Diabetic patients with acute coronary syndromes in contemporary European registries: characteristics and outcomes

[Use of metformin in patients with type 2 diabetes and acute myocardial infarction: safety and impact on glycemic control]

BACKGROUND

Myocardial infarction (MI) in patients with diabetes type 2 (T2DM) occurs 1.5-3.0 times higher than in general population. Metformin is contraindicated for patients with T2DM and acute coronary syndrome due to the risk of developing lactic acidosis. Using metformin more than 48 hours of MI is a topical question, which will help to improve patient's safety.

AIM

To evaluate the safety and quality of glycemic control using metformin in patients with T2DM during inpatient treatment for MIMATERIALS AND METHODS: The study included 161 patients with T2DM, who were hospitalized consecutively with acute MI with ST-elevation and underwent percutaneous coronary intervention (PCI). Average time of metformin initiation was 5th day from admission. Creatinine was assessed at admission and 48 hours after PCI. The acid-base balance and lactate were assessed at admission and on the 3rd day after the start of using metformin. Criteria for the effectiveness of glycemic control was the proportion of glycemic measurements in target range of 6.1-10.0 mmol/l during hospitalization ("hospital time in range", hTIR). hTIR >55% was considered to be a critical level. The long-term outcome was estimated at 365 days after hospitalization.

RESULTS

Metformin was prescribed to 99 patients (61%) ("M+"group) during the hospitalization, 62 patients were in "M-"group. Use of metformin was accompanied with better glycemic control in the «M+» group compared to the «M-»: mean glycemia 9.3 ± 1.6 vs 10.3 ± 2.3 mmol/l (p=0,002), SD 2.87 ± 1.1 vs 3.26 ± 1.8 (p=0,049), hTIR 60 ± 18% vs 48 ± 23% (p<0,001). There were clinically insignificant changes in acid-base balance on the 3rd day from the start of metformin use in the "M+" group, the lactate level did not increase. Use of metformin before to hospitalization with MI was not associated with an increased risk of developing acute kidney injury (AKI): RR 0.85 (0.37-1.96), p=0,691.

CONCLUSION

Use of metformin in patients with T2DM and acute MI is associated with better glycemic control. Carrying out angiography in patients, treated with metformin before the hospitalization, is not accompanied by an increased risk of developing AKI. Appointment of metformin in 3-7 days after angiography does not lead to an increase level of lactate and significant deviations in acid-base balance.

Interaction effects of diabetes and brain-derived neurotrophic factor on suicidal ideation in patients with acute coronary syndrome

Acute coronary syndrome (ACS) is related to an increased risk of suicide. Although both diabetes and the brain-derived neurotrophic factor (BDNF) pathway are closely associated with ACS and suicide, the effects of these factors on suicidal behavior in ACS patients have not been assessed. We investigated the individual and interaction effects of diabetes and BDNF-related markers, namely the serum BDNF (sBDNF) level and the BDNF Val66Met polymorphism, on suicidal ideation (SI) in ACS patients. The presence of diabetes was ascertained, and sBDNF levels and the presence of the BDNF Val66Met polymorphism were measured in 969 patients within 2 weeks after an ACS episode. 711 patients were followed up at 1 year after the ACS episode. SI was assessed using the relevant items of the Montgomery–Åsberg Depression Rating Scale at baseline (acute SI) and the 1-year follow-up (chronic SI). Significant individual effects of low sBDNF levels were found on acute SI. The presence of both diabetes and a low sBDNF level or the BDNF Met/Met genotype was associated with acute SI, with multivariate logistic regression analyses revealing significant interaction effects. The highest frequency of chronic SI was seen in diabetic patients with an sBDNF level in the lowest tertile or with the BDNF Met/Met genotype, although the interaction terms were not statistically significant. Our study suggests that the combination of diabetes and BDNF-related markers, such as the sBDNF level and the BDNF Val66Met polymorphism, might provide a useful predictor of acute SI in ACS patients.

Clinical implications of diabetes mellitus in patients with acute coronary syndrome: Prognostic role and use of new P2Y12 receptor inhibitors

AIMS

We investigated the impact of diabetes mellitus (DM) in acute coronary syndrome (ACS) patients, and the 2-year prognosis based on antiplatelet therapy.

METHODS

This is a prospective and multicenter registry including hospitalized ACS patients. Clinical management and antiplatelet therapy at discharge were recorded. Bleeding events, all-cause mortality and major adverse cardiovascular events (MACEs) were recorded during 2-years and compared according to DM and the P2Y₁₂ receptor inhibitor.

RESULTS

From 1717 ACS patients, 653 (38%) had DM. Diabetic patients were older, more commonly females, with higher prevalence of comorbidities and more conservative management. After excluding antiplatelet monotherapy or oral anticoagulation, clopidogrel was prescribed in 59.6% of DM patients. Cox regression analysis showed that DM was an independent risk factor for MACE (aHR 1.39, 95% CI 1.05-1.83). The use of clopidogrel instead of ticagrelor/prasugrel was also independently associated with MACE (aHR 1.71, 95% CI 1.11-2.63), and all-cause mortality (aHR 2.47, 95% CI 1.23-4.96) in diabetic patients (log-rank p-values < 0.001).

CONCLUSIONS

In ACS patients, DM was associated with higher risk of MACE. In such patients, the use of ticagrelor/prasugrel reduced MACE and mortality compared to clopidogrel. Novel P2Y₁₂ receptor inhibitors might be used as the first therapeutic choice in these high-risk patients.

Antiplatelet and Antithrombotic Therapy in Type I Diabetes Mellitus: Update on Current Data

Diabetes mellitus type 1 (T1DM) is an autoimmune disease characterized by a markedly elevated cardiovascular (CV) risk due to premature atherosclerosis. Previous studies have shown that intense glycemic control reduces the incidence of CV disease. Antiplatelet therapy is considered to be a very important therapy for secondary prevention of recurrent atherothrombotic events in patients with DM, while it may be considered for primary prevention in individuals with T1DM with additional CV risk factors. The aim of the present review is to summarize existing literature data regarding the thrombotic risk in T1DM patients and discuss current treatment strategies.

Ranolazine Improves Glycemic Variability and Endothelial Function in Patients with Diabetes and Chronic Coronary Syndromes: Results from an Experimental Study

BACKGROUND

Ranolazine is a second-line drug for the management of chronic coronary syndromes (CCS). Glucose-lowering and endothelial effects have also been reported with this agent. However, whether ranolazine may improve short-term glycemic variability (GV), strictly related to the prognosis of patients with type 2 diabetes (T2D), is unknown. Thus, we aimed to explore the effects of adding ranolazine to standard anti-ischemic and glucose-lowering therapy on long- and short-term GV as well as on endothelial function and oxidative stress in patients with T2D and CCS.

METHODS

Patients starting ranolazine (n = 16) were evaluated for short-term GV, haemoglobin 1Ac (Hb1Ac) levels, endothelial-dependent flow-mediated vasodilation (FMD), and oxidative stress levels at enrolment and after 3-month follow-up. The same measurements were collected from 16 patients with CCS and T2D that did not receive ranolazine, matched for age, gender, and body mass index.

RESULTS

A significant decline in Hb1Ac levels was reported after 3-month ranolazine treatment (mean change -0.60%; 2-way ANOVA p = 0.025). Moreover, among patients receiving ranolazine, short-term GV indexes were significantly improved over time compared with baseline (p = 0.001 for time in range; 2-way ANOVA p = 0.010). Conversely, no significant changes were reported in patients without ranolazine. Finally, greater FMD and lower oxidative stress levels were observed in patients on ranolazine at 3 months.

CONCLUSIONS

Ranolazine added to standard anti-ischemic and glucose-lowering therapy demonstrated benefit in improving the glycemic status of patients with T2D and CCS. How this improvement contributes to the overall myocardial benefit of ranolazine requires further studies.

Prediction of the long-term risk of adverse cardiovascular events after an episode of acute coronary syndrome in patients with type 2 diabetes

Aim. To determine independent predictors of adverse cardiovascular events (ACE) and to develop a long-term (12 months) prognostic model after an episode of acute coronary syndrome (ACS) in patients with type 2 diabetes (T2D).

Material and methods. The study included 120 T2D patients hospitalized due to ACS in the period from January 2016 to February 2017. All patients underwent standard diagnostic tests. Twelve months after ACS, the incidence of ACE in T2D patients was assessed: cardiovascular mortality, myocardial infarction, emergency surgical revascularization. Additionally, we analyzed composite endpoint (CEP), including all of the adverse outcomes listed. Patients were divided into 2 groups: group 1 (n=34) — patients with ACE; group 2 (n=86) — patients without ACE. Factors associated with the CEP were then included in the logistic regression to determine independent predictors of ACE. In order to predict the development of CEP in patients with ACS and T2D, a logit model was created. To process the model, a ROC analysis was performed.

Results. Independent factors associated with ACE for 12 months in T2D patients after an ACS were established: MI of moderate severity (D.M. Aronov classification); hypertriglyceridemia; decreased heart rate variability (SDNN <0 ms); segments with significant coronary stenosis in the amount of ≥3; no surgical revascularization during acute MI. Based on independent factors, a logit model was developed for assessing 12-month risk of ACE in T2D patients after an ACS.

Conclusion. The developed risk prediction model for T2D patients after ACS, based on accessible diagnostic tests, allows to determine the probability of ACE within 12 months.

Drug therapy in elderly heart failure patients

Although heart failure (HF) is considered as a cardiogeriatric syndrome, elderly and very elderly patients are under-represented in the vast majority of clinical trials investigating novel drugs and therapies in this population. The homoeostatic systems of elderly subjects are very fragile, and the management of HF accompanied by numerous comorbidities requires a holistic approach towards the patient, with special emphasis not only on psychosomatic problems but also on the individual (including social) needs of each particular patient, along with the support for the family and/or caregivers. In this article, we summarize current evidence regarding pharmacotherapy of elderly patients with HF and summarize the clinical problems occurring in this population.

[Evaluation of hyperglycemia impact on outcomes of acute coronary syndrome in elderly and senile patients.]

Acute coronary syndrome (ACS) in elderly and senile patients has a number of features and requires special attention to providing medical care. These patients is associated with significant comorbidity and atypical symptoms in the course of the disease. Diabetes mellitus is a common background disease in patients with ACS.A retrospective cohort study was performed, 2945 patients with ACS were examined. Patients were divided into three age groups: group 1 - patients aged 18 to 63 years; group 2 - patients aged 64 to 75 years; group 3 - patients older than 75 years. Number of patients with glucose concentrations above 11.1 mmol/L is significantly higher in elderly and senile groups than in group of patients from 35 to 59 years old. The number of patients with impaired renal function after administration of a contrast medium in the study group with ACS increased with increasing age. Significant difference was revealed between the middle and senile age groups, as well as between the elderly and senile age groups. An increase in the relative number of patients with fatal outcomes in groups with a significant increase in glucose levels was revealed. The connection between the pathological level of glucose and repeated myocardial infarction is proved. Conclusion. The presented statistical picture suggests a particularly high risk of recurring cardiovascular events among patients with ACS and pathological glucose levels. The correlation between the number of deaths and glucose levels during the initial examination allows the use of glucose tests as an additional criterion in the stratification of risks and outcomes in patients with ACS.

Impact of type 2 diabetes mellitus on in-hospital-mortality after major cardiovascular events in Spain (2002-2014)

BACKGROUND

Diabetes mellitus has long been associated with cardiovascular events. Nevertheless, the higher burden of traditional cardiovascular risk factors reported in high-income countries is offset by a more widespread use of preventive measures and revascularization or other invasive procedures. The aim of this investigation is to describe trends in number of cases and outcomes, in-hospital mortality (IHM) and length of hospital stay (LHS), of hospital admissions for major cardiovascular events between type 2 diabetes (T2DM) and matched non-diabetes patients.

METHODS

Retrospective study using National Hospital Discharge Database, analyzed in 4 years 2002, 2006, 2010, 2014, in Spain. We included patients (≥ 40 years old) with a primary diagnosis of myocardial infarction, ischemic and hemorrhagic stroke, aortic aneurysm and dissection and acute lower limb ischemia in people with T2DM. Cases were matched with controls (without T2DM) by ICD-9-CM codes, sex, age, province of residence and year.

RESULTS

We selected 130,011 matched couples (50,427 with myocardial infarction, 60,236 with stroke, 2599 with aortic aneurysm and dissection and 16,749 with acute lower limb ischemia. Among T2DM patients we found increasing numbers of admissions overtime for stroke (10,794 in 2002 vs 17,559 in 2014), aortic aneurysm and dissection (390 vs 841) and acute lower limb ischemia (3854 vs. 4548). People were progressively older (except for myocardial infarction), had more comorbidities (especially T2DM patients), and were more frequently coded overtime for cardiovascular risk factors (smoking, obesity, hypertension, lipid disorders) and renal diseases. LHS and IHM declined overtime, though IHM only did it significantly in T2DM patients. Multivariable adjustment showed that T2DM patients had a significantly 15% higher mortality rate during admission for myocardial infarction, a 6% higher mortality for stroke, and a 6% higher mortality rate for "all cardiovascular events combined", than non-diabetic matched controls.

CONCLUSIONS

The number of hospital admissions for stroke, aortic aneurysm and dissection and acute lower limb ischemia increased overtime, but remained stable for myocardial infarction. T2DM is associated to higher IHM after major cardiovascular events. Further research is needed to help us understand the reasons for an apparently increased mortality in T2DM patients when admitted to hospital for some major cardiovascular events.