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Chambers ME, Nuibe EH, Reno-Bernstein CM. Brain Regulation of Cardiac Function during Hypoglycemia. Metabolites 2023; 13:1089. [PMID: 37887414 PMCID: PMC10608630 DOI: 10.3390/metabo13101089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/02/2023] [Accepted: 10/16/2023] [Indexed: 10/28/2023] Open
Abstract
Hypoglycemia occurs frequently in people with type 1 and type 2 diabetes. Hypoglycemia activates the counter-regulatory response. Besides peripheral glucose sensors located in the pancreas, mouth, gastrointestinal tract, portal vein, and carotid body, many brain regions also contain glucose-sensing neurons that detect this fall in glucose. The autonomic nervous system innervates the heart, and during hypoglycemia, can cause many changes. Clinical and animal studies have revealed changes in electrocardiograms during hypoglycemia. Cardiac repolarization defects (QTc prolongation) occur during moderate levels of hypoglycemia. When hypoglycemia is severe, it can be fatal. Cardiac arrhythmias are thought to be the major mediator of sudden death due to severe hypoglycemia. Both the sympathetic and parasympathetic nervous systems of the brain have been implicated in regulating these arrhythmias. Besides cardiac arrhythmias, hypoglycemia can have profound changes in the heart and most of these changes are exacerbated in the setting of diabetes. A better understanding of how the brain regulates cardiac changes during hypoglycemia will allow for better therapeutic intervention to prevent cardiovascular death associated with hypoglycemia in people with diabetes. The aim of this paper is to provide a narrative review of what is known in the field regarding how the brain regulates the heart during hypoglycemia.
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Affiliation(s)
| | | | - Candace M. Reno-Bernstein
- Division of Endocrinology, Metabolism, and Diabetes, University of Utah School of Medicine, Salt Lake City, UT 84112, USA (E.H.N.)
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Sun DK, Zhang N, Liu Y, Qiu JC, Tse G, Li GP, Roever L, Liu T. Dysglycemia and arrhythmias. World J Diabetes 2023; 14:1163-1177. [PMID: 37664481 PMCID: PMC10473954 DOI: 10.4239/wjd.v14.i8.1163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/19/2023] [Accepted: 07/05/2023] [Indexed: 08/11/2023] Open
Abstract
Disorders in glucose metabolism can be divided into three separate but interrelated domains, namely hyperglycemia, hypoglycemia, and glycemic variability. Intensive glycemic control in patients with diabetes might increase the risk of hypoglycemic incidents and glucose fluctuations. These three dysglycemic states occur not only amongst patients with diabetes, but are frequently present in other clinical settings, such as during critically ill. A growing body of evidence has focused on the relationships between these dysglycemic domains with cardiac arrhythmias, including supraventricular arrhythmias (primarily atrial fibrillation), ventricular arrhythmias (malignant ventricular arrhythmias and QT interval prolongation), and bradyarrhythmias (bradycardia and heart block). Different mechanisms by which these dysglycemic states might provoke cardiac arr-hythmias have been identified in experimental studies. A customized glycemic control strategy to minimize the risk of hyperglycemia, hypoglycemia and glucose variability is of the utmost importance in order to mitigate the risk of cardiac arrhythmias.
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Affiliation(s)
- Dong-Kun Sun
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Nan Zhang
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Ying Liu
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Jiu-Chun Qiu
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Gary Tse
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
- Kent and Medway Medical School, Kent CT2 7NT, Canterbury, United Kingdom
- School of Nursing and Health Studies, Metropolitan University, Hong Kong 999077, China
| | - Guang-Ping Li
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Leonardo Roever
- Department of Clinical Research, Federal University of Uberlândia, Uberlândia, 38400384, MG, Brazil
| | - Tong Liu
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
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Esdaile H, Hill N, Mayet J, Oliver N. Glycaemic control in people with diabetes following acute myocardial infarction. Diabetes Res Clin Pract 2023; 199:110644. [PMID: 36997029 DOI: 10.1016/j.diabres.2023.110644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/09/2023] [Accepted: 03/22/2023] [Indexed: 03/31/2023]
Abstract
Diabetes is a highly prevalent disease associated with considerable cardiovascular end organ damage and mortality. Despite significant changes to the management of acute myocardial infarction over the last two decades, people with diabetes remain at risk of complications and mortality following a myocardial infarct for a multitude of reasons, including increased coronary atherosclerosis, associated coronary microvascular dysfunction, and diabetic cardiomyopathy. Dysglycaemia causes significant endothelial dysfunction and upregulation of inflammation within the vasculature and epigenetic changes mean that these deleterious effects may persist despite subsequent efforts to tighten glycaemic control. Whilst clinical guidelines advocate for the avoidance of both hyper- and hypoglcyaemia in the peri-infarct period, the evidence base is lacking, and currently there is no consensus on the benefits of glycaemic control beyond this period. Glycaemic variability contributes to the glycaemic milieu and may have prognostic importance following myocardial infarct. The use of continuous glucose monitoring means that glucose trends and parameters can now be captured and interrogated, and its use, along with newer medicines, may provide novel opportunities for intervention after myocardial infarction in people with diabetes.
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Affiliation(s)
- Harriet Esdaile
- Faculty of Medicine, Department of Metabolism, Digestion and Reproduction, Imperial Centre for Translational and Experimental Medicine, Imperial College London, Du Cane Road, London, W12 0NN, London, United Kingdom.
| | - Neil Hill
- Faculty of Medicine, Department of Metabolism, Digestion and Reproduction Imperial College London, London, United Kingdom
| | - Jamil Mayet
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Nick Oliver
- Faculty of Medicine, Department of Metabolism Digestion and Reproduction, Imperial College London, London, United Kingdom
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Mistry S, Gouripeddi R, Reno CM, Abdelrahman S, Fisher SJ, Facelli JC. Detecting hypoglycemia-induced electrocardiogram changes in a rodent model of type 1 diabetes using shape-based clustering. PLoS One 2023; 18:e0284622. [PMID: 37200277 PMCID: PMC10194943 DOI: 10.1371/journal.pone.0284622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 04/04/2023] [Indexed: 05/20/2023] Open
Abstract
Sudden death related to hypoglycemia is thought to be due to cardiac arrhythmias. A clearer understanding of the cardiac changes associated with hypoglycemia is needed to reduce mortality. The objective of this work was to identify distinct patterns of electrocardiogram heartbeat changes that correlated with glycemic level, diabetes status, and mortality using a rodent model. Electrocardiogram and glucose measurements were collected from 54 diabetic and 37 non-diabetic rats undergoing insulin-induced hypoglycemic clamps. Shape-based unsupervised clustering was performed to identify distinct clusters of electrocardiogram heartbeats, and clustering performance was assessed using internal evaluation metrics. Clusters were evaluated by experimental conditions of diabetes status, glycemic level, and death status. Overall, shape-based unsupervised clustering identified 10 clusters of ECG heartbeats across multiple internal evaluation metrics. Several clusters demonstrating normal ECG morphology were specific to hypoglycemia conditions (Clusters 3, 5, and 8), non-diabetic rats (Cluster 4), or were generalized among all experimental conditions (Cluster 1). In contrast, clusters demonstrating QT prolongation alone or a combination of QT, PR, and QRS prolongation were specific to severe hypoglycemia experimental conditions and were stratified heartbeats by non-diabetic (Clusters 2 and 6) or diabetic status (Clusters 9 and 10). One cluster demonstrated an arrthymogenic waveform with premature ventricular contractions and was specific to heartbeats from severe hypoglycemia conditions (Cluster 7). Overall, this study provides the first data-driven characterization of ECG heartbeats in a rodent model of diabetes during hypoglycemia.
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Affiliation(s)
- Sejal Mistry
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States of America
| | - Ramkiran Gouripeddi
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States of America
- Center for Clinical and Translational Science, University of Utah, Salt Lake City, Utah, United States of America
| | - Candace M Reno
- Division of Endocrinology, Metabolism, and Diabetes, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Samir Abdelrahman
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States of America
| | - Simon J Fisher
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky, United States of America
| | - Julio C Facelli
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States of America
- Center for Clinical and Translational Science, University of Utah, Salt Lake City, Utah, United States of America
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Sanchez-Rangel E, Deajon-Jackson J, Hwang JJ. Pathophysiology and management of hypoglycemia in diabetes. Ann N Y Acad Sci 2022; 1518:25-46. [PMID: 36202764 DOI: 10.1111/nyas.14904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
In the century since the discovery of insulin, diabetes has changed from an early death sentence to a manageable chronic disease. This change in longevity and duration of diabetes coupled with significant advances in therapeutic options for patients has fundamentally changed the landscape of diabetes management, particularly in patients with type 1 diabetes mellitus. However, hypoglycemia remains a major barrier to achieving optimal glycemic control. Current understanding of the mechanisms of hypoglycemia has expanded to include not only counter-regulatory hormonal responses but also direct changes in brain glucose, fuel sensing, and utilization, as well as changes in neural networks that modulate behavior, mood, and cognition. Different strategies to prevent and treat hypoglycemia have been developed, including educational strategies, new insulin formulations, delivery devices, novel technologies, and pharmacologic targets. This review article will discuss current literature contributing to our understanding of the myriad of factors that lead to the development of clinically meaningful hypoglycemia and review established and novel therapies for the prevention and treatment of hypoglycemia.
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Affiliation(s)
- Elizabeth Sanchez-Rangel
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jelani Deajon-Jackson
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Janice Jin Hwang
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA.,Division of Endocrinology, Department of Internal Medicine, University of North Carolina - Chapel Hill, Chapel Hill, North Carolina, USA
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Metformin treatment is associated with improved outcome in patients with diabetes and advanced heart failure (HFrEF). Sci Rep 2022; 12:13038. [PMID: 35906276 PMCID: PMC9338272 DOI: 10.1038/s41598-022-17327-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 07/25/2022] [Indexed: 11/17/2022] Open
Abstract
The role of metformin (MET) in the treatment of patients with advanced HFrEF and type 2 diabetes mellitus (DM) is not firmly established. We studied the impact of MET on metabolic profile, quality of life (QoL) and survival in these patients. A total of 847 stable patients with advanced HFrEF (57.4 ± 11.3 years, 67.7% NYHA III/IV, LVEF 23.6 ± 5.8%) underwent clinical and laboratory evaluation and were prospectively followed for a median of 1126 (IQRs 410; 1781) days for occurrence of death, urgent heart transplantation or mechanical circulatory support implantation. A subgroup of 380 patients (44.9%) had DM, 87 of DM patients (22.9%) were treated with MET. Despite worse insulin sensitivity and more severe DM (higher BMI, HbA1c, worse insulin resistance), MET-treated patients exhibited more stable HF marked by lower BNP level (400 vs. 642 ng/l), better LV and RV function, lower mitral and tricuspid regurgitation severity, were using smaller doses of diuretics (all p < 0.05). Further, they had higher eGFR (69.23 vs. 63.34 ml/min/1.73 m2) and better QoL (MLHFQ: 36 vs. 48 points, p = 0.002). Compared to diabetics treated with other glucose-lowering agents, MET-treated patients had better event-free survival even after adjustment for BNP, BMI and eGFR (p = 0.035). Propensity score-matched analysis with 17 covariates yielded 81 pairs of patients and showed a significantly better survival for MET-treated subgroup (p = 0.01). MET treatment in patients with advanced HFrEF and DM is associated with improved outcome by mechanisms beyond the improvement of blood glucose control.
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Haas A, Borsook D, Adler G, Freeman R. Stress, hypoglycemia, and the autonomic nervous system. Auton Neurosci 2022; 240:102983. [PMID: 35417827 DOI: 10.1016/j.autneu.2022.102983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/30/2022] [Accepted: 04/01/2022] [Indexed: 11/29/2022]
Abstract
Stress can be classified as either psychosocial or physiologic. Physiologic stress refers to stresses due to acute illness, trauma, pain, hypoglycemia, and sleep deprivation-much less is known regarding its health consequences. This review focuses on hypoglycemia as a model to further investigate physiological stress. Experimental mild to moderate hypoglycemia is a paradigmatic physiological stress that evokes autonomic, neuroendocrine, and immune responses. Hypoglycemic stress is an ideal model to examine the interactions and consequences of physiological stress on the autonomic nervous system. Acute hypoglycemia has been demonstrated to increase inflammatory markers, prolong QTc, and impair cardiac-vagal baroreflex sensitivity. Some of these consequences may not reverse completely when euglycemia is restored. For example, there is attenuation of the cardiac-vagal baroreflex, attenuation of the vascular sympathetic baroreflex (muscle sympathetic nerve activity response to transient hypotension), and attenuation of the catecholamine response to lower body negative pressure that is present the next day after hypoglycemia has resolved.
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Affiliation(s)
- Andrea Haas
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, MA, USA
| | - David Borsook
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Gail Adler
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, MA, USA
| | - Roy Freeman
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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Wei X, Chang ACH, Chang H, Xu S, Xue Y, Zhang Y, Lei M, Chang ACY, Zhang Q. Hypoglycemia-Exacerbated Mitochondrial Connexin 43 Accumulation Aggravates Cardiac Dysfunction in Diabetic Cardiomyopathy. Front Cardiovasc Med 2022; 9:800185. [PMID: 35369285 PMCID: PMC8967291 DOI: 10.3389/fcvm.2022.800185] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 02/10/2022] [Indexed: 11/29/2022] Open
Abstract
Background Diabetic cardiomyopathy (DCM) is a complex multifaceted disease responsible for elevated heart failure (HF) morbidity and mortality in patients with diabetes mellitus (DM). Patients with DCM exhibit subclinical diastolic dysfunction, progression toward systolic impairment, and abnormal electrophysiology. Hypoglycemia events that occur spontaneously or due to excess insulin administration threaten the lives of patients with DM—with the increased risk of sudden death. However, the molecular underpinnings of this fatal disease remain to be elucidated. Methods and Results Here, we used the established streptozotocin-induced DCM murine model to investigate how hypoglycemia aggravates DCM progression. We confirmed connexin 43 (Cx43) dissociation from cell–cell interaction and accumulation at mitochondrial inner membrane both in the cardiomyocytes of patients with DM and DCM murine. Here, we observed that cardiac diastolic function, induced by chronic hyperglycemia, was further aggravated upon hypoglycemia challenge. Similar contractile defects were recapitulated using neonatal mouse ventricular myocytes (NMVMs) under glucose fluctuation challenges. Using immunoprecipitation mass spectrometry, we identified and validated that hypoglycemia challenge activates the mitogen-activated protein kinase kinase (MAPK kinase) (MEK)/extracellular regulated protein kinase (ERK) and inhibits phosphoinositide 3-kinase (PI3K)/Akt pathways, which results in Cx43 phosphorylation by Src protein and translocation to mitochondria in cardiomyocytes. To determine causality, we overexpressed a mitochondrial targeting Cx43 (mtCx43) using adeno-associated virus serotype 2 (AAV2)/9. At normal blood glucose levels, mtCx43 overexpression recapitulated cardiac diastolic dysfunction as well as aberrant electrophysiology in vivo. Our findings give support for therapeutic targeting of MEK/ERK/Src and PI3K/Akt/Src pathways to prevent mtCx43-driven DCM. Conclusion DCM presents compensatory adaptation of mild mtCx43 accumulation, yet acute hypoglycemia challenges result in further accumulation of mtCx43 through the MEK/ERK/Src and PI3K/Akt/Src pathways. We provide evidence that Cx43 mislocalization is present in hearts of patients with DM hearts, STZ-induced DCM murine model, and glucose fluctuation challenged NMVMs. Mechanistically, we demonstrated that mtCx43 is responsible for inducing aberrant contraction and disrupts electrophysiology in cardiomyocytes and our results support targeting of mtCx43 in treating DCM.
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Affiliation(s)
- Xing Wei
- Department of Cardiology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Andrew Chia Hao Chang
- Shanghai Institute of Precision Medicine, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haishuang Chang
- Shanghai Institute of Precision Medicine, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shan Xu
- Shanghai Institute of Precision Medicine, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yilin Xue
- Shanghai Institute of Precision Medicine, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuanxin Zhang
- Department of Cardiology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ming Lei
- Shanghai Institute of Precision Medicine, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Alex Chia Yu Chang
- Department of Cardiology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Institute of Precision Medicine, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Alex Chia Yu Chang
| | - Qingyong Zhang
- Department of Cardiology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Qingyong Zhang
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Lubberding AF, Juhl CR, Skovhøj EZ, Kanters JK, Mandrup‐Poulsen T, Torekov SS. Celebrities in the heart, strangers in the pancreatic beta cell: Voltage-gated potassium channels K v 7.1 and K v 11.1 bridge long QT syndrome with hyperinsulinaemia as well as type 2 diabetes. Acta Physiol (Oxf) 2022; 234:e13781. [PMID: 34990074 PMCID: PMC9286829 DOI: 10.1111/apha.13781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 12/20/2021] [Accepted: 01/02/2022] [Indexed: 12/13/2022]
Abstract
Voltage‐gated potassium (Kv) channels play an important role in the repolarization of a variety of excitable tissues, including in the cardiomyocyte and the pancreatic beta cell. Recently, individuals carrying loss‐of‐function (LoF) mutations in KCNQ1, encoding Kv7.1, and KCNH2 (hERG), encoding Kv11.1, were found to exhibit post‐prandial hyperinsulinaemia and episodes of hypoglycaemia. These LoF mutations also cause the cardiac disorder long QT syndrome (LQTS), which can be aggravated by hypoglycaemia. Interestingly, patients with LQTS also have a higher burden of diabetes compared to the background population, an apparent paradox in relation to the hyperinsulinaemic phenotype, and KCNQ1 has been identified as a type 2 diabetes risk gene. This review article summarizes the involvement of delayed rectifier K+ channels in pancreatic beta cell function, with emphasis on Kv7.1 and Kv11.1, using the cardiomyocyte for context. The functional and clinical consequences of LoF mutations and polymorphisms in these channels on blood glucose homeostasis are explored using evidence from pre‐clinical, clinical and genome‐wide association studies, thereby evaluating the link between LQTS, hyperinsulinaemia and type 2 diabetes.
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Affiliation(s)
- Anniek F. Lubberding
- Department of Biomedical Sciences Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
| | - Christian R. Juhl
- Department of Biomedical Sciences Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
| | - Emil Z. Skovhøj
- Department of Biomedical Sciences Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
| | - Jørgen K. Kanters
- Department of Biomedical Sciences Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
| | - Thomas Mandrup‐Poulsen
- Department of Biomedical Sciences Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
| | - Signe S. Torekov
- Department of Biomedical Sciences Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
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Tomlinson B, Patil NG, Fok M, Chan P, Lam CWK. The role of sulfonylureas in the treatment of type 2 diabetes. Expert Opin Pharmacother 2021; 23:387-403. [PMID: 34758676 DOI: 10.1080/14656566.2021.1999413] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Type 2 diabetes (T2D) is increasingly prevalent and associated with increased risk for cardiovascular and renal disease. After lifestyle modification, metformin is usually the first-line pharmacotherapy and sulfonylureas are traditionally added after metformin failure. However, with newer glucose lowering drugs that may have less risk of hypoglycemia or that may reduce cardiovascular and renal events, the position of sulfonylureas is being reevaluated. AREAS COVERED In this article, the authors review relevant publications related to the use of sulfonylureas. EXPERT OPINION Sulfonylureas are potent glucose lowering drugs. The risk of hypoglycemia varies with different drugs within the class and can be minimized by using the safer drugs, possibly in lower doses. Cardiovascular events do not appear to be increased with some of the newer generation drugs. The durability of glycemic control also appears comparable to other newer agents. Sulfonylureas are the preferred treatment for some types of monogenic diabetes and selection of T2D patients who may have greater benefit from sulfonylureas based on certain phenotypes and genotypes is likely to be refined further by precision medicine. Sulfonylureas are inexpensive and readily available everywhere and they are still the most frequently used second-line treatment for T2D in many parts of the world.
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Affiliation(s)
- Brian Tomlinson
- Faculty of Medicine, Macau University of Science and Technology, Macau, China
| | | | - Manson Fok
- Faculty of Medicine, Macau University of Science and Technology, Macau, China
| | - Paul Chan
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei City, Taiwan
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11
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Andersen A, Bagger JI, Baldassarre MPA, Christensen MB, Abelin KU, Faber J, Pedersen-Bjergaard U, Holst JJ, Lindhardt TB, Gislason G, Knop FK, Vilsbøll T. Acute hypoglycemia and risk of cardiac arrhythmias in insulin-treated type 2 diabetes and controls. Eur J Endocrinol 2021; 185:343-353. [PMID: 34085953 PMCID: PMC8345897 DOI: 10.1530/eje-21-0232] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 06/03/2021] [Indexed: 12/04/2022]
Abstract
OBJECTIVE Hypoglycemia is associated with an increased risk of cardiovascular disease including cardiac arrhythmias. We investigated the effect of hypoglycemia in the setting of acute glycemic fluctuations on cardiac rhythm and cardiac repolarization in insulin-treated patients with type 2 diabetes compared with matched controls without diabetes. DESIGN A non-randomized, mechanistic intervention study. METHODS Insulin-treated patients with type 2 diabetes (n = 21, age (mean ± s.d.): 62.8 ± 6.5 years, BMI: 29.0 ± 4.2 kg/m2, HbA1c: 6.8 ± 0.5% (51.0 ± 5.4 mmol/mol)) and matched controls (n = 21, age: 62.2 ± 8.3 years, BMI 29.2 ± 3.5 kg/m2, HbA1c: 5.3 ± 0.3% (34.3 ± 3.3 mmol/mol)) underwent a sequential hyperglycemic and hypoglycemic clamp with three steady-states of plasma glucose: (i) fasting plasma glucose, (ii) hyperglycemia (fasting plasma glucose +10 mmol/L) and (iii) hyperinsulinemic hypoglycemia (plasma glucose < 3.0 mmol/L). Participants underwent continuous ECG monitoring and blood samples for counterregulatory hormones and plasma potassium were obtained. RESULTS Both groups experienced progressively increasing heart rate corrected QT (Fridericia's formula) interval prolongations during hypoglycemia ((∆mean (95% CI): 31 ms (16, 45) and 39 ms (24, 53) in the group of patients with type 2 diabetes and controls, respectively) with similar increases from baseline at the end of the hypoglycemic phase (P = 0.43). The incidence of ventricular premature beats increased significantly in both groups during hypoglycemia (P = 0.033 and P < 0.0001, respectively). One patient with type 2 diabetes developed atrial fibrillation during recovery from hypoglycemia. CONCLUSIONS In insulin-treated patients with type 2 diabetes and controls without diabetes, hypoglycemia causes clinically significant and similar increases in cardiac repolarization that might increase vulnerability for serious cardiac arrhythmias and sudden cardiac death.
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Affiliation(s)
- Andreas Andersen
- Steno Diabetes Center Copenhagen, Gentofte Hospital, Hellerup, Denmark
- Center for Clinical Metabolic Research, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Jonatan I Bagger
- Steno Diabetes Center Copenhagen, Gentofte Hospital, Hellerup, Denmark
- Center for Clinical Metabolic Research, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Maria P A Baldassarre
- Center for Clinical Metabolic Research, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Medicine and Aging Sciences, G. d’Annunzio University, Chieti, Italy
| | - Mikkel B Christensen
- Center for Clinical Metabolic Research, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Pharmacology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Kirsten U Abelin
- Steno Diabetes Center Copenhagen, Gentofte Hospital, Hellerup, Denmark
- Center for Clinical Metabolic Research, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Jens Faber
- Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ulrik Pedersen-Bjergaard
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Endocrinology and Nephrology, Nordsjællands Hospital Hillerød, University of Copenhagen, Hillerød, Denmark
| | - Jens J Holst
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tommi B Lindhardt
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Gunnar Gislason
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- The Danish Heart Foundation, Copenhagen, Denmark
| | - Filip K Knop
- Steno Diabetes Center Copenhagen, Gentofte Hospital, Hellerup, Denmark
- Center for Clinical Metabolic Research, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tina Vilsbøll
- Steno Diabetes Center Copenhagen, Gentofte Hospital, Hellerup, Denmark
- Center for Clinical Metabolic Research, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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12
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Cagiltay E, Pouwels S, Erbas O, Taskiran D, Kalkanli Tas S, Aslan I. The Prophylactic Effects of Metoprolol, Diltiazem, and Pilocarpine on Hypoglycemia-Induced Prolongation of QT Interval. Cureus 2021; 13:e14058. [PMID: 33898141 PMCID: PMC8061426 DOI: 10.7759/cureus.14058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 01/08/2023] Open
Abstract
Background Insulin-induced hypoglycemia has been demonstrated to prolong the corrected QT (QTc) interval. Prolongation of the QTc interval, especially in diabetic patients using insulin, can cause fatal ventricular arrhythmias. The aim of this study was to evaluate the effects of metoprolol, diltiazem, and pilocarpine on hypoglycemia-induced QTc prolongation. Methods Thirty male rats were randomly distributed into the following five groups: Group 1 (1 mL/kg saline, n=6), Group 2 (40 U/kg crystalline insulin + saline, n=6), Group 3 (40 U/kg crystalline insulin + 1 mg/kg metoprolol, n=6), Group 4 (40 U/kg crystalline insulin + 0.8 mg/kg pilocarpine, n=6), and Group 5 (40 U/kg crystalline insulin + 2 mg/kg diltiazem, n=6). Three hours after insulin injection, the blood glucose level was measured in all groups. Blood glucose <40 mg/dl was defined as hypoglycemia. Electrocardiograms (ECG) were taken in lead I (DI), and QTc was calculated by using Bazett's formula. Results Group 2 (insulin + saline) showed that it had a significantly prolonged QTc interval as compared to the control group (p<0.0001). However, treatments of the rats with metoprolol, pilocarpine, and diltiazem significantly prevented prolongation of the QTc interval as compared to the insulin + saline group (p<0.005, p<0.005, and p<0.01, respectively). Conclusion The findings of the present study demonstrated the efficacy of metoprolol, pilocarpine, and diltiazem in the prevention of hypoglycemia-induced QTc prolongation in male rats.
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Affiliation(s)
- Eylem Cagiltay
- Department of Physiology, Istanbul Bilim University School of Medicine, Istanbul, TUR
| | - Sjaak Pouwels
- Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, NLD
| | - Oytun Erbas
- Department of Physiology, Istanbul Bilim University School of Medicine, Istanbul, TUR
| | - Dilek Taskiran
- Department of Physiology, Ege University School of Medicine, Izmir, TUR
| | - Sevgi Kalkanli Tas
- Department of Immunology, University of Health Sciences, Faculty of Medicine, Istanbul, TUR
| | - Ismael Aslan
- Department of Pharmacy, University of Health Sciences, Institute of Health Sciences, Istanbul, TUR
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13
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Lee S, Zhou J, Guo CL, Wong WT, Liu T, Wong ICK, Jeevaratnam K, Zhang Q, Tse G. Predictive scores for identifying patients with type 2 diabetes mellitus at risk of acute myocardial infarction and sudden cardiac death. ENDOCRINOLOGY DIABETES & METABOLISM 2021; 4:e00240. [PMID: 34277965 PMCID: PMC8279628 DOI: 10.1002/edm2.240] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/08/2021] [Accepted: 02/09/2021] [Indexed: 12/11/2022]
Abstract
Introduction The present study evaluated the application of incorporating non‐linear J/U‐shaped relationships between mean HbA1c and cholesterol levels into risk scores for predicting acute myocardial infarction (AMI) and non‐AMI‐related sudden cardiac death (SCD) respectively, amongst patients with type 2 diabetes mellitus. Methods This was a territory‐wide cohort study of patients with type 2 diabetes mellitus above the age 40 and free from prior AMI and SCD, with or without prescriptions of anti‐diabetic agents between January 1st, 2009 to December 31st, 2009 at government‐funded hospitals and clinics in Hong Kong. Patients recruited were followed up until 31 December 2019 or their date of death. Risk scores were developed for predicting incident AMI and non‐AMI‐related SCD. The performance of conditional inference survival forest (CISF) model compared to that of random survival forests (RSF) model and multivariate Cox model. Results This study included 261 308 patients (age = 66.0 ± 11.8 years old, male = 47.6%, follow‐up duration = 3552 ± 1201 days, diabetes duration = 4.77 ± 2.29 years). Mean HbA1c and low high‐density lipoprotein‐cholesterol (HDL‐C) were significant predictors of AMI on multivariate Cox regression. Mean HbA1c was linearly associated with AMI, whilst HDL‐C was inversely associated with AMI. Mean HbA1c and total cholesterol were significant multivariate predictors with a J‐shaped relationship with non‐AMI‐related SCD. The AMI and SCD risk scores had an area under the curve (AUC) of 0.666 (95% confidence interval (CI) = [0.662, 0.669]) and 0.677 (95% CI = [0.673, 0.682]), respectively. CISF significantly improves prediction performance of both outcomes compared to RSF and multivariate Cox models. Conclusion A holistic combination of demographic, clinical and laboratory indices can be used for the risk stratification of patients with type 2 diabetes mellitus for AMI and SCD.
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Affiliation(s)
- Sharen Lee
- Cardiovascular Analytics Group Laboratory of Cardiovascular Physiology Hong Kong China
| | - Jiandong Zhou
- School of Data Science City University of Hong Kong Hong Kong Hong Kong China
| | - Cosmos Liutao Guo
- Li Ka Shing Institute of Health Sciences Chinese University of Hong Kong Hong Kong China
| | - Wing Tak Wong
- School of Life Sciences Chinese University of Hong Kong Hong Kong China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease Department of Cardiology Tianjin Institute of Cardiology Second Hospital of Tianjin Medical University Tianjin China
| | - Ian Chi Kei Wong
- Department of Pharmacology and Pharmacy University of Hong Kong Pokfulam Hong Kong China.,Medicines Optimisation Research and Education (CMORE UCL School of Pharmacy London UK
| | | | - Qingpeng Zhang
- School of Data Science City University of Hong Kong Hong Kong Hong Kong China
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease Department of Cardiology Tianjin Institute of Cardiology Second Hospital of Tianjin Medical University Tianjin China.,Faculty of Health and Medical Sciences University of Surrey Guildford UK
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14
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Dei Cas A, Aldigeri R, Ridolfi V, Vazzana A, Ciardullo AV, Manicardi V, Sforza A, Tomasi F, Zavaroni D, Zavaroni I, Bonadonna RC. A performance score of the quality of inpatient diabetes care is a marker of clinical outcomes and suggests a cause-effect relationship between hypoglycaemia and the risk of in-hospital mortality. Diabetes Metab Res Rev 2020; 36:e3347. [PMID: 32445284 DOI: 10.1002/dmrr.3347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/04/2020] [Accepted: 05/10/2020] [Indexed: 12/17/2022]
Abstract
AIMS To build a tool to assess the management of inpatients with diabetes mellitus and to investigate its relationship, if any, with clinical outcomes. MATERIALS AND METHODS A total of 678 patients from different settings, Internal Medicine (IMU, n = 255), General Surgery (GSU, n = 230) and Intensive Care (ICU, n = 193) Units, were enrolled. A work-flow of clinical care of diabetes was created according to guidelines. The workflow was divided into five different domains: (a) initial assessment; (b) glucose monitoring; (c) medical therapy; (d) consultancies; (e) discharge. Each domain was assessed by a performance score (PS), computed as the sum of the scores achieved in a set of indicators of clinical appropriateness, management and patient empowerment. Appropriate glucose goals were included as intermediate phenotypes. Clinical outcomes included: hypoglycaemia, survival rate and clinical conditions at discharge. RESULTS The total PS and those of initial assessment and glucose monitoring were significantly lower in GSU with respect to IMU and ICU (P < .0001). The glucose monitoring PS was associated with lower risk of hypoglycaemia (OR = 0.55; P < .0001), whereas both the PSs of glucose monitoring and medical therapy resulted associated with higher in-hospital survival only in the IMU ward (OR = 6.67 P = .001 and OR = 2.38 P = .03, respectively). Instrumental variable analysis with the aid of PS of glucose monitoring showed that hypoglycaemia may play a causal role in in-hospital mortality (P = .04). CONCLUSIONS The quality of in-hospital care of diabetes may affect patient outcomes, including glucose control and the risk of hypoglycaemia, and through the latter it may influence the risk of in-hospital mortality.
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Affiliation(s)
- Alessandra Dei Cas
- Department of Medicine and Surgery, Università di Parma, Parma, Italy
- Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | | | - Valentina Ridolfi
- Department of Medicine and Surgery, Università di Parma, Parma, Italy
- Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Angela Vazzana
- Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | | | | | | | | | | | - Ivana Zavaroni
- Department of Medicine and Surgery, Università di Parma, Parma, Italy
- Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Riccardo C Bonadonna
- Department of Medicine and Surgery, Università di Parma, Parma, Italy
- Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
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15
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Singleton MJ, Soliman EZ, Bertoni AG, Whalen SP, Bhave PD, Yeboah J. Effect of Intensive Glycemic and Blood Pressure Control on QT Prolongation in Diabetes: The ACCORD Trial. Diabetes 2020; 69:2186-2193. [PMID: 32732305 PMCID: PMC7809716 DOI: 10.2337/db20-0401] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/16/2020] [Indexed: 01/14/2023]
Abstract
Compared with standard glycemic control, intensive glycemic control caused increased mortality in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Preliminary data from several studies suggest that intensive glycemic control is associated with QT prolongation, which may lead to ventricular arrhythmias as a possible explanation of this increased mortality. We sought to assess the effects of intensive glycemic control and intensive blood pressure control on the risk of incident QT prolongation. Cox proportional hazards models were used to compare the risk of incident QT prolongation (>460 ms in women or >450 ms in men) in the intensive versus standard glycemic control arms. Over a combined 48,634 person-years of follow-up (mean 4.9), 634 participants (6.4%) developed a prolonged QTc. Participants in the intensive glycemic control arm did not have an increased risk of QT prolongation. Similarly, a strategy of intensive blood pressure control did not result in a significant change in risk of prolonged QTc. Sensitivity analyses using alternative QT correction formulas (Hodges and Bazett) yielded overall similar findings. In conclusion, the increased mortality observed in the intensive glycemic control arm in the ACCORD trial is not likely to be explained by QT prolongation leading to lethal ventricular arrhythmias.
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Affiliation(s)
- Matthew J Singleton
- Section of Cardiology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Elsayed Z Soliman
- Section of Cardiology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
- Epidemiological Cardiology Research Center, Wake Forest School of Medicine, Winston-Salem, NC
| | - Alain G Bertoni
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC
| | - S Patrick Whalen
- Section of Cardiology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Prashant D Bhave
- Section of Cardiology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Joseph Yeboah
- Section of Cardiology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
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Abstract
PURPOSE OF REVIEW Persons with diabetes mellitus (DM) have increased morbidity and mortality rates compared with persons without DM. Sudden cardiac death (SCD) is a leading cause of death, and multiple studies have found an increased risk of SCD among individuals with DM. This review sought to collect the latest knowledge of the epidemiological and pathophysiological interplay between DM and SCD. RECENT FINDINGS Persons with DM have a two- to tenfold increased risk of SCD compared with persons without DM. The underlying mechanisms for the increased risk of SCD are complex and multifactorial. The main pathophysiological contributors are DM-induced cardiac autonomic neuropathy (CAN), metabolic changes, silent ischemia, and polypharmacy. Persons with DM have an increased risk of SCD. Future studies should focus on CAN and the combined risk of QT prolongation from the interplay between CAN, hypoglycemia, and polypharmacy. Genes and pathways involved in control of the autonomic nervous system and cardiac ion channels could be a future focal point.
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17
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Teshima Y, Shiga R, Saito S, Kondo H, Fukui A, Fukuda T, Okada N, Akioka H, Shinohara T, Akiyoshi K, Yufu K, Nakagawa M, Takahashi N. Potential Risk of Hypoglycemia in Patients with Heart Failure. Int Heart J 2020; 61:776-780. [PMID: 32684608 DOI: 10.1536/ihj.20-134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The properties of glucose changes in patients with chronic heart failure remain elusive. In the present study, we investigated the sequential changes of interstitial glucose concentrations in patients with chronic heart failure and heart disease who were not undergoing antidiabetic therapy.A glucose monitoring device (FreeStyle Libre Pro) was attached to the backside of an upper arm and the interstitial glucose concentration was monitored every 15 minutes for 1 week. Eleven patients with chronic heart failure (Heart failure (+) ) and 7 patients with chronic heart diseases but not with heart failure (Heart failure (-) ) were enrolled. The average level and peak value of interstitial glucose concentrations, and the duration of hyperglycemia (≥ 140 mg/dL) were not significantly different between Heart failure (+) and Heart failure (-). The duration of hypoglycemia (< 80 mg/dL) was significantly longer and the trough value was significantly lower in Heart failure (+) compared with Heart failure (-). Most of the patients in Heart failure (+) were exposed to a long duration of hypoglycemia from midnight to morning. Importantly, none of the patients who showed hypoglycemia complained of any subjective symptoms during hypoglycemia. Malabsorption may be one of the mechanisms of hypoglycemia.In summary, patients with chronic heart failure are at risk of developing hypoglycemia even if they do not undergo any antidiabetic therapy.
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Affiliation(s)
- Yasushi Teshima
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Ryosuke Shiga
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Shotaro Saito
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Hidekazu Kondo
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Akira Fukui
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Tomoko Fukuda
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Norihiro Okada
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Hidefumi Akioka
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Tetsuji Shinohara
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Kumiko Akiyoshi
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Kunio Yufu
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Mikiko Nakagawa
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
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18
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Rezende PC, Hlatky MA, Hueb W, Garcia RMR, da Silva Selistre L, Lima EG, Garzillo CL, Scudeler TL, Boros GAB, Ribas FF, Serrano CV, Ramires JAF, Kalil Filho R. Association of Longitudinal Values of Glycated Hemoglobin With Cardiovascular Events in Patients With Type 2 Diabetes and Multivessel Coronary Artery Disease. JAMA Netw Open 2020; 3:e1919666. [PMID: 31968117 PMCID: PMC6991270 DOI: 10.1001/jamanetworkopen.2019.19666] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE Glycated hemoglobin (HbA1c) values are used to guide glycemic control, but in patients with type 2 diabetes and multivessel coronary artery disease (CAD), the association of the longitudinal values of HbA1c with cardiovascular outcomes is unclear. OBJECTIVE To assess whether longitudinal variation of HbA1c is associated with cardiovascular events in long-term follow-up among patients with diabetes and multivessel CAD. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 888 patients with type 2 diabetes and multivessel CAD in the Medicine, Angioplasty, or Surgery Study (MASS) Registry of the Heart Institute of the University of São Paulo from January 2003 to December 2007. Data were analyzed from January 15, 2018, to October 15, 2019. EXPOSURE Longitudinal HbA1c values. MAIN OUTCOMES AND MEASURES The combined outcome of all-cause mortality, myocardial infarction, and ischemic stroke. RESULTS Of 888 patients with type 2 diabetes and multivessel CAD, 725 (81.6%; median [range] age, 62.4 [55.7-68.0] years; 467 [64.4%] men) had complete clinical and HbA1c information during a median (interquartile range) follow-up period of 10.0 (8.0-12.3) years, with a mean (SD) of 9.5 (3.8) HbA1c values for each patient. The composite end point of death, myocardial infarction, or ischemic stroke occurred in 262 patients (36.1%). A 1-point increase in the longitudinal value of HbA1c was significantly associated with a 14% higher risk of the combined end point of all-cause mortality, myocardial infarction, and ischemic stroke (hazard ratio, 1.14; 95% CI, 1.04-1.24; P = .002) in the unadjusted analysis. After adjusting for baseline factors (ie, age, sex, 2-vessel or 3-vessel CAD, initial CAD treatments, ejection fraction, and creatinine and low-density lipoprotein cholesterol levels), a 1-point increase in the longitudinal value of HbA1c was associated with a 22% higher risk of the combined end point (hazard ratio, 1.22; 95% CI, 1.12-1.35; P < .001). CONCLUSIONS AND RELEVANCE Longitudinal increase of HbA1c was independently associated with higher rates of cardiovascular events in patients with type 2 diabetes and multivessel CAD.
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Affiliation(s)
- Paulo Cury Rezende
- Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Whady Hueb
- Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Rosa Maria Rahmi Garcia
- Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Eduardo Gomes Lima
- Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Cibele Larrosa Garzillo
- Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Thiago Luis Scudeler
- Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Gustavo Andre Boeing Boros
- Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Fernando Faglioni Ribas
- Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Carlos Vicente Serrano
- Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Jose Antonio Franchini Ramires
- Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Roberto Kalil Filho
- Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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19
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Andersen A, Jørgensen PG, Knop FK, Vilsbøll T. Hypoglycaemia and cardiac arrhythmias in diabetes. Ther Adv Endocrinol Metab 2020; 11:2042018820911803. [PMID: 32489579 PMCID: PMC7238305 DOI: 10.1177/2042018820911803] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/30/2020] [Indexed: 01/11/2023] Open
Abstract
Hypoglycaemia remains an inevitable risk in insulin-treated type 1 diabetes and type 2 diabetes and has been associated with multiple adverse outcomes. Whether hypoglycaemia is a cause of fatal cardiac arrhythmias in diabetes, or merely a marker of vulnerability, is still unknown. Since a pivotal report in 1991, hypoglycaemia has been suspected to induce cardiac arrhythmias in patients with type 1 diabetes, the so-called 'dead-in-bed syndrome'. This suspicion has subsequently been supported by the coexistence of an increased mortality and a three-fold increase in severe hypoglycaemia in patients with type 2 diabetes receiving intensive glucose-lowering treatment in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Studies have investigated the association between hypoglycaemia-induced cardiac arrhythmias. In a rat-model, severe hypoglycaemia resulted in a specific pattern of cardiac arrhythmias including QT-prolongation, ventricular tachycardia, second- and third-degree AV block and ultimately cardiorespiratory arrest. In clinical studies of experimentally induced hypoglycaemia, QTc-prolongation, a risk factor of ventricular arrhythmias, is an almost consistent finding. The extent of QT-prolongation seems to be modified by several factors, including antecedent hypoglycaemia, diabetes duration and cardiac autonomic neuropathy. Observational studies indicate diurnal differences in the pattern of electrocardiographic alterations during hypoglycaemia with larger QTc-prolongations during daytime, whereas the risk of bradyarrhythmias may be increased during sleep. Daytime periods of hypoglycaemia are characterized by shorter duration, increased awareness and a larger increase in catecholamines. The counterregulatory response is reduced during nightly episodes of hypoglycaemia, resulting in prolonged periods of hypoglycaemia with multiple nadirs. An initial sympathetic activity at plasma glucose nadir is replaced by increased vagal activity, which results in bradycardia. Here, we provide an overview of the existing literature exploring potential mechanisms for hypoglycaemia-induced cardiac arrhythmias and studies linking hypoglycaemia to cardiac arrhythmias in patients with diabetes.
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Affiliation(s)
- Andreas Andersen
- Steno Diabetes Center Copenhagen, Gentofte
Hospital, Hellerup, Denmark
- Center for Clinical Metabolic Research, Herlev
and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Peter G. Jørgensen
- Department of Cardiology, Herlev and Gentofte
Hospital, University of Copenhagen, Hellerup, Denmark
| | - Filip K. Knop
- Center for Clinical Metabolic Research, Herlev
and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Steno Diabetes Center Copenhagen, Gentofte
Hospital, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of
Health and Medical Sciences, University of Copenhagen, Copenhagen,
Denmark
- Novo Nordisk Foundation Center for Basic
Metabolic Research, Faculty of Health and Medical Sciences, University of
Copenhagen, Copenhagen, Denmark
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Hypoglycaemia, cardiovascular disease, and mortality in diabetes: epidemiology, pathogenesis, and management. Lancet Diabetes Endocrinol 2019; 7:385-396. [PMID: 30926258 DOI: 10.1016/s2213-8587(18)30315-2] [Citation(s) in RCA: 255] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 10/11/2018] [Accepted: 10/29/2018] [Indexed: 02/09/2023]
Abstract
Hypoglycaemia has long been recognised as a dangerous side-effect of treatment of diabetes with insulin or insulin secretagogues. With its potential to disrupt cerebral function, hypoglycaemia can have a major effect on peoples' lives. Study findings have suggested that hypoglycaemia is associated with an increased risk of cardiovascular events and mortality. Different mechanisms by which hypoglycaemia might provoke cardiovascular events have been identified in experimental studies, and in clinical studies cardiac arrhythmias have been reported to be induced by hypoglycaemia, with one report describing sudden death during a severe episode. Emerging evidence suggests that the association between hypoglycaemia and cardiovascular events and mortality is likely to be multifactorial. The association is probably partly caused by confounding, with hypoglycaemia occurring more frequently in people with comorbidities who are also more likely to die than those without. However, people with type 1 or type 2 diabetes also seem at risk of hypoglycaemia-induced cardiovascular effects. This risk should be recognised by clinicians when agreeing glycaemic goals with patients and choosing appropriate glucose-lowering therapies.
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21
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Santamarina M, Carlson CJ. Review of the cardiovascular safety of dipeptidyl peptidase-4 inhibitors and the clinical relevance of the CAROLINA trial. BMC Cardiovasc Disord 2019; 19:60. [PMID: 30876392 PMCID: PMC6419798 DOI: 10.1186/s12872-019-1036-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 02/27/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cardiovascular (CV) disease (CVD) is a well-recognized complication of type 2 diabetes mellitus (T2DM) and there is a clinical need for glucose-lowering therapies that do not further increase CV risk in this population. Although sulfonylureas (SUs) may be used as second-line therapy for patients requiring additional therapy after first-line metformin to improve glycemic control, their long-term effects on CV outcomes remain uncertain, and a wide range of alternative agents exist including dipeptidyl peptidase-4 (DPP-4) inhibitors. METHODS Literature searches in PubMed (2013-2018) were conducted with terms for DPP-4 inhibitors combined with CV terms, with preference given to cardiovascular outcomes trials (CVOTs). Reference lists from retrieved articles and diabetes guidelines were also considered. RESULTS This narrative review discusses current evidence for the CV safety of these agents, describes the long-term CV effects of DPP-4 inhibitors, including effects on CV events, mortality, the risk for heart failure hospitalization, and highlights the need for further research into the CV effects of SU therapy. Although SUs remain a treatment option for T2DM, the long-term effects of these agents on CV outcomes are unclear, and further long-term studies are required. For DPP-4 inhibitors, uncertainties have been raised about their long-term effect on hospitalization for heart failure in light of the results of SAVOR-TIMI 53, although the findings of other DPP-4 inhibitor CVOTs in T2DM and data analyses have suggested these agents do not increase the occurrence of adverse CV outcomes. CONCLUSIONS Based on recent CVOTs and guideline updates, the choice of add-on to metformin therapy for patients with T2DM and established CV disease should be a sodium-glucose co-transporter-2 inhibitor or a glucagon-like peptide-1 agonist with proven CV benefit. Additional treatment options for those individuals who require therapy intensification, as well as in patients with T2DM and without established CVD include DPP-4 inhibitors and SUs. Since few head-to-head trials have compared the effects of different oral glucose-lowering agents on CV outcomes in T2DM, with most CVOTs using placebo as a comparator, the CAROLINA trial will provide important information on the comparative CV safety of a commonly prescribed SU and a DPP-4 inhibitor.
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Affiliation(s)
- Marile Santamarina
- Gregory School of Pharmacy, Palm Beach Atlantic University, 901 South Flagler Drive, West Palm Beach, FL, 33416, USA.
| | - Curt J Carlson
- Gregory School of Pharmacy, Palm Beach Atlantic University, 901 South Flagler Drive, West Palm Beach, FL, 33416, USA
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Dangers of Hypoglycemia in Cardiac Patients With Diabetes: Time to Switch to Safer, Newer Drugs. J Am Coll Cardiol 2018; 72:1787-1789. [PMID: 30286921 DOI: 10.1016/j.jacc.2018.08.2138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 08/20/2018] [Indexed: 12/31/2022]
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Rezende PC, Everett BM, Brooks MM, Vlachos H, Orchard TJ, Frye RL, Bhatt DL, Hlatky MA. Hypoglycemia and Elevated Troponin in Patients With Diabetes and Coronary Artery Disease. J Am Coll Cardiol 2018; 72:1778-1786. [DOI: 10.1016/j.jacc.2018.07.067] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 07/22/2018] [Accepted: 07/23/2018] [Indexed: 01/29/2023]
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Fitzpatrick C, Chatterjee S, Seidu S, Bodicoat DH, Ng GA, Davies MJ, Khunti K. Association of hypoglycaemia and risk of cardiac arrhythmia in patients with diabetes mellitus: A systematic review and meta-analysis. Diabetes Obes Metab 2018; 20:2169-2178. [PMID: 29740922 DOI: 10.1111/dom.13348] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 04/18/2018] [Accepted: 05/02/2018] [Indexed: 01/11/2023]
Abstract
AIMS Hypoglycaemia is associated with increased cardiovascular risk among individuals with diabetes mellitus. It has been hypothesized that hypoglycaemia may trigger autonomic changes leading to increased cardiac arrhythmia risk. We conducted a systematic review and meta-analysis to explore this association. MATERIALS AND METHODS Ovid Medline, Embase, Scopus, Web of Science and Cochrane were searched from inception to October 10, 2017. We included studies of adults with diabetes (Type 1 or Type 2) that compared acute electrocardiogram (ECG) changes during episodes of hypoglycaemia and euglycaemia. RESULTS Our search resulted in 4625 citations, among which 20 studies met the predefined inclusion criteria. Finally, 12 studies were included in the descriptive analysis and 15 in the meta-analysis. Overall hypoglycaemia was associated with a reduction in heart rate variability and an increase in arrhythmia occurrence. QTc interval length was more significantly prolonged during hypoglycaemia compared to euglycaemia (pooled mean difference [95% confidence intervals] [0.64 (0.27-1.01], P = ·001). Subgroup analysis based on diabetes type showed that QTc prolongation occurred in individuals with Type 1 and Type 2 diabetes; however, the change between euglycaemia reached statistical significance only among individuals with Type 1 diabetes. CONCLUSION Our findings suggest that hypoglycaemia results in ECG alterations that are associated with increased risk of cardiac arrhythmia, which is associated with increased cardiovascular events and mortality. More clinical studies are needed to determine the cardiac risks of hypoglycaemia in individuals with diabetes, especially in Type 2 diabetes.
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Affiliation(s)
- Claire Fitzpatrick
- Diabetes Research Centre, University of Leicester, Leicester, UK
- Leicester Diabetes Centre, Leicester General Hospital, Leicester, UK
| | - Sudesna Chatterjee
- Diabetes Research Centre, University of Leicester, Leicester, UK
- Leicester Diabetes Centre, Leicester General Hospital, Leicester, UK
| | - Samuel Seidu
- Leicester Diabetes Centre, Leicester General Hospital, Leicester, UK
| | - Danielle H Bodicoat
- Diabetes Research Centre, University of Leicester, Leicester, UK
- Leicester Diabetes Centre, Leicester General Hospital, Leicester, UK
| | - G Andre Ng
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- National Institute for Health Research, Leicester Biomedical Research Centre, Leicester, UK
| | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK
- Leicester Diabetes Centre, Leicester General Hospital, Leicester, UK
- National Institute for Health Research, Leicester Biomedical Research Centre, Leicester, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
- Leicester Diabetes Centre, Leicester General Hospital, Leicester, UK
- National Institute for Health Research, Leicester Biomedical Research Centre, Leicester, UK
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Dissanayake HA, Keerthisena GSP, Gamage KKK, Liyanage JH, Ihalagama IRHS, Wijetunga WMUA, Tillekaratne TAD, Katulanda GW, Katulanda P. Hypoglycaemia in diabetes: do we think enough of the cause? An observational study on prevalence and causes of hypoglycaemia among patients with type 2 diabetes in an out-patient setting in Sri Lanka. BMC Endocr Disord 2018; 18:35. [PMID: 29884151 PMCID: PMC5994038 DOI: 10.1186/s12902-018-0264-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 06/01/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Hypoglycaemia is a feared experience for people with diabetes. We aimed to study the prevalence and causes of hypoglycaemia among Sri Lankans with diabetes. METHODS One thousand patients with diabetes attending a private sector diabetic clinic were interviewed using a structured questionnaire. Hypoglycaemic episodes within the preceding month were inquired and severity was graded according to clinical features and/or capillary blood glucose levels. RESULTS Mean age 55.0 years (± 12.5), 58.6% were males, mean diabetes duration 10.6 years (± 8.1), mean FPG 7.48 mmol/l (± 2.79) and mean HbA1c 7.82% (± 1.71) (62 mmol/mol). Of them, 26.1%. (mild 20.7%, moderate 3.9%, and severe 1.5%) experienced symptomatic hypoglycaemia. Sudden change diet (46.7%), unaccustomed exercise (15.7%) and increase in antihyperglycaemic therapy dosage (14.9%) were the recognized causes. Cause was not recognized by 16.3%. Non-prescribed native food items accounted for hypoglycaemia in 16.9% of patients (Momordica charantia 54.5%, Costus speciosus 52.3%, Salacia prinoides 11.4%, Coccinia grandis 6.8%, Adenanthera pavonina 4.5%). Severity of hypoglycaemia was positively correlated to age and duration of diabetes but not to HbA1C. CONCLUSION Hypoglycaemia is common among patients with diabetes. Patients need advice on regular diet and exercise. Consumption of non-prescribed native foods should be considered as a possible cause.
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Affiliation(s)
- H. A. Dissanayake
- Diabetes Research Unit, Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
- University Medical Unit, National Hospital of Sri Lanka, Colombo 10, Sri Lanka
| | - G. S. P. Keerthisena
- Diabetes Research Unit, Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - K. K. K. Gamage
- Diabetes Research Unit, Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - J. H. Liyanage
- Diabetes Research Unit, Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - I. R. H. S. Ihalagama
- Diabetes Research Unit, Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - W. M. U. A. Wijetunga
- Diabetes Research Unit, Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - T. A. D. Tillekaratne
- Diabetes Research Unit, Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | | | - P. Katulanda
- Diabetes Research Unit, Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
- Cruddas Link Fellow, Harris Manchester University, University of Oxford, Oxford, UK
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26
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Mezquita-Raya P, Reyes-García R, de Torres-Sánchez A, Matarín MG, Cepero-García D, Pérez de Isla L. Electrical changes during hypoglycaemia in patients with type 1 and type 2 diabetes and high cardiovascular risk. Diabetes Res Clin Pract 2018; 138:44-46. [PMID: 29382586 DOI: 10.1016/j.diabres.2018.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 12/14/2017] [Accepted: 01/23/2018] [Indexed: 11/28/2022]
Abstract
The relationship between glycaemia, arrhythmia and changes in electrocardiogram (ECG) has been addressed showing mixed results. The objective of this study was to evaluate the changes in ECG, evaluated by Holter monitoring, induced by clinical hypoglycaemia in patients with type 1 diabetes (T1DM) and type 2 diabetes (T2DM), aged 50 or older, with high cardiovascular risk. Five-lead Holter monitoring (BL-900 Braemar, Inc, Norav Medical NH301-2.4.5 software), and blinded interstitial continuous glucose monitoring (CGM) (Dexcom G4-Platinum, range 40-400 mg/dl) was performed with time synchronization. In the Holter registry, in patients with hypoglycemic episodes, mean QTc during hypoglycaemia was longer compared to mean QTc in total group (+4.6 ms, p = 0.037) and T1DM patients (+5.5 ms, p = 0.048) but not in T2DM patients (+3 ms, p = 0.459). During hypoglycaemia, non-clinical significant disturbances in heart rhythm were observed. In conclusion, we observed a prolongation in QTc during hypoglycemia, mainly in T1DM. However, our study does not show a relationship between episodes of hypoglycaemia and clinical arrhythmias, at least in T1DM and T2DM patients with high cardiovascular risk.
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Affiliation(s)
- Pedro Mezquita-Raya
- Clínica San Pedro, Endocrinology and Nutrition Unit, Almería, Spain; Hospital Torrecárdenas, Endocrinology and Nutrition Unit, Almería, Spain.
| | - Rebeca Reyes-García
- Clínica San Pedro, Endocrinology and Nutrition Unit, Almería, Spain; Hospital Torrecárdenas, Endocrinology and Nutrition Unit, Almería, Spain
| | | | - Miguel Gómez Matarín
- Clínica San Pedro, Cardiology Unit, Almería, Spain; Hospital de Poniente, Cardiology Service, Almería, Spain
| | - Daniel Cepero-García
- Clínica San Pedro, Endocrinology and Nutrition Unit, Almería, Spain; Hospital Torrecárdenas, Endocrinology and Nutrition Unit, Almería, Spain
| | - Leopoldo Pérez de Isla
- Cardiology Department, Hospital Clínico San Carlos, IDISSC, Universidad Complutense, Madrid, Spain
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van Dalem J, Brouwers MCGJ, Stehouwer CDA, Krings A, Klungel OH, Driessen JHM, de Vries F, Burden AM. Risk of a first-ever acute myocardial infarction and all-cause mortality with sulphonylurea treatment: A population-based cohort study. Diabetes Obes Metab 2018; 20:1056-1060. [PMID: 29171906 PMCID: PMC5873381 DOI: 10.1111/dom.13168] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 10/27/2017] [Accepted: 11/19/2017] [Indexed: 01/08/2023]
Abstract
We investigated the association between the current use of individual sulphonylureas and the risk of a first-ever acute myocardial infarction (AMI) and all-cause mortality, in a population-based cohort study, using primary care data from the Clinical Practice Research Datalink database (2004-2012). New users (N = 121 869), aged ≥18 years, with at least one prescription for a non-insulin antidiabetic agent were included. The first prescription defined start of follow-up. Time-dependent Cox proportional hazard models were used to estimate the risk of a first-ever AMI and all-cause mortality associated with the use of individual sulphonylureas, and other non-insulin glucose-lowering drugs. No differences in risk of a first-ever AMI (adjusted hazard ratio [HR] 1.02, 95% confidence interval [CI] 0.70-1.50) or all-cause mortality (adjusted HR 0.97, 95% CI 0.80-1.17) were observed when comparing gliclazide use with non-gliclazide sulphonylurea use. Similar results were found for each individual sulphonylurea. As evidence is accumulating that gliclazide is no safer than other sulphonylureas, current guidelines suggesting superiority should be carefully evaluated.
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Affiliation(s)
- Judith van Dalem
- Department of Clinical PharmacyMaastricht University Medical Centre+MaastrichtThe Netherlands
- Care and Public Health Research InstituteMaastricht UniversityMaastrichtThe Netherlands
| | - Martijn C. G. J. Brouwers
- Department of Internal Medicine, Division of EndocrinologyCardiovascular Research Institute Maastricht, Maastricht University Medical Centre+MaastrichtThe Netherlands
| | - Coen D. A. Stehouwer
- Department of Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM)Maastricht University Medical Centre+MaastrichtThe Netherlands
| | - André Krings
- Department of Clinical PharmacyZuyderland MCHeerlenThe Netherlands
| | - Olaf H. Klungel
- Division of Pharmacoepidemiology and Clinical PharmacologyUtrecht Institute of Pharmaceutical Sciences, Utrecht UniversityUtrechtThe Netherlands
| | - Johanna H. M. Driessen
- Department of Clinical PharmacyMaastricht University Medical Centre+MaastrichtThe Netherlands
- Care and Public Health Research InstituteMaastricht UniversityMaastrichtThe Netherlands
- Division of Pharmacoepidemiology and Clinical PharmacologyUtrecht Institute of Pharmaceutical Sciences, Utrecht UniversityUtrechtThe Netherlands
- NUTRIM School for Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtThe Netherlands
| | - Frank de Vries
- Department of Clinical PharmacyMaastricht University Medical Centre+MaastrichtThe Netherlands
- Care and Public Health Research InstituteMaastricht UniversityMaastrichtThe Netherlands
- Division of Pharmacoepidemiology and Clinical PharmacologyUtrecht Institute of Pharmaceutical Sciences, Utrecht UniversityUtrechtThe Netherlands
| | - Andrea M. Burden
- Department of Clinical PharmacyMaastricht University Medical Centre+MaastrichtThe Netherlands
- Care and Public Health Research InstituteMaastricht UniversityMaastrichtThe Netherlands
- Division of Pharmacoepidemiology and Clinical PharmacologyUtrecht Institute of Pharmaceutical Sciences, Utrecht UniversityUtrechtThe Netherlands
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28
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Wang S, He Y, Xu L, Zhang S, Gu X, Gu J, Shi J, Shen Y, Tang Z. Association between QTc interval prolongation and outcomes of diabetic foot ulcers: Data from a 4-year follow-up study in China. Diabetes Res Clin Pract 2018; 138:26-34. [PMID: 29382590 DOI: 10.1016/j.diabres.2018.01.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 12/30/2017] [Accepted: 01/23/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To examine whether QTc interval prolongation is an independent risk factor of outcomes in patients with diabetic foot ulcers (DFU). RESEARCH DESIGN AND METHODS 331 patients with type 2 diabetes and DFU hospitalized in a Chinese tertiary hospital were recruited. ECG was done at baseline and QTc interval was calculated through Bazett's formula. Participants were classified into 2 groups according to the QTc interval as prolonged (≥440 ms) or not (<440 ms). These patients were followed-up for an average of 48 months to observe the outcomes, including ulcer healing, ulcer recurrence, nonfatal cerebral or cardiovascular events (NCCVE), cerebral cardiovascular death, cardiac death and all-cause death. The associations between the risk of outcomes and QTc interval prolongation, as well as per 1-SD increase in QTc interval were analyzed by Cox proportional-hazards models. RESULTS In terms of the univariate Cox proportional hazard models, patients with QTc interval prolongation had a higher all-cause mortality (HR = 1.621, 95%CI: 1.040-2.526, P = .013), higher cardiac mortality (HR = 2.011 95%CI: 1.106-3.657, P = .019), higher cerebral cardiovascular mortality (HR = 1.525, 95%CI: 0.8151-2.852, P = .045). The multivariate analysis showed that QTc prolongation was an independent risk factor for cardiac death (HR = 5.465, 95%CI: 2.818-8.112, P = .039). Similar results were obtained when QTc interval was used as a continue variable, a 1-SD increase in QTc interval was associated with an 5.883 times risk for cardiac mortality (HR = 6.883, 95%CI: 4.153-9.613, P = .012). The association between QTc interval prolongation with ulcer healing, recurrence and NCCVE were not observed either in univariate or multivariate analysis (P > .05). CONCLUSION QTc interval prolongation was a plausible predictor for cardiac death in DFU patients, but it cannot accurately predict ulcer healing or recurrence.
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Affiliation(s)
- Shumin Wang
- Shanghai Clinical Center for Endocrine and Metabolism Diseases, Yuanyang Subdivision for Diabetic Foot Disease, Shanghai Institute of Endocrine and Metabolism Disease, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Yang He
- Shanghai Clinical Center for Endocrine and Metabolism Diseases, Yuanyang Subdivision for Diabetic Foot Disease, Shanghai Institute of Endocrine and Metabolism Disease, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Lei Xu
- Shanghai Clinical Center for Endocrine and Metabolism Diseases, Yuanyang Subdivision for Diabetic Foot Disease, Shanghai Institute of Endocrine and Metabolism Disease, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Shanshan Zhang
- Shanghai Clinical Center for Endocrine and Metabolism Diseases, Yuanyang Subdivision for Diabetic Foot Disease, Shanghai Institute of Endocrine and Metabolism Disease, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Xueming Gu
- Department of Internal Medicine, Shanghai Yuanyang Hospital, Shanghai 200031, China
| | - Junyi Gu
- Department of Internal Medicine, Shanghai Yuanyang Hospital, Shanghai 200031, China
| | - Jianyuan Shi
- Department of Internal Medicine, Shanghai Yuanyang Hospital, Shanghai 200031, China
| | - Yaping Shen
- Department of Internal Medicine, Shanghai Yuanyang Hospital, Shanghai 200031, China
| | - Zhengyi Tang
- Shanghai Clinical Center for Endocrine and Metabolism Diseases, Yuanyang Subdivision for Diabetic Foot Disease, Shanghai Institute of Endocrine and Metabolism Disease, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai 200025, China; Department of Internal Medicine, Shanghai Yuanyang Hospital, Shanghai 200031, China.
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29
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Anfinogenova Y, Grakova EV, Shvedova M, Kopieva KV, Teplyakov AT, Popov SV. Interdisciplinary approach to compensation of hypoglycemia in diabetic patients with chronic heart failure. Heart Fail Rev 2017; 23:481-497. [PMID: 28849410 DOI: 10.1007/s10741-017-9647-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Diabetes mellitus is a chronic disease requiring lifelong control with hypoglycemic agents that must demonstrate excellent efficacy and safety profiles. In patients taking glucose-lowering drugs, hypoglycemia is a common cause of death associated with arrhythmias, increased thrombus formation, and specific effects of catecholamines due to sympathoadrenal activation. Focus is now shifting from merely glycemic control to multifactorial approach. In the context of individual drugs and classes, this article reviews interdisciplinary strategies evaluating metabolic effects of drugs for treatment of chronic heart failure (CHF) which can mask characteristic hypoglycemia symptoms. Hypoglycemia unawareness and cardiac autonomic neuropathy are discussed. Data suggesting that hypoglycemia modulates immune response are reviewed. The potential role of gut microbiota in improving health of patients with diabetes and CHF is emphasized. Reports stating that nondiabetic CHF patients can have life-threatening hypoglycemia associated with imbalance of thyroid hormones are discussed. Regular glycemic control based on HbA1c measurements and adequate pharmacotherapy remain the priorities in diabetes management. New antihyperglycemic drugs with safer profiles should be preferred in vulnerable CHF patients. Multidrug interactions must be considered. Emerging therapies with reduced hypoglycemia risk, telemedicine, sensor technologies, and genetic testing predicting hypoglycemia risk may help solving the challenges of hypoglycemia in CHF patients with diabetes. Interdisciplinary work may involve cardiologists, diabetologists/endocrinologists, immunologists, gastroenterologists, microbiologists, nutritionists, imaging specialists, geneticists, telemedicine experts, and other relevant specialists. This review emphasizes that systematic knowledge on pathophysiology of hypoglycemia in diabetic patients with CHF is largely lacking and the gaps in our understanding require further discoveries.
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Affiliation(s)
- Yana Anfinogenova
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111-a Kievskaya Street, Tomsk, Russia, 634012. .,National Research Tomsk Polytechnic University, 30 Lenin Avenue, Tomsk, Russia, 634050.
| | - Elena V Grakova
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111-a Kievskaya Street, Tomsk, Russia, 634012
| | - Maria Shvedova
- Cardiovascular Research Center (CVRC), Massachusetts General Hospital, 149 13th Street, Charlestown, MA, 02129, USA
| | - Kristina V Kopieva
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111-a Kievskaya Street, Tomsk, Russia, 634012
| | - Alexander T Teplyakov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111-a Kievskaya Street, Tomsk, Russia, 634012
| | - Sergey V Popov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111-a Kievskaya Street, Tomsk, Russia, 634012
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30
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Leonard CE, Hennessy S, Han X, Siscovick DS, Flory JH, Deo R. Pro- and Antiarrhythmic Actions of Sulfonylureas: Mechanistic and Clinical Evidence. Trends Endocrinol Metab 2017; 28:561-586. [PMID: 28545784 PMCID: PMC5522643 DOI: 10.1016/j.tem.2017.04.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 04/18/2017] [Accepted: 04/19/2017] [Indexed: 12/19/2022]
Abstract
Sulfonylureas are the most commonly used second-line drug class for treating type 2 diabetes mellitus (T2DM). While the cardiovascular safety of sulfonylureas has been examined in several trials and nonrandomized studies, little is known of their specific effects on sudden cardiac arrest (SCA) and related serious arrhythmic outcomes. This knowledge gap is striking, because persons with DM are at increased risk of SCA. In this review, we explore the influence of sulfonylureas on the risk of serious arrhythmias, with specific foci on ischemic preconditioning, cardiac excitability, and serious hypoglycemia as putative mechanisms. Elucidating the relationship between individual sulfonylureas and serious arrhythmias is critical, especially as the diabetes epidemic intensifies and SCA incidence increases in persons with diabetes.
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Affiliation(s)
- Charles E Leonard
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Xu Han
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - David S Siscovick
- The New York Academy of Medicine, New York, NY 10029, USA; Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA 98195, USA
| | - James H Flory
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Healthcare Policy and Research, Division of Comparative Effectiveness, Weill Cornell Medicine, Cornell University, New York, NY 10065, USA; Memorial Sloan Kettering Cancer Center, New York, NY 10022, USA
| | - Rajat Deo
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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31
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Lee G, Oh SW, Hwang SS, Yoon JW, Kang S, Joh HK, Kwon H, Kim J, Park D. Comparative effectiveness of oral antidiabetic drugs in preventing cardiovascular mortality and morbidity: A network meta-analysis. PLoS One 2017; 12:e0177646. [PMID: 28542373 PMCID: PMC5444626 DOI: 10.1371/journal.pone.0177646] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 04/30/2017] [Indexed: 12/16/2022] Open
Abstract
In the Guidance for Industry from the Food and Drug Administration in 2008, excess cardiovascular risk should be ruled out in trials of all new antidiabetic drugs; however, relatively few studies have focused on cardiovascular safety with antidiabetic drug use. We aimed to examine mortality and cardiovascular risk using a network meta-analysis. We searched the Medline, Embase, Cochrane, and ClinicalTrials.gov registry databases in March 2016 to identify randomized controlled trials reporting cardiovascular risk with the following oral antidiabetic drugs: metformin, sulfonylureas, thiazolidinedione (TZD), dipeptidyl peptidase-4 (DPP4) inhibitors, and sodium-glucose co-transporter-2 (SGLT2) inhibitors. We assessed the differences in the risks of all-cause mortality, cardiovascular-related mortality, acute coronary syndrome (ACS), and myocardial infarction (MI) among antidiabetic drugs with fixed effect models for direct pairwise comparisons and Bayesian network meta-analyses to integrate direct and indirect comparisons. Of the 101,183 patients in 73 randomized controlled trials, 3,434 (3.4%) died. The relative risks of all-cause mortality with SGLT2 inhibitor use were 0.68 (95% credible interval: 0.57–0.80), 0.74 (0.49–1.10), 0.63 (0.46–0.87), 0.71 (0.55–0.90), and 0.65 (0.54–0.78), compared with placebo, metformin, sulfonylurea, TZD, and DPP4 inhibitor, respectively. The relative risks of cardiovascular-related mortality with SGLT2 inhibitor use were 0.61 (0.50–0.76), 0.81(0.36–1.90), 0.52(0.31–0.88), 0.66(0.49–0.91), and 0.61(0.48–0.77), compared with placebo, metformin, sulfonylurea, TZD, and DPP4 inhibitor, respectively. The relative risks of ACS with SGLT2 inhibitor use was consistent with that of all-cause mortality. SGLT2 inhibitor use was associated with a lower risk of ACS than the other OADs and placebo. The relative risks of MI with SGLT2 inhibitor use were 0.77 (0.63–0.93) and 0.75 (0.60–0.94), compared with placebo and DPP4 inhibitor, respectively. The currently available data provide the evidence of cardiovascular benefit from use of SGLT2 inhibitors to patients with type 2 diabetes, although additional results from ongoing studies will be pivotal.
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Affiliation(s)
- Gyeongsil Lee
- Department of Family Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seung-Won Oh
- Department of Family Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
- * E-mail:
| | - Seung-Sik Hwang
- Department of Public Health Science, Graduate School of Public Health, Seoul National University, Seoul, Korea
| | - Ji Won Yoon
- Department of Internal Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Sungchan Kang
- Department of Public Health Science, Graduate School of Public Health, Seoul National University, Seoul, Korea
| | - Hee-Kyung Joh
- Department of Medicine, Seoul National University College of Medicine; Department of Family Medicine, Seoul National University Health Service Center, Seoul, Korea
| | - Hyuktae Kwon
- Department of Family Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jeehyun Kim
- Department of Family Medicine, Seoul National University Hospital, Seoul, Korea
| | - Danbee Park
- Department of Family Medicine, Seoul National University Hospital, Seoul, Korea
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32
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Koivikko ML, Kenttä T, Salmela PI, Huikuri HV, Perkiömäki JS. Changes in cardiac repolarisation during spontaneous nocturnal hypoglycaemia in subjects with type 1 diabetes: a preliminary report. Acta Diabetol 2017; 54:251-256. [PMID: 27933514 DOI: 10.1007/s00592-016-0941-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 11/05/2016] [Indexed: 10/20/2022]
Abstract
AIMS Experimental studies have revealed that hypoglycaemia can result in morphological changes in electrocardiographic repolarisation in subjects with type 1 diabetes. However, the influence of spontaneous nocturnal hypoglycaemia on repolarisation morphology in a 'real life' situation is not clear. METHODS Adults with type 1 diabetes (n = 11) underwent continuous glucose monitoring with a subcutaneous sensor and digital 12-lead ECG recording for three nights. T-wave morphology was analysed with custom-made software during both hypoglycaemia (glucose <3.5 mmol/l at least 20 min) from ten consecutive heart beats in the middle of the deepest hypoglycaemia and from a control nonhypoglycaemic period (glucose ≥5.0 mmol/l) from the same recording. RESULTS In the comparison of 10 hypoglycaemia-control pairs, heart rate (65 ± 12 beats/min during normoglycaemia versus 85 ± 19 beats/min during hypoglycaemia, p = 0.028) increased and the QTc interval (439 ± 5 vs. 373 ± 5 ms, respectively, p = 0.025) decreased significantly during hypoglycaemia. The spatial QRS-T angle (TCRT) was reduced, and the roughness of the T-wave loop (T-E) increased significantly (p = 0.037 for both) in the patients during hypoglycaemia. CONCLUSIONS In adults with type 1 diabetes, spontaneous nocturnal hypoglycaemia results in morphological changes and increased heterogeneity of global cardiac repolarisation. These changes may contribute to the risk of 'dead in bed' syndrome encountered in young individuals with type 1 diabetes.
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Affiliation(s)
- Minna L Koivikko
- Department of Internal Medicine, Institute of Clinical Medicine, University of Oulu, P.O.Box 5000, Kajaanintie 50, Oulu, Finland.
| | - Tuomas Kenttä
- Department of Internal Medicine, Institute of Clinical Medicine, University of Oulu, P.O.Box 5000, Kajaanintie 50, Oulu, Finland
| | - Pasi I Salmela
- Department of Internal Medicine, Institute of Clinical Medicine, University of Oulu, P.O.Box 5000, Kajaanintie 50, Oulu, Finland
| | - Heikki V Huikuri
- Department of Internal Medicine, Institute of Clinical Medicine, University of Oulu, P.O.Box 5000, Kajaanintie 50, Oulu, Finland
| | - Juha S Perkiömäki
- Department of Internal Medicine, Institute of Clinical Medicine, University of Oulu, P.O.Box 5000, Kajaanintie 50, Oulu, Finland
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Kacheva S, Karges B, Göller K, Marx N, Mischke K, Karges W. QT prolongation caused by insulin-induced hypoglycaemia - An interventional study in 119 individuals. Diabetes Res Clin Pract 2017; 123:165-172. [PMID: 28024277 DOI: 10.1016/j.diabres.2016.11.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 11/03/2016] [Accepted: 11/27/2016] [Indexed: 02/03/2023]
Abstract
AIMS Hypoglycaemia is associated with increased risk of cardiovascular events and mortality in patients with diabetes, but the extent and mechanisms of this link are ill defined. We here prospectively studied cardiac repolarization abnormalities during insulin-induced hypoglycaemia in humans. METHODS 119 individuals (69 males, age 47.5±13.4years, range 18-82years) were assessed during hypoglycaemia after the injection of 0.1-0.25units/kg human insulin. Corrected QT intervals (QTc) and QT dispersion (QTd) were calculated from serially recorded twelve lead electrocardiograms, and plasma glucose and other endocrine markers were studied. RESULTS QTc increased from 415.1±21.9ms (mean±standard deviation) at baseline to 444.9±26.5ms during hypoglycaemia (plasma glucose nadir, 1.6±0.5mmol/L, p=0.001), accompanied by an increase of QTd from 45.0±22.7ms to 64.1±40.0ms (p<0.001). Hypoglycaemia-induced abnormal QTc prolongation (defined as ⩾460ms in females and ⩾450ms in males) occurred in 17% (9/54) of females and 26% (17/65) of males. 97 of 119 of individuals (82%) developed transient hypokalaemia (K+ ⩽3.6mmol/L), and plasma epinephrine increased from 220.4±169.5pmol/L at baseline to 2945.6±2421.4pmol/L during hypoglycaemia. Baseline QTc, but not age or gender, was a significant predictor of hypoglycaemia-induced QTc prolongation (p=0.001). CONCLUSIONS Insulin-induced hypoglycaemia frequently causes abnormal QT prolongation and is associated with hypokalaemia and sympathoadrenal activation, thereby increasing the potential risk for ventricular arrhythmias, particularly in individuals with pre-existing high normal QTc.
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Affiliation(s)
- Stella Kacheva
- Division of Endocrinology and Diabetes, Medical Faculty, RWTH Aachen University, Aachen, Germany.
| | - Beate Karges
- Division of Endocrinology and Diabetes, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Katrin Göller
- Division of Endocrinology and Diabetes, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Nikolaus Marx
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Karl Mischke
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Wolfram Karges
- Division of Endocrinology and Diabetes, Medical Faculty, RWTH Aachen University, Aachen, Germany
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Giorgino F, Home PD, Tuomilehto J. Glucose Control and Vascular Outcomes in Type 2 Diabetes: Is the Picture Clear? Diabetes Care 2016; 39 Suppl 2:S187-95. [PMID: 27440832 DOI: 10.2337/dcs15-3023] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The overall impact of glucose lowering on vascular complications and major clinical outcomes, including mortality, in type 2 diabetes is still an open issue. While intensive glucose control has undoubted benefit for microvascular end points, the relationship between glucose-lowering approaches and reduced incidence and/or progression of macrovascular complications is less clear. This review article will discuss the effect of glucose lowering per se as well as the effects of specific glucose-lowering therapies on vascular outcomes in type 2 diabetes. The role of lifestyle changes on cardiovascular outcomes will be also addressed. Recent analyses from large cardiovascular outcome studies (ACCORD, ADVANCE, and VADT) provide new information on factors that modulate the impact of intensive glucose lowering on outcomes, helping to identify the specific clinical characteristics of the patients receiving the intervention that would show a better response. While several studies on cardiovascular outcomes with diabetes drugs are available, they do not clearly highlight a benefit from using a specific medication or will require additional evidence, as for the sodium-glucose cotransporter 2 blockers.
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Affiliation(s)
- Francesco Giorgino
- Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Philip D Home
- Institute for Cellular Medicine-Diabetes, Newcastle University, Newcastle-upon-Tyne, U.K
| | - Jaakko Tuomilehto
- Chronic Disease Prevention Unit, National Institute for Health and Welfare, Helsinki, Finland Center for Vascular Prevention, Danube-University Krems, Krems, Austria Dasman Diabetes Institute, Dasman, Kuwait Diabetes Research Group, King Abdulaziz University, Jeddah, Saudi Arabia
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Hanefeld M, Frier BM, Pistrosch F. Hypoglycemia and Cardiovascular Risk: Is There a Major Link? Diabetes Care 2016; 39 Suppl 2:S205-9. [PMID: 27440834 DOI: 10.2337/dcs15-3014] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Severe hypoglycemia is recognized to be one of the strongest predictors of macrovascular events, adverse clinical outcomes, and mortality in patients with type 2 diabetes. However, it is uncertain whether a direct pathophysiological link exists or whether hypoglycemia is primarily a marker of vulnerability to these events. Large clinical trials have reported an increased hazard ratio for all-cause mortality and cardiovascular events in patients with type 2 diabetes and severe hypoglycemia, but such an association has not been demonstrated in prospective trials of people with type 1 diabetes. Several cardiovascular effects occur during hypoglycemia either as a result of low blood glucose levels per se or through activation of the sympathoadrenal response: hemodynamic changes with an increase in cardiac work load and potential attenuation of myocardial perfusion, electrophysiological changes that may be arrhythmogenic, induction of a prothrombotic state, and release of inflammatory markers. Although the potential for a causal relationship has been demonstrated in mechanistic studies, the evidence from large prospective studies that hypoglycemia is a major causal contributor to cardiovascular events is limited to date. Other preexisting cardiovascular risk factors in addition to hypoglycemia may be the major link to the final cardiovascular event, but a low blood glucose level can trigger these events in patients with a high cardiovascular risk.
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Affiliation(s)
- Markolf Hanefeld
- Study Centre Professor Hanefeld, GWT-TU Dresden GmbH, Dresden, Germany Medical Clinic III, Universitätsklinikum "Carl Gustav Carus," Dresden, Germany
| | - Brian M Frier
- British Heart Foundation Centre for Cardiovascular Science, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, Scotland, U.K
| | - Frank Pistrosch
- Study Centre Professor Hanefeld, GWT-TU Dresden GmbH, Dresden, Germany Medical Clinic III, Universitätsklinikum "Carl Gustav Carus," Dresden, Germany
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Abstract
Diabetes mellitus is the commonest cause of an autonomic neuropathy in the developed world. Diabetic autonomic neuropathy causes a constellation of symptoms and signs affecting cardiovascular, urogenital, gastrointestinal, pupillomotor, thermoregulatory, and sudomotor systems. Several discrete syndromes associated with diabetes cause autonomic dysfunction. The most prevalent of these are: generalized diabetic autonomic neuropathy, autonomic neuropathy associated with the prediabetic state, treatment-induced painful and autonomic neuropathy, and transient hypoglycemia-associated autonomic neuropathy. These autonomic manifestations of diabetes are responsible for the most troublesome and disabling features of diabetic peripheral neuropathy and result in a significant proportion of the mortality and morbidity associated with the disease.
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Affiliation(s)
- Roy Freeman
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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37
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Death due to hypoglycemia: medico-legal implications. Int J Diabetes Dev Ctries 2015. [DOI: 10.1007/s13410-015-0331-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abstract
Severe hypoglycemia is recognized to be one of the strongest predictors of macrovascular events, adverse clinical outcomes, and mortality in patients with type 2 diabetes. Large clinical trials have reported an increased hazard ratio for all-cause mortality and cardiovascular events in patients with type 2 diabetes and severe hypoglycemia. However, these trials also reported an increased hypoglycemia-associated mortality rate in patients allocated to standard treatment by a factor of 1.5-2 despite a significant 50 % to 70 % lower incidence of hypoglycemia compared to the intensive treatment group. Although the potential for a causal relationship has been demonstrated in mechanistic studies, the evidence from large prospective studies suggest that other pre-existing cardiovascular risk factors in addition to hypoglycemia may be the major link to the final cardiovascular event, and that a low blood glucose level can trigger these events in patients with a high cardiovascular risk.
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Affiliation(s)
- Frank Pistrosch
- Study Center Professor Hanefeld, GWT TU-Dresden GmbH, Fiedlerstrasse 34, 01307, Dresden, Germany.
- Medical Clinic III, Universitätsklinikum "Carl Gustav Carus", Dresden, Germany.
| | - Markolf Hanefeld
- Study Center Professor Hanefeld, GWT TU-Dresden GmbH, Fiedlerstrasse 34, 01307, Dresden, Germany
- Medical Clinic III, Universitätsklinikum "Carl Gustav Carus", Dresden, Germany
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Fagher K, Katzman P, Löndahl M. Hyperbaric oxygen therapy reduces the risk of QTc interval prolongation in patients with diabetes and hard-to-heal foot ulcers. J Diabetes Complications 2015; 29:1198-202. [PMID: 26321368 DOI: 10.1016/j.jdiacomp.2015.07.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/23/2015] [Accepted: 07/24/2015] [Indexed: 12/01/2022]
Abstract
AIMS Heart rate corrected QT (QTc) interval prolongation is a risk factor associated with increased mortality. Hyperbaric oxygen therapy (HBO) has previously been shown to have acute beneficial effects on QTc dispersion. The aim of this study was to evaluate long-term effects of HBO on QTc time in diabetic patients with hard-to-heal foot ulcers. METHODS In a prospective, double-blinded placebo-controlled study, patients were randomized to 40 treatment sessions with either HBO or air (placebo), at 2.5 ATA. Patients fulfilling >35 completed treatment sessions were included in the evaluation. RESULTS Of the initial 75 patients (38 HBO/37 placebo), two were excluded due to pacemaker use. Baseline characteristics were similar between groups. At the 2-year follow-up, QTc time was significantly shorter in the HBO compared to the placebo group (438 vs. 453ms, p<0.05). Further, fewer HBO treated patients had a QTc time >450ms (22 vs. 53 %, p<0.02). This difference seemed to be caused by a significant prolongation of the QTc interval in the placebo group (427 (419-459) at baseline vs. 456ms (424-469) after 2years), whereas no significant change was seen in HBO treated patients. CONCLUSIONS HBO treatment might protect against QTc prolongation in this high-risk diabetic population.
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Affiliation(s)
- Katarina Fagher
- Clinical Sciences in Lund, Lund University, Lund, Sweden; Department of Endocrinology, Skåne University Hospital, Sweden.
| | - Per Katzman
- Clinical Sciences in Lund, Lund University, Lund, Sweden; Department of Endocrinology, Skåne University Hospital, Sweden
| | - Magnus Löndahl
- Clinical Sciences in Lund, Lund University, Lund, Sweden; Department of Endocrinology, Skåne University Hospital, Sweden
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Kang MY. Blood electrolyte disturbances during severe hypoglycemia in Korean patients with type 2 diabetes. Korean J Intern Med 2015; 30:648-56. [PMID: 26354059 PMCID: PMC4578021 DOI: 10.3904/kjim.2015.30.5.648] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 12/26/2014] [Accepted: 04/05/2015] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS To investigate abnormalities in blood electrolyte levels during severe hypoglycemia in Korean patients with type 2 diabetes mellitus (T2DM) in a clinical setting. METHODS Blood electrolyte levels in adult T2DM patients during severe hypoglycemia were collected from January 1, 2008 to December 31, 2012. Patients who maintained normal serum creatinine and blood urea nitrogen levels were utilized in the study. Severe hypoglycemia was defined as a condition requiring medical assistance, such as administering carbohydrates when serum glucose levels less than 70 mg/dL were observed, in conjunction with other symptoms of hypoglycemia. RESULTS A total of 1,068 patients who visited the emergency room with severe hypoglycemia were screened, of which 219 patients were included in this study. The incidence of abnormal levels for any electrolyte was 47%. Hypokalemia (< 3.5 mmol/L) was the most common type of electrolyte disturbance observed at 21.9%. A decrease in serum potassium levels was associated with decreases in blood glucose levels (r = 0.151, p = 0.025). During severe hypoglycemia, median blood glucose levels, incidence of tachycardia (> 100 beats per minute) and severe hypertension (≥ 180/120 mmHg) were 30 mg/dL (range, 14 to 62) and 35 mg/dL (range, 10 to 69; p = 0.04), 18.8% and 7.2% (p = 0.02), and 20.8% and 10.2% (p = 0.05) in the hypokalemia and normokalemia groups, respectively. CONCLUSIONS During severe hypoglycemia, hypokalemia occurred in 21.9% of T2DM patients and was associated with tachycardia and severe hypertension. Therefore, the results suggest that severe hypoglycemia may increase cardiovascular events in T2DM.
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Affiliation(s)
- Mi Yeon Kang
- Correspondence to Mi Yeon Kang, M.D. Department of Internal Medicine, Saint Carollo Hospital, 221 Sungwang-ro, Suncheon 57931, Korea Tel: +82-61-720-2428 Fax: +82-61-720-6000 E-mail:
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Kappel BA, Marx N, Federici M. Oral hypoglycemic agents and the heart failure conundrum: Lessons from and for outcome trials. Nutr Metab Cardiovasc Dis 2015; 25:697-705. [PMID: 26164634 DOI: 10.1016/j.numecd.2015.06.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 06/13/2015] [Accepted: 06/13/2015] [Indexed: 11/23/2022]
Abstract
AIM Type 2 diabetes is not only an independent risk factor for cardiovascular (CV) disease but is also associated with a greater incidence of heart failure (HF). The aim of this review is to examine the effects of oral antidiabetic drugs on CV disease and HF. DATA SYNTHESIS Trials of anti-diabetic agents are now designed to assess CV safety, but frequently HF is not included as a primary endpoint. However, HF in patients with diabetes is more frequent than other CV events and seems to be underestimated. A burning question is therefore if the most used trial design to monitor CV safety, i.e. non-inferiority, allows clinical translation of trial findings. Available data further suggest that the CV effects of anti-diabetic drugs may be rather class-specific and are only partly due to their glucose-lowering actions. Metformin, recommended as first line in most guidelines, shows positive CV effects while other classes like thiazolidinediones may precipitate HF. Experimental results on the relatively novel dipeptidyl peptidase IV (DPP IV) inhibitors imply CV protective effects, but the non-inferiority trials published to date show an overall neutral CV outcome and a potential increase in HF by saxagliptin. However, results on sitagliptin of the recently released TECOS indicate that HF is not a class-dependent effect of DPP IV inhibitors. CONCLUSION Further basic research and long-term outcome studies to clarify the effects of antidiabetic agents on CV and HF are required so that we can select the optimal antidiabetic therapy for our patients.
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Affiliation(s)
- B A Kappel
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy; Department of Internal Medicine I, University Hospital Aachen, Germany
| | - N Marx
- Department of Internal Medicine I, University Hospital Aachen, Germany
| | - M Federici
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy; Center for Atherosclerosis, Policlinico Tor Vergata, Rome, Italy.
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Shahreyar M, Mupiddi V, Choudhuri I, Sra J, Tajik AJ, Jahangir A. Implantable cardioverter defibrillators in diabetics: efficacy and safety in patients at risk of sudden cardiac death. Expert Rev Cardiovasc Ther 2015; 13:897-906. [PMID: 26098816 DOI: 10.1586/14779072.2015.1059276] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Diabetes mellitus is a major risk factor for arrhythmogenesis and is associated with a two-fold increase in all-cause mortality and a four-fold increase in cardiovascular mortality including sudden cardiac death when compared with nondiabetics. Implantable cardioverter defibrillators (ICD) have been shown to effectively reduce arrhythmic death and all-cause mortality in patients with severe myocardial dysfunction. With a high competing risk of nonarrhythmic cardiac and noncardiac death, survival benefit of ICD in patients with diabetes mellitus could be reduced, but the subanalysis of diabetic patients in randomized clinical trials provides reassurance regarding a similar beneficial survival effect of ICD and cardiac resynchronization therapy in diabetics, as observed in the overall population with advanced heart disease. In this article, the authors highlight some of the clinical issues related to diabetes, summarize the data on the efficacy of ICD in diabetics when compared with nondiabetics and discuss concerns related to ICD implantation in patients with diabetes.
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Affiliation(s)
- Muhammad Shahreyar
- Sheikh Khalifa bin Hamad Al Thani Center for Integrative Research on Cardiovascular Aging (CIRCA), Aurora University of Wisconsin Medical Group, Milwaukee, WI, USA
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Abdelmoneim AS, Eurich DT, Light PE, Senior PA, Seubert JM, Makowsky MJ, Simpson SH. Cardiovascular safety of sulphonylureas: over 40 years of continuous controversy without an answer. Diabetes Obes Metab 2015; 17:523-532. [PMID: 25711240 DOI: 10.1111/dom.12456] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 10/10/2015] [Accepted: 02/20/2015] [Indexed: 12/12/2022]
Abstract
More than 40 years after publication of the University Group Diabetes Program trial, the cardiovascular safety of sulphonylureas is still contentious. Although several hypotheses linking sulphonylureas to adverse cardiovascular effects exist, none provide conclusive evidence. Adding to the controversy, current clinical trials and observational studies provide inconsistent, and sometimes conflicting, evidence for the cardiovascular effects of sulphonylureas. Overall, observational evidence suggests that an increased risk of adverse cardiovascular outcomes is associated with sulphonylureas; however, these data may be subject to residual confounding and bias. Although evidence from randomized controlled trials has suggested a neutral effect, the majority of these studies were not specifically designed to assess the effect of sulphonylureas on adverse cardiovascular event risk. Current ongoing large clinical trials may provide some clarity on the cardiovascular safety of sulphonylureas, but the results are not expected for several years. With the continued uncertainties concerning the cardiovascular safety of all antidiabetic drugs, a clear answer with regard to sulphonylureas is warranted. The objectives of the present article were to provide an overview of the controversy surrounding sulphonylurea-related cardiovascular effects, to discuss the limitations of the current literature, and to provide recommendations for future studies aiming to elucidate the true relationship between sulphonylureas and adverse cardiovascular effects in people with type 2 diabetes.
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Affiliation(s)
- A S Abdelmoneim
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - D T Eurich
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - P E Light
- Department of Pharmacology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - P A Senior
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - J M Seubert
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
- Department of Pharmacology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - M J Makowsky
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - S H Simpson
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
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Fagher K, Nilsson A, Löndahl M. Heart rate-corrected QT interval prolongation as a prognostic marker for 3-year survival in people with Type 2 diabetes undergoing above-ankle amputation. Diabet Med 2015; 32:679-85. [PMID: 25388827 DOI: 10.1111/dme.12632] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2014] [Indexed: 12/15/2022]
Abstract
AIM To evaluate whether heart rate-corrected QT interval is a plausible prognostic factor for survival after major amputation in people with Type 2 diabetes. METHODS All people with Type 2 diabetes aged < 80 years who underwent a major amputation at two hospitals with multidisciplinary diabetic foot teams were evaluated and grouped according to whether their heart rate-corrected QT interval was ≤ or > 440 ms. RESULTS A total of 70 patients with a median age of 72 years were included in the study. During the 3 years of follow-up, 38 patients (54%) died. Heart rate-corrected QT interval prolongation was present in 51.4% of the patients and was strongly associated with 3-year mortality (73 vs 36%; P < 0.001). In a Cox proportional hazard model, heart rate-corrected QT interval prolongation was the strongest independent risk factor for 3-year mortality [hazard ratio 2.20 (95% CI 1.11-4.38)]. Treatment with metformin seemed to have a protective effect [hazard ratio 0.22 (95% CI 0.05-0.94)]. CONCLUSIONS The findings of the present study indicate that heart rate-corrected QT interval prolongation is associated with increased mortality in people with Type 2 diabetes undergoing above-ankle amputation.
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Affiliation(s)
- K Fagher
- Clinical Sciences in Lund, Lund University, Lund, Sweden; Department of Endocrinology, Skåne University Hospital, Ängelholm, Sweden
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Huang Y, Abdelmoneim AS, Light P, Qiu W, Simpson SH. Comparative cardiovascular safety of insulin secretagogues following hospitalization for ischemic heart disease among type 2 diabetes patients: a cohort study. J Diabetes Complications 2015; 29:196-202. [PMID: 25534984 DOI: 10.1016/j.jdiacomp.2014.11.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 11/20/2014] [Accepted: 11/21/2014] [Indexed: 12/25/2022]
Abstract
AIM To evaluate the association between insulin secretagogues and adverse cardiovascular sequelae in type 2 diabetes patients hospitalized for ischemic heart disease (IHD). METHODS Administrative health records from Alberta, Canada between 1998 and 2010 were used to identify 2,254 gliclazide, 3,289 glyburide and 740 repaglinide users prior to an IHD-related hospitalization. Multivariable Cox regression models were used to compare the 30-day risk of a composite outcome of all-cause mortality or new onset of atrial fibrillation, stroke, heart failure or myocardial infarction according to insulin secretagogue use. RESULTS Mean (SD) age was 76.1 (6.9) years, and 60.7% were men. The composite outcome occurred in 322 (30.2%) gliclazide users, 455 (28.1%) glyburide users and 81 (23.4%) repaglinide users within 30 days of IHD hospitalization. There were no differences in risk for glyburide use (adjusted hazard ratio [aHR] 0.91; 95% confidence interval [CI] 0.78-1.05) or repaglinide use (aHR 0.80; 95% CI 0.63-1.03) compared to gliclazide. Similar results were observed in analyses for each element of the composite outcome. CONCLUSIONS In older patients with type 2 diabetes hospitalized for IHD, prior use of gliclazide, glyburide, or repaglinide appears to be associated with a similar risk of adverse cardiovascular sequelae.
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Affiliation(s)
- Yuhao Huang
- Department of Biochemistry, Faculty of Medicine and Dentistry, University of Alberta, 8440 122St. NW, Edmonton, Alberta, Canada, T6G 2R7.
| | - Ahmed S Abdelmoneim
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, 11405 87 Ave. NW,St. Edmonton, Alberta, Canada, T6G 1C9.
| | - Peter Light
- Department of Pharmacology, Faculty of Medicine and Dentistry, University of Alberta, 8440 122St. NW, Edmonton, Alberta, Canada, T6G 2R7.
| | - Weiyu Qiu
- School of Public Health, University of Alberta, 11405-87 Ave, Edmonton, Alberta, Canada, T6G 1C9.
| | - Scot H Simpson
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, 11405 87 Ave. NW,St. Edmonton, Alberta, Canada, T6G 1C9.
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Abstract
Hypoglycemia is a common and potentially life-threatening adverse effect of inappropriate diabetes treatment. Typical cardiac complications are ischemia with angina pectoris, myocardial infarction, stroke and arrhythmias, such as atrial fibrillation (AF), ventricular tachycardia and heart failure. Elderly multimorbid patients with type 2 diabetes and polypharmacy and/or cardiac autonomous neuropathy represent a very high risk group for cardiovascular complications associated with hypoglycemia. Targets for glycemic control have to be adapted to the risk of hypoglycemia with a priority of stable glucose homeostasis without rapid fluctuations. Elderly patients with diabetes have a >20% risk of AF. At blood glucose levels of <3 mmol/l with a duration of >30 min, prolongation of QTc time and ventricular tachycardia occur with an increased risk of ventricular fibrillation and sudden death. Ventricular arrhythmias and AF significantly increase mortality in patients with heart failure. Rapid fluctuations with a mean amplitude of glucose excursion (MAGE) >5 mmol/l promote vulnerability of electrical stability of the heart, particularly in frail patients with preexisting coronary heart disease and autonomic neuropathy. Antihyperglycemic agents, such as metformin, acarbose and sodium glucose cotransporter 2 (SGLT2) inhibitors have only a low risk of severe hypoglycemia. Dipeptidyl peptase 4 (DPP-IV) inhibitors and glucagon-like peptide 1 (GLP1) analogues as insulin secretagogues have a lower risk for hypoglycemia than sulfonylurea and insulin. Early basal insulin treatment in patients insufficiently controlled with metformin is efficient, safe and convenient. Targets for glucose control and HbA1c have to be individualized and the choice of drugs must be risk-adjusted. Risk of hypoglycemia should be used as guide in decision-making for safe treatment of diabetes.
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Simpson SH, Lee J, Choi S, Vandermeer B, Abdelmoneim AS, Featherstone TR. Mortality risk among sulfonylureas: a systematic review and network meta-analysis. Lancet Diabetes Endocrinol 2015; 3:43-51. [PMID: 25466239 DOI: 10.1016/s2213-8587(14)70213-x] [Citation(s) in RCA: 151] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Sulfonylureas are common second-line options for management of type 2 diabetes; however, they are associated with a higher risk of cardiovascular events compared with other antidiabetic drugs. Since tissue selectivity and risk of hypoglycaemia differ among sulfonylureas, we aimed to assess whether mortality and the risk of cardiovascular events also varies. METHODS We searched Medline and Embase from inception to June 11, 2014, to identify controlled studies reporting the risk of all-cause mortality, cardiovascular-related mortality, or myocardial infarction for at least two sulfonylureas. We examined differences in cardiovascular event risk among sulfonylureas with random effects models for direct pairwise comparisons and network meta-analyses to incorporate direct and indirect data. FINDINGS 14 970 (9%) of 167 327 patients in 18 studies died: 841 (4%) of 19 334 gliclazide users, 5482 (11%) of 49 389 glimepiride users, 2106 (15%) of 14 464 glipizide users, 5296 (7%) of 77 169 glibenclamide users, 1066 (17%) of 6187 tolbutamide users, and 179 (23%) of 784 chlorpropamide users. Inconsistency was low for the network meta-analysis of all-cause mortality, and the relative risk of death compared with glibenclamide was 0·65 (95% credible interval 0·53-0·79) for gliclazide, 0·83 (0·68-1·00) for glimepiride, 0·98 (0·80-1·19) for glipizide, 1·13 (0·90-1·42) for tolbutamide, and 1·34 (0·98-1·86) for chlorpropamide. Similar associations were noted for cardiovascular-related mortality: the relative risk compared with glibenclamide was 0·60 (95% credible interval 0·45-0·84) for gliclazide, 0·79 (0·57-1·11) for glimepiride, 1·01 (0·72-1·43) for glipizide, 1·11 (0·79-1·55) for tolbutamide, and 1·45 (0·88-2·44) for chlorpropamide. INTERPRETATION Gliclazide and glimepiride were associated with a lower risk of all-cause and cardiovascular-related mortality compared with glibenclamide. Clinicians should consider possible differences in risk of mortality when selecting a sulfonylurea. FUNDING None.
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Affiliation(s)
- Scot H Simpson
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada.
| | - Jayson Lee
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Sabina Choi
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Ben Vandermeer
- Alberta Research Centre for Health Evidence, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Ahmed S Abdelmoneim
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Travis R Featherstone
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
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Rajendran R, Rayman G. Serious harm from inpatient hypoglycaemia: a survey of hospitals in the UK. Diabet Med 2014; 31:1218-21. [PMID: 24702036 DOI: 10.1111/dme.12457] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 02/05/2014] [Accepted: 03/29/2014] [Indexed: 11/25/2022]
Abstract
AIM To estimate the incidence of serious harm to inpatients with diabetes from hypoglycaemia. METHOD An anonymised questionnaire was e-mailed to lead organisers at the 142 acute NHS Trusts that contributed to the National Diabetes Inpatient Audit 2012. Each diabetes team was asked collectively to recall and report any serious adverse events from inpatient hypoglycaemia in the previous year. A total of 83 Trusts agreed to participate. Serious harm was defined as death, a cardiac or cerebral event or a fall resulting in permanent physical injury or fracture. RESULTS A total of 41 Trusts returned the survey. Of these, only 28 (68.3%) were confident that robust methods existed in their Trust to ensure all such events were reported, and only 23 (56.1%) were confident that all such events were reported to the diabetes team. Despite these reporting concerns, the retrospective nature of the survey and the reliance on recall, 12 serious adverse events were reported from nine trusts: three deaths; two cases of permanent cerebral damage; two successfully resuscitated cardiac arrests; three seizures; and two undefined events. Insulin therapy was implicated in 10 events. Importantly, three events with two deaths occurred in patients who had received insulin/dextrose to correct hyperkalaemia; only one of whom had diabetes. CONCLUSIONS An alarming number of serious adverse events was reported: 12 serious adverse events with three deaths over a 1-year period in 41 Trusts. This may be the tip of the iceberg, considering the potential under-reporting. Robust reporting mechanisms are required to determine the full extent of this serious preventable harm.
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Affiliation(s)
- R Rajendran
- Department of Diabetes and Endocrinology, The Ipswich Hospital NHS Trust, Ipswich, UK
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QTc prolongation and ventricular premature complexes secondary to insulin-induced hypoglycemia in a diabetic patient. Cardiovasc Endocrinol 2014. [DOI: 10.1097/xce.0000000000000015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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50
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Maffioli P, Derosa G. Hypoglycemia, its implications in clinical practice, and possible ways to prevent it. Curr Med Res Opin 2014; 30:771-3. [PMID: 24479383 DOI: 10.1185/03007995.2014.890096] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Pamela Maffioli
- Department of Internal Medicine and Therapeutics, University of Pavia and Fondazione IRCCS Policlinico S. Matteo , Pavia , Italy
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