3.45) for T2D-CKD compared with the baseline T2D risk. The highest event rate (T2D-CKD) was 0.15 per person-year. The adjusted HR of one-year CV death was 2.75 (95% CI: 2.19-3.46) for T2D-CKD and 2.59 (1.72-3.91) for T2D-HF. The non-fatal MACE risk was significantly increased in T2D-HF or T2D-CKD compared with T2D (2.82 (CI95%: 2.34-3.41) for T2D-CKD vs. 1.90 (CI95%: 1.66-2.17) for T2D-CKD) with a 32% event rate in non-fatal MACEs.

CONCLUSIONS

Coexistence of HF or CKD is associated with increased premature mortality as well as non-fatal CV events in T2D patients under 65 years old.

Management of Type 2 Diabetes in Stage C Heart Failure with Reduced Ejection Fraction

Type 2 diabetes is an increasingly common comorbidity of stage C heart failure with reduced ejection fraction (HFrEF). The two diseases are risk factors for each other and can bidirectionally independently worsen outcomes. The regulatory requirement of cardiovascular outcomes trials for antidiabetic agents has led to an emergence of novel therapies with robust benefits in heart failure, and clinicians must now ensure they are familiar with the management of patients with concurrent diabetes and stage C HFrEF. This review summarises the current evidence for the management of type 2 diabetes in stage C HFrEF, recapitulating data from landmark heart failure trials regarding the use of guideline-directed medical therapy for heart failure in patients with diabetes. It also provides a preview of upcoming clinical trials in these populations.

Silk Fibroin-Based Therapeutics for Impaired Wound Healing

Impaired wound healing can lead to local hypoxia or tissue necrosis and ultimately result in amputation or even death. Various factors can influence the wound healing environment, including bacterial or fungal infections, different disease states, desiccation, edema, and even systemic viral infections such as COVID-19. Silk fibroin, the fibrous structural-protein component in silk, has emerged as a promising treatment for these impaired processes by promoting functional tissue regeneration. Silk fibroin’s dynamic properties allow for customizable nanoarchitectures, which can be tailored for effectively treating several wound healing impairments. Different forms of silk fibroin include nanoparticles, biosensors, tissue scaffolds, wound dressings, and novel drug-delivery systems. Silk fibroin can be combined with other biomaterials, such as chitosan or microRNA-bound cerium oxide nanoparticles (CNP), to have a synergistic effect on improving impaired wound healing. This review focuses on the different applications of silk-fibroin-based nanotechnology in improving the wound healing process; here we discuss silk fibroin as a tissue scaffold, topical solution, biosensor, and nanoparticle.

Diabetes Mellitus in Advanced Heart Failure

BACKGROUND

Diabetes mellitus is associated with increased rates of mortality in patients with less severe (stage C) heart failure (HF). The prevalence of diabetes and its complications in advanced (stage D) HF and their contributions to mortality risk are unknown.

METHODS AND RESULTS

We conducted a retrospective population-based cohort study of all adult residents of Olmsted County, Minnesota, who had advanced HF between 2007 and 2017. Patients with diabetes were identified by using the criteria of the Healthcare Effectiveness Data and Information Set. Diabetes complications were captured by using the Diabetes Complications Severity Index. Of 936 patients with advanced HF, 338 (36.1%) had diabetes. Overall, median survival time after development of advanced HF was 13.1 (3.9-33.1) months; mortality did not vary by diabetes status (aHR 1.06, 95% CI 0.90-1.25; P = 0.45) or by glycated hemoglobin levels in those with diabetes (aHR 1.01 per 1% increase, 95% CI 0.93-1.10; P = 0.82). However, patients with diabetes and 4 (aHR 1.24, 95% CI 0.92-1.67) or 5-7 (aHR 1.49, 95% CI 1.09-2.03) diabetes complications were at increased risk of mortality compared to those with ≤ 3 complications.

CONCLUSIONS

More than one-third of patients with advanced HF have diabetes. In advanced HF, overall prognosis is poor, but we found no evidence that diabetes is associated with a significantly higher mortality risk.

Prevalence and trends of type 2 diabetes mellitus and prediabetes among community-dwelling heart failure patients in the United States

AIMS

This study estimated national prevalence and trends of diagnosed and undiagnosed type 2 diabetes mellitus (T2DM) and prediabetes among heart failure (HF) patients in the U.S.

METHODS

This cross-sectional study included 527 participants aged 20+ years with a diagnosis of HF, using data from the National Health and Nutrition Examination Survey 2005-2016. We assessed prevalence estimates of diagnosed and undiagnosed T2DM and prediabetes stratified by age-standardized sociodemographic and health characteristics. Trends of T2DM and prediabetes prevalence were examined using logistic regressions.

RESULTS

Prevalence rates of diagnosed and undiagnosed T2DM among HF patients were 34.7% (95% confidence interval (CI), 29.2-40.3%) and 12.8% (95% CI, 9.2-16.9%), respectively. Prediabetes affected 39.1% (95% CI, 33.6-44.9%) of HF patients. Prevalence estimates of diagnosed T2DM were significantly different between non-Hispanic White (20.1% [95% CI, 13.5-27.6%]) and Hispanic participants (52.1% [95% CI, 35.9-68.0%]) (P < 0.001). The prevalence of T2DM and prediabetes did not significantly change between 2005 and 2016.

CONCLUSIONS

Prevalence rates of T2DM and prediabetes among community-dwelling HF patients in the U.S. remained high between 2005 and 2016. Prevention of and targeted intervention for T2DM among at-risk HF patients is needed, particularly among those of Hispanic origin.

Patient selection for heart transplant: balancing risk

PURPOSE OF REVIEW

Heart failure incidence continues to rise despite a relatively static number of available donor hearts. Selecting an appropriate heart transplant candidate requires evaluation of numerous factors to balance patient benefit while maximizing the utility of scarce donor hearts. Recent research has provided new insights into refining recipient risk assessment, providing additional tools to further define and balance risk when considering heart transplantation.

RECENT FINDINGS

Recent publications have developed models to assist in risk stratifying potential heart transplant recipients based on cardiac and noncardiac factors. These studies provide additional tools to assist clinicians in balancing individual risk and benefit of heart transplantation in the context of a limited donor organ supply.

SUMMARY

The primary goal of heart transplantation is to improve survival and maximize quality of life. To meet this goal, a careful assessment of patient-specific risks is essential. The optimal approach to patient selection relies on integrating recent prognostication models with a multifactorial assessment of established clinical characteristics, comorbidities and psychosocial factors.

Non-alcoholic fatty liver disease and type 2 diabetes - An Update

The global prevalence of non‐alcoholic fatty liver disease (NAFLD) is rising, along with the epidemic of diabesity. NAFLD is present in >70% of individuals with type 2 diabetes. Although the mutually detrimental relationship between NAFLD and type 2 diabetes has been well established, a multitude of recent studies have further shown that type 2 diabetes is closely linked to the development of cirrhosis, hepatocellular carcinoma, liver‐related morbidity and mortality. In contrast, NAFLD also negatively impacts type 2 diabetes both in terms of its incidence and related adverse clinical outcomes, including cardiovascular and chronic kidney diseases. In response to these global health threats, clinical care pathways for NAFLD and guidelines for metabolic dysfunction‐associated fatty liver disease have been developed. Several antidiabetic agents have been evaluated for their potential hepatic benefits with promising results. Furthermore, type 2 diabetes patients are increasingly represented in clinical trials of novel therapeutics for NAFLD. However, despite the wealth of knowledge in NAFLD and type 2 diabetes, lack of awareness of the disease and the potential weight of this problem remains a major challenge, especially among clinicians who are outside the field of hepatology and gastroenterology. This review therefore aimed to provide all diabetes care providers with a summary of the latest evidence that supports NAFLD as an emerging diabetic complication of increasing importance, and to present the current recommendations, focusing on the assessment and therapeutic strategies, on the management of NAFLD among type 2 diabetes patients.

Eligibility of Dapagliflozin and Empagliflozin in a Real-World Heart Failure Population

Aims

This study is aimed at investigating the eligibility in a real-world heart failure population for the DAPA-HF (testing dapagliflozin) and EMPEROR-reduced (testing empagliflozin) trials, comparing the eligible real-world patients to trial participants and to characterize the noneligible patients.

Methods

Medical records of all heart failure patients who had a diagnosis of heart failure from the Heart Centre or Department of Internal Medicine at Umeå University Hospital were reviewed.

Results

2433 of the hospital's uptake population of 150 000 had a diagnosis of heart failure. 681 patients had left ventricle ejection fraction ≤ 40%, and of these 352 (52%) and 268 (39%) patients met eligibility criteria for DAPA-HF and EMPEROR-reduced, respectively. Comparing eligible patients in our population with the DAPA-HF- and EMPEROR-reduced trial populations, we found that eligible real-world patients were older (79.0 vs. 66.2 years and 80.3 vs. 67.2 years, respectively), had worse renal function (eGFR 54.4 vs. 66.0 ml/min/1.73m² and 49.5 vs. 61.8 ml/min/1.73m², respectively), higher prevalence of atrial fibrillation (56.0% vs. 36.1% and 53.0% vs. 35.6%, respectively), and lower prevalence of diabetes mellitus (21.0% vs. 41.8% and 26.1% vs. 49.8%, respectively). The main reasons for ineligibility were low NT-proBNP or low eGFR. Noneligible patients differed according to reason for ineligibility, where patients with low NT-proBNP were generally younger and healthier, and patients with low eGFR were older and had more comorbidities.

Conclusions

39-52% of patients with heart failure and reduced ejection fraction in this real-world heart failure population were eligible for SGLT2-inhibitor treatment, corresponding to 11-14% of all heart failure patients. Compared to trial participants, eligible real-world patients were significantly older with worse renal function, more atrial fibrillation, and less diabetes mellitus. Trial entry criteria exclude comparatively young and healthy patients, as well as comparatively old patients with more comorbid conditions.

10. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Case of type 2 diabetes mellitus with edema resulting in subcutaneous insulin resistance syndrome

Subcutaneous insulin resistance syndrome caused by obesity, induration at the injection site, skin temperature and other factors is common clinically, whereas resistance events caused by edema are relatively rare. This article introduced a case of a woman with type 2 diabetes mellitus with heart failure edema. Her blood glucose control was significantly associated with the level of edema. Excluding other factors, it can be concluded that edema might lead to subcutaneous insulin resistance syndrome, even if the edema at the injection site is not obvious.

Dyslipidaemia pattern and prevalence among type 2 diabetes mellitus patients on lipid-lowering therapy at a tertiary hospital in central South Africa

BACKGROUND

Atherosclerotic cardiovascular disease (ASCVD) is a major cause of death worldwide. A large number of deaths due to ASCVD occurs among people with diabetes mellitus (DM). One of the important modifiable risk factors associated with ASCVD is dyslipidaemia and its prevalence is not known in central South Africa (SA). This study aimed to determine the pattern and prevalence of dyslipidaemia among type 2 diabetes mellitus (T2DM) patients on lipid-lowering therapy.

METHODS

This descriptive, retrospective study of patients' records was conducted at Universitas Academic Hospital in Bloemfontein, SA. The study population included 143 consecutive T2DM patients of any age that attended the Diabetes Clinic from 1 January to 31 March 2019. The patients had to be on lipid-lowering therapy for a minimum duration of 3 months. Data were sourced from the clinic files and included the patient's lipid profile, anthropometric and demographic data. Dyslipidaemia was defined using the 2018 SA dyslipidaemia guidelines.

RESULTS

The median age of the participants was 63 years (interquartile range [IQR] 52-71 years). The majority of the participants were female (n = 92; 64.3 %). The median duration since the DM diagnosis was 18 years (IQR 13-23 years). The prevalence of dyslipidaemia was 86.7 % (n = 124). Combined dyslipidaemia, namely either triglycerides (TG) + low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL) + TG or HDL + LDL, was the most common pattern (n = 51; 42.5 %) largely due to raised TG + LDL contributing 37.2 % (n = 19) to this pattern. The second and third most common patterns were isolated (either LDL, HDL or TG) and mixed dyslipidaemia (TG + HDL + LDL) at 40.8 % (n = 49) and 16.7 % (n = 20), respectively. The most frequent lipid abnormality (n = 84; 70.0 %) was LDL of ≥ 1.8 mmol/L. Of the 140 participants on statin therapy, only 5 % were on high-intensity therapy.

CONCLUSIONS

A high prevalence of dyslipidaemia among DM patients was observed, despite the use of lipid-lowering therapy in this small observational study. Our findings highlight the need to better educate healthcare providers regarding the intensification of lipid-lowering therapy, along with improved strategies to address poor glycaemic control and other modifiable lifestyle factors.

Prospective association of serum adipocyte fatty acid-binding protein with heart failure hospitalization in diabetes

AIMS

Adipocyte fatty acid-binding protein (AFABP) is associated with cardiovascular diseases in type 2 diabetes. Whether circulating AFABP levels are associated with the risk of heart failure (HF) in type 2 diabetes remains undefined. We investigated the prospective association of circulating AFABP levels with incident HF hospitalization in type 2 diabetes, and its relationship to the use of sodium glucose co-transporter 2 inhibitors (SGLT2i) which reduce HF risk.

METHODS AND RESULTS

Baseline serum AFABP level was measured in 3322 Chinese participants without known history of cardiovascular diseases or hospitalization for HF, recruited from the Hong Kong West Diabetes Registry. Its association with incident HF hospitalization was evaluated using multivariable Cox regression analysis. Use of SGLT2i was included as a time-dependent covariate. Among these 3322 participants (52.9% men; mean age 60.0 ± 12.6), 176 (5.3%) developed HF hospitalization over a median follow-up of 8 years. Seven hundred and thirty-one (22%) were started on SGLT2i during the study period (empagliflozin 55.1%, dapagliflozin 44.2%, canagliflozin 0.4%, and ertugliflozin 0.3%). Serum AFABP levels were significantly higher in participants who developed HF hospitalization than those who did not (men: 14.8 vs. 8.3 ng/mL; women: 21.5 vs. 14.6 ng/mL; all: 18.6 vs. 10.9 ng/mL, P < 0.001). In multivariable Cox regression analysis, baseline serum AFABP level was significantly associated with incident HF hospitalization [hazard ratio (HR) 1.38, 95% confidence interval (CI) 1.06-1.80, P = 0.019] independent of the use of SGLT2i, in a model also consisting of age; sex; body mass index; smoking status; duration of diabetes; hypertension, dyslipidaemia; atrial fibrillation; presence of chronic kidney disease and albuminuria; glycated haemoglobin and high-sensitivity C-reactive protein levels; and use of metformin, insulin, aspirin, furosemide, and beta-blockers at baseline. High cumulative defined daily dose (cDDD) of SGLT2i was protective of incident HF hospitalization (HR 0.10, 95% CI 0.01-0.68, P = 0.019). The addition of circulating AFABP level to a clinical model of conventional HF risk factors provided significant improvement in the category-free net reclassification index (11.5%, 95% CI 1.6-22.1, P = 0.02) and integrated discrimination improvement (0.3%, 95% CI 0.1-1.7, P = 0.04). A dose-dependent reduction in cumulative incidence of HF hospitalization in response to SGLT2i, based on cDDD, was more clearly observed in participants with a higher baseline AFABP level above the sex-specific median (P for trend <0.01).

CONCLUSIONS

Circulating AFABP level is independently associated with incident HF hospitalization in type 2 diabetes and is potentially helpful in risk stratification for the prevention of HF hospitalization.

FNDC5/Irisin attenuates diabetic cardiomyopathy in a type 2 diabetes mouse model by activation of integrin αV/β5-AKT signaling and reduction of oxidative/nitrosative stress

Irisin, the cleaved form of the fibronectin type III domain containing 5 (FNDC5) protein, is involved in metabolism and inflammation. Recent findings indicated that irisin participated in cardiovascular physiology and pathology. In this study, we investigated the effects of FNDC5/irisin on diabetic cardiomyopathy (DCM) in type 2 diabetic db/db mice. Downregulation of myocardial FNDC5/irisin protein expression and plasma irisin levels was observed in db/db mice compared to db/+ controls. Moreover, echocardiography revealed that db/db mice exhibited normal cardiac systolic function and impaired diastolic function. Adverse structural remodeling, including cardiomyocyte apoptosis, myocardial fibrosis, and cardiac hypertrophy were observed in the hearts of db/db mice. Sixteen-week-old db/db mice were intramyocardially injected with adenovirus encoding FNDC5 or treated with recombinant human irisin via a peritoneal implant osmotic pump for 4 weeks. Both overexpression of myocardial FNDC5 and exogenous irisin administration attenuated diastolic dysfunction and cardiac structural remodeling in db/db mice. Results from in vitro studies revealed that FNDC5/irisin protein expression was decreased in high glucose (HG)/high fat (HF)-treated cardiomyocytes. Increased levels of inducible nitric oxide synthase (iNOS), NADPH oxidase 2 (NOX2), 3-nitrotyrosine (3-NT), reactive oxygen species (ROS), and peroxynitrite (ONOO^-) in HG/HF-treated H9C2 cells provided evidence of oxidative/nitrosative stress, which was alleviated by treatment with FNDC5/irisin. Moreover, the mitochondria membrane potential (ΔΨm) was decreased and cytochrome C was released from mitochondria with increased levels of cleaved caspase-3 in HG/HF-treated H9C2 cells, indicating the presence of mitochondria-dependent apoptosis, which was partially reversed by FNDC5/irisin treatment. Mechanistic studies showed that activation of integrin αVβ5-AKT signaling and attenuation of oxidative/nitrosative stress were responsible for the cardioprotective effects of FNDC5/irisin. Therefore, FNDC5/irisin mediates cardioprotection in DCM by inhibiting myocardial apoptosis, myocardial fibrosis, and cardiac hypertrophy. These findings implicate that FNDC5/irisin as a potential therapeutic intervention for DCM, especially in type 2 diabetes mellitus (T2DM).

BMP-2 alleviates heart failure with type 2 diabetes mellitus and doxorubicin-induced AC16 cell injury by inhibiting NLRP3 inflammasome-mediated pyroptosis

Chronic heart failure (CHF) and diabetes mellitus are associated with morbidity and mortality. CHF and diabetes generally simultaneously occur, resulting in adverse outcomes. Diabetes complicates cardiomyopathy and exacerbates heart failure conditions. An increase in natriuretic peptides, including atrial natriuretic peptide (ANP), and another endsogenously generated peptide, brain natriuretic peptide (BNP), serves an essential role in CHF. The aim of this study was to explore the molecular regulation between bone morphogenetic protein-2 (BMP-2) and ANP or BNP in diabetes-associated cardiomyopathy. In total, 25 serum samples were collected from patients with CHF with or without type 2 diabetes mellitus to compare with 25 controls. Cardiomyopathy and hyperglycemia were induced in rats by doxorubicin and streptozotocin, respectively. AC16 cells were used to study molecular mechanisms. BMP, ANP and BNP concentration in patients and rats were measured by ELISA. Flow cytometry was performed to analyze cell pyroptosis and ROS production. Reverse transcription-quantitative PCR and western blotting were used to examine mRNA and protein expression of NOD-, LRR- and pyrin domain-containing protein 3 (NLRP3), pro-caspase-1, caspase-1 (p20) and gasdermin D. BMP-2 was negatively correlated with ANP and BNP in CHF patients with type 2 diabetes mellitus. Similar results were obtained in rats and AC16 cells. BMP-2 decreased the NLRP3 inflammasome activation and cell pyroptosis. The present study found evidence that the cardioprotective effects of BMP-2 act through ANP and BNP both in vivo and in vitro. BMP-2 inhibits inflammasome formation. The results suggested that BMP-2 may serve as a novel therapeutic target for the treatment of diabetic heart conditions.

A Review of the Role of Type 2 Diabetes and SGLT2 Inhibitors in Heart Failure with Preserved Ejection Fraction

Previous research has demonstrated that patients with Type 2 Diabetes (T2DM) are at an increased risk for cardiovascular events, including heart failure. Moreover, there's a higher risk of mortality in individuals who have both T2DM and heart failure with preserved ejection fraction (HFpEF). Although there are antidiabetic agents that have shown both cardiovascular safety and improved cardiovascular outcomes, only certain agents have been associated with heart failure benefits, such as sodium-glucose cotransporter-2 (SGLT2) inhibitors. This study aims to review the pathophysiology of HFpEF in the setting of T2DM, and more specifically the role of SGLT2 inhibitors in HFpEF outcomes.

Impact of SGLT2 Inhibitors on Heart Failure: From Pathophysiology to Clinical Effects

Heart failure (HF) affects up to over 20% of patients with type 2 diabetes (T2DM), even more in the elderly. Although, in T2DM, both hyperglycemia and the proinflammatory status induced by insulin resistance are crucial in cardiac function impairment, SGLT2i cardioprotective mechanisms against HF are several. In particular, these beneficial effects seem attributable to the significant reduction of intracellular sodium levels, well-known to exert a cardioprotective role in the prevention of oxidative stress and consequent cardiomyocyte death. From a molecular perspective, patients’ exposure to gliflozins’ treatment mimics nutrient and oxygen deprivation, with consequent autophagy stimulation. This allows to maintain the cellular homeostasis through different degradative pathways. Thus, since their introduction in the clinical practice, the hypotheses on SGLT2i mechanisms of action have changed: from simple glycosuric drugs, with consequent glucose lowering, erythropoiesis enhancing and ketogenesis stimulating, to intracellular sodium-lowering molecules. This provides their consequent cardioprotective effect, which justifies its significant reduction in CV events, especially in populations at higher risk. Finally, the updated clinical evidence of SGLT2i benefits on HF was summarized. Thus, this review aimed to analyze the cardioprotective mechanisms of sodium glucose transporter 2 inhibitors (SGLT2i) in patients with HF, as well as their clinical impact on cardiovascular events.

Detection of Early Vascular Atherosclerosis in Type 2 Diabetes Mellitus Using Ultrasound Radiofrequency-Data Technique

OBJECTIVES

To quantitatively evaluate changes in vascular elasticity and intima-media thickness (IMT) of the common carotid artery (CCA) with Ultrasound radiofrequency (RF)-data technology in asymptomatic patients with type-2 diabetes mellitus (T2DM) and controls.

MATERIALS AND METHODS

Thirty-seven T2DM patients and 39 controls were enrolled. Arterial elasticity and CCA-IMT were quantitatively assessed by RF-data technology. The CCA diameters in the diastolic and systolic phases, carotid distensibility (CD), IMT, values of stiffness (β) and local pulse wave velocity (PWVβ) were measured and compared between the two groups.

RESULTS

The T2DM group had significantly larger CCA diastolic and systolic diameter, lower CD values, higher IMT measurements (all p < 0.001), and higher values of β and PWVβ (all P < 0.05) than the controls. Significant differences were not revealed in the mean values of IMT, β, PWVβ and CD across both sides of the CCA (all P > 0.05).

CONCLUSIONS

Higher IMT measurement and lower arterial elasticity of the CCA are significantly pronounced in asymptomatic T2DM patients and may suggest atherosclerotic changes, and the ultrasound RF-data technique may be used as a potential approach for detection of early-stage atherosclerosis.

Refocusing on the Primary Prevention of Heart Failure

Purpose of review

The burden of heart failure (HF) is a significant national and global public health problem, with prevalence rates on the rise. Given the significant morbidity, mortality, and healthcare costs attributable to HF, it is of utmost importance to utilize preventive strategies to prevent the development of HF. Therefore, we sought to address how a multi-modal risk assessment approach can be used to stratify patients for HF risk and guide implementation of therapeutic strategies to prevent HF.

Recent findings

New externally validated, multivariate prediction models for incident HF can be applied in the general population and may be used to aide clinicians in assessing individualized HF risk and screening for HF. Recent clinical trial data suggest a natriuretic peptide biomarker-based screening approach coupled with team-based cardiovascular care to focus on optimization of guideline-directed medical therapy may help prevent new-onset HF. However, widespread implementation of clinical risk scores and/or biomarkers is needed.

Summary

In addition to promoting a heart healthy lifestyle, prevention and management of modifiable risk factors, including intensive blood pressure lowering and use of sodium-glucose cotransporter-2 inhibitors, can prevent incident HF.

Association between TNF-α G-308A (rs1800629) polymorphism and susceptibility to chronic periodontitis and type 2 diabetes mellitus: A meta-analysis

BACKGROUND AND OBJECTIVE

Although the association between tumor necrosis factor-α (TNF-α) G-308A (rs1800629) polymorphism and chronic periodontitis (CP), chronic periodontitis with type 2 diabetes mellitus (DP) is assumed, results of this association have been contradictory. The aim of this study was to assess the relationship between rs1800629 polymorphism and CP/DP susceptibility.

METHODS

We searched for studies on PubMed, Web of Science, MEDLINE, Chinese National Infrastructure, and WanFang databases. Study selection was performed using specific inclusion and exclusion criteria and fulfilled the PECO (participant, exposure, comparison, and outcome) format. The relationship between rs1800629 polymorphism and CP/DP susceptibility was evaluated by the effect summary odds ratio (OR) and 95% confidence intervals (CIs). Allele, dominant, and recessive genetic models were computed to assess the strength of the association.

RESULTS

A total of 25 case-control studies were included in the analysis. In the Asian population, TNF-α rs1800629 polymorphism was found to be significantly associated with CP in the overall analyses and for all genetic contrasts, while no significant risks were found among Caucasian populations for all genetic contrasts. The TNF-α rs1800629 polymorphism was also associated with increased DP risk in Asians under the fixed-effects model, but not in the recessive comparison.

CONCLUSION

The meta-analysis suggested that TNF-α rs1800629 polymorphism might affect the risk of CP and DP, particularly in individuals of Asian descent.