The influence of diabetes and prediabetes on left heart remodeling: A population-based study

Impact of diabetes and glycemic status on ventricular-arterial coupling in the general population

BACKGROUND/AIMS

Ventricular-arterial coupling (VAC) plays a crucial role in cardiovascular physiology, affecting cardiac function and arterial properties for optimal organ perfusion. Considering that diabetes mellitus (DM) is a known risk factor for incident heart disease and vascular damage, this study aims to investigate whether changes in VAC due to DM occur earlier, even before the onset of clinically evident cardiovascular disease in the general population.

METHODS

This retrospective study included 2,884 participants (mean age 57 years, 48% male) of the Swedish CArdioPulmonary BioImage Study (SCAPIS), where data on echocardiography and Pulse wave velocity (PWV) were available. Of these, 162 individuals (6%) had prevalent type 2 diabetes (DM), and 334 (12%) had prediabetes. VAC was quantified as the ratio of PWV to Global longitudinal strain (GLS). Linear regression models were used to assess associations between glycemic status (DM, prediabetes), HbA1c, fasting plasma glucose (fP-glucose), and VAC, adjusting for relevant covariates.

RESULTS

I the fully adjusted model, prevalent DM and the combination of DM and prediabetes were significantly associated with increased values of PWV/GLS (Beta = 0.28, p < 0.001 and Beta = 0.14, p < 0.001 respectively), while no significant association was found between prediabetes and PWV/GLS. Increasing values of HbA1c and fP-glucose were significantly associated with higher values of PWV/GLS (Beta = 0.01,p < 0.001 and Beta = 0.07,p < 0.001, respectively) signaling worse VAC. In participants without prevalent DM, higher HbA1c levels were linked to increased PWV/GLS in the age- and sex-adjusted model; however, this association was attenuated after further adjustment for additional confounders. Conversely, fP-glucose remained significantly associated with elevated PWV/GLS across all adjusted models.

CONCLUSIONS

This study demonstrates a significant association between DM and impaired VAC, as reflected by elevated PWV/GLS, while no such link was observed in prediabetes. The transition from prediabetes to DM appears critical for VAC deterioration. Additionally, higher HbA1c and fP-glucose levels, even in non-diabetic individuals, were associated with worsened VAC, highlighting the impact of glycemic control on vascular function.

Predicting outcomes in persistent atrial fibrillation: the impact of surface ECG f-wave amplitude following pulmonary vein isolation

BACKGROUND

Fibrillatory wave amplitude (fWA) on 12-lead ECG predicts the outcome of ablation in atrial fibrillation (AF). We hypothesized that changes in fWA following wide circumferential isolation of pulmonary veins (WPVI) in persistent AF (peAF) is a better predictor of ablation outcome compared to baseline fWA.

METHODS

Eighty-nine patients (sustained peAF 7 ± 7 months) underwent a first-time WPVI. Sixty-second ECG signals devoid of QRST waves were recorded at baseline and at the end of the WPVI (endWPVI). fWA for each ECG lead and mean fWA (meanfWA) across the 12-lead ECG were computed. Patients with recurrence after the index WPVI underwent a redo to ensure complete PVI. The primary endpoint was long-term AF freedom OFF antiarrhythmics drugs (AADs) after one or two WPVI (SUCCESS group). The FAILURE group was defined as AF recurrence post-redo.

RESULTS

Over a mean follow-up of 35 ± 10 months, freedom from AF OFF AADs was achieved in 61% (SUCCESS group), while 29% had AF recurrence after redo WPVI (FAILURE group). The SUCCESS group showed significantly higher fWA values in ECG leads V1, V4, and V5 at baseline (p < 0.05), as well as in leads III, aVL, aVF, and V4, and in meanfWA at endWPVI (p < 0.05) compared to the FAILURE group. A baseline mean fWA ≥ 0.044 mV or a decrease in mean fWA ≤ 11% following WPVI predicted long-term sinus rhythm restoration with a sensitivity of 81% and a specificity of 69% (p < 0.05).

CONCLUSION

Low fWA values and a significant reduction in fWA following WPVI are associated with a high risk of AF recurrence in patients with peAF.

Evaluation of cardiothoracic ratio as a potential predictor of cardiovascular abnormalities in individuals with type II diabetes mellitus: a case-control study

Cardiovascular complications represent a significant health concern for individuals with diabetes mellitus. The relationship between diabetes and cardiovascular diseases is complex and multifaceted, involving a variety of pathophysiological mechanisms. This study aimed to investigate the potential role of the cardiothoracic ratio as a prognostic tool for cardiovascular disorders in patients with diabetes. A retrospective case-control study of 530 adult patients referred to a tertiary care hospital in Saudi Arabia was conducted. Medical records, including chest X-rays, were analyzed to determine the cardiothoracic ratio. Patients diagnosed with diabetes who experienced cardiac disorders had significantly higher cardiothoracic ratios compared to patients with diabetes alone and controls. HbA1c was significantly elevated among patients with diabetes and cardiovascular disorders (mean = 71.5 ± 25.43 mmol/mol) compared to the other patients. There was a significant positive correlation between the duration of diabetes and the cardiothoracic ratio (r = 0.64, P < 0.001). Furthermore, the cardiothoracic ratio above 0.51 was a good discriminator of cardiovascular disorders in patients with diabetes, with an area under the curve of 0.737, sensitivity of 97.1%, and specificity of 87.2%. This study provided comprehensive evidence supporting the association between cardiothoracic ratio and subsequent cardiovascular adverse outcomes in patients with diabetes. We recommend adopting the cardiothoracic ratio as a valuable prognostic tool for risk stratification among people with diabetes.

Impact of atrial fibrillation phenotype and left atrial volume on outcome after pulmonary vein isolation

AIMS

Pulmonary vein isolation (PVI) is increasingly performed in patients with atrial fibrillation (AF). Both AF phenotype and left atrial (LA) volume have been shown to influence ablation outcome. The inter-relationship of the two is incompletely understood. We aimed to investigate the impact of AF phenotype vs. LA volume on outcome after PVI.

METHODS AND RESULTS

In a retrospective analysis of a prospective registry of patients undergoing a first PVI, the association of AF phenotype and LA volume index (LAVI) was assessed as well as their impact on AF recurrence during follow-up. Overall, 476 patients were enrolled (median age 63 years, 29% females, 65.8% paroxysmal AF). Obesity, hypertension, chronic kidney disease, and heart failure were all significantly more frequent in persistent AF. After 1 year, single-procedure, freedom from arrhythmia recurrence was 61.5%. Patients with paroxysmal AF had better outcomes compared with patients with persistent AF (65.6 vs. 52.7%, P = 0.003), as had patients with no/mild vs. moderate/severe LA dilation (LAVI <42 mL/m2 67.1% vs. LAVI ≥42 mL/m2 53%, P < 0.001). The combination of both parameters refined prediction of 1-year recurrence (P < 0.001). After adjustment for additional clinical risk factors in multivariable Cox proportional hazard analysis, both AF phenotype and LAVI ≥42 mL/m2 contributed significantly towards the prediction of 1-year recurrence.

CONCLUSION

Atrial fibrillation phenotype and LA volume are independent predictors of outcome after PVI. Persistent AF with no/mild LA dilation has a similar risk of recurrence as paroxysmal AF with a moderate/severe LA dilation and should be given similar priority for ablation.

A narrative review on prediabetes or diabetes and atrial fibrillation: From molecular mechanisms to clinical practice

Based on glucose levels, people fall into three groups, normal individuals, prediabetic patients, and diabetic mellitus (DM) patients. Prediabetes (pre-DM) is an intermediate condition that exists between normal glucose levels and DM. Atrial fibrillation (AF), one of the most prevalent cardiac arrhythmias in medical practice, contributes to a considerable morbidity and mortality rate. In this review, we looked at the clinical symptoms, pathological alterations, molecular mechanisms, and associated risk factors of pre-DM, type 2 DM (T2DM), and AF. In clinical practice, pre-DM can increase the prevalence of AF. In the hyperglycemic state, oxidative stress, inflammation, and endoplasmic reticulum stress can cause alterations in atrial cell or cardiac fibroblast function through tumor necrosis factor-α/nuclear factor-κB (NF-κB)/transforming growth factor-β, mitogen-activated protein kinase-matrix metalloproteinase-9 and PARP-1 is poly (ADP-ribose) polymerase 1. IκB kinase-α/NF-κB pathways, and further cause atria undergo structural, electrical, and neural remodeling which lead to the occurrence and persistence of AF. In addition, pre-DM and T2DM may worsen as a result of obesity, obstructive sleep apnea, and arterial hypertension. Furthermore, clinical researches have demonstrated that lifestyle interventions and/or pharmacotherapy in pre-DM patients can effectively delay the progresssion of pre-DM to T2DM. Individualized glycemic management and AF management should be provided to AF patients with pre-DM or DM.

Predictive Value of the Age, Creatinine, and Ejection Fraction (ACEF) Score in Cardiovascular Disease among Middle-Aged Population

PURPOSE

To explore the predictive value of ACEF scores for identifying the risk of cardiovascular disease (CVD) in the general population.

METHODS

A total of 8613 participants without a history of CVD were enrolled in the follow-up. The endpoint was CVD incidence, defined as stroke or coronary heart disease (CHD) diagnosed during the follow-up period. Cox regression analyses were used to calculate hazard ratios (HRs) with respect to the age, creatinine, and ejection fraction (ACEF) scores and CVD. A Kaplan-Meier curve was used to analyze the probability of CVD in different quartiles of ACEF. Restricted cubic spline was used to further explore whether the relationship between ACEF and CVD was linear. Finally, we assessed the discriminatory ability of ACEF for CVD using C-statistics, net reclassification index, and integrated discrimination improvement (IDI).

RESULTS

During a median follow-up period of 4.66 years, 388 participants were diagnosed with CVD. The Kaplan-Meier curve showed that ACEF was associated with CVD, and participants with high ACEF scores were significantly more likely to be diagnosed with CVD compared to participants with low ACEF scores in the general population. In the multivariate Cox regression analysis, the adjusted HRs for four quartiles of ACEF were as follows: the first quartile was used as a reference; the second quartile: HR = 2.33; the third quartile: HR = 4.81; the fourth quartile: HR = 8.00. Moreover, after adding ACEF to the original risk prediction model, we observed that new models had higher C-statistic values of CVD than the traditional model. Furthermore, the results of both NRI and IDI were positive, indicating that ACEF enhanced the prediction of CVD.

CONCLUSIONS

Our study showed that the ACEF score was associated with CVD in the general population in northeastern China. Furthermore, ACEF could be a new tool for identifying patients at high risk of primary CVD in the general population.

Low educational status correlates with a high incidence of mortality among hypertensive subjects from Northeast Rural China

Objective

Cumulative evidence indicates that education plays a major role in predicting cardiovascular risk factors. In this study, we intend to examine the possible relationship between education status and mortality in a large general subject from rural China.

Methods

Adult hypertensive subjects (n = 5,227, age = 57.22 ± 10.18 years; 49.1% men) were recruited from general population surveys (Northeast China Rural Cardiovascular Health Study). Their educational status was categorized into two groups as follows: (1) Low education (illiterate or lower than primary school) and (2) medium-high education (higher than primary school). Cardiometabolic comorbidities, related cardiovascular risk factors, and echocardiographic measurements were analyzed in both groups.

Results

Less educated hypertensive subjects had significantly higher prevalence of obesity, diabetes, dyslipidemia, and left ventricular hypertrophy than medium-high educated hypertensive subjects. In the medium-high educated subjects, a significant increase in left ventricular ejection fraction and lower rate of antihypertensive medication was found. Cox proportional hazards analysis indicated that medium-high education was independently associated with all-cause mortality (hazard ratio = 0.76; 95% confidence interval, 0.58, 0.99; P = 0.043) and cardiovascular mortality (hazard ratio = 0.65; 95% confidence interval, 0.44, 0.96; P = 0.028).

Conclusion

Education may act as the best predictor of all-cause and cardiovascular mortality in rural hypertensive subjects. This finding suggests that in rural areas, education is likely to represent a cardiovascular specific risk factor and should be evaluated in the strategies of hypertension.

Tale of two kinases: Protein kinase A and Ca2+/calmodulin-dependent protein kinase II in pre-diabetic cardiomyopathy

Metabolic syndrome is a pre-diabetic state characterized by several biochemical and physiological alterations, including insulin resistance, visceral fat accumulation, and dyslipidemias, which increase the risk for developing cardiovascular disease. Metabolic syndrome is associated with augmented sympathetic tone, which could account for the etiology of pre-diabetic cardiomyopathy. This review summarizes the current knowledge of the pathophysiological consequences of enhanced and sustained β-adrenergic response in pre-diabetes, focusing on cardiac dysfunction reported in diet-induced experimental models of pre-diabetic cardiomyopathy. The research reviewed indicates that both protein kinase A and Ca²⁺/calmodulin-dependent protein kinase II play important roles in functional responses mediated by β₁-adrenoceptors; therefore, alterations in the expression or function of these kinases can be deleterious. This review also outlines recent information on the role of protein kinase A and Ca²⁺/calmodulin-dependent protein kinase II in abnormal Ca²⁺ handling by cardiomyocytes from diet-induced models of pre-diabetic cardiomyopathy.

The Diabetic Cardiomyopathy: The Contributing Pathophysiological Mechanisms

Individuals with diabetes mellitus (DM) disclose a higher incidence and a poorer prognosis of heart failure (HF) than non-diabetic people, even in the absence of other HF risk factors. The adverse impact of diabetes on HF likely reflects an underlying “diabetic cardiomyopathy” (DM–CMP), which may by exacerbated by left ventricular hypertrophy and coronary artery disease (CAD). The pathogenesis of DM-CMP has been a hot topic of research since its first description and is still under active investigation, as a complex interplay among multiple mechanisms may play a role at systemic, myocardial, and cellular/molecular levels. Among these, metabolic abnormalities such as lipotoxicity and glucotoxicity, mitochondrial damage and dysfunction, oxidative stress, abnormal calcium signaling, inflammation, epigenetic factors, and others. These disturbances predispose the diabetic heart to extracellular remodeling and hypertrophy, thus leading to left ventricular diastolic and systolic dysfunction. This Review aims to outline the major pathophysiological changes and the underlying mechanisms leading to myocardial remodeling and cardiac functional derangement in DM-CMP.

Echocardiographic left ventricular geometry profiles for prediction of stroke, coronary heart disease and all-cause mortality in the Chinese community: a rural cohort population study

Background

The utility of echocardiographic left ventricular (LV) geometry in the prediction of stroke/coronary heart disease (CHD) and all-cause mortality is not well characterized. This study aimed to evaluate the overall and sex-specific prognostic value of different geometric patterns on the incidence of stroke/CHD and all-cause mortality in a Chinese population-based cohort.

Methods

We conducted a prospective study in the general population in Northeast China, and a total of 9940 participants aged ≥ 35 years underwent echocardiography for LV geometry and were successfully followed up for incident stroke/CHD and all-cause death. Cox proportional hazards models were utilized to estimate the association of baseline LV geometry with adverse outcomes.

Results

Over a median follow-up of 4.66 years, abnormal LV geometric patterns had increased crude incident rates of stroke/CHD and all-cause mortality compared with normal geometry in overall population and each sex group (all P < 0.05). Multivariable Cox analysis reported that LV concentric and eccentric hypertrophy were associated with incident stroke/CHD (concentric hypertrophy: hazard ratio (HR) = 1.39, 95% confidence interval (CI) = 1.04–1.86; eccentric hypertrophy: HR = 1.42, 95% CI = 1.11–1.82) and all-cause mortality (concentric hypertrophy: HR = 1.50, 95% CI = 1.07–2.12; eccentric hypertrophy: HR = 1.58, 95% CI = 1.19–2.10), and LV concentric remodeling was related to stroke/CHD incidence (HR = 1.42, 95% CI = 1.09–1.84) in total population compared to normal geometry after the adjustment for potential confounders. In men, a significant increase was observed from LV eccentric hypertrophy for incident stroke/CHD, whereas in women, LV concentric hypertrophy was associated with elevated incidence of both stroke/CHD and all-cause death, and eccentric hypertrophy was correlated with increased all-cause mortality (all P < 0.05).

Conclusions

Our prospective cohort supports that abnormal LV geometry by echocardiography has a prognostic significance for incident stroke/CHD and all-cause mortality, implying that early detection and intervention of LV structural remodeling in rural China are urgently needed to prevent adverse outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02055-w.