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Minguito-Carazo C, Sánchez Muñoz E, Rodríguez Mañero M, Martínez-Sande JL, Fidalgo Andrés ML, García Seara J, González Rebollo JM, Rodríguez Santamarta M, González Melchor L, González Ferrero T, Romero Roche L, Fernández López JA, Tundidor Sanz E, Fernández Vázquez F, González-Juanatey JR. Impact of initiation of SGLT2 inhibitor treatment on the development of arrhythmias in patients with implantable cardiac devices. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:481-489. [PMID: 38246269 DOI: 10.1016/j.rec.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024]
Abstract
INTRODUCTION AND OBJECTIVES Sodium-glucose cotransporter type 2 inhibitors (SGLT2i) have been associated with improved prognosis in patients with heart failure, but their impact on atrial arrhythmic (AA) and ventricular arrhythmic (VA) events is not fully understood. METHODS This multicenter retrospective study included patients with implantable cardioverter-defibrillators who initiated treatment with SGLT2i. AA and VA events were compared in 2 time periods for each patient: 1 year before and 1 year after starting SGLT2i. RESULTS The study included 195 patients (66.8 [61.3-73.1] years, 18.5% women). In the post-SGLT2i period, there was a reduction in the percentage of patients with any VA (pre: 52.3% vs post: 30.3%; P<.001) and clinically relevant VA (excluding nonsustained ventricular tachycardia) (pre: 21.5% vs post: 8.7%; P<.001). There was also a decrease in the number of episodes per patient/y of nonsustained ventricular tachycardia (pre: 2 (1-5) vs post: 1 (0-2); P<.001) and sustained ventricular tachycardia (pre: 1 (1-3) vs post: 0 (0-2); P=0.046). However, no differences were observed in the prevalence of AA (24.7% vs 18.8%; P=.117) or the burden of atrial fibrillation (pre: 0% (0-0.1) vs post: 0% (0-0); P=.097). CONCLUSIONS Initiation of SGLT2i treatment was associated with a decrease in the percentage of patients with relevant VA but this effect was not observed for AA.
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Affiliation(s)
- Carlos Minguito-Carazo
- Servicio de Cardiología, Hospital Universitario de Santiago de Compostela (CHUS), Santiago de Compostela, A Coruña, Spain.
| | | | - Moisés Rodríguez Mañero
- Servicio de Cardiología, Hospital Universitario de Santiago de Compostela (CHUS), Santiago de Compostela, A Coruña, Spain; Grupo de Cardiología Traslacional, Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santiago de Compostela, A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - José Luis Martínez-Sande
- Servicio de Cardiología, Hospital Universitario de Santiago de Compostela (CHUS), Santiago de Compostela, A Coruña, Spain
| | | | - Javier García Seara
- Servicio de Cardiología, Hospital Universitario de Santiago de Compostela (CHUS), Santiago de Compostela, A Coruña, Spain
| | | | | | - Laila González Melchor
- Servicio de Cardiología, Hospital Universitario de Santiago de Compostela (CHUS), Santiago de Compostela, A Coruña, Spain
| | - Teba González Ferrero
- Servicio de Cardiología, Hospital Universitario de Santiago de Compostela (CHUS), Santiago de Compostela, A Coruña, Spain
| | - Laura Romero Roche
- Servicio de Cardiología, Complejo Asistencial Universitario de León, León, Spain
| | - Jesús Alberto Fernández López
- Servicio de Cardiología, Hospital Universitario de Santiago de Compostela (CHUS), Santiago de Compostela, A Coruña, Spain
| | - Elena Tundidor Sanz
- Servicio de Cardiología, Complejo Asistencial Universitario de León, León, Spain
| | | | - José Ramón González-Juanatey
- Servicio de Cardiología, Hospital Universitario de Santiago de Compostela (CHUS), Santiago de Compostela, A Coruña, Spain; Grupo de Cardiología Traslacional, Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santiago de Compostela, A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
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2
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Frederiksen TC, Benjamin EJ, Trinquart L, Lin H, Dahm CC, Christiansen MK, Jensen HK, Preis SR, Kornej J. Bidirectional Association Between Atrial Fibrillation and Myocardial Infarction, and Relation to Mortality in the Framingham Heart Study. J Am Heart Assoc 2024:e032226. [PMID: 38780172 DOI: 10.1161/jaha.123.032226] [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: 10/13/2023] [Accepted: 01/11/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Individuals with both atrial fibrillation (AF) and myocardial infarction (MI) have higher mortality compared with individuals with only 1 condition. Whether mortality differs according to the temporal order of AF and MI is unclear. METHODS AND RESULTS We included participants from the FHS (Framingham Heart Study) from 1960 and onwards. We assessed the hazard ratio (HR) of new-onset AF and MI, and mortality according to MI and AF status (prevalent and interim) using multivariable-adjusted Cox proportional hazards models. Interim diseases were modeled as time-varying variables. For the analysis of new-onset AF, 10 923 participants (55% women; mean±SD age, 54±8 years) were included. For new-onset MI, 10 804 participants (55% women; mean±SD age, 54±8 years) were included. Compared with no MI, the hazard of new-onset AF was higher in participants with prevalent (HR, 1.60 [95% CI, 1.32-1.94]) and interim MI (HR, 3.96 [95% CI, 3.18-4.91]). Both ST-segment-elevation MI and non-ST-segment-elevation MI were associated with new-onset AF. Interim AF, not prevalent AF, was associated with higher hazard rate of new-onset MI (HR, 2.21 [95% CI, 1.67-2.92]). Interim AF was associated with both ST-segment-elevation MI and non-ST-segment-elevation MI. Mortality was significantly greater among participants with AF and MI compared with participants with 1 of the 2, regardless of temporal order. CONCLUSIONS We report a bidirectional association between AF and MI, which was observed for both non-ST-segment-elevation MI and ST-segment-elevation MI. Participants with both AF and MI had considerably higher mortality compared with participants with only 1 of the 2 conditions, regardless of order.
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Affiliation(s)
- Tanja Charlotte Frederiksen
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine, Health Aarhus University Aarhus Denmark
| | - Emelia J Benjamin
- Department of Epidemiology Boston University School of Public Health Boston MA
- Section of Cardiovascular Medicine Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine Boston MA
- National Heart, Lung, and Blood Institute and Boston University's FHS (Framingham Heart Study) Framingham MA
| | - Ludovic Trinquart
- Institute for Clinical Research and Health Policy Studies Tufts Medical Center Boston MA
- Tufts Clinical and Translational Science Institute Tufts University Boston MA
| | - Honghuang Lin
- Department of Medicine University of Massachusetts Chan Medical School Worcester MA
| | | | | | - Henrik Kjærulf Jensen
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine, Health Aarhus University Aarhus Denmark
| | - Sarah R Preis
- National Heart, Lung, and Blood Institute and Boston University's FHS (Framingham Heart Study) Framingham MA
- Department of Biostatistics Boston University School of Public Health Boston MA
| | - Jelena Kornej
- Section of Cardiovascular Medicine Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine Boston MA
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3
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Villaschi A, Cesani N, Chiarito M. SGLT2 inhibitors: a therapy for everybody but not for anything? Eur J Prev Cardiol 2024; 31:768-769. [PMID: 38057154 DOI: 10.1093/eurjpc/zwad372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 12/04/2023] [Indexed: 12/08/2023]
Affiliation(s)
- Alessandro Villaschi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20072 Pieve Emanuele, Milan, Italy
- Cardio Center, IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089 Rozzano, Milan, Italy
| | - Nicola Cesani
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20072 Pieve Emanuele, Milan, Italy
- Cardio Center, IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089 Rozzano, Milan, Italy
| | - Mauro Chiarito
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20072 Pieve Emanuele, Milan, Italy
- Cardio Center, IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089 Rozzano, Milan, Italy
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4
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Zhang HD, Ding L, Mi LJ, Zhang AK, Zhang K, Jiang ZH, Yu FY, Yan XX, Shen YJ, Tang M. Sodium-glucose co-transporter-2 inhibitors for the prevention of atrial fibrillation: a systemic review and meta-analysis. Eur J Prev Cardiol 2024; 31:770-779. [PMID: 37966828 DOI: 10.1093/eurjpc/zwad356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 10/22/2023] [Accepted: 11/09/2023] [Indexed: 11/16/2023]
Abstract
AIMS Sodium-glucose co-transporter-2 (SGLT2) inhibitors are reported to have cardiac benefits. The effects of SGLT2 inhibitors on the prevention of atrial fibrillation (AF) remain inconclusive. We aimed to investigate whether SGLT2 inhibitors can prevent AF occurrence in patients with cardiometabolic diseases. METHODS AND RESULTS We searched MEDLINE, EMBASE, and the Cochrane CENTRAL database up to 1 July 2023. Randomized, placebo-controlled trials of SGLT2 inhibitors in patients with diabetes, heart failure, chronic kidney diseases (CKDs), or cardiometabolic risk factors were included. The primary outcome was AF occurrence. Relative risks (RRs) with 95% confidence intervals (CIs) were calculated in the overall population and selected subgroups. Forty-six trials comprising 101 100 patients were included. Overall, no significant risk reduction of AF occurrence was observed with SGLT2 inhibitors, although there was a favourable trend (RR 0.90, 95% CI 0.80-1.01). In trials with follow-up durations of over 1 year, a similar result was achieved (RR 0.90, 95% CI 0.80-1.01). The results were consistent across different SGLT2 inhibitors, with RRs (95% CIs) of 0.82 (0.60-1.12) for canagliflozin, 0.87 (0.73-1.03) for dapagliflozin, 0.97 (0.78-1.22) for empagliflozin, 0.99 (0.66-1.50) for sotagliflozin, and 0.87 (0.58-1.29) for ertugliflozin. Analyses in different doses of SGLT2 inhibitors yielded similar results. The associations between SGLT2 inhibitors and AF occurrence were also absent in patients with diabetes, heart failure, and CKDs. CONCLUSION For patients with cardiometabolic diseases or risk factors, SGLT2 inhibitors did not decrease the risk of AF occurrence, regardless of follow-up duration, type or dose of the drug, or the patient population.
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Affiliation(s)
- Hong-Da Zhang
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Fuwai Hospital, 167 Beilishi Road, Xicheng District, Beijing 100037, China
| | - Lei Ding
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Fuwai Hospital, 167 Beilishi Road, Xicheng District, Beijing 100037, China
| | - Li-Jie Mi
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Fuwai Hospital, 167 Beilishi Road, Xicheng District, Beijing 100037, China
| | - Ai-Kai Zhang
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Fuwai Hospital, 167 Beilishi Road, Xicheng District, Beijing 100037, China
| | - Kuo Zhang
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Fuwai Hospital, 167 Beilishi Road, Xicheng District, Beijing 100037, China
| | - Zi-Han Jiang
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Fuwai Hospital, 167 Beilishi Road, Xicheng District, Beijing 100037, China
| | - Feng-Yuan Yu
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Fuwai Hospital, 167 Beilishi Road, Xicheng District, Beijing 100037, China
| | - Xin-Xin Yan
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Fuwai Hospital, 167 Beilishi Road, Xicheng District, Beijing 100037, China
| | - Yu-Jing Shen
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Fuwai Hospital, 167 Beilishi Road, Xicheng District, Beijing 100037, China
| | - Min Tang
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Fuwai Hospital, 167 Beilishi Road, Xicheng District, Beijing 100037, China
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5
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Preda A, Montecucco F, Carbone F, Camici GG, Lüscher TF, Kraler S, Liberale L. SGLT2 inhibitors: from glucose-lowering to cardiovascular benefits. Cardiovasc Res 2024; 120:443-460. [PMID: 38456601 DOI: 10.1093/cvr/cvae047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/03/2024] [Accepted: 02/05/2024] [Indexed: 03/09/2024] Open
Abstract
An increasing number of individuals are at high risk of type 2 diabetes (T2D) and its cardiovascular complications, including heart failure (HF), chronic kidney disease (CKD), and eventually premature death. The sodium-glucose co-transporter-2 (SGLT2) protein sits in the proximal tubule of human nephrons to regulate glucose reabsorption and its inhibition by gliflozins represents the cornerstone of contemporary T2D and HF management. Herein, we aim to provide an updated overview of the pleiotropy of gliflozins, provide mechanistic insights and delineate related cardiovascular (CV) benefits. By discussing contemporary evidence obtained in preclinical models and landmark randomized controlled trials, we move from bench to bedside across the broad spectrum of cardio- and cerebrovascular diseases. With landmark randomized controlled trials confirming a reduction in major adverse CV events (MACE; composite endpoint of CV death, non-fatal myocardial infarction, and non-fatal stroke), SGLT2 inhibitors strongly mitigate the risk for heart failure hospitalization in diabetics and non-diabetics alike while conferring renoprotection in specific patient populations. Along four major pathophysiological axes (i.e. at systemic, vascular, cardiac, and renal levels), we provide insights into the key mechanisms that may underlie their beneficial effects, including gliflozins' role in the modulation of inflammation, oxidative stress, cellular energy metabolism, and housekeeping mechanisms. We also discuss how this drug class controls hyperglycaemia, ketogenesis, natriuresis, and hyperuricaemia, collectively contributing to their pleiotropic effects. Finally, evolving data in the setting of cerebrovascular diseases and arrhythmias are presented and potential implications for future research and clinical practice are comprehensively reviewed.
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Affiliation(s)
- Alberto Preda
- Department of Clinical Cardiology, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Fabrizio Montecucco
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
| | - Federico Carbone
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
| | - Giovanni G Camici
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland
- Department of Research and Education, University Hospital Zurich, Zurich, Switzerland
| | - Thomas F Lüscher
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland
- Royal Brompton and Harefield Hospitals and Imperial College and King's College, London, United Kingdom
| | - Simon Kraler
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland
- Department of Internal Medicine, Cantonal Hospital Baden, Baden, Switzerland
| | - Luca Liberale
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
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6
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Ballatore A, Gatti M, Mella S, Tore D, Xhakupi H, Giorgino F, Saglietto A, Carmagnola L, Roagna E, De Ferrari GM, Faletti R, Anselmino M. Epicardial Atrial Fat at Cardiac Magnetic Resonance Imaging and AF Recurrence after Transcatheter Ablation. J Cardiovasc Dev Dis 2024; 11:137. [PMID: 38786958 PMCID: PMC11122251 DOI: 10.3390/jcdd11050137] [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: 03/20/2024] [Revised: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 05/25/2024] Open
Abstract
The relationship between epicardial adipose tissue (EAT) and atrial fibrillation (AF) has gained interest in recent years. The previous literature on the topic presents great heterogeneity, focusing especially on computed tomography imaging. The aim of the present study is to determine whether an increased volume of left atrial (LA) EAT evaluated at routine pre-procedural cardiac magnetic resonance imaging (MRI) relates to AF recurrences after catheter ablation. A total of 50 patients undergoing AF cryoballoon ablation and pre-procedural cardiac MRI allowing quantification of LA EAT were enrolled. In one patient, the segmentation of LA EAT could not be achieved. After a median follow-up of 16.0 months, AF recurrences occurred in 17 patients (34%). The absolute volume of EAT was not different in patients with and without AF recurrences (10.35 mL vs. 10.29 mL; p-value = 0.963), whereas the volume of EAT indexed on the LA volume (EATi) was lower, albeit non-statistically significant, in patients free from arrhythmias (12.77% vs. 14.06%; p-value = 0.467). The receiver operating characteristic curve testing the ability of LA EATi to predict AF recurrence after catheter ablation showed sub-optimal performance (AUC: 0.588). The finest identified cut-off of LA EATi was 10.65%, achieving a sensitivity of 0.5, a specificity of 0.82, a positive predictive value of 0.59 and a negative predictive value of 0.76. Patients with values of LA EATi lower than 10.65% showed greater survival, free from arrhythmias, than patients with values above this cut-off (84% vs. 48%; p-value = 0.04). In conclusion, EAT volume indexed on the LA volume evaluated at cardiac MRI emerges as a possible independent predictor of arrhythmia recurrence after AF cryoballoon ablation. Nevertheless, prospective studies are needed to confirm this finding and eventually sustain routine EAT evaluation in the management of patients undergoing AF catheter ablation.
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Affiliation(s)
- Andrea Ballatore
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, 10126 Turin, Italy (L.C.); (E.R.)
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy;
| | - Marco Gatti
- Radiology Unit, Department of Diagnostic Imaging and Interventional Radiology, “Città della Salute e della Scienza” Hospital, 10126 Turin, Italy; (M.G.); (R.F.)
- Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
| | - Serena Mella
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy;
| | - Davide Tore
- Radiology Unit, Department of Diagnostic Imaging and Interventional Radiology, “Città della Salute e della Scienza” Hospital, 10126 Turin, Italy; (M.G.); (R.F.)
- Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
| | - Henri Xhakupi
- Dipartimento di Medicina Interna, Università Degli Studi di Genova, 16126 Genoa, Italy
| | - Fabio Giorgino
- Radiology Unit, Department of Diagnostic Imaging and Interventional Radiology, “Città della Salute e della Scienza” Hospital, 10126 Turin, Italy; (M.G.); (R.F.)
- Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
| | - Andrea Saglietto
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, 10126 Turin, Italy (L.C.); (E.R.)
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy;
| | - Ludovica Carmagnola
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, 10126 Turin, Italy (L.C.); (E.R.)
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy;
| | - Edoardo Roagna
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, 10126 Turin, Italy (L.C.); (E.R.)
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy;
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, 10126 Turin, Italy (L.C.); (E.R.)
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy;
| | - Riccardo Faletti
- Radiology Unit, Department of Diagnostic Imaging and Interventional Radiology, “Città della Salute e della Scienza” Hospital, 10126 Turin, Italy; (M.G.); (R.F.)
- Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
| | - Matteo Anselmino
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, 10126 Turin, Italy (L.C.); (E.R.)
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy;
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7
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Tzeis S, Gerstenfeld EP, Kalman J, Saad E, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01771-5. [PMID: 38609733 DOI: 10.1007/s10840-024-01771-5] [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] [Indexed: 04/14/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.
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Affiliation(s)
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Nikolaos Dagres
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Gerhard Hindricks
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | - Gregory F Michaud
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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Tzeis S, Gerstenfeld EP, Kalman J, Saad E, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. European Heart Rhythm Association (EHRA)/Heart Rhythm Society (HRS)/Asia Pacific Heart Rhythm Society (APHRS)/Latin American Heart Rhythm Society (LAHRS) expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2024:S1547-5271(24)00261-3. [PMID: 38597857 DOI: 10.1016/j.hrthm.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 04/11/2024]
Affiliation(s)
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital and Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil and Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, California, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France and Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, USA
| | - Ngai-Yin Chan
- Department of Medicine & Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Nikolaos Dagres
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Cardiac Electrophysiology and Stimulation Department, Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Katia Dyrda
- Department of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Gerhard Hindricks
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Cardiac Electrophysiology and Stimulation Department, Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, and Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas and Case Western Reserve University, Cleveland, Ohio and Interventional Electrophysiology, Scripps Clinic, San Diego, California, USA
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología «Ignacio Chávez», Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, USA
| | - Kevin L Thomas
- Duke University Medical Center, Durham, North Carolina, USA
| | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Sepehri Shamloo A, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O’Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace 2024; 26:euae043. [PMID: 38587017 PMCID: PMC11000153 DOI: 10.1093/europace/euae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 04/09/2024] Open
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología ‘Ignacio Chávez’, Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O’Neill
- Cardiovascular Directorate, St. Thomas’ Hospital and King’s College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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Oraii A, Healey JS, Kowalik K, Pandey AK, Benz AP, Wong JA, Conen D, McIntyre WF. Mineralocorticoid receptor antagonists and atrial fibrillation: a meta-analysis of clinical trials. Eur Heart J 2024; 45:756-774. [PMID: 38195054 DOI: 10.1093/eurheartj/ehad811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/05/2023] [Accepted: 11/28/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND AND AIMS Mineralocorticoid receptor antagonists (MRAs) improve cardiovascular outcomes in a variety of settings. This study aimed to assess whether cardioprotective effects of MRAs are modified by heart failure (HF) and atrial fibrillation (AF) status and to study their impact on AF events. METHODS MEDLINE, Embase, and Cochrane Central databases were searched to 24 March 2023 for randomized controlled trials evaluating the efficacy of MRAs as compared with placebo or usual care in reducing cardiovascular outcomes and AF events in patients with or at risk for cardiovascular diseases. Random-effects models and interaction analyses were used to test for effect modification. RESULTS Meta-analysis of seven trials (20 741 participants, mean age: 65.6 years, 32% women) showed that the efficacy of MRAs, as compared with placebo, in reducing a composite of cardiovascular death or HF hospitalization remains consistent across patients with HF [risk ratio = 0.81; 95% confidence interval (CI): 0.67-0.98] and without HF (risk ratio = 0.84; 95% CI: 0.75-0.93; interaction P = .77). Among patients with HF, MRAs reduced cardiovascular death or HF hospitalization in patients with AF (hazard ratio = 0.95; 95% CI: 0.54-1.66) to a similar extent as in those without AF (hazard ratio = 0.82; 95% CI: 0.63-1.07; interaction P = .65). Pooled data from 20 trials (21 791 participants, mean age: 65.2 years, 31.3% women) showed that MRAs reduce AF events (risk ratio = 0.76; 95% CI: 0.67-0.87) in both patients with and without prior AF. CONCLUSIONS Mineralocorticoid receptor antagonists are similarly effective in preventing cardiovascular events in patients with and without HF and most likely retain their efficacy regardless of AF status. Mineralocorticoid receptor antagonists may also be moderately effective in preventing incident or recurrent AF events.
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Affiliation(s)
- Alireza Oraii
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
- Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
| | - Krzysztof Kowalik
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Avinash K Pandey
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Alexander P Benz
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
| | - Jorge A Wong
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
- Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
| | - David Conen
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
- Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
| | - William F McIntyre
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
- Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
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11
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Fichadiya A, Quinn A, Au F, Campbell D, Lau D, Ronksley P, Beall R, Campbell DJT, Wilton SB, Chew DS. Association between sodium-glucose cotransporter-2 inhibitors and arrhythmic outcomes in patients with diabetes and pre-existing atrial fibrillation. Europace 2024; 26:euae054. [PMID: 38484180 PMCID: PMC10939462 DOI: 10.1093/europace/euae054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 02/16/2024] [Indexed: 03/18/2024] Open
Abstract
AIMS Prior studies suggest that sodium-glucose cotransporter-2 inhibitors (SGLT2is) may decrease the incidence of atrial fibrillation (AF). However, it is unknown whether SGLT2i can attenuate the disease course of AF among patients with pre-existing AF and Type II diabetes mellitus (DM). In this study, our objective was to examine the association between SGLT2i prescription and arrhythmic outcomes among patients with DM and pre-existing AF. METHODS AND RESULTS We conducted a population-based cohort study of adults with DM and AF between 2014 and 2019. Using a prevalent new-user design, individuals prescribed SGLT2i were matched 1:1 to those prescribed dipeptidyl peptidase-4 inhibitors (DPP4is) based on time-conditional propensity scores. The primary endpoint was a composite of AF-related healthcare utilization (i.e. hospitalization, emergency department visits, electrical cardioversion, or catheter ablation). Secondary outcome measures included all-cause mortality, heart failure (HF) hospitalization, and ischaemic stroke or transient ischaemic attack (TIA). Cox proportional hazard models were used to examine the association of SGLT2i with the study endpoint. Among 2242 patients with DM and AF followed for an average of 3.0 years, the primary endpoint occurred in 8.7% (n = 97) of patients in the SGLT2i group vs. 10.0% (n = 112) of patients in the DPP4i group [adjusted hazard ratio 0.73 (95% confidence interval 0.55-0.96; P = 0.03)]. Sodium-glucose cotransporter-2 inhibitors were associated with significant reductions in all-cause mortality and HF hospitalization, but there was no difference in the risk of ischaemic stroke/TIA. CONCLUSION Among patients with DM and pre-existing AF, SGLT2is are associated with decreased AF-related health resource utilization and improved arrhythmic outcomes compared with DPP4is.
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Affiliation(s)
- Akash Fichadiya
- Libin Cardiovascular Institute, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, T2N 4N1, Calgary, AB, Canada
| | - Amity Quinn
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, T2N 4Z6 Calgary, AB, Canada
- O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, T2N 4Z6 Calgary, AB, Canada
| | - Flora Au
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, T2N 4Z6 Calgary, AB, Canada
| | - Dennis Campbell
- Department of Medicine, University of Alberta, 13-103 Clinical Sciences Building, 11350 - 83 Avenue NW, T6G 2G3 Edmonton, AB, Canada
| | - Darren Lau
- Department of Medicine, University of Alberta, 13-103 Clinical Sciences Building, 11350 - 83 Avenue NW, T6G 2G3 Edmonton, AB, Canada
| | - Paul Ronksley
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, T2N 4Z6 Calgary, AB, Canada
- O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, T2N 4Z6 Calgary, AB, Canada
| | - Reed Beall
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, T2N 4Z6 Calgary, AB, Canada
- O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, T2N 4Z6 Calgary, AB, Canada
| | - David J T Campbell
- Libin Cardiovascular Institute, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, T2N 4N1, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, T2N 4Z6 Calgary, AB, Canada
- O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, T2N 4Z6 Calgary, AB, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, T2N 4N1 Calgary, AB, Canada
| | - Stephen B Wilton
- Libin Cardiovascular Institute, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, T2N 4N1, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, T2N 4Z6 Calgary, AB, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, T2N 4N1 Calgary, AB, Canada
| | - Derek S Chew
- Libin Cardiovascular Institute, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, T2N 4N1, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, T2N 4Z6 Calgary, AB, Canada
- O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, T2N 4Z6 Calgary, AB, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, T2N 4N1 Calgary, AB, Canada
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12
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Chen Z, Zhang R, Zhang X, Xu W. Association between baseline glycated hemoglobin level and atrial fibrillation recurrence following cryoballoon ablation among patients with and without diabetes. BMC Cardiovasc Disord 2024; 24:111. [PMID: 38365602 PMCID: PMC10874084 DOI: 10.1186/s12872-024-03784-4] [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: 12/29/2023] [Accepted: 02/12/2024] [Indexed: 02/18/2024] Open
Abstract
OBJECTIVES The study aims to assess the effect of baseline glycated hemoglobin (HbA1c) levels on atrial fibrillation (AF) recurrence following cryoballoon ablation in patients with and without diabetes. METHODS Consecutive AF patients receiving first cryoballoon ablation between April 2018 and April 2021 were included. AF recurrence and other clinical outcomes were recorded for a minimum of 12 months post-ablation, with regular assessments at 3, 6, and 12 months, followed by annual check-ups. The primary outcome was AF recurrence after ablation at longest follow-up. Multivariate Cox proportional hazards regression models were utilized to calculate the hazard ratio (HR) and 95% CI per standard deviation (SD) increase of baseline HbA1c level. RESULTS 335 patients were included in the analysis. The mean age was 61.7 years, 61.8% were male. 12.8% had type 2 diabetes, and 81.7% of patients had paroxysmal AF. The median level of HbA1c was 5.3%, and the mean CHA2DS2-VASc score was 1.8. All cryoballoon ablation procedures, utilizing a 28-mm balloon, achieved successful pulmonary vein isolation. Over a median follow-up of 18 months, 105 patients (31.3%) experienced AF recurrence. In multivariate Cox proportional hazards analysis, a higher HbA1c level, persistent AF (HR 1.91, 95% CI 1.08 to 3.39, P = 0.026), alcohol consumption (HR 2.67, 95% CI 1.33 to 5.37, P = 0.006), and Nadir RSPV (HR 1.04, 95% CI 1.00 to 1.08, P = 0.005) were significant predictors of AF recurrence. Per-SD increase of HbA1c was associated with a 1.75-fold increase risk of AF recurrence (HR 1.75, 95% CI 1.39 to 2.21, P < 0.001). Subgroup analysis revealed that a higher HbA1c level was associated with a higher risk of AF recurrence in patients with and without diabetes, and in patients with paroxysmal and persistent AF. CONCLUSION Baseline HbA1c level was an independent predictor of AF recurrence following cryoablation, both in patients with and without diabetes.
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Affiliation(s)
- Zheng Chen
- Department of Cardiology, Drum Tower Clinical College of Nanjing Medical University, No. 321, Zhongshan Road, Nanjing, 210008, China
- Department of Cardiology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, No. 321, Zhongshan Road, Nanjing, 210008, China
| | - Ruixin Zhang
- Cardiovascular Medicine, Baoshan Branch of Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinlin Zhang
- Department of Cardiology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, No. 321, Zhongshan Road, Nanjing, 210008, China.
| | - Wei Xu
- Department of Cardiology, Drum Tower Clinical College of Nanjing Medical University, No. 321, Zhongshan Road, Nanjing, 210008, China.
- Department of Cardiology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, No. 321, Zhongshan Road, Nanjing, 210008, China.
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13
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Lim J, Kwak S, Choi Y, Rhee T, Park CS, Kim B, Han K, Lee H, Park J, Kim Y, Lee H, Kim H. Differing Efficacy of Dapagliflozin Versus Empagliflozin on the Risk of Incident Atrial Fibrillation in Patients With Type 2 Diabetes: A Real-World Observation Using a Nationwide, Population-Based Cohort. J Am Heart Assoc 2024; 13:e030552. [PMID: 38258668 PMCID: PMC11056122 DOI: 10.1161/jaha.123.030552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 12/08/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Meta-analyses of large clinical trials investigating SGLT2 (sodium-glucose cotransporter-2) inhibitors have suggested their protective effects against atrial fibrillation in patients with type 2 diabetes. However, the results were predominantly driven from trials involving dapagliflozin. METHODS AND RESULTS We used a nationwide, population-based cohort of patients with type 2 diabetes who initiated either dapagliflozin or empagliflozin between May 2016 and December 2018. An active-comparator, new-user design was used, and the 2 groups of patients were matched using propensity scores. The primary outcome was incident nonvalvular atrial fibrillation, which was analyzed using both the main intention-to-treat and sensitivity analysis that censored patients who skipped their medications for ≥30 days. Men ≥55 years of age and women ≥60 years of age with ≥1 traditional risk factor or those with established cardiovascular disease were categorized as high cardiovascular risk group. Patients not included in the high-risk group were categorized as low risk. After 1:1 propensity-score matching, a total of 137 928 patients (mean age, 55 years; 58% men) were included and followed up for 2.2±0.6 years. The risk of incident atrial fibrillation was significantly lower in the dapagliflozin group in both the main (hazard ratio [HR], 0.885 [95% CI, 0.789-0.992]) and sensitivity analyses (HR, 0.835 [95% CI, 0.719-0.970]). Notably, this was consistent in both the low and high cardiovascular risk groups. There was no effect modification by age, sex, body mass index, duration of diabetes, or renal function. CONCLUSIONS This real-world, population-based study demonstrates that patients with type 2 diabetes using dapagliflozin may have a lower risk of developing nonvalvular atrial fibrillation than those using empagliflozin.
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Affiliation(s)
- Jaehyun Lim
- Department of Internal MedicineSeoul National University HospitalSeoulRepublic of Korea
- Department of Internal MedicineSeoul National University College of MedicineSeoulRepublic of Korea
| | - Soongu Kwak
- Department of Internal MedicineSeoul National University HospitalSeoulRepublic of Korea
- Department of Internal MedicineSeoul National University College of MedicineSeoulRepublic of Korea
| | - You‐Jung Choi
- Division of Cardiology, Department of Internal MedicineKorea University College of MedicineSeoulRepublic of Korea
| | - Tae‐Min Rhee
- Division of Cardiology, Department of Internal MedicineSeoul National University Hospital Healthcare System Gangnam CenterSeoulRepublic of Korea
| | - Chan Soon Park
- Department of Internal MedicineSeoul National University HospitalSeoulRepublic of Korea
| | - Bongseong Kim
- Department of Statistics and Actuarial ScienceSoongsil UniversitySeoulRepublic of Korea
| | - Kyung‐Do Han
- Department of Statistics and Actuarial ScienceSoongsil UniversitySeoulRepublic of Korea
| | - Heesun Lee
- Division of Cardiology, Department of Internal MedicineSeoul National University Hospital Healthcare System Gangnam CenterSeoulRepublic of Korea
| | - Jun‐Bean Park
- Department of Internal MedicineSeoul National University HospitalSeoulRepublic of Korea
- Department of Internal MedicineSeoul National University College of MedicineSeoulRepublic of Korea
| | - Yong‐Jin Kim
- Department of Internal MedicineSeoul National University HospitalSeoulRepublic of Korea
- Department of Internal MedicineSeoul National University College of MedicineSeoulRepublic of Korea
| | - Hyun‐Jung Lee
- Division of CardiologySeverance Hospital, Yonsei University College of MedicineSeoulRepublic of Korea
| | - Hyung‐Kwan Kim
- Department of Internal MedicineSeoul National University HospitalSeoulRepublic of Korea
- Department of Internal MedicineSeoul National University College of MedicineSeoulRepublic of Korea
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14
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Perelman MG, Brzezinski RY, Waissengrin B, Leshem Y, Bainhoren O, Rubinstein TA, Perelman M, Rozenbaum Z, Havakuk O, Topilsky Y, Banai S, Wolf I, Laufer-Perl M. Sodium-glucose co-transporter-2 inhibitors in patients treated with immune checkpoint inhibitors. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2024; 10:2. [PMID: 38212825 PMCID: PMC10782769 DOI: 10.1186/s40959-023-00199-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/26/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have revolutionized the prognosis of cancer. Diabetes mellitus (DM) has been shown to have a negative effect on patients treated with ICIs. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are effective antidiabetic therapies associated with reduced all-cause mortality and cardiovascular (CV) outcomes. OBJECTIVE To evaluate the prognostic value of SGLT2i on all-cause mortality and cardiotoxicity among patients treated with ICIs. METHODS We performed a retrospective analysis of patients diagnosed with cancer and type 2 DM (DM2) and treated with ICIs at our center. Patients were divided into two groups according to baseline treatment with or without SGLT2i. The primary endpoint was all-cause mortality and the secondary endpoint was MACE, including myocarditis, acute coronary syndrome, heart failure, and arrhythmia. RESULTS The cohort included 119 patients, with 24 (20%) patients assigned to the SGLT2i group. Both groups exhibited a comparable prevalence of cardiac risk factors, although the SGLT2i group displayed a higher incidence of ischemic heart disease. Over a median follow-up of 28 months, 61 (51%) patients died, with a significantly lower all-cause mortality rate in the SGLT2i group (21% vs. 59%, p = 0.002). While there were no significant differences in MACE, we observed zero cases of myocarditis and atrial fibrillation in the SGLT2i, compared to 2 and 6 cases in the non-SGLT2i group. CONCLUSIONS SGLT2i therapy was associated with a lower all-cause mortality rate in patients diagnosed with cancer and DM2 and treated with ICIs. Further studies are needed to understand the mechanism and evaluate its benefit on cardiotoxicity.
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Affiliation(s)
- Moran Gvili Perelman
- Division of Cardiology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rafael Y Brzezinski
- Division of Cardiology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Barliz Waissengrin
- Division of Oncology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yasmin Leshem
- Division of Oncology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Or Bainhoren
- Division of Oncology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tammi Arbel Rubinstein
- Division of Oncology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Maxim Perelman
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Internal Medicine T, Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Zach Rozenbaum
- Division of Cardiology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Tulane University, New Orleans, LA, USA
| | - Ofer Havakuk
- Division of Cardiology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yan Topilsky
- Division of Cardiology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shmuel Banai
- Division of Cardiology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ido Wolf
- Division of Oncology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Laufer-Perl
- Division of Cardiology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel.
- School of Medicine, Tel Aviv University, Tel Aviv, Israel.
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15
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Zhu J, Wilding JPH. Body Fat Depletion: the Yin Paradigm for Treating Type 2 Diabetes. Curr Atheroscler Rep 2024; 26:1-10. [PMID: 38148417 PMCID: PMC10776473 DOI: 10.1007/s11883-023-01181-4] [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] [Accepted: 12/04/2023] [Indexed: 12/28/2023]
Abstract
PURPOSE OF REVIEW To highlight that body fat depletion (the Yin paradigm) with glucose-lowering treatments (the Yang paradigm) are associated with metabolic benefits for patients with type 2 diabetes mellitus (T2DM). RECENT FINDINGS The sodium-glucose cotransporter-2 inhibitor-mediated sodium/glucose deprivation can directly improve glycemic control and kidney outcome in patients with T2DM. The glucose deprivation might also promote systemic fatty acid β-oxidation to deplete ectopic/visceral fat and thereby contribute to the prevention of cardiovascular diseases. As with metabolic surgery, bioengineered incretin-based medications with potent anorexigenic and insulinotropic efficacy can significantly reduce blood glucose as well as body weight (especially in the ectopic/visceral fat depots). The latter effects could be a key contributor to their cardiovascular-renal protective effects. In addition to a healthy diet, the newer glucose-lowering medications, with body fat reduction effects, should be prioritized when treating patients with T2DM, especially for those with established cardiovascular/renal risks or diseases.
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Affiliation(s)
- Jingjing Zhu
- Department of Endocrinology and Metabolism, the Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Clinical Sciences Centre, Liverpool University Hospitals NHS Foundation Trust, Longmoor Lane, Liverpool, UK
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
- Clinical Sciences Centre, Liverpool University Hospitals NHS Foundation Trust, Longmoor Lane, Liverpool, UK.
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16
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Zheng S, Lai Y, Jiang C, He L, Zhao Z, Li W, Tang R, Sang C, Long D, Du X, Ma C, Dong J. Effect of SGLT2 inhibitors on cardiovascular events in patients with atrial fibrillation: A systematic review and meta-analysis of randomized controlled trials. Pacing Clin Electrophysiol 2024; 47:58-65. [PMID: 38010824 DOI: 10.1111/pace.14880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/14/2023] [Accepted: 11/08/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitors (SGLT2i) is reported to reduce incident atrial fibrillation (AF) in patients with or without diabetes; however, its cardiovascular (CV) benefit for AF patients remains unclear. SS AIMS To investigate the effect of SGLT2i on the incidence of CV events in patients with AF. METHODS Six randomized controlled trials (RCTs) assessing the effects of SGLT2i on CV outcomes in patients with or without AF were included (PROSPERO: CRD 42023431535). The primary endpoint was the composite outcome of heart failure (HF) hospitalization and CV death. Additionally, we assessed the effects of treatment in prespecified subgroups on HF hospitalization, CV death, and all-cause mortality. RESULTS Among 38,529 participants from all trials, 5018 patients with AF were treated with SGLT2i. The follow-up period of these trials ranged from 2.3 to 3.3 years. SGLT2i treatment was significantly associated with the risk reduction of primary endpoint in patients with AF (risk ratio [RR] 0.81, 95% confidence interval [CI] 0.74-0.88; p < 0.001), consistent with the finding in the general population (p for interaction = 0.76). SGLT2i was also associated with a consistent reduction in the risk of HF hospitalization in patients with AF (RR 0.76, 95% CI 0.69-0.84; p < 0.001) or not (RR 0.72, 95% CI 0.64-0.80; p < 0.0001), with no statistical difference between them (p for interaction = 0.41). Meta-regression further revealed no significant association between the prevalence of HF with reduced ejection fraction or diabetes and the effect size of SGLT2i. CONCLUSIONS The treatment effects of SGLT2i were associated with a lower incidence of CV events, especially HF hospitalization, in patients with AF.
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Affiliation(s)
- Shiyue Zheng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yiwei Lai
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Chao Jiang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Liu He
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Zixu Zhao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wenjie Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ribo Tang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Caihua Sang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Deyong Long
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xin Du
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jianzeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
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17
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Zhao Z, Jiang C, He L, Zheng S, Wang Y, Gao M, Lai Y, Zhang J, Li M, Dai W, Zuo S, Guo X, Li S, Jiang C, Liu N, Tang R, Long D, Du X, Sang C, Dong J, Ma C. Impact of Sodium-Glucose Cotransporter 2 Inhibitor on Recurrence After Catheter Ablation for Atrial Fibrillation in Patients With Diabetes: A Propensity-Score Matching Study and Meta-Analysis. J Am Heart Assoc 2023; 12:e031269. [PMID: 38084708 PMCID: PMC10863762 DOI: 10.1161/jaha.123.031269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 09/12/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND The association between sodium-glucose cotransporter 2 inhibitors (SGLT2i) and atrial fibrillation (AF) recurrence after catheter ablation among patients with diabetes and AF remains unclear. METHODS AND RESULTS Patients with AF undergoing initial catheter ablation with a history of diabetes from the China AF registry were included. Patients using SGLT2i were identified and matched by propensity score with non-SGLT2i patients in a 1:3 ratio. The main outcome was AF recurrence during the 18-month follow-up. A total of 138 patients with diabetes with SGLT2i therapy and 387 without SGLT2i were analyzed. AF recurrence occurred in 37 patients (26.8%) in the SGLT2i group and 152 patients (39.3%) in the non-SGLT2i group during a total of 593.3 person-years follow-up. The SGLT2i group was associated with lower AF recurrence compared with the non-SGLT2i group (hazard ratio, 0.63 [95% CI, 0.44-0.90], P=0.007). A total of 4 studies were analyzed in our meta-analysis demonstrating that SGLT2i was associated with lower AF recurrence after catheter ablation (odds ratio, 0.61 [95% CI, 0.54-0.69]; P<0.001, I2=0.0%). CONCLUSIONS Our prospective study coupled with a meta-analysis demonstrated a lower risk of AF recurrence with the use of SGLT2i among patients with diabetes after AF ablation.
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Affiliation(s)
- Zixu Zhao
- Department of Cardiology, Beijing Anzhen HospitalCapital Medical University and National Clinical Research Center for Cardiovascular DiseasesBeijingChina
| | - Chao Jiang
- Department of Cardiology, Beijing Anzhen HospitalCapital Medical University and National Clinical Research Center for Cardiovascular DiseasesBeijingChina
| | - Liu He
- Department of Cardiology, Beijing Anzhen HospitalCapital Medical University and National Clinical Research Center for Cardiovascular DiseasesBeijingChina
| | - Shiyue Zheng
- Department of Cardiology, Beijing Anzhen HospitalCapital Medical University and National Clinical Research Center for Cardiovascular DiseasesBeijingChina
| | - Yufeng Wang
- Department of Cardiology, Beijing Anzhen HospitalCapital Medical University and National Clinical Research Center for Cardiovascular DiseasesBeijingChina
| | - Mingyang Gao
- Department of Cardiology, Beijing Anzhen HospitalCapital Medical University and National Clinical Research Center for Cardiovascular DiseasesBeijingChina
| | - Yiwei Lai
- Department of Cardiology, Beijing Anzhen HospitalCapital Medical University and National Clinical Research Center for Cardiovascular DiseasesBeijingChina
| | - Jingrui Zhang
- Department of Cardiology, Beijing Anzhen HospitalCapital Medical University and National Clinical Research Center for Cardiovascular DiseasesBeijingChina
| | - Mingxiao Li
- Department of Cardiology, Beijing Anzhen HospitalCapital Medical University and National Clinical Research Center for Cardiovascular DiseasesBeijingChina
| | - Wenli Dai
- Department of Cardiology, Beijing Anzhen HospitalCapital Medical University and National Clinical Research Center for Cardiovascular DiseasesBeijingChina
| | - Song Zuo
- Department of Cardiology, Beijing Anzhen HospitalCapital Medical University and National Clinical Research Center for Cardiovascular DiseasesBeijingChina
| | - Xueyuan Guo
- Department of Cardiology, Beijing Anzhen HospitalCapital Medical University and National Clinical Research Center for Cardiovascular DiseasesBeijingChina
| | - Songnan Li
- Department of Cardiology, Beijing Anzhen HospitalCapital Medical University and National Clinical Research Center for Cardiovascular DiseasesBeijingChina
| | - Chenxi Jiang
- Department of Cardiology, Beijing Anzhen HospitalCapital Medical University and National Clinical Research Center for Cardiovascular DiseasesBeijingChina
| | - Nian Liu
- Department of Cardiology, Beijing Anzhen HospitalCapital Medical University and National Clinical Research Center for Cardiovascular DiseasesBeijingChina
| | - Ribo Tang
- Department of Cardiology, Beijing Anzhen HospitalCapital Medical University and National Clinical Research Center for Cardiovascular DiseasesBeijingChina
| | - Deyong Long
- Department of Cardiology, Beijing Anzhen HospitalCapital Medical University and National Clinical Research Center for Cardiovascular DiseasesBeijingChina
| | - Xin Du
- Department of Cardiology, Beijing Anzhen HospitalCapital Medical University and National Clinical Research Center for Cardiovascular DiseasesBeijingChina
- Heart Health Research CenterBeijingChina
| | - Caihua Sang
- Department of Cardiology, Beijing Anzhen HospitalCapital Medical University and National Clinical Research Center for Cardiovascular DiseasesBeijingChina
| | - Jianzeng Dong
- Department of Cardiology, Beijing Anzhen HospitalCapital Medical University and National Clinical Research Center for Cardiovascular DiseasesBeijingChina
- Department of CardiologyThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouHenan ProvinceChina
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen HospitalCapital Medical University and National Clinical Research Center for Cardiovascular DiseasesBeijingChina
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18
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O'Keefe JH, Weidling R, O'Keefe EL, Franco WG. SGLT inhibitors for improving Healthspan and lifespan. Prog Cardiovasc Dis 2023; 81:2-9. [PMID: 37852518 PMCID: PMC10831928 DOI: 10.1016/j.pcad.2023.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 10/15/2023] [Indexed: 10/20/2023]
Abstract
Sodium-glucose cotransporter inhibitor/inhibition (SGLTi), initially approved as a glucose-lowering therapy for type 2 diabetes, is associated with decreased risks for many of the most common conditions of aging, including heart failure, chronic kidney disease, all-cause hospitalization, atrial fibrillation, cancer, gout, emphysema, neurodegenerative disease/dementia, emphysema, non-alcoholic fatty liver disease, atherosclerotic disease, and infections. Studies also show that SGLTi improves overall life expectancy and reduces risks of cardiovascular death and cancer death. These wide-ranging health benefits are largely unexplained by the SGLTi's modest improvements in standard risk factors. SGLTi produces upregulation of nutrient deprivation signaling and downregulation of nutrient surplus signaling. This in turn promotes autophagy, which helps to optimize cellular integrity and prevent apoptotic cell death. SGLTi decreases oxidative stress and endoplasmic reticulum stress, restores of mitochondrial health, stimulates mitochondrial biogenesis, and diminishes proinflammatory and profibrotic pathways. These actions help to revitalize senescent cells, tissues, and organs. In summary, SGLTi appears to slow aging, prevent disease, and improve life expectancy, and its mechanisms of action lend strong biological plausibility to this hypothesis. Further randomized trials are warranted to test whether SGLTi, a safe and well-tolerated, once-daily pill, might improve healthspan and lifespan.
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Affiliation(s)
- James H O'Keefe
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO, United States of America.
| | - Robert Weidling
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO, United States of America
| | - Evan L O'Keefe
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO, United States of America
| | - W Grant Franco
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO, United States of America
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19
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Pandey AK, Bhatt DL, Pandey A, Marx N, Cosentino F, Pandey A, Verma S. Mechanisms of benefits of sodium-glucose cotransporter 2 inhibitors in heart failure with preserved ejection fraction. Eur Heart J 2023; 44:3640-3651. [PMID: 37674356 DOI: 10.1093/eurheartj/ehad389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/07/2023] [Accepted: 05/29/2023] [Indexed: 09/08/2023] Open
Abstract
For decades, heart failure with preserved ejection fraction (HFpEF) proved an elusive entity to treat. Sodium-glucose cotransporter 2 (SGLT2) inhibitors have recently been shown to reduce the composite of heart failure hospitalization or cardiovascular death in patients with HFpEF in the landmark DELIVER and EMPEROR-Preserved trials. While improvements in blood sugar, blood pressure, and attenuation of kidney disease progression all may play some role, preclinical and translational research have identified additional mechanisms of these agents. The SGLT2 inhibitors have intriguingly been shown to induce a nutrient-deprivation and hypoxic-like transcriptional paradigm, with increased ketosis, erythropoietin, and autophagic flux in addition to altering iron homeostasis, which may contribute to improved cardiac energetics and function. These agents also reduce epicardial adipose tissue and alter adipokine signalling, which may play a role in the reductions in inflammation and oxidative stress observed with SGLT2 inhibition. Emerging evidence also indicates that these drugs impact cardiomyocyte ionic homeostasis although whether this is through indirect mechanisms or via direct, off-target effects on other ion channels has yet to be clearly characterized. Finally, SGLT2 inhibitors have been shown to reduce myofilament stiffness as well as extracellular matrix remodelling/fibrosis in the heart, improving diastolic function. The SGLT2 inhibitors have established themselves as robust, disease-modifying therapies and as recent trial results are incorporated into clinical guidelines, will likely become foundational in the therapy of HFpEF.
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Affiliation(s)
- Arjun K Pandey
- Michael G. DeGroote School of Medicine, McMaster University, 90 Main Street West, Hamilton, Ontario L8P 1H6, Canada
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, 1 Gustave L. Levy Place, New York, NY 10029, USA
| | - Avinash Pandey
- Department of Medicine, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, Ontario K1Y 4W7, Canada
| | - Nikolaus Marx
- Department of Internal Medicine, University Hospital Aachen, RWTH Aachen University, Templergraben 55, 52062 Aachen, Germany
| | - Francesco Cosentino
- Division of Cardiology, Department of Medicine, Solna, Karolinska Institutet, Norrbacka S1:02, Stockholm, SE 17177, Sweden
- Heart, Vascular and Neuro Theme, Department of Cardiology, Karolinska University Hospital, Anna Steckséns gata 41, 171 64 Solna, Sweden
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Subodh Verma
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, Canada
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20
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Manolis AA, Manolis TA, Melita H, Manolis AS. Sodium-glucose cotransporter type 2 inhibitors and cardiac arrhythmias. Trends Cardiovasc Med 2023; 33:418-428. [PMID: 35447305 DOI: 10.1016/j.tcm.2022.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/02/2022] [Accepted: 04/15/2022] [Indexed: 02/06/2023]
Abstract
The introduction of sodium-glucose cotransporter 2 (SGLT2) inhibitors as a new and effective class of therapeutic agents for type 2 diabetes (T2D) preventing the reabsorption of glucose in the kidneys and thus facilitating glucose excretion in the urine, but also as agents with cardiovascular benefits, particularly in patients with heart failure (HF), regardless of the diabetic status, has ushered in a new era in treating patients with T2D and/or HF. In addition, data have recently emerged indicating an antiarrhythmic effect of the SGLT2 inhibitors in patients with and without diabetes. Prospective studies, randomized controlled trials and meta-analyses have provided robust evidence for a protective and beneficial effect of these agents against atrial fibrillation, ventricular arrhythmias and sudden cardiac death. The antiarrhythmic mechanisms involved include reverse atrial and ventricular remodeling, amelioration of mitochondrial function, reduction of hypoglycemic episodes with their attendant arrhythmogenic effects, attenuated sympathetic nervous system activity, regulation of sodium and calcium homeostasis, and suppression of prolonged ventricular repolarization. These new data on antiarrhythmic actions of SGLT2 inhibitors are herein reviewed, potential mechanisms involved are discussed and pictorially illustrated, and treatment results on specific arrhythmias are described and tabulated.
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Affiliation(s)
| | | | | | - Antonis S Manolis
- First Department of Cardiology, Athens University School of Medicine, Athens, Greece.
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21
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Saljic A, Heijman J, Dobrev D. Recent Advances in Antiarrhythmic Drug Therapy. Drugs 2023; 83:1147-1160. [PMID: 37540446 PMCID: PMC10462572 DOI: 10.1007/s40265-023-01923-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 08/05/2023]
Abstract
Cardiac arrhythmias remain a common cause of death and disability. Antiarrhythmic drugs (AADs) and antiarrhythmic agents remain a cornerstone of current cardiac arrhythmia management, despite moderate efficacy and the potential for significant adverse proarrhythmic effects. Due to conceptual, regulatory and financial considerations, the number of novel antiarrhythmic targets and agents in the development pipeline has decreased substantially during the last few decades. However, several promising candidates remain and there are exciting developments in repurposing and reformulating already existing drugs for indications related to cardiac arrhythmias. This review discusses the key conceptual considerations for the development of new antiarrhythmic agents, summarizes new compounds and formulations currently in clinical development for rhythm control of atrial fibrillation, and highlights the potential for drug repurposing. Finally, future directions in AAD development are discussed. Together with an ever-increasing understanding of the molecular mechanisms underlying cardiac arrhythmias, these components support a cautiously optimistic outlook towards improved pharmacological treatment opportunities for patients suffering from cardiac arrhythmias.
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Affiliation(s)
- Arnela Saljic
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany
| | - Jordi Heijman
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Dobromir Dobrev
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
- Montréal Heart Institute and University de Montréal, Medicine and Research Center, Montréal, Canada.
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, USA.
- , Hufelandstrasse 55, 45122, Essen, Germany.
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Sfairopoulos D, Liu T, Zhang N, Tse G, Bazoukis G, Letsas K, Goudis C, Milionis H, Vrettos A, Korantzopoulos P. Association between sodium-glucose cotransporter-2 inhibitors and incident atrial fibrillation/atrial flutter in heart failure patients with reduced ejection fraction: a meta-analysis of randomized controlled trials. Heart Fail Rev 2023; 28:925-936. [PMID: 36282460 PMCID: PMC10289933 DOI: 10.1007/s10741-022-10281-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 11/26/2022]
Abstract
Atrial fibrillation (AF) and atrial flutter (AFL) are associated with adverse outcomes in patients with heart failure and reduced ejection fraction (HFrEF). We investigated the effects of sodium-glucose cotransporter-2 inhibitors (SGLT2i) on the incidence of AF and/or AFL in HFrEF patients. PubMed and ClinicalTrials.gov were systematically searched until March 2022 for randomized controlled trials (RCTs) that enrolled patients with HFrEF. A total of six RCTs with 9467 patients were included (N = 4731 in the SGLT2i arms; N = 4736 in the placebo arms). Compared to placebo, SGLT2i treatment was associated with a significant reduction in the risk of AF [relative risk (RR) 0.62, 95% confidence interval CI 0.44-0.86; P = 0.005] and AF/AFL (RR 0.64, 95% CI 0.47-0.87; P = 0.004). Subgroup analysis showed that empagliflozin use resulted in a significant reduction in the risk of AF (RR 0.55, 95% CI 0.34-0.89; P = 0.01) and AF/AFL (RR 0.50, 95% CI 0.32-0.77; P = 0.002). By contrast, dapagliflozin use was not associated with a significant reduction in the risk of AF (RR 0.69, 95% CI 0.43-1.11; P = 0.12) or AF/AFL (RR 0.82, 95% CI 0.53-1.27; P = 0.38). Additionally, a "shorter" duration (< 1.5 years) of treatment with SGLT2i remained associated with a reduction in the risk of AF (< 1.5 years; RR 0.58, 95% CI 0.36-0.91; P = 0.02) and AF/AFL (< 1.5 years; RR 0.52, 95% CI 0.34-0.80; P = 0.003). In conclusion, SGLT2i therapy was associated with a significant reduction in the risk of AF and AF/AFL in patients with HFrEF. These results reinforce the value of using SGLT2i in this setting.
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Affiliation(s)
| | - 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
| | - Nan Zhang
- 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
| | - 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
- Kent and Medway Medical School, Kent, UK
| | - George Bazoukis
- Department of Cardiology, Larnaca General Hospital, Larnaca, Cyprus
| | - Konstantinos Letsas
- Laboratory of Cardiac Electrophysiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Christos Goudis
- Department of Cardiology, Serres General Hospital, 45110, Serres, Greece
| | - Haralampos Milionis
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Apostolos Vrettos
- Department of Cardiology, Royal Brompton and Harefield Hospitals, London, UK
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23
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Forzano I, Wilson S, Lombardi A, Jankauskas SS, Kansakar U, Mone P, Varzideh F, Santulli G. SGLT2 inhibitors: an evidence-based update on cardiovascular implications. Expert Opin Investig Drugs 2023; 32:839-847. [PMID: 37740906 PMCID: PMC10591907 DOI: 10.1080/13543784.2023.2263354] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 09/22/2023] [Indexed: 09/25/2023]
Abstract
INTRODUCTION Sodium Glucose co-Transporter 2 (SGLT2) inhibitors (also known as 'gliflozins') represent a cornerstone to treat diabetes mellitus. Moreover, recent randomized clinical trials have demonstrated important cardioprotective effects of gliflozins, independent of the presence of diabetes. Herein, we summarize the recent therapeutic progress in the cardiovascular field obtained with SGLT2 inhibitors. AREA COVERED We critically examine the rationale and results of recent clinical studies examining the effects of SGLT2 inhibitors on cardiovascular outcomes, along with a brief overview of the main ongoing trials that have been designed in order to answer the many pending questions in the field of gliflozins and cardiovascular disease. EXPERT OPINION The favorable results of several clinical trials have broadened the therapeutic scenario for SGLT2 inhibitors, opening, at the same time, new challenges. Additionally, recent preclinical findings have evidenced off-target effects of SGLT2 inhibitors.
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Affiliation(s)
| | - Scott Wilson
- Department of Medicine, Albert Einstein College of Medicine, New York City, NY, USA
| | - Angela Lombardi
- Department of Medicine, Albert Einstein College of Medicine, New York City, NY, USA
| | | | - Urna Kansakar
- Department of Medicine, Albert Einstein College of Medicine, New York City, NY, USA
| | - Pasquale Mone
- Department of Medicine, Albert Einstein College of Medicine, New York City, NY, USA
| | - Fahimeh Varzideh
- Department of Medicine, Albert Einstein College of Medicine, New York City, NY, USA
| | - Gaetano Santulli
- University of Naples “Federico II”
- Department of Medicine, Albert Einstein College of Medicine, New York City, NY, USA
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24
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Li L, Hua C, Liu X, Wang Y, Zhao L, Zhang Y, Wang L, Su P, Yang MF, Xie B. SGLT2i alleviates epicardial adipose tissue inflammation by modulating ketone body-glyceraldehyde-3-phosphate dehydrogenase malonylation pathway. J Cardiovasc Med (Hagerstown) 2023; 24:232-243. [PMID: 36938811 DOI: 10.2459/jcm.0000000000001453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
AIMS Inflammation in the epicardial adipose tissue (EAT) is a contributor to atrial fibrillation. Studies have reported that sodium glucose co-transporter 2 inhibitor (SGLT2i) can alleviate EAT inflammation. However, the mechanism remains elusive. This study aims to investigate the molecular mechanism of SGLT2i in reducing EAT inflammation and to explore the effects of SGLT2i on atrial fibrosis in atrial fibrillation. METHODS Sprague-Dawley rats were injected with angiotensin II to induce atrial fibrillation and randomly assigned to receive SGLT2i ( n = 6) or vehicle ( n = 6). Macrophages (RAW264.7) were treated with ketone bodies; ACC1 knockdown/overexpression and malonyl-CoA overexpression were performed in vitro . The levels of inflammatory cytokines, ACC1, and malonyl-CoA were examined by ELISA. GAPDH malonylation was measured by co-immunoprecipitation. RESULTS In atrial fibrillation rats, SGLT2i increased the ketone body levels and decreased the expression of ACC1 and alleviated EAT inflammation and atrial fibrosis. In RAW264.7 cells, ketone bodies decreased the levels of ACC1, malonyl-CoA, and GAPDH malonylation, accompanied by reduced inflammatory cytokines. ACC1 knockdown decreased the expression of malonyl-CoA and GAPDH malonylation and alleviated lipopolysaccharide (LPS)-induced macrophage inflammation; these effects were inhibited by malonyl-CoA overexpression. Furthermore, the protective effects of ketone bodies on macrophage inflammation were abrogated by ACC1 overexpression. CONCLUSION SGLT2i alleviates EAT inflammation by reducing GAPDH malonylation via downregulating the expression of ACC1 through increasing ketone bodies, thus attenuating atrial fibrosis.
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Affiliation(s)
- Lina Li
- Department of Nuclear Medicine
| | - Cuncun Hua
- Cardiac Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xiaoyan Liu
- Cardiac Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yidan Wang
- Cardiac Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Lei Zhao
- Cardiac Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yeping Zhang
- Cardiac Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Li Wang
- Department of Nuclear Medicine
| | - Pixiong Su
- Cardiac Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | | | - Boqia Xie
- Cardiac Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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25
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Engström A, Wintzell V, Melbye M, Hviid A, Eliasson B, Gudbjörnsdottir S, Hveem K, Jonasson C, Svanström H, Pasternak B, Ueda P. Sodium-Glucose Cotransporter 2 Inhibitor Treatment and Risk of Atrial Fibrillation: Scandinavian Cohort Study. Diabetes Care 2023; 46:351-360. [PMID: 36508322 DOI: 10.2337/dc22-0714] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 11/14/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess the association between use of sodium-glucose cotransporter 2 (SGLT2) inhibitors and the risk of new-onset atrial fibrillation (AF) in routine clinical practice. RESEARCH DESIGN AND METHODS We used nationwide registers in Denmark, Norway, and Sweden from 2013 to 2018 in order to include patients without a history of AF who were newly prescribed an SGLT2 inhibitor or an active comparator (glucagon-like peptide 1 [GLP-1] receptor agonist). We performed a cohort study to assess new-onset AF in intention-to-treat analyses using Cox regression, adjusted for baseline covariates with propensity score weighting. RESULTS We identified 79,343 new users of SGLT2 inhibitors (59.2% dapagliflozin, 40.0% empagliflozin, 0.8% canagliflozin, <0.1% ertugliflozin) and 57,613 new users of GLP-1 receptor agonists. Mean age of the study cohort was 61 years and 60% were men. The adjusted incidence rate of new-onset AF was 8.6 per 1,000 person-years for new users of SGLT2 inhibitors compared with 10.0 per 1,000 person-years for new users of GLP-1 receptor agonists. The adjusted hazard ratio (aHR) was 0.89 (95% CI 0.81-0.96), and the rate difference was 1.4 fewer events per 1,000 person-years (95% CI 0.6-2.1). Using an as-treated exposure definition, the aHR for new-onset AF was 0.87 (95% CI 0.76-0.99). No statistically significant heterogeneity of the aHRs was observed between subgroups of patients with and without a history of heart failure or major cardiovascular disease. CONCLUSIONS In this cohort study using nationwide data from three countries, use of SGLT2 inhibitors, compared with GLP-1 receptor agonists, was associated with a modestly reduced risk of new-onset AF.
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Affiliation(s)
- Arvid Engström
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institute, Stockholm, Sweden
| | - Viktor Wintzell
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institute, Stockholm, Sweden
| | - Mads Melbye
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
- K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Trondheim, Norway
- Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Anders Hviid
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
- Pharmacovigilance Research Center, Department of Drug Development and Clinical Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Björn Eliasson
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Soffia Gudbjörnsdottir
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Swedish National Diabetes Register, Vastra Gotalandsregionen, Gothenburg, Sweden
| | - Kristian Hveem
- K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Trondheim, Norway
- HUNT Research Center, Faculty of Medicine, Norwegian University of Science and Technology, Levanger, Norway
- Division of Health Data and Digitalization, The Norwegian Institute of Public Health, Oslo, Norway
| | - Christian Jonasson
- K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Trondheim, Norway
- HUNT Research Center, Faculty of Medicine, Norwegian University of Science and Technology, Levanger, Norway
| | - Henrik Svanström
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institute, Stockholm, Sweden
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Björn Pasternak
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institute, Stockholm, Sweden
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Peter Ueda
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institute, Stockholm, Sweden
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26
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Donniacuo M, De Angelis A, Telesca M, Bellocchio G, Riemma MA, Paolisso P, Scisciola L, Cianflone E, Torella D, Castaldo G, Capuano A, Urbanek K, Berrino L, Rossi F, Cappetta D. Atrial fibrillation: Epigenetic aspects and role of sodium-glucose cotransporter 2 inhibitors. Pharmacol Res 2023; 188:106591. [PMID: 36502999 DOI: 10.1016/j.phrs.2022.106591] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/30/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022]
Abstract
Atrial fibrillation (AF) is the most frequent arrhythmia and is associated with substantial morbidity and mortality. Pathophysiological aspects consist in the activation of pro-fibrotic signaling and Ca2+ handling abnormalities at atrial level. Structural and electrical remodeling creates a substrate for AF by triggering conduction abnormalities and cardiac arrhythmias. The care of AF patients focuses predominantly on anticoagulation, symptoms control and the management of risk factors and comorbidities. The goal of AF therapy points to restore sinus rhythm, re-establish atrioventricular synchrony and improve atrial contribution to the stroke volume. New layer of information to better comprehend AF pathophysiology, and identify targets for novel pharmacological interventions consists of the epigenetic phenomena including, among others, DNA methylation, histone modifications and noncoding RNAs. Moreover, the benefits of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in diabetic and non-diabetic patients at cardiovascular risk as well as emerging evidence on the ability of SGLT2i to modify epigenetic signature in cardiovascular diseases provide a solid background to investigate a possible role of this drug class in the onset and progression of AF. In this review, following a summary of pathophysiology and management, epigenetic mechanisms in AF and the potential of sodium-glucose SGLT2i in AF patients are discussed.
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Affiliation(s)
- M Donniacuo
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Via Costantinopoli 16, 80138 Naples, Italy
| | - A De Angelis
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Via Costantinopoli 16, 80138 Naples, Italy
| | - M Telesca
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Via Costantinopoli 16, 80138 Naples, Italy
| | - G Bellocchio
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Via Costantinopoli 16, 80138 Naples, Italy
| | - M A Riemma
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Via Costantinopoli 16, 80138 Naples, Italy
| | - P Paolisso
- Cardiovascular Center Aalst, OLV Hospital, Aalst, Belgium; Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via A. Pansini 5, 80131 Naples, Italy
| | - L Scisciola
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Via Costantinopoli 16, 80138 Naples, Italy
| | - E Cianflone
- Department of Medical and Surgical Sciences, Magna Graecia University, Viale Europa, 88100 Catanzaro, Italy
| | - D Torella
- Department of Experimental and Clinical Medicine, Magna Graecia University, Viale Europa, 88100 Catanzaro, Italy
| | - G Castaldo
- Department of Molecular Medicine and Medical Biotechnologies, University of Naples "Federico II", Via A. Pansini 5, 80131 Naples, Italy; CEINGE-Advanced, Via G. Salvatore 486, 80131 Naples, Italy
| | - A Capuano
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Via Costantinopoli 16, 80138 Naples, Italy
| | - K Urbanek
- Department of Molecular Medicine and Medical Biotechnologies, University of Naples "Federico II", Via A. Pansini 5, 80131 Naples, Italy; CEINGE-Advanced, Via G. Salvatore 486, 80131 Naples, Italy.
| | - L Berrino
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Via Costantinopoli 16, 80138 Naples, Italy
| | - F Rossi
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Via Costantinopoli 16, 80138 Naples, Italy
| | - D Cappetta
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Via Costantinopoli 16, 80138 Naples, Italy
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27
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Scheen AJ. Antidiabetic agents and risk of atrial fibrillation/flutter: A comparative critical analysis with a focus on differences between SGLT2 inhibitors and GLP-1 receptor agonists. DIABETES & METABOLISM 2022; 48:101390. [DOI: 10.1016/j.diabet.2022.101390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/22/2022] [Accepted: 09/22/2022] [Indexed: 04/11/2023]
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Patel KHK, Reddy RK, Sau A, Sivanandarajah P, Ardissino M, Ng FS. Obesity as a risk factor for cardiac arrhythmias. BMJ MEDICINE 2022; 1:e000308. [PMID: 36936556 PMCID: PMC9951386 DOI: 10.1136/bmjmed-2022-000308] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 09/26/2022] [Indexed: 11/05/2022]
Abstract
Obesity is global health problem with an estimated three billion people worldwide being classified as overweight or obese. In addition to being associated with a range of adverse health outcomes, obesity is linked to higher risks of atrial and ventricular arrhythmias, as well as sudden cardiac death. Obesity is a multifactorial disease that often co-exists with hypertension, diabetes, and sleep apnoea, which are also independent risk factors for cardiac arrhythmias. Nevertheless, compelling evidence suggests that increasing adiposity is an independent proarrhythmic risk factor and that weight loss can be a mitigating and preventative intervention to reduce arrhythmia incidence. This review briefly outlines the economic and social burden of obesity and summarises evidence for the direct and indirect effects of increasing adiposity on risk of atrial and ventricular arrhythmias. The paper also summarises the evidence for electrocardiographic changes indicative of obesity-related atrial and ventricular remodelling and how weight reduction and management of comorbidity might reduce arrhythmic burden.
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Affiliation(s)
| | - Rohin K Reddy
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Arunashis Sau
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Maddalena Ardissino
- National Heart and Lung Institute, Imperial College London, London, UK
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Fu Siong Ng
- National Heart and Lung Institute, Imperial College London, London, UK
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29
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Zhuo M, D’Andrea E, Paik JM, Wexler DJ, Everett BM, Glynn RJ, Kim SC, Patorno E. Association of Sodium-Glucose Cotransporter-2 Inhibitors With Incident Atrial Fibrillation in Older Adults With Type 2 Diabetes. JAMA Netw Open 2022; 5:e2235995. [PMID: 36219443 PMCID: PMC9554705 DOI: 10.1001/jamanetworkopen.2022.35995] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE Sodium-glucose cotransporter-2 inhibitors (SGLT-2is) have demonstrated many cardiovascular and kidney function benefits for patients with type 2 diabetes (T2D). However, the results of SGLT-2i use in primary prevention of atrial fibrillation (AF) were inconsistent in clinical trials, and incident AF was not a prespecified end point. OBJECTIVE To examine incident AF with initiation of an SGLT-2i compared with initiation of a dipeptidyl peptidase-4 inhibitor (DPP-4i) or a glucagonlike peptide-1 receptor agonist (GLP-1RA) among older adults (aged ≥66 years) with T2D in routine clinical practice. DESIGN, SETTING, AND PARTICIPANTS A population-based new-user cohort study included older adults with T2D who had no history of AF and were enrolled in Medicare fee-for-service from April 1, 2013, to December 31, 2018. Data analysis was performed from June 28 to December 1, 2021. EXPOSURES To control for potential confounding, new users of SGLT-2i were 1:1 propensity score (PS)-matched to new users of DPP-4is or GLP-1RAs in 2 pairwise comparisons based on 138 baseline covariates. MAIN OUTCOMES AND MEASURES The primary outcome was incident AF, defined as an inpatient diagnosis code for AF. Hazard ratios (HRs) and rate differences (RDs) per 1000 person-years, with their 95% CIs, were estimated in the PS-matched groups. RESULTS New users of SGLT-2is were 1:1 PS-matched to new users of a DPP-4i (n = 74 868) or GLP-1RA (n = 80 475). Overall, the mean (SD) age of study participants was 72 (5) years, and 165 984 were women (53.4%). The risk of incident AF was lower in the SGLT-2i group than the matched DPP-4i group (HR, 0.82; 95% CI, 0.76 to 0.89; RD, -3.7; 95% CI, -5.2 to -2.2 per 1000 person-years) or the matched GLP-1RA group (HR, 0.90; 95% CI, 0.83 to 0.98; RD, -1.8; 95% CI, -3.2 to -0.3 per 1000 person-years). Results were consistent across several sensitivity and subgroup analyses. CONCLUSIONS AND RELEVANCE The findings of this study suggest that the initiation of an SGLT-2i was associated with a reduced risk of incident AF compared with a DPP-4i or GLP-1RA. The results may be helpful when weighing the potential risks and benefits of various glucose level-lowering agents in older adults with T2D.
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Affiliation(s)
- Min Zhuo
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Elvira D’Andrea
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Julie M. Paik
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- New England Geriatric Research, Education and Clinical Center, VA Boston Healthcare System, Boston, Massachusetts
| | - Deborah J. Wexler
- Diabetes Center, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Brendan M. Everett
- Divisions of Cardiovascular and Preventive Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Robert J. Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Seoyoung C. Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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30
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Cesaro A, Gragnano F, Paolisso P, Bergamaschi L, Gallinoro E, Sardu C, Mileva N, Foà A, Armillotta M, Sansonetti A, Amicone S, Impellizzeri A, Esposito G, Morici N, Oreglia JA, Casella G, Mauro C, Vassilev D, Galie N, Santulli G, Pizzi C, Barbato E, Calabrò P, Marfella R. In-hospital arrhythmic burden reduction in diabetic patients with acute myocardial infarction treated with SGLT2-inhibitors: Insights from the SGLT2-I AMI PROTECT study. Front Cardiovasc Med 2022; 9:1012220. [PMID: 36237914 PMCID: PMC9551177 DOI: 10.3389/fcvm.2022.1012220] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 08/29/2022] [Indexed: 01/05/2023] Open
Abstract
Background Sodium-glucose co-transporter 2 inhibitors (SGLT2-i) have shown significant cardiovascular benefits in patients with and without type 2 diabetes mellitus (T2DM). They have also gained interest for their potential anti-arrhythmic role and their ability to reduce the occurrence of atrial fibrillation (AF) and ventricular arrhythmias (VAs) in T2DM and heart failure patients. Objectives To investigate in-hospital new-onset cardiac arrhythmias in a cohort of T2DM patients presenting with acute myocardial infarction (AMI) treated with SGLT2-i vs. other oral anti-diabetic agents (non-SGLT2-i users). Methods Patients from the SGLT2-I AMI PROTECT registry (NCT05261867) were stratified according to the use of SGLT2-i before admission for AMI, divided into SGLT2-i users vs. non-SGLT2-i users. In-hospital outcomes included the occurrence of in-hospital new-onset cardiac arrhythmias (NOCAs), defined as a composite of new-onset AF and sustained new-onset ventricular tachycardia (VT) and/or ventricular fibrillation (VF) during hospitalization. Results The study population comprised 646 AMI patients categorized into SGLT2-i users (111 patients) and non-SGLT2-i users (535 patients). SGLT2-i users had a lower rate of NOCAs compared with non-SGLT2-i users (6.3 vs. 15.7%, p = 0.010). Moreover, SGLT2-i was associated with a lower rate of AF and VT/VF considered individually (p = 0.032). In the multivariate logistic regression model, after adjusting for all confounding factors, the use of SGLT2-i was identified as an independent predictor of the lower occurrence of NOCAs (OR = 0.35; 95%CI 0.14-0.86; p = 0.022). At multinomial logistic regression, after adjusting for potential confounders, SGLT2-i therapy remained an independent predictor of VT/VF occurrence (OR = 0.20; 95%CI 0.04-0.97; p = 0.046) but not of AF occurrence. Conclusions In T2DM patients, the use of SGLT2-i was associated with a lower risk of new-onset arrhythmic events during hospitalization for AMI. In particular, the primary effect was expressed in the reduction of VAs. These findings emphasize the cardioprotective effects of SGLT2-i in the setting of AMI beyond glycemic control. Trial registration Data are part of the observational international registry: SGLT2-I AMI PROTECT. ClinicalTrials.gov, identifier: NCT05261867.
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Affiliation(s)
- Arturo Cesaro
- Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli', Naples, Italy,Division of Cardiology, A.O.R.N. “Sant'Anna e San Sebastiano”, Caserta, Italy,*Correspondence: Arturo Cesaro
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli', Naples, Italy,Division of Cardiology, A.O.R.N. “Sant'Anna e San Sebastiano”, Caserta, Italy
| | - Pasquale Paolisso
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium,Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Luca Bergamaschi
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy,Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | - Emanuele Gallinoro
- Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli', Naples, Italy,Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Celestino Sardu
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Niya Mileva
- Cardiology Clinic, “Alexandrovska” University Hospital, Medical University of Sofia, Sofia, Bulgaria
| | - Alberto Foà
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy,Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | - Matteo Armillotta
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy,Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | - Angelo Sansonetti
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy,Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | - Sara Amicone
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy,Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | - Andrea Impellizzeri
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy,Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | - Giuseppe Esposito
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy,Interventional Cardiology Unit, De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy
| | - Nuccia Morici
- IRCCS S. Maria Nascente - Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - Jacopo Andrea Oreglia
- Interventional Cardiology Unit, De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy
| | | | - Ciro Mauro
- Department of Cardiology, Hospital Cardarelli, Naples, Italy
| | | | - Nazzareno Galie
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy,Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | - Gaetano Santulli
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy,International Translational Research and Medical Education (ITME) Consortium, Naples, Italy,Department of Medicine (Division of Cardiology) and Department of Molecular Pharmacology, Wilf Family Cardiovascular Research Institute, Einstein-Sinai Diabetes Research Center, The Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine, New York, NY, United States
| | - Carmine Pizzi
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy,Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | - Emanuele Barbato
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium,Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli', Naples, Italy,Division of Cardiology, A.O.R.N. “Sant'Anna e San Sebastiano”, Caserta, Italy
| | - Raffaele Marfella
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy,Mediterranea Cardiocentro, Naples, Italy
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Oraii A, Healey JS, Benz AP, Pandey AK, Wong JA, Fonguh S, Wang J, Conen D, Gerstein HC, Connolly SJ, McIntyre WF. Association of Eligibility for a Sodium-Glucose Cotransporter 2 Inhibitor and Cardiovascular Events in Patients With Atrial Fibrillation. Can J Cardiol 2022; 38:1434-1441. [PMID: 35562018 DOI: 10.1016/j.cjca.2022.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/28/2022] [Accepted: 05/02/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitors (SGLT2i) reduce heart failure (HF) in a broad range of populations, but they have not been studied specifically in patients with atrial fibrillation (AF). We aimed to examine the association between SGLT2i eligibility and cardiovascular events in patients with AF to evaluate the potential utility of SGLT2is for AF management. METHODS We pooled data from 2 randomized controlled trials (RCTs) of patients with AF (RE-LY and ACTIVE-W). Among patients assigned to anticoagulation arms, those meeting the enrollment criteria from at least 1 of the phase 3 SGLT2i RCTs were classified as "SGLT2i eligible" and the remainder as "SGLT2i ineligible." The primary outcome was the composite of HF hospitalization or cardiovascular death. RESULTS A total of 21,484 patients with AF (mean age: 71.2 ± 8.8, 36.1% women, median CHA2DS2-VASc Score = 3) were included. The proportion of patients with AF eligible for SGLT2i was 41.2%. SGLT2i-eligible patients had higher rates of cardiovascular death or hospitalization for HF (5.8 vs 3.2 per 100 person-years, Plog-rank < 0.001), cardiovascular death (3.9 vs 1.5 per 100 person-years, Plog-rank < 0.001), and hospitalization for HF (2.5 vs 1.9 per 100 person-years, Plog-rank < 0.001). The age- and sex-adjusted model showed that SGLT2i-eligible patients were at a higher risk of cardiovascular death and hospitalization for HF (hazard ratio [HR], 1.97; 95% confidence interval [CI], 1.79-2.17; P < 0.001), cardiovascular death (HR, 2.75; 95% CI, 2.41-3.13; P < 0.001), and hospitalization for HF (HR, 1.41; 95% CI, 1.23-1.62; P < 0.001) than ineligible patients. CONCLUSIONS Most patients with AF do not currently have indications for SGLT2is but still have substantial risk of cardiovascular events. Future randomized trials should evaluate the efficacy of SGLT2is in patients with AF.
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Affiliation(s)
- Alireza Oraii
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jeff S Healey
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Arjun K Pandey
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jorge A Wong
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sylvanus Fonguh
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jia Wang
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - David Conen
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Hertzel C Gerstein
- Population Health Research Institute, Hamilton, Ontario, Canada; Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - William F McIntyre
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
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Jang HY, Kim IW, Oh JM. Using real-world data for supporting regulatory decision making: Comparison of cardiovascular and safety outcomes of an empagliflozin randomized clinical trial versus real-world data. Front Pharmacol 2022; 13:928121. [PMID: 36110539 PMCID: PMC9468970 DOI: 10.3389/fphar.2022.928121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 07/20/2022] [Indexed: 11/13/2022] Open
Abstract
Aims: In countries where a randomized clinical trial (RCT) is difficult to perform, a real-world evidence (RWE) study with a design similar to an RCT may be an option for drug regulatory decision-making. In this study, the objective was to find out to what extent the safety of empagliflozin from the RWE study in Korea is different from the one in RCT by emulating the design of foreign RCT. The outcome covers various safety outcomes including cardiovascular safety. Methods: The EMPA-REG OUTCOME trial (NCT01131676) was selected for comparison. The inclusion/exclusion criteria and follow-up method for the RWE were matched to the comparison RCT. Major adverse cardiovascular events (MACEs) were used as a primary outcome and 15 other outcomes were also included for analysis. Result: We followed 23,126 matched patients with type 2 diabetes mellitus (11,563 empagliflozin users and 11,563 sitagliptin users) for 2.7 years (median). Empagliflozin use was associated with a significantly decreased risk of MACEs [EMPA-REG DUPLICATE RWE: adjusted HR 0.87, 95% confidence interval (CI) 0.79–0.96]. The predefined estimate agreement, regulatory agreement, and standardized difference for RCT duplication were achieved [EMPA-REG OUTCOME RCT: adjusted HR 0.86, 95% (CI) 0.74–0.99]. According to the predefined criteria for 15 outcomes, 10 outcomes were evaluated as good, and three as moderate. Conclusion: Our study results suggest that RWE in one country in comparison with an RCT has the potential for providing evidence for future regulatory decision-making in an environment where RCT could not be performed.
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33
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Reddy YNV, Borlaug BA, Gersh BJ. Management of Atrial Fibrillation Across the Spectrum of Heart Failure With Preserved and Reduced Ejection Fraction. Circulation 2022; 146:339-357. [PMID: 35877831 DOI: 10.1161/circulationaha.122.057444] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia among patients with heart failure (HF), and HF is the most common cause of death for patients presenting with clinical AF. AF is frequently associated with pathological atrial myocardial dysfunction and remodeling, a triad that has been called atrial myopathy. AF can be the cause or consequence of clinical HF, and the directionality varies between individual patients and across the spectrum of HF. Although initial trials suggested no advantage for a systematic rhythm control strategy in HF with reduced ejection fraction, recent data suggest that select patients may benefit from attempts to maintain sinus rhythm with catheter ablation. Preliminary data also show a close relationship among AF, left atrial myopathy, mitral regurgitation, and HF with preserved ejection, with potential clinical benefits to catheter ablation therapy. The modern management of AF in HF also requires consideration of the degree of atrial myopathy and chronicity of AF, in addition to the pathogenesis and phenotype of the underlying left ventricular HF. In this review, we summarize the contemporary management of AF and provide practical guidance and areas in need of future investigation.
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Affiliation(s)
- Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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34
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Karayiannides S, Norhammar A, Landstedt-Hallin L, Friberg L, Pia L. Prognostic impact of type 1 and type 2 diabetes mellitus in atrial fibrillation and the effect of severe hypoglycaemia: A nationwide cohort study. Eur J Prev Cardiol 2022; 29:1759-1769. [PMID: 35580601 DOI: 10.1093/eurjpc/zwac093] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 04/24/2022] [Accepted: 05/11/2022] [Indexed: 11/14/2022]
Abstract
AIMS To compare prognosis between individuals without diabetes, type 1 and type 2 diabetes in a nationwide atrial fibrillation cohort in Sweden and study the significance of severe hypoglycaemia. METHODS Using data from all-inclusive national registers, 309,611 patients with non-valvular atrial fibrillation were enrolled during 2013-2014. Of these, 2,221 had type 1 and 58,073 had type 2 diabetes. Patients were followed for all-cause mortality until March 27, 2017, and for myocardial infarction, ischaemic stroke and first-ever diagnosis of heart failure or dementia until December 31, 2015. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated using Cox and competing risk regression. RESULTS Using individuals without diabetes as reference (HR = 1), the adjusted HRs in type 1 versus type 2 diabetes were for mortality 1.87 (CI 1.73-2.02) vs. 1.51 (CI 1.47-1.55), heart failure 1.59 (CI 1.42-1.78) vs. 1.41 (CI 1.34-1.48), myocardial infarction 2.49 (CI 2.17-2.85) vs. 1.70 (CI 1.59-1.81), ischaemic stroke 1.59 (CI 1.35-1.87) vs. 1.31 (CI 1.22-1.40) and dementia 1.46 (CI 1.15-1.85) vs. 1.28 (CI 1.18-1.40). Among individuals with type 2 diabetes, those with previous severe hypoglycaemia had increased risk of mortality (HR 1.26; CI 1.17-1.36) and dementia (HR 1.37; CI 1.08-1.73) compared with those without previous severe hypoglycaemia. CONCLUSION Presence of diabetes-regardless of type- in atrial fibrillation is associated with an increased risk of premature death, cardiovascular events and dementia. This increase is more pronounced in type 1 than in type 2 diabetes. A history of severe hypoglycaemia is associated with a worsened prognosis in type 2 diabetes.
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Affiliation(s)
- Stelios Karayiannides
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden.,Center for Diabetes, Academic Specialist Center, Region Stockholm, Sweden
| | - Anna Norhammar
- Cardiology Unit, Department of Medicine K2, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Physiology, Capio St Görans Hospital, Stockholm, Sweden
| | - Lena Landstedt-Hallin
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Leif Friberg
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Lundman Pia
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden.,Department of Cardiology, Danderyd University Hospital, Stockholm, Sweden
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35
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Måneheim A, Engström G, Juhlin T, Persson A, Zaigham S, Johnson LS. Elevated Premature Ventricular Complex counts on 24-hour ECG predict incident atrial fibrillation and heart failure - A prospective population-based cohort study. Heart Rhythm O2 2022; 3:344-350. [PMID: 36097468 PMCID: PMC9463710 DOI: 10.1016/j.hroo.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Objectives Methods Results Conclusion
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36
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Papazoglou AS, Kartas A, Moysidis DV, Tsagkaris C, Papadakos SP, Bekiaridou A, Samaras A, Karagiannidis E, Papadakis M, Giannakoulas G. Glycemic control and atrial fibrillation: an intricate relationship, yet under investigation. Cardiovasc Diabetol 2022; 21:39. [PMID: 35287684 PMCID: PMC8922816 DOI: 10.1186/s12933-022-01473-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 02/25/2022] [Indexed: 12/26/2022] Open
Abstract
Atrial fibrillation (AF) and diabetes mellitus (DM) constitute two major closely inter-related chronic cardiovascular disorders whose concurrent prevalence rates are steadily increasing. Although, the pathogenic mechanisms behind the AF and DM comorbidity are still vague, it is now clear that DM precipitates AF occurrence. DM also affects the clinical course of established AF; it is associated with significant increase in the incidence of stroke, AF recurrence, and cardiovascular mortality. The impact of DM on AF management and prognosis has been adequately investigated. However, evidence on the relative impact of glycemic control using glycated hemoglobin levels is scarce. This review assesses up-to-date literature on the association between DM and AF. It also highlights the usefulness of glycated hemoglobin measurement for the prediction of AF and AF-related adverse events. Additionally, this review evaluates current anti-hyperglycemic treatment in the context of AF, and discusses AF-related decision-making in comorbid DM. Finally, it quotes significant remaining questions and sets some future strategies with the potential to effectively deal with this prevalent comorbidity.
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Affiliation(s)
- Andreas S Papazoglou
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece.,Athens Naval Hospital, Athens, Greece
| | - Anastasios Kartas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Dimitrios V Moysidis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | | | - Stavros P Papadakos
- First Department of Pathology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandra Bekiaridou
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Athanasios Samaras
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Efstratios Karagiannidis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Marios Papadakis
- University Hospital Witten-Herdecke, University of Witten-Herdecke, Heusnerstrasse 40, 42283, Wuppertal, Germany.
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
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37
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Kolesnik E, Scherr D, Rohrer U, Benedikt M, Manninger M, Sourij H, von Lewinski D. SGLT2 Inhibitors and Their Antiarrhythmic Properties. Int J Mol Sci 2022; 23:1678. [PMID: 35163599 PMCID: PMC8835896 DOI: 10.3390/ijms23031678] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 01/23/2022] [Accepted: 01/24/2022] [Indexed: 12/13/2022] Open
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors are gaining ground as standard therapy for heart failure with a class-I recommendation in the recently updated heart failure guidelines from the European Society of Cardiology. Different gliflozins have shown impressive beneficial effects in patients with and without diabetes mellitus type 2, especially in reducing the rates for hospitalization for heart failure, yet little is known on their antiarrhythmic properties. Atrial and ventricular arrhythmias were reported by clinical outcome trials with SGLT2 inhibitors as adverse events, and SGLT2 inhibitors seemed to reduce the rate of arrhythmias compared to placebo treatment in those trials. Mechanistical links are mainly unrevealed, since hardly any experiments investigated their impact on arrhythmias. Prospective trials are currently ongoing, but no results have been published so far. Arrhythmias are common in the heart failure population, therefore the understanding of possible interactions with SGLT2 inhibitors is crucial. This review summarizes evidence from clinical data as well as the sparse experimental data of SGLT2 inhibitors and their effects on arrhythmias.
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Affiliation(s)
- Ewald Kolesnik
- Department of Cardiology, University Heart Centre Graz, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria
| | - Daniel Scherr
- Department of Cardiology, University Heart Centre Graz, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria
| | - Ursula Rohrer
- Department of Cardiology, University Heart Centre Graz, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria
| | - Martin Benedikt
- Department of Cardiology, University Heart Centre Graz, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria
| | - Martin Manninger
- Department of Cardiology, University Heart Centre Graz, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria
| | - Harald Sourij
- Department of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria
| | - Dirk von Lewinski
- Department of Cardiology, University Heart Centre Graz, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria
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