Unstable angina. A comparison of angioscopic findings between diabetic and nondiabetic patients

Intravascular imaging-guided versus angiography-guided percutaneous coronary intervention in patients with diabetes mellitus: Rationale and design of an international, multicenter, randomized IVI-DIABETES trial

BACKGROUND

Intravascular imaging (IVI)- guided percutaneous coronary intervention (PCI) can improve clinical outcomes compared with angiography guidance in patients with complex lesions or acute coronary syndrome. However, the impact of this approach among diabetic patients remains unknown.

TRIAL DESIGN

IVI-DIABETES trial is an investigator-initiated, prospective, international, multicenter, randomized trial, involving at least 30 sites, aiming to enroll 1,332 diabetic patients with obstructive coronary artery disease undergoing PCI. All enrolled patients are randomly assigned in a 1:1 fashion to undergo IVI- guided PCI or angiography- guided PCI. The choice between intravascular ultrasound or optical coherence tomography is at the discretion of the operator. The primary endpoint is target vessel failure (TVF) at 12 months, defined by the composite of cardiac death, target vessel myocardial infarction (MI), or clinically-driven target vessel revascularization. The major secondary endpoint is TVF without procedure-related MI. After hospital discharge, follow-up is conducted through clinical visits or telephone contact at 1, 6, and 12 months. The follow-up will continue annually until 5 years after the index procedure to assess the long-term outcomes.

CONCLUSION

IVI-DIABETES trial is the first study designed to investigate the clinical efficacy and safety of IVI-guided PCI in diabetic patients compared to angiography-guided PCI.

TRIAL REGISTRATION

clinicaltrials.gov, NCT06380868.

IVUS-Guided vs Angiography-Guided PCI in Patients With Diabetes With Acute Coronary Syndromes: The IVUS-ACS Trial

BACKGROUND

Intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) reduces the risk for clinical events in patients with acute coronary syndromes (ACS), compared with angiographic guidance. However, the benefits of IVUS guidance in high-risk patients with diabetes with ACS is uncertain.

OBJECTIVES

The aim of this prespecified stratified subgroup analysis from the IVUS-ACS randomized trial was to determine the effectiveness of IVUS-guided PCI vs angiography-guided PCI in patients with diabetes with ACS.

METHODS

From August 20, 2019, to October 27, 2022, 1,105 patients with diabetes with ACS were randomized, including 554 patients in the IVUS-guided group and 551 in the angiography-guided group. The primary endpoint was the rate of target vessel failure (TVF) at 1 year, defined as the composite of cardiac death, target vessel myocardial infarction, or clinically driven target vessel revascularization.

RESULTS

At 1-year follow-up, TVF occurred in 20 patients in the IVUS guidance group and in 46 patients in the angiographic guidance group (Kaplan-Meier rates 3.6% vs 8.3%; HR: 0.46; 95% CI: 0.27-0.81; P = 0.007), driven by a reduction in clinically driven target vessel revascularization (0.9% vs 3.8%; P = 0.003). IVUS-guided PCI also reduced the risk for TVF without procedural myocardial infarction (2.0% vs 6.7%; HR: 0.29; 95% CI: 0.15-0.57; P < 0.001) and all-cause mortality (HR: 0.30; 95% CI: 0.10-0.93; P = 0.037). There were no significant differences in the rates of stent thrombosis or major bleeding between the groups.

CONCLUSIONS

In the large-scale IVUS-ACS trial, IVUS-guided PCI improved 1-year clinical outcomes in high-risk patients with diabetes with ACS. (1-Month vs 12-Month DAPT for ACS Patients Who Underwent PCI Stratified by IVUS: IVUS-ACS and ULTIMATE-DAPT Trials; NCT03971500).

Impact of diabetes mellitus on long-term clinical and graft outcomes after off-pump coronary artery bypass grafting with pure bilateral skeletonized internal thoracic artery grafts

BACKGROUND

The effect of diabetes mellitus (DM) on the long-term outcomes of coronary artery bypass graft (CABG) remained debatable and various strategies exist for CABG; hence, clarifying the effects of DM on CABG outcomes is difficult. The current study aimed to evaluate the effect of DM on clinical and graft-related outcomes after CABG with bilateral internal thoracic artery (BITA) grafts.

METHODS

From January 2001 to December 2017, 3395 patients who underwent off-pump CABG (OPCAB) with BITA grafts were enrolled. The study population was stratified according to preoperative DM. The primary endpoint was cardiac death and the secondary endpoints were myocardial infarction (MI), revascularization, graft failure, stroke, postoperative wound infection, and a composite endpoint of cardiac death, MI, and revascularization. Multiple sensitivity analyses, including Cox proportional hazard regression and propensity-score matching analyses, were performed to adjust baseline differences.

RESULTS

After CABG, the DM group showed similar rates of cardiac death, MI, or revascularization and lower rates of graft failure at 10 years (DM vs. non-DM, 19.0% vs. 24.3%, hazard ratio [HR] 0.711, 95% confidence interval [CI] 0.549-0.925; P = 0.009) compared to the non-DM group. These findings were consistent after multiple sensitivity analyses. In the subgroup analysis, the well-controlled DM group, which is defined as preoperative hemoglobin A1c (HbA1c) of < 7%, showed lower postoperative wound infection rates (well-controlled DM vs. poorly controlled DM, 3.7% vs. 7.3%, HR 0.411, 95% CI 0.225-0.751; P = 0.004) compared to the poorly controlled DM group, which was consistent after propensity-score matched analysis.

CONCLUSIONS

OPCAB with BITA grafts showed excellent and comparable long-term clinical outcomes in patients with and without DM. DM might have a protective effect on competition and graft failure of ITA. Strict preoperative hyperglycemia control with target HbA1c of < 7% might reduce postoperative wound infection and facilitate the use of BITA in CABG.

Activin receptor-like kinase 7 promotes apoptosis of vascular smooth muscle cells via activating Smad2/3 signaling in diabetic atherosclerosis

Vascular smooth muscle cells (VSMCs) is a vital accelerator in the late phase of diabetic atherosclerosis, but the underlying mechanism remains unclear. The aim of our study was to investigate whether activin receptor-like kinase 7 (ALK7)-Smad2/3 pathway plays an important role in VSMC apoptosis of diabetic atherosclerosis. It was shown that ALK7 expression was obviously elevated in the aorta of ApoE−/− mice with type 2 diabetes mellitus. Inhibition of ALK7 expression significantly improved the stability of atherosclerotic plaques and reduced cell apoptosis. Further experiments showed that ALK7 knockdown stabilized atherosclerotic plaques by reducing VSMC apoptosis via activating Smad2/3. Our study uncovered the important role of ALK7-Smad2/3 signaling in VSMCs apoptosis, which might be a potential therapeutic target in diabetic atherosclerosis.

Diabetes, heart failure, and myocardial revascularization: Is there a new message from the ISCHEMIA trial?

There is no evidence that the indications for myocardial revascularization differ between patients with and without diabetes. Accepted indications include stable angina that cannot be adequately managed by medication, acute coronary syndromes, severely reduced left ventricular (LV) function due to coronary artery disease, left main stenosis, and advanced coronary artery disease causing substantial inducible ischemia. The recent ISCHEMIA trial challenged the criterion of ischemia. With respect to its primary endpoint, ISCHEMIA showed no benefit of an invasive strategy with systematic myocardial revascularization in patients with stable angina and moderate-to-severe ischemia compared with a conservative strategy. However, myocardial revascularization resulted in a statistically significant and clinically meaningful reduction in angina and an improvement in quality of life. There was a significant reduction in prognostically relevant spontaneous myocardial infarction (MI) in the long term, which came at the cost of an increased rate of peri-interventional MI that was of minor prognostic relevance. The risk profile and number of patients included in the ISCHEMIA trial, as well as the duration of follow-up, are not sufficient to show that the lower incidence of spontaneous infarcts improved survival. In ISCHEMIA, there was no heterogeneity in treatment effect depending on diabetes.

Raised Glycated Hemoglobin (HbA1c) Level as a Risk Factor for Myocardial Infarction in Diabetic Patients: A Hospital-Based, Cross-Sectional Study in Peshawar

Background

Diabetes is a rapidly rising chronic illness in developing countries. The main objective of this research is to compare the frequency of myocardial infarction (MI) in controlled and uncontrolled diabetics in Pakistan, especially in the underprivileged district of Peshawar, and to determine raised blood glucose as a risk factor for MI.

Methodology

This cross-sectional study involving 237 diabetic patients aged 30-80 years was conducted in three major tertiary care hospitals in Peshawar, Pakistan. The inclusion criteria were diabetic patients with glycated hemoglobin (HbA1C) levels of less than 7% considered to be “controlled diabetics” and above 7% considered to be “uncontrolled diabetics.” Data were collected using structured questionnaires, past medical records, and patient history and were analyzed using SPSS software (IBM Corp., Armonk, NY, USA). The study was concluded in March 2022.

Results

The highest number of MIs occurred in diabetics with HbA1c levels of 8-9% (47.9% of all MIs). There was a significant association between increasing HbA1c levels and the incidence of MI (p = 0.002). The adjusted prevalence odds ratio for MI in uncontrolled diabetics was 6.105 (95% confidence interval = 2.42-15.43), that is, six times increased incidence of MI in patients with HbA1c of more than 7%. Furthermore, with a 1% increase in HbA1c, there was a 10% increase in the proportion of MIs.

Conclusions

From this study, it is clear that HbA1c levels of 8-9% were most significantly associated with the risk of MI in uncontrolled diabetics, and with rising levels of HbA1c, the risk of MI increased significantly. Thus, this study highlights the importance of HbA1c control in diabetic patients to prevent a heart attack.

Correlation between Occupational Stress and Coronary Heart Disease in Northwestern China: A Case Study of Xinjiang

Objective

To study the correlation between occupational stress and coronary heart disease in western China.

Method

A case-control design was used. From June 2016 to May 2017, 310 patients with coronary heart disease (CHD) confirmed by coronary angiography (CAG) at the Heart Center of the First Affiliated Hospital of Xinjiang Medical University were recruited by cluster sampling, along with 536 healthy controls. The questionnaire was developed based on a Job Content Questionnaire (JCQ). An epidemiological survey was conducted to collect clinical data. Chi-squared test, analysis of variance, and binary logistic regression analysis were adopted.

Results

(1) In the Han population, there were statistically significant differences in the composition of smoking, diets, sleep duration, sleep quality, and physical activity between two groups (all P < 0.05). In the Uygur population, statistically significant differences in the composition of smoking, drinking, diets, sleep quality, and physical activity were found between two groups (all P < 0.05). (2) Differences in sleep duration and physical activity between the Han and Uygur case groups were statistically significant (P < 0.05). (3) Differences in Gensini scores between the Han and Uygur case groups were statistically significant (P < 0.05). Differences in coronary artery lesions between the Han and Uygur case groups were statistically significant (P < 0.05). (4) In the Uygur population, the difference between the occupational stress level and CHD were statistically significant (P < 0.05). (5) The differences between the number of different pathological changes and the level of occupational stress in the Han and Uygur case groups were not statistically significant (P > 0.05). In the Han and Uygur case groups, the difference between the occupational stress level and Gensini high-level group were statistically significant (P < 0.05). (6) After adjustment for age and sex, significant increased risk effects for Han patients with CHD were found to be associated with sleep quality (OR = 1.88; 95% CI: 1.047-1.782; P < 0.05). Uygur patients with CHD was significantly associated with smoking (OR = 3.094; 95% CI: 1.025-1.103; P < 0.05) and occupation stress (OR = 1.523; 95% CI: 1.757-3.062; P < 0.05).

Conclusion

Occupational stress is correlated with CHD for the Uygur population.

Outcomes in prediabetes vs. diabetes in patients with non-ST-segment elevation myocardial infarction undergoing percutaneous intervention

OBJECTIVE

The comparative long-term clinical outcomes between patients with prediabetes and diabetes in patients with non-ST-elevation myocardial infarction (NSTEMI) and multivessel disease (MVD) who were undergoing percutaneous coronary intervention (PCI) are not well known. We therefore compared the 2-year clinical outcomes in such patients.

METHODS

A total of 2963 patients with NSTEMI and MVD [normoglycemia (group A, n = 629), prediabetes (group B, n = 802), and diabetes (group C, n = 1532)] were evaluated. The primary outcomes were the occurrence of major adverse cardiac events (MACE) defined as all-cause death, recurrent myocardial infarction (Re-MI), and any repeat revascularization. The secondary outcome was stent thrombosis.

RESULTS

The cumulative incidence of MACE as well as for death or MI in group B and C were similar when compared to each other. However, they (P = 0.048 and P = 0.017, respectively and P = 0.022 and P = 0.001, respectively) were significantly higher than in group A. The cumulative incidence of all-cause death in group B (P = 0.042) and all-cause death and cardiac death in group C (P = 0.001 and P = 0.028, respectively) were significantly higher than in group A. However, those of all-cause death, cardiac death, Re-MI, any repeat revascularization, and ST were not significantly different between groups B and C.

CONCLUSION

In this study, patients with NSTEMI and MVD who underwent successful implantation of newer-generation DES and were prediabetic had worse outcomes compared to normoglycemics and comparable to those with diabetes.

Comparison of Long-Term Mortality in Patients With Single Coronary Narrowing and Diabetes Mellitus to That of Patients With Multivessel Coronary Narrowing Without Diabetes Mellitus

It is well recognized that patients with diabetes mellitus (DM) and multivessel coronary artery disease (MVD) undergoing percutaneous coronary intervention (PCI) have poorer long-term outcomes compared with those undergoing coronary artery bypass grafting. However, the relative impact of DM status and extent of coronary artery disease on long term mortality in patients undergoing PCI is unknown. We sought to compare patients with DM undergoing PCI for single and multivessel disease to their non-DM counterparts. Overall, 34,690 consecutive patients undergoing PCI from the Melbourne Interventional Group registry (2005 to 2017) were included (mean age 64.5 ± 12 years, 76.6% male). Our cohort was stratified by the presence of DM and extent of CAD (DM-SVD [single-vessel disease] [n = 2,669], DM-MVD [n = 6,118], no-DM-SVD [n = 10,993], no-DM-MVD [n = 14,910]). DM-SVD and no-DM-MVD cohorts demonstrated comparable baseline cardiovascular risk profiles, although the no-DM-MVD cohort had higher rates of prior myocardial infarction, while the DM-SVD cohort had a higher proportion of patients with renal impairment. Over a median follow-up of 4.8 (IQR 2.0 to 8.2) years, 6,031 (17.5%) patients died. Using the no-DM-SVD group as the reference category, adjusted risk of mortality was highest in the MVD-DM cohort (HR 1.90; 95% CI 1.71 to 2.09). Similar adjusted risk of long-term mortality was observed in the DM-SVD (HR 1.32, 95%CI 1.15 to 1.51) and no-DM-MVD (HR 1.30, 95%CI 1.20 to 1.40) groups. In conclusion, we found that the long-term mortality of patients with DM and SVD undergoing PCI was the risk equivalent of non-DM patients with MVD.

Clinical characteristics and management of patients with diabetes mellitus and stable coronary artery disease in daily clinical practice. The SCAD-DM Registry

BACKGROUND

Patients with diabetes mellitus (DM) and coronary artery disease (CAD) represent a high-risk population, where comorbidities are common and the progression of coronary heart disease is relatively rapid and extensive. The present survey, conducted nationwide in a Eurozone country, Greece, with a properly organized national health system, aimed to record specific data from a significant number of patients with diabetes and documented stable CAD (SCAD).

METHODS AND RESULTS

We conducted our survey across the country, in private and public primary, secondary, and tertiary care centers. A total of 1900 patients aged 71 ± 10 years old who suffered from both DM and chronic coronary syndromes were registered. Of the patients registered, 574 (30.24%) were women. It was found that 506 (26.6%) of the 1900 surveyed patients showed typical angina symptoms, while another 560 (29.5%) patients had developed angina-equivalent symptoms according to their history. Additionally, 324 (17%) patients had atypical symptoms that could not easily be attributed to existing CAD and the remaining 510 (26.8%) of the 1900 patients did not exhibit any angina symptoms during their daily activities. Functional testing for myocardial ischemia was not performed in 833 patients (43.8%). Myocardial scintigraphy was the most commonly used noninvasive technique (644 patients, 34%), while 492 patients (25.9%) had an exercise test and 159 (8.4%) underwent stress echocardiography.

CONCLUSION

Real-world data in this specific high-risk population of diabetic patients with SCAD offer the opportunity to identify and improve diagnostic and therapeutic practice in the healthcare system of a European Union country.

ApPropRiateness of myOcardial revascUlarization assessed by SYNTAX Scores in patients with type 2 diabetes melliTus: the PROUST study

INTRODUCTION

Results of currently available trials have shown divergent outcomes in diabetic patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Current guidelines do not recommend PCI in patients with diabetes and a SYNTAX score ≥ 23.

AIM

To compare all-cause 4-year mortality after revascularization for complex coronary artery disease (CAD) in diabetics.

MATERIAL AND METHODS

The study group comprised consecutive patients with three-vessel CAD and/or unprotected left main CAD (≥ 50% diameter stenosis) without major hemodynamic instability, who were treated in two institutions with PCI or referred for CABG.

RESULTS

Out of 342 diabetics, 177 patients underwent PCI and 165 patients were referred for CABG. The incidence of all-cause death was different between diabetics treated with PCI or CABG at 4 years (16/177, 9.0% vs. 26/165, 15.8%, respectively, p = 0.03). The difference was not evident in non-diabetics (PCI: 41/450, 9.1% vs. CABG: 19/249, 7.6%, p = 0.173). In diabetics, there was a higher incidence of all-cause mortality in PCI patients with intermediate-high (≥ 23) SYNTAX scores compared with those with low (0-22) SYNTAX scores (10/56, 17.9% vs. 6/121, 5.0%, respectively, p < 0.01). On the other hand, diabetics who underwent CABG showed similar mortality rates irrespective of the SYNTAX scores (SYNTAX 0-22: 3/29, 10.3%; SYNTAX ≥ 23: 23/136, 11.9%, p = 0.46). In the subgroup analysis, there was no interaction according to presence or absence of left main CAD (p for interaction = 0.12) as well as according to diabetes status (p for interaction = 0.38), whereas gender and SYNTAX scores were differentiators between PCI and CABG with a p for interaction < 0.1.

CONCLUSIONS

Our analysis supports recent evidence that diabetes is not a differentiator between PCI and CABG.

Impact of glycemic control status on patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention

Background

The combined effects of diabetes mellitus (DM), admission plasma glucose (APG), and glycated hemoglobin (HbA1c) levels on predicting long-term clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI) are unknown. Therefore, we evaluated their combined effects on long-term clinical outcomes in STEMI patients treated with pPCI.

Methods

In total, 350 consecutive patients with STEMI undergoing pPCI were enrolled. Patients were divided into 3 groups according to DM history and APG and HbA1c levels. The cumulative rates of 24-month all-cause deaths and major adverse cardiac and cerebrovascular events (MACCEs) were calculated.

Results

Both the incidence of all-cause deaths and cumulative rates of MACCEs were significantly the lowest in patients without a DM history and admission HbA1c level < 6.5%. DM patients with poor glycemic control or stress hyperglycemia on admission experienced the highest rates of all-cause deaths, MACCEs, and cardiac deaths. Admission HbA1c levels, Triglyceride (TG) levels, hemoglobin levels, DM history, and admission Killip class > 1 correlated with 24-month all-cause death; HbA1c levels on admission, DM history, APG levels, history of stroke, history of coronary heart disease, and TG levels on admission were significantly associated with MACCEs through the 24-month follow-up. The predictive effects of combining DM and APG and HbA1c levels were such that for STEMI patients undergoing pPCI, DM patients with poor glycemic control or with stress hyperglycemia on admission had worse prognosis than other patients.

Conclusion

Strict control of glycemic status may improve the survival of patients who have both DM and coronary heart diseases.

Highlights from the 2019 International Aspirin Foundation Scientific Conference, Rome, 28 June 2019: benefits and risks of antithrombotic therapy for cardiovascular disease prevention

At the 2019 International Aspirin Foundation Scientific Conference 'Benefits and Risks of Antithrombotic Therapy for Cardiovascular Disease Prevention', held in Rome, Italy, international experts sought to discuss and debate the optimal antithrombotic strategy for the secondary prevention of cardiovascular disease (CVD) and to seek agreement around dosing and target populations for aspirin use in primary disease prevention. Getting the best evidence to support real-life decisions in the clinic can be complex, and individualising management in order to balance both the risks and benefits of different disease prevention strategies appears to be the best approach. It is hoped that future decision-making tools and biomarkers will help direct treatments at those most likely to benefit.

Glucose Management and the Sex Difference in Excess Cardiovascular Disease Risk in Long-Duration Type 1 Diabetes

PURPOSE OF REVIEW

The protection against CVD observed in women compared to men in the general population is essentially erased in type 1 diabetes. This review will discuss evidence regarding the role of glucose management on CVD risk by sex, with a particular focus on studies of long-duration type 1 diabetes of > 20 years.

RECENT FINDINGS

Across studies, women with type 1 diabetes have similar or worse glycemic control compared to men, despite higher rates of intensive insulin therapy. The association between HbA1c and CVD risk does not seem to differ by sex, but few studies have reported on sex-specific analyses. Beyond HbA1c, there is a lack of published data regarding the relationship between other aspects of glucose management and CVD risk by sex in type 1 diabetes. Glucose management factors do not seem to directly account for the increased CVD risk in women with type 1 diabetes, but may influence other risk factors that play a more direct role.

Refractory angina frequencies during 7 weeks treatment by enhanced external counterpulsation in coronary artery disease patients with and without diabetes

BACKGROUND

Refractory angina is a clinical diagnosis which implies to chronic pain due to coronary artery insufficiency and it is often resistant to routine cardiac treatment. The present study conducted to compare changes in refractory angina frequencies during 7 weeks treatment by enhanced external counterpulsation (EECP) in coronary artery disease (CAD) patients with and without diabetes.

METHODS

In this retrospective study, 94 CAD patients (30 diabetics vs. 64 nondiabetics) who referred to cardiac rehabilitation department of Imam Ali Hospital of Kermanshah, Iran, during January 2006-2014 were assessed. The interventional method was EECP and medical records and frequencies of self-reported chest pain were research instruments. Data were analyzed through Chi-square test, mixed repeated measures, and Bonferroni test.

RESULTS

Frequencies of pain in both diabetic and nondiabetic groups during 7 weeks had linear reduction, but this reduction was significant only among nondiabetic patients (P < 0.0005). Furthermore, the significant reduction in frequencies of pain among this group begins after the 5th week.

DISCUSSION

Diabetes is one of the obstacles to the successful control of pain frequencies by the EECP in patients with CAD. Future studies may pay attention to the confounding role of diabetes in improving the severity of chest pain.

FREQUENCY OF TRIPLE-VESSEL CORONARY ARTERY DISEASE IN ADULT TYPE 2 DIABETICS VERSUS NON-DIABETICS IN CORONARY ARTERY DISEASE POPULATION OF ISLAMABAD, PAKISTAN

Background: Coronary artery disease is a major cause of morbidity and mortality globally as well as in Pakistan. The objective of the study was to compare the frequency of triple-vessel coronary artery disease (triple-vessel CAD) in adult type 2 diabetics versus non-diabetics in coronary artery disease (CAD) population of Islamabad, Pakistan. Materials and Methods: This cross-sectional study was conducted in Department of Cardiology, Pakistan Institute of Medical Sciences, Islamabad, Pakistan from June 21, 2016 to December 20, 2016. 300 patients were selected from population including adult CAD patients who were candidates for coronary angiography. Those with conduction defects, renal failure and prior CABG surgery were excluded. 150 diabetics and 150 non-diabetics were subjected to coronary angiography. Age, sex and presence of triple-vessel CAD were research variables. Age was analyzed by mean and SD while sex and presence of triple-vessel CAD were analyzed by count and percentage for each group separately. Confidence interval for proportion was calculated at 80% confidence level for each group. Frequency of presence of triple-vessel CAD in two groups was compared using McNemar chi-square test at alpha 0.5. Results: Mean age was 55.02±8.48 for diabetics and 54.02±24.4 years for non-diabetics. Out of 300 patients with CAD, 184 (61.33%) were men and 116 (38.67%) were women. Triple-vessel CAD was present in 60/150 (40%) cases in diabetics and in 3/150 (2%) cases in non-diabetics. Frequency of triple-vessel CAD was significantly higher in adult type 2 diabetics versus non-diabetics in CAD population of Islamabad, Pakistan (p

Effect of renal insufficiency and diabetes mellitus on in-hospital mortality after acute coronary syndromes treated with primary PCI. Results from the ALKK PCI Registry

BACKGROUND

It is known that patients with acute coronary syndromes (ACS) and diabetes mellitus (DM) are at higher risk for in-hospital adverse events. However, we hypothesized that the higher event rate is due to the patients' subgroup with renal failure (RF), a common sequel of DM.

METHODS AND RESULTS

We used data of the prospective ALKK-PCI registry including all consecutive percutaneous coronary interventions (PCI) for ACS of 48 hospitals between 2008 and 2013. We divided 69,651 patients in four groups according to their history of DM and RF (GFR < 60 ml/min). All-cause, in-hospital mortality of the following four groups: noDM/noRF, DM/noRF, DM/RF, RF/noDM, was: 3.5%, 6.6%, 21.9%, and 14.1% for STEMI and 1.5%, 2.1%, 7.2%, and 5.4% for NSTE-ACS. In a multivariate analysis we looked for independent mortality-predictors. Odds ratios with confidence intervals for the following variables: DM without RF, DM with RF, RF without DM were: 1.62 (1.37-1.90), 3.02 (2.43-3.76), and 2.13 (1.80-2.52) for STEMI and 1.20 (0.99-1.45), 2.72 (2.18-3.88), and 2.08 (1.69-2.56) for NSTE-ACS. We also calculated mortality in four groups (60-90, 45-60, 45-30, <30 ml/min) according to the estimated glomerular filtration rate (eGFR). Mortality rates were: 5.0%, 12.8%, 17.7%, and 31.5% for STEMI and 2.1%, 3.8%, 7.1%, and 12.0% for NSTE-ACS (p for trend <0.0001 for both).

CONCLUSIONS

In-hospital death after PCI in patients with ACS and DM is mainly observed in the subgroup with co-existing RF. In a multivariate analysis, DM without RF was a significant mortality-predictor in STEMI, but not in NSTE-ACS. RF, irrespective of co-existent DM, was a stronger predictor than DM alone for both ACS-types (OR > 3) and mortality increased with decreasing eGFR.

Type-2 diabetes mellitus and cardiovascular disease

The global prevalence of diabetes has risen in adults from 4.7% in 1980 to 8.5% in 2014. 90–95% of adults with diabetes have Type 2 diabetes (T2D). This paper focuses on the diagnosis and treatment of T2D patients who have or are at risk for cardiovascular disease. Hyperglycemia, insulin resistance and excess fatty acids increase oxidative stress, disrupt protein kinase C signaling and increase advanced glycation end-products that result in vascular inflammation, vasoconstriction, thrombosis and atherogenesis. Intensive T2D treatment produces a ≥10% risk reduction in major macrovascular and microvascular events. Glucose-lowering therapies must be individualized. Metformin is an optimal drug for monotherapy. If hemoglobin A1c is not at goal, a sodium-glucose cotransporter-2 inhibitor or a dipeptidyl peptidase-4 inhibitor should be considered for therapy with metformin. Coronary angioplasty/stenting is recommended for diabetic patients with acute myocardial infarctions. Coronary artery bypass grafting is recommended for symptomatic diabetic patients with multivessel disease.

Hyperglycemia Aggravates Diet-Induced Coronary Artery Disease and Myocardial Infarction in SR-B1-Knockout/ApoE-Hypomorphic Mice

Diabetes is a risk factor for development of atherosclerotic cardiovascular disease. Animal model studies in mice revealed that hyperglycemia increases development of atherosclerosis in the aorta as well as myocardial fibrosis in surgical models of coronary artery ligation; however, the impact of hyperglycemia on coronary artery atherosclerosis and subsequent heart disease is less clear. To investigate the effect of hyperglycemia on atherosclerosis and coronary heart disease, we used a mouse model of diet-induced coronary artery atherosclerosis and myocardial infarction, the high fat/high cholesterol (HFC) diet fed SR-B1 knockout (KO)/apoE-hypomorphic (HypoE) mouse. Hyperglycemia was induced in these mice by streptozotocin (STZ) treatment. This increased HFC diet-dependent atherosclerosis development (p = 0.02) and necrotic core formation (p = 0.0008) in atherosclerotic plaques in the aortic sinus but did not increase the extent of atherosclerosis in coronary arteries. However, it did increase the extent of platelet accumulation in atherosclerotic coronary arteries (p = 0.017). This was accompanied by increased myocardial fibrosis (p = 0.005) and reduced survival (p = 0.01) compared to control-treated, normoglycemic mice. These results demonstrate that STZ-treatment exerted differential effects on the level of atherosclerosis in the aortic sinus and coronary arteries. These results also suggest that SR-B1-KO/HypoE mice may be a useful non-surgical model of diabetic cardiomyopathy in the context of coronary artery atherothrombosis.

Prasugrel or ticagrelor in patients with acute coronary syndrome and diabetes: a propensity matched substudy of RENAMI

Introduction:

The safety and efficacy of prasugrel and ticagrelor in patients with diabetes mellitus presenting with acute coronary syndrome and treated with percutaneous coronary intervention remain to be assessed.

Methods:

All diabetes patients admitted for acute coronary syndrome and enrolled in the REgistry of New Antiplatelets in patients with Myocardial Infarction (RENAMI) were compared before and after propensity score matching. Net adverse cardiovascular events (composite of death, stroke, myocardial infarction and BARC 3–5 bleedings) and major adverse cardiovascular events (composite of death, stroke and myocardial infarction) were the co-primary endpoints. Single components of primary endpoints were secondary endpoints.

Results:

Among 4424 patients enrolled in RENAMI, 462 and 862 diabetes patients treated with prasugrel and ticagrelor, respectively, were considered. After propensity score matching, 386 patients from each group were selected. At 19±5 months, major adverse cardiovascular events and net adverse cardiovascular events were similar in the prasugrel and ticagrelor groups (5.4% vs. 3.4%, P=0.16 and 6.7% vs. 4.1%, P=0.11, respectively). Ticagrelor was associated with a lower risk of death and BARC 2–5 bleeding when compared to prasugrel (2.8% vs. 0.8%, P=0.031 and 6.0% vs. 2.6%, P=0.02, respectively) and a clear but not significant trend for a reduction of BARC 3–5 bleeding (2.3% vs. 0.8%, P=0.08). There were no significant differences in myocardial infarction recurrence and stent thrombosis.

Conclusion:

Diabetes patients admitted for acute coronary syndrome seem to benefit equally in terms of major adverse cardiovascular events from ticagrelor or prasugrel use. Ticagrelor was associated with a significant reduction in all-cause death and bleedings, without differences in recurrent ischaemic events, which should be confirmed in dedicated randomised controlled trials.

Apoptotic β-cells induce macrophage reprogramming under diabetic conditions

Type 2 diabetes mellitus (T2DM) occurs when insulin-producing pancreatic β-cells fail to secrete sufficient insulin to compensate for insulin resistance. As T2DM progresses, apoptotic β-cells need to be removed by macrophages through efferocytosis that is anti-inflammatory by nature. Paradoxically, infiltrating macrophages are a main source of inflammatory cytokines that leads to T2DM. It is unclear how apoptotic β-cells impact macrophage function. We show under diabetic conditions, phagocytosis of apoptotic β-cells causes lysosomal permeabilization and generates reactive oxygen species that lead to inflammasome activation and cytokine secretion in macrophages. Efferocytosis-induced lipid accumulation transforms islet macrophages into foam cell-like outside the context of atherosclerosis. Our study suggests that whereas macrophages normally play a protective anti-inflammatory role, the increasing demand of clearing apoptotic cells may trigger them to undergo proinflammatory reprogramming as T2DM progresses. This shift in the balance between opposing macrophage inflammatory responses could contribute to chronic inflammation involved in metabolic diseases. Our study highlights the importance of preserving macrophage lysosomal function as a therapeutic intervention for diabetes progression.

Coronary Plaque Characteristics in Patients With Diabetes Mellitus Who Presented With Acute Coronary Syndromes

BACKGROUND

Diabetes mellitus (DM) is a major risk factor for cardiovascular events. We aimed to investigate the coronary plaque phenotype of diabetic patients who presented with acute coronary syndromes by optical coherence tomography.

METHODS AND RESULTS

A total of 322 patients with acute coronary syndromes who underwent preintervention optical coherence tomography imaging of the culprit lesion were included. Culprit plaque characteristics were compared between patients with DM (n=95) and those without DM (n=227). In the subgroup of 250 patients in whom sufficient length of nonculprit region in the culprit vessel was imaged by optical coherence tomography, the characteristics of nonculprit plaques were also evaluated. Patients with DM had a higher prevalence of lipid-rich plaque (58.9% versus 44.9%, P=0.030) and macrophage accumulation (60.0% versus 44.9%, P=0.019) in the culprit lesion compared with patients without DM. The prevalence of plaque rupture (33.7% versus 30.4%, P=0.896) and plaque erosion (21.1% versus 22.0%, P=0.458) was similar. In the nonculprit lesions, the DM group had greater maximal lipid arc (248.9°±83.9° versus 179.9°±58.3°, P=0.006), thinner fibrous cap thickness (103.3±56.2 μm versus 140.7±70.0 μm, P=0.013), and a higher prevalence of thin-cap fibroatheroma (17.2% versus 6.3%, P=0.031), compared with the non-DM group.

CONCLUSIONS

Compared with patients without DM, those with DM had more vulnerable features in both culprit and nonculprit lesions, thus indicating a higher level of panvascular instability.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01110538.

Hemoglobin A1c Level and Cardiovascular Disease Incidence in Persons With Type 1 Diabetes: An Application of Joint Modeling of Longitudinal and Time-to-Event Data in the Pittsburgh Epidemiology of Diabetes Complications Study

Type 1 diabetes (T1D) is associated with increased risk of cardiovascular disease (CVD), but hyperglycemia (measured by hemoglobin A1c (HbA1c) level), which characterizes T1D, has itself been an inconsistent predictor of CVD incidence. However, only baseline HbA1c or a summary measure (e.g., mean level over follow-up) is usually analyzed. Joint models allow simultaneous modeling of repeatedly measured longitudinal covariates, using random effects, and time-to-event data. We evaluated data from the Pittsburgh Epidemiology of Diabetes Complications Study, an ongoing prospective cohort study of childhood-onset T1D that has followed participants since 1986-1988 and has repeatedly found little association between baseline HbA1c or mean follow-up HbA1c and coronary artery disease incidence. Of 561 participants without CVD at baseline, 263 (46.9%) developed CVD over a period of 25 years (1986-2014). In joint models, each 1% unit increase in HbA1c trajectory was associated with a 1.26-fold increased risk of CVD (95% confidence interval: 1.07, 1.45), after adjustment for baseline levels of other CVD risk factors, and a 1.13-fold increased risk (95% confidence interval: 0.99, 1.32) after adjustment for updated mean levels of other CVD risk factors. These findings, which support the need for good glycemic control to prevent CVD in persons with T1D, underscore the importance of utilizing methods incorporating within-subject variation over time when analyzing and interpreting longitudinal cohort study data.

Long-term Prognosis and Clinical Characteristics of Patients with Newly Diagnosed Diabetes Mellitus Detected after First Acute Myocardial Infarction: from KAMIR-NIH Registry

BACKGROUND AND OBJECTIVES

After the first acute myocardial infarction (AMI), a considerable proportion of patients are newly diagnosed with diabetes mellitus (DM). However, in AMI, controversy remains regarding the disparity in prognosis between previously diagnosed DM (known-DM) and newly diagnosed DM (new-DM).

METHODS

The study included 10,455 patients with AMI (non-DM, 6,236; new-DM, 659; known-DM, 3,560) admitted to one of 15 participating centers in Korea between November 2011 and January 2016 (average follow-up, 523 days). We compared the characteristics and clinical course of patients with known-DM and those with new- or non-DM.

RESULTS

Compared to patients with known-DM, those with new-DM or non-DM were younger, more likely to be male, and less likely to have hypertension, dyslipidemia, prior stroke, angina, or myocardial infarction. Compared to patients with new-DM or non-DM (reference), those with known-DM had higher risks of major adverse cardiac events (hazard ratio [HR], 1.20; 95% confidence interval [CI], 1.06-1.35; p=0.004), cardiac death (HR, 1.26; 95% CI, 1.01-1.57; p=0.042), and congestive heart failure (HR, 1.58; 95% CI, 1.20-2.08). Unlike known-DM, new-DM did not increase the risk of cardiac events (including death).

CONCLUSIONS

Known-DM was associated with a significantly higher risk of cardiovascular events after AMI, while new-DM had a similar risk of cardiac events as that noted for non-DM. There were different cardiovascular outcomes according to diabetes status in patients with AMI.

Rotational atherectomy and new-generation drug-eluting stent implantation

OBJECTIVES

The aim of this study was to evaluate the clinical outcomes of rotational atherectomy (RA) followed by new-generation drug-eluting stent (DES) implantation in patients with an extensive amount of calcified and fibrotic plaque.

BACKGROUND

RA followed by new-generation DES implantation for complex lesions has not been thoroughly evaluated.

METHODS

A total of 744 consecutive patients (770 lesions) treated with new-generation DES implantation following RA for de novo lesions between January 2013 and November 2015 were retrospectively identified using our institutional database. Clinical outcomes at 12 months were evaluated and the independent predictors of all-cause death and target vessel failure (TVF) were assessed using Cox regression models.

RESULTS

Target lesion revascularization occurred in 22 lesions (2.9%) and TVF occurred in 51 lesions (6.6%). In a multivariate analysis, hemodialysis, non-ST-segment elevation acute coronary syndrome, low ejection fraction, and HbA1c ≧ 7% were associated with 12-month mortality. Hemodialysis and right coronary artery were identified as independent predictors of TVF (hazard ratio (HR) 4.107, 95% confidence interval (CI) 2.194-7.685, P < .001; HR 2.491, 95% CI 1.023-6.062, P = .044, respectively).

CONCLUSIONS

A good debulking with RA followed by new-generation DES implantation is recommended for patients with an excessive amount of calcified and fibrotic plaque, as this will likely improve the clinical outcomes.

Revascularization for Advanced Coronary Artery Disease in Type 2 Diabetic Patients: Choosing Wisely Between PCI and Surgery

PURPOSE OF REVIEW

Patients with type 2 diabetes mellitus (T2DM) are at an increased risk of systemic atherosclerosis and advanced coronary artery disease (CAD). Herein, we review clinical trials comparing surgical to percutaneous revascularization in the context of the unique pathophysiology in this patient population, and seek to answer the question of optimal strategy of revascularization.

RECENT FINDINGS

Early studies showed a signal towards benefit of surgical revascularization over percutaneous revascularization in this group, but there was a paucity of randomized clinical trials (RCT) to directly support this finding. The Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM), a large-scale international RCT, was then undertaken and established the benefit of coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI) in terms of mortality, myocardial infarction and repeat revascularization; CABG was inferior to PCI with regards to stroke. The quality of life and cost effectiveness also demonstrated a long-term benefit for surgery. The decision as to choice of mode of revascularization in patients with T2DM and advanced CAD depends upon a multitude of factors, including the coronary anatomy, co-morbidities and the patient's surgical risk. These factors influence the recommendation of the cardiovascular team, which should result in a balanced presentation of the short and long-term risks and benefits of either mode of revascularization to the patient and his/her family.

Comparison of clinical outcomes after drug-eluting stent implantation in diabetic versus nondiabetic patients in China: A retrospective study

Diabetes mellitus (DM) has been proved to be a predictor of adverse outcomes after percutaneous coronary intervention (PCI). Drug-eluting stents (DESs) could reduce the adverse events in DM patients. In this study, we aimed to analyze the clinical outcome after DES implantation in diabetic versus nondiabetic patients in China. Totally, 200 Chinese DM patients and 400 Chinese non-DM patients were enrolled in this retrospective study. Compared with non-DM patients, DM patients were more likely to have a higher incidence of cardiac death (3.5% vs. 1.0%, P = .048), stent thrombosis (2.5% vs. 0.5%, P = .044), target lesion revascularization (6.0% vs. 1.8%, P = .005), target vessel failure (15.5% vs. 8.0%, P < .001), target lesion failure (14.0% vs. 4.3%, P < .001), myocardial infarction (4.5% vs. 1.5%, P = .030), and major adverse cardiac events (12.5% vs. 5.0%, P = .001) at 2-year follow-up. However, the incidence of target vessel revascularization (7.5% vs. 5.5%, P = .340) was similar between DB and non-DB patients. Patients with DB (hazard ratio [HR] = 2.54, P = .001), older than 80 years (HR = 1.33, P = .027) with hypercholesterolemia (HR = 1.03, P < .001), serum creatinine >177 μmol/L (HR = 3.04, P = .011), a history of cerebral vascular accident (HR = 4.29, P = .010), or a history of myocardial infarction (HR = 31.4, P < .001) were more likely to experience adverse events. In China, DM could also be served as an independent predictor of adverse outcomes after DES implantation. These patients should be reexamined more frequently.

Optimal approaches to diabetic patients with multivessel disease

The pathophysiology of diabetes and systemic insulin resistance contributes to the nature of diffuse atherosclerosis and a high prevalence of multivessel coronary artery disease (CAD) in diabetic patients. The optimal approach to this patient population remains a subject of an ongoing discussion. In this review, we give an overview of the unique pathophysiology of CAD in patients with diabetes, summarize the current state of therapies available, and compare modalities of revascularization that have been investigated in recent clinical trials. We conclude by highlighting the importance of a comprehensive heart team approach to every patient while accommodating both patient preference and quality-of-life decisions.

Management of acute coronary syndrome in special subgroups: female, older, diabetic and Indigenous patients

While the evidence base for management of acute coronary syndrome (ACS) is extensive, some subgroups have been underrepresented or excluded from relevant clinical trials. These subgroups - such as women, older people, diabetic patients and Indigenous Australians - present clinical challenges for which there is limited evidence to guide optimal therapy. Women may have a different pattern of presentation, with potential for delays in diagnosis and worse outcomes in ST-elevation myocardial infarction, but there is no evidence that treatments affect them differently from men. Older people suffer from a high-risk, low-treatment paradox. This may be due to under-appreciation of the benefits of treatments for older people, or to good clinical judgement in avoiding harm from worsening age-related comorbidities. Patients with diabetes have a high risk of ACS and suffer worse outcomes. Moderate glycaemic control with close monitoring and avoidance of hypoglycaemia are recommended. Coronary artery bypass grafting is preferred to percutaneous coronary intervention for patients with diabetes and multivessel disease, although the latter is reasonable in single-vessel disease. Indigenous patients have a high prevalence of coronary disease, with more frequent coronary events at a young age, a heavy load of risk factors and poor outcomes after ACS. The complex sociocultural barriers to treatment are yet to be addressed adequately.

The complementary effects of atorvastatin and exercise treatment on the composition and stability of the atherosclerotic plaques in ApoE knockout mice

Aim

This study aimed to investigate the effects of combined atorvastatin and exercise treatment on the composition and stability of the atherosclerotic plaques in apolipoproteinE (apoE) knockout mice.

Methods

Forty male, apoE^−/− mice were fed a high-fat diet for 16 weeks. Thereafter, while maintained on high-fat diet, they were randomized into four (n = 10) groups for 8 additional weeks: Group CO: Control. Group AT: Atorvastatin treatment (10 mg/Kg/day). Group EX: Exercise-training on treadmill. Group AT+EX: Atorvastatin and simultaneous exercise training. At the study’s end, plasma cholesterol levels, lipids and triglycerides were measured, along with the circulating concentrations of matrix-metalloproteinases (MMP-2,3,8,9) and their inhibitors (TIMP-1,2,3). Plaque area and the relative concentrations of collagen, elastin, macrophages, smooth muscle cells, MMP-2,3,8,9 and TIMP-1,2,3 within plaques were determined. Lastly, MMP activity was assessed in the aortic arch.

Results

All intervention groups showed a lower degree of lumen stenosis, with atheromatous plaques containing more collagen and elastin. AT+EX group had less stenosis and more elastin compared to single intervention groups. MMP-3,-8 -9 and macrophage intra-plaque levels were reduced in all intervention groups. EX group had increased TIMP-1 levels within the lesions, while TIMP-2 was decreased in all intervention groups. The blood levels of the above molecules increased during atherosclerosis development, but they did not change after the therapeutic interventions in accordance to their intra-plaque levels.

Conclusion

The two therapeutic strategies act with synergy regarding the extent of the lesions and lumen stenosis. They stabilize the plaque, increasing its content in elastin and collagen, by influencing the MMP/TIMP equilibrium, which is mainly associated with the macrophage amount. While the increased MMP-2,-3,-8 -9, as well as TIMP-1 and TIMP-2 circulating levels are markers of atherosclerosis, they are not correlated with their corresponding concentrations within the lesions after the therapeutic interventions, and cannot serve as markers for the disease development/amelioration.

Concomitant diabetes mellitus and heart failure

The prevalence of patients with concomitant diabetes mellitus (DM) and heart failure (HF) is growing exponentially. Patients with HF and DM show specific metabolic, neurohormonal, and structural heart abnormalities, which potentially contribute to worse HF outcomes than seen in patients without comorbid DM. Subgroup analysis of recent trials suggest that patients with HF and DM may respond differently to standard therapy, and data are emerging on the possible increase in the risk of hospitalizations for HF in patients with DM treated with specific class of antidiabetic agents, pointing to the need of developing specific medications to be tested in dedicated future studies to address the unique metabolic and hemodynamic alterations seen in these patients.

Interventions for coronary artery disease (surgery vs angioplasty) in diabetic patients

Patients with diabetes develop more widespread and more severe atherosclerotic coronary artery disease than patients without diabetes. Medical management of this coronary disease is inferior to revascularization for more complex or more widespread disease. Revascularization by percutaneous intervention (PCI) for patients with diabetes is associated with high mortality and complication rates. Surgical revascularization by coronary artery bypass grafting, yields superior results to PCI for patients with diabetes and coronary artery disease. Patients with diabetes benefit from the same medical management of their coronary artery disease and secondary risk modification as patients without diabetes.

Impact of plaque composition on long-term clinical outcomes in patients with coronary artery occlusive disease

BACKGROUND AND OBJECTIVES

It is unclear which plaque component is related with long-term clinical outcomes in patients with coronary artery occlusive disease (CAOD). We assessed the relationship between plaque compositions and long-term clinical outcomes in those patients.

SUBJECTS AND METHODS

The study subjects consisted of 339 consecutive patients (mean 61.7±12.2 years old, 239 males) who underwent coronary angiogram and a virtual histology-intravascular ultrasound examination. Major adverse cardiac and cerebrovascular events (MACCE), including all-cause death, non-fatal myocardial infarction, cerebrovascular events, and target vessel revascularization were evaluated during a mean 28-month follow-up period.

RESULTS

Patients with high fibrofatty volume (FFV, >8.90 mm(3), n=169) had a higher incidence of MACCE (25.4% vs. 14.7%, p=0.015), male sex (75.7% vs. 65.3%, p=0.043), acute coronary syndrome (53.3% vs. 35.9%, p=0.002), multivessel disease (62.7% vs. 41.8%, p<0.001) and post-stent slow flow (10.7% vs. 2.4%, p=0.002) than those with low FFV (FFV≤8.90 mm(3), n=170). Other plaque composition factors such as fibrous area/volume, dense calcified area/volume, and necrotic core area/volume did not show any impact on MACCE. Cardiogenic shock {hazard ratio (HR)=8.44; 95% confidence interval (CI)=3.00-23.79; p<0.001} and FFV (HR=1.85; 95% CI=1.12-3.07; p=0.016) were the independent predictors of MACCE by Cox regression analysis. Thin-cap fibroatheroma, necrotic core area, and necrotic core volume were not associated with MACCE.

CONCLUSION

FFV of a culprit lesion was associated with unfavorable long-term clinical outcomes in patients with CAOD.

Update on type 2 diabetes as a cardiovascular disease risk equivalent

Type 2 diabetes increases the risk of cardiovascular disease (CVD) from two- to four-fold. In our large Finnish population-based study published in 1998 subjects with medication for type 2 diabetes had as high a risk of fatal and nonfatal myocardial infarction (MI) during the 7- year follow-up as non-diabetic subjects with a prior MI, suggesting that type 2 diabetes is a CVD equivalent. In another large study, including all 3.3 million residents of Denmark, subjects requiring glucose-lowering therapy exhibited a CVD risk similar to that of non-diabetic subjects with a prior MI. Subsequent studies have not systematically replicated aforementioned results. Some studies have supported the concept that type 2 diabetes is a CVD equivalent only in some subgroups, and many studies have reported negative findings. This is likely to be due to many differences across the studies published, for example ethnicity, gender, age and other demographic factors of the populations involved, study design, validation of diabetes status and CVD events, statistical analyses (adjustments for confounding factors), duration of diabetes, and treatment of hyperglycemia among diabetic participants. Varying results reflect the fact that not all diabetic patients are at a similar risk for CVD. Therefore, CVD risk assessment and the tailoring of preventive measures should be done individually, taking into consideration each patient's long-term risk of developing cardiovascular events.

Diabetes alters activation and repression of pro- and anti-inflammatory signaling pathways in the vasculature

A central mechanism driving vascular disease in diabetes is immune cell-mediated inflammation. In diabetes, enhanced oxidation and glycation of macromolecules, such as lipoproteins, insults the endothelium, and activates both innate and adaptive arms of the immune system by generating new antigens for presentation to adaptive immune cells. Chronic inflammation of the endothelium in diabetes leads to continuous infiltration and accumulation of leukocytes at sites of endothelial cell injury. We will describe the central role of the macrophage as a source of signaling molecules and damaging by-products which activate infiltrating lymphocytes in the tissue and contribute to the pro-oxidant and pro-inflammatory microenvironment. An important aspect to be considered is the diabetes-associated defects in the immune system, such as fewer or dysfunctional athero-protective leukocyte subsets in the diabetic lesion compared to non-diabetic lesions. This review will discuss the key pro-inflammatory signaling pathways responsible for leukocyte recruitment and activation in the injured vessel, with particular focus on pro- and anti-inflammatory pathways aberrantly activated or repressed in diabetes. We aim to describe the interaction between advanced glycation end products and their principle receptor RAGE, angiotensin II, and the Ang II type 1 receptor, in addition to reactive oxygen species (ROS) production by NADPH-oxidase enzymes that are relevant to vascular and immune cell function in the context of diabetic vasculopathy. Furthermore, we will touch on recent advances in epigenetic medicine that have revealed high glucose-mediated changes in the transcription of genes with known pro-inflammatory downstream targets. Finally, novel anti-atherosclerosis strategies that target the vascular immune interface will be explored; such as vaccination against modified low-density lipoprotein and pharmacological inhibition of ROS-producing enzymes.

Review of guidelines on primary prevention of cardiovascular disease with aspirin: how much evidence is needed to turn a tanker?

AIMS

There are numerous national and international guidelines on the use of aspirin for the primary prevention of cardiovascular disease. Given the uncertainties about aspirin in primary prevention, our aim was to compare the recommendations and the reported evidence in guidelines for the treatment with aspirin of subjects free of cardiovascular disease with or without diabetes.

METHODS AND RESULTS

Guidelines were retrieved through Medline and other electronic databases and through a web-based search for guideline development organizations. The content of the recommendations and the underlying evidence were analysed with qualitative and bibliometric methods. In addition, we searched for recent studies to assess whether they underscore the current recommendations. We included 12 guidelines: six European, three North American, and one each from New Zealand, Australia, and the World Health Organization. Recommendations differ with regard to outcome (morbidity, mortality), time span (years of risk), cut-off percentage between high and low risk, and the dose of aspirin. Most guidelines are not in line with recent evidence, which show that aspirin is of uncertain net value as the reduction in absolute risk for occlusive CV events needs to be weighed against an increase in the risk of major bleeds.

CONCLUSION

We found conflicting recommendations in various guidelines about the use of aspirin for the primary prevention of cardiovascular events, which reflect differences in selection of the evidence and in the timing of publication. According to recent evidence, in general, the use of aspirin seems no longer justifiable in primary prevention in patients with or without diabetes.