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Wang M, Zou J, Wang J, Liu M, Liu K, Wang N, Wang K. Aberrant HSF1 signaling activation underlies metformin amelioration of myocardial infarction in mice. MOLECULAR THERAPY - NUCLEIC ACIDS 2022; 29:312-328. [PMID: 35950214 PMCID: PMC9352811 DOI: 10.1016/j.omtn.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 07/08/2022] [Indexed: 11/05/2022]
Abstract
Myocardial infarction (MI) is a cardiovascular disease with high morbidity and mortality. Clinically, rehabilitation after massive MI often has a poor prognosis. Therefore, it is necessary to explore the therapeutic methods of myocardial protection after MI. As a first-line treatment for type 2 diabetes, metformin has been found to have a certain protective effect on myocardial tissue. However, its pharmacological mechanism remains unclear. In this study, we investigated key factors that reduced MI with metformin. Through in vivo, in vitro, and in silico analyses, we identified HSF1 as a key target for metformin. HSF1 could up-regulate the transcriptional level of AMPKα2 through transcriptional activation and stimulate the activity of the downstream AMPK/mTOR signaling pathway. Metformin stimulated cardiomyocytes to form stress granules (SGs), and knockdown of HSF1 reversed this process. Furthermore, HSF1 exhibited better in vitro affinity for metformin than AMPK, suggesting that HSF1 may be a more sensitive target for metformin.
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Metformin treatment is associated with improved outcome in patients with diabetes and advanced heart failure (HFrEF). Sci Rep 2022; 12:13038. [PMID: 35906276 PMCID: PMC9338272 DOI: 10.1038/s41598-022-17327-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 07/25/2022] [Indexed: 11/17/2022] Open
Abstract
The role of metformin (MET) in the treatment of patients with advanced HFrEF and type 2 diabetes mellitus (DM) is not firmly established. We studied the impact of MET on metabolic profile, quality of life (QoL) and survival in these patients. A total of 847 stable patients with advanced HFrEF (57.4 ± 11.3 years, 67.7% NYHA III/IV, LVEF 23.6 ± 5.8%) underwent clinical and laboratory evaluation and were prospectively followed for a median of 1126 (IQRs 410; 1781) days for occurrence of death, urgent heart transplantation or mechanical circulatory support implantation. A subgroup of 380 patients (44.9%) had DM, 87 of DM patients (22.9%) were treated with MET. Despite worse insulin sensitivity and more severe DM (higher BMI, HbA1c, worse insulin resistance), MET-treated patients exhibited more stable HF marked by lower BNP level (400 vs. 642 ng/l), better LV and RV function, lower mitral and tricuspid regurgitation severity, were using smaller doses of diuretics (all p < 0.05). Further, they had higher eGFR (69.23 vs. 63.34 ml/min/1.73 m2) and better QoL (MLHFQ: 36 vs. 48 points, p = 0.002). Compared to diabetics treated with other glucose-lowering agents, MET-treated patients had better event-free survival even after adjustment for BNP, BMI and eGFR (p = 0.035). Propensity score-matched analysis with 17 covariates yielded 81 pairs of patients and showed a significantly better survival for MET-treated subgroup (p = 0.01). MET treatment in patients with advanced HFrEF and DM is associated with improved outcome by mechanisms beyond the improvement of blood glucose control.
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Wilson S, Mone P, Kansakar U, Jankauskas SS, Donkor K, Adebayo A, Varzideh F, Eacobacci M, Gambardella J, Lombardi A, Santulli G. Diabetes and restenosis. Cardiovasc Diabetol 2022; 21:23. [PMID: 35164744 PMCID: PMC8845371 DOI: 10.1186/s12933-022-01460-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/21/2022] [Indexed: 01/05/2023] Open
Abstract
Restenosis, defined as the re-narrowing of an arterial lumen after revascularization, represents an increasingly important issue in clinical practice. Indeed, as the number of stent placements has risen to an estimate that exceeds 3 million annually worldwide, revascularization procedures have become much more common. Several investigators have demonstrated that vessels in patients with diabetes mellitus have an increased risk restenosis. Here we present a systematic overview of the effects of diabetes on in-stent restenosis. Current classification and updated epidemiology of restenosis are discussed, alongside the main mechanisms underlying the pathophysiology of this event. Then, we summarize the clinical presentation of restenosis, emphasizing the importance of glycemic control in diabetic patients. Indeed, in diabetic patients who underwent revascularization procedures a proper glycemic control remains imperative.
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Affiliation(s)
- Scott Wilson
- grid.251993.50000000121791997Department of Medicine, Einstein Institute for Aging Research, Einstein-Mount Sinai Diabetes Research Center (ES-DRC), The Fleischer Institute for Diabetes and Metabolism (FIDAM), Albert Einstein College of Medicine, New York, NY USA
| | - Pasquale Mone
- grid.251993.50000000121791997Department of Medicine, Einstein Institute for Aging Research, Einstein-Mount Sinai Diabetes Research Center (ES-DRC), The Fleischer Institute for Diabetes and Metabolism (FIDAM), Albert Einstein College of Medicine, New York, NY USA ,grid.251993.50000000121791997Department of Molecular Pharmacology, Wilf Family Cardiovascular Research Institute, Institute for Neuroimmunology and Inflammation (INI),, Albert Einstein College of Medicine, New York, NY USA
| | - Urna Kansakar
- grid.251993.50000000121791997Department of Medicine, Einstein Institute for Aging Research, Einstein-Mount Sinai Diabetes Research Center (ES-DRC), The Fleischer Institute for Diabetes and Metabolism (FIDAM), Albert Einstein College of Medicine, New York, NY USA ,grid.251993.50000000121791997Department of Molecular Pharmacology, Wilf Family Cardiovascular Research Institute, Institute for Neuroimmunology and Inflammation (INI),, Albert Einstein College of Medicine, New York, NY USA
| | - Stanislovas S. Jankauskas
- grid.251993.50000000121791997Department of Medicine, Einstein Institute for Aging Research, Einstein-Mount Sinai Diabetes Research Center (ES-DRC), The Fleischer Institute for Diabetes and Metabolism (FIDAM), Albert Einstein College of Medicine, New York, NY USA ,grid.251993.50000000121791997Department of Molecular Pharmacology, Wilf Family Cardiovascular Research Institute, Institute for Neuroimmunology and Inflammation (INI),, Albert Einstein College of Medicine, New York, NY USA
| | - Kwame Donkor
- grid.251993.50000000121791997Department of Medicine, Einstein Institute for Aging Research, Einstein-Mount Sinai Diabetes Research Center (ES-DRC), The Fleischer Institute for Diabetes and Metabolism (FIDAM), Albert Einstein College of Medicine, New York, NY USA
| | - Ayobami Adebayo
- grid.251993.50000000121791997Department of Medicine, Einstein Institute for Aging Research, Einstein-Mount Sinai Diabetes Research Center (ES-DRC), The Fleischer Institute for Diabetes and Metabolism (FIDAM), Albert Einstein College of Medicine, New York, NY USA
| | - Fahimeh Varzideh
- grid.251993.50000000121791997Department of Medicine, Einstein Institute for Aging Research, Einstein-Mount Sinai Diabetes Research Center (ES-DRC), The Fleischer Institute for Diabetes and Metabolism (FIDAM), Albert Einstein College of Medicine, New York, NY USA ,grid.251993.50000000121791997Department of Molecular Pharmacology, Wilf Family Cardiovascular Research Institute, Institute for Neuroimmunology and Inflammation (INI),, Albert Einstein College of Medicine, New York, NY USA
| | - Michael Eacobacci
- grid.251993.50000000121791997Department of Medicine, Einstein Institute for Aging Research, Einstein-Mount Sinai Diabetes Research Center (ES-DRC), The Fleischer Institute for Diabetes and Metabolism (FIDAM), Albert Einstein College of Medicine, New York, NY USA
| | - Jessica Gambardella
- grid.251993.50000000121791997Department of Molecular Pharmacology, Wilf Family Cardiovascular Research Institute, Institute for Neuroimmunology and Inflammation (INI),, Albert Einstein College of Medicine, New York, NY USA ,grid.4691.a0000 0001 0790 385XInternational Translational Research and Medical Education (ITME) Consortium, Department of Advanced Biomedical Sciences, “Federico II” University, Naples, Italy
| | - Angela Lombardi
- grid.251993.50000000121791997Department of Medicine, Einstein Institute for Aging Research, Einstein-Mount Sinai Diabetes Research Center (ES-DRC), The Fleischer Institute for Diabetes and Metabolism (FIDAM), Albert Einstein College of Medicine, New York, NY USA
| | - Gaetano Santulli
- grid.251993.50000000121791997Department of Medicine, Einstein Institute for Aging Research, Einstein-Mount Sinai Diabetes Research Center (ES-DRC), The Fleischer Institute for Diabetes and Metabolism (FIDAM), Albert Einstein College of Medicine, New York, NY USA ,grid.251993.50000000121791997Department of Molecular Pharmacology, Wilf Family Cardiovascular Research Institute, Institute for Neuroimmunology and Inflammation (INI),, Albert Einstein College of Medicine, New York, NY USA ,grid.4691.a0000 0001 0790 385XInternational Translational Research and Medical Education (ITME) Consortium, Department of Advanced Biomedical Sciences, “Federico II” University, Naples, Italy
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4
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Li T, Providencia R, Jiang W, Liu M, Yu L, Gu C, Chang ACY, Ma H. Association of Metformin with the Mortality and Incidence of Cardiovascular Events in Patients with Pre-existing Cardiovascular Diseases. Drugs 2022; 82:311-322. [PMID: 35032305 DOI: 10.1007/s40265-021-01665-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Whether metformin reduces all-cause cardiovascular mortality and the incidence of cardiovascular events in patients with pre-existing cardiovascular diseases (CVD) remains inconclusive. Some randomised controlled trials (RCTs) and cohort studies have shown that metformin is associated with an increased risk of mortality and cardiovascular events. METHODS We conducted a pooling synthesis to assess the effects of metformin in all-cause cardiovascular mortality and incidence of cardiovascular events in patients with CVD. Studies published up to October 2021 in PubMed or Embase with a registration in PROSPERO (CRD42020189905) were collected. Both RCT and cohort studies were included. Hazard ratios (HR) with 95% CI were pooled across various trials using the random-effects model. RESULTS This study enrolled 35 published studies (in 14 publications) for qualitative synthesis and identified 33 studies (published in 26 publications) for quantitative analysis. We analysed a total of 61,704 patients, among them 58,271 patients were used to calculate all-cause mortality while 12,814 patients were used to calculate cardiovascular mortality. Compared with non-metformin control, metformin usage is associated with a reduction in all-cause mortality (HR: 0.90; 95% CI 0.83, 0.98; p = 0.01), cardiovascular mortality (HR: 0.89; 95% CI 0.85, 0.94; p < 0.0001), incidence of coronary revascularisation (HR: 0.79; 95% CI 0.64, 0.98; p = 0.03), and heart failure (HR: 0.90; 95% CI 0.87, 0.94; p < 0.0001) in patients with pre-existing cardiovascular diseases. CONCLUSION Metformin use is associated with a reduction in all-cause mortality, cardiovascular mortality, incidence of coronary revascularisation, and heart failure in patients with CVD; however, metformin usage was not associated with reduction in the incidence of myocardial infarction, angina, or stroke.
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Affiliation(s)
- Tian Li
- Department of Physiology and Pathophysiology, Fourth Military Medical University, No. 169 Changle West Rd, Xi'an, 710032, China
| | | | - Wenhua Jiang
- Department of Physiology and Pathophysiology, Fourth Military Medical University, No. 169 Changle West Rd, Xi'an, 710032, China
| | - Manling Liu
- Department of Physiology and Pathophysiology, Fourth Military Medical University, No. 169 Changle West Rd, Xi'an, 710032, China
| | - Lu Yu
- Department of Pathology, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Chunhu Gu
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Alex Chia Yu Chang
- Department of Cardiology and Shanghai Institute of Precision Medicine, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 211125, China.
| | - Heng Ma
- Department of Physiology and Pathophysiology, Fourth Military Medical University, No. 169 Changle West Rd, Xi'an, 710032, China.
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5
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Baker C, Retzik-Stahr C, Singh V, Plomondon R, Anderson V, Rasouli N. Should metformin remain the first-line therapy for treatment of type 2 diabetes? Ther Adv Endocrinol Metab 2021; 12:2042018820980225. [PMID: 33489086 PMCID: PMC7809522 DOI: 10.1177/2042018820980225] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 11/20/2020] [Indexed: 12/17/2022] Open
Abstract
Metformin is a biguanide that is used as first-line treatment of type 2 diabetes mellitus and is effective as monotherapy and in combination with other glucose-lowering medications. It is generally well-tolerated with minimal side effects and is affordable. Although the safety and efficacy of metformin have been well-established, there is discussion regarding whether metformin should continue to be the first choice for therapy as other anti-hyperglycemic medications exhibit additional advantages in certain populations. Despite a long-standing history of metformin use, there are limited cardiovascular outcomes data for metformin. Furthermore, the available studies fail to provide strong evidence due to either small sample size or short duration. Recent data from glucagon-like peptide-1 receptor agonist and sodium-glucose cotransporter-2 inhibitor cardiovascular and renal outcomes trials demonstrated additional protection from diabetes complications for some high-risk patients, which has impacted the guidelines for diabetes management. Post-hoc analyses comparing hazard ratios for participants taking metformin at baseline versus not taking metformin are inconclusive for these two groups. There are no data to suggest that metformin should not be initiated soon after the diagnosis of diabetes. Furthermore, the initiation of newer glycemic-lowering medications with cardiovascular benefits should be considered in high-risk patients regardless of glycemic control or target HbA1c. However, cost remains a major factor in determining appropriate treatment.
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Affiliation(s)
| | - Cimmaron Retzik-Stahr
- Department of Medicine, University of Colorado School of Medicine and Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
| | - Vatsala Singh
- Department of Medicine, University of Colorado School of Medicine and Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
| | - Renee Plomondon
- Department of Medicine, University of Colorado School of Medicine and Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
| | - Victoria Anderson
- Department of Medicine, University of Colorado School of Medicine and Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
| | - Neda Rasouli
- Department of Medicine, University of Colorado and Division of Endocrinology, University of Colorado School of Medicine and Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
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6
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Halabi A, Yang H, Wright L, Potter E, Huynh Q, Negishi K, Marwick TH. Evolution of Myocardial Dysfunction in Asymptomatic Patients at Risk of Heart Failure. JACC Cardiovasc Imaging 2020; 14:350-361. [PMID: 33221236 DOI: 10.1016/j.jcmg.2020.09.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 09/01/2020] [Accepted: 09/08/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVES The determinants of changes in systolic and diastolic parameters in patients age >65 years, at risk of heart failure (HF), and with and without asymptomatic type 2 diabetes mellitus (T2DM) was assessed by echocardiography. The association between metformin and myocardial function was also assessed. BACKGROUND The increasing prevalence of T2DM will likely further fuel the epidemic of HF. Understanding the development or progression of left ventricular (LV) dysfunction may inform effective measures for HF prevention. METHODS A total of 982 patients with at least one HF risk factor (hypertension, obesity, or T2DM) were recruited from 2 community-based populations and divided into 2 groups: T2DM (n = 431, age 71 ± 4 years) and non-T2DM (n = 551, age 71 ± 5 years). Associations of metformin therapy were evaluated in the T2DM group. All underwent a comprehensive echocardiogram, including global longitudinal strain (GLS) and diastolic function (transmitral flow [E], annular velocity [e']) at baseline and follow-up (median 19 months [interquartile range: 17 to 26 months]). Comparisons were facilitated by propensity matching. RESULTS A reduction in GLS was observed in the T2DM group (baseline -17.8 ± 2.6% vs. follow-up -17.4 ± 2.8%; p = 0.003), but not in the non-T2DM group (-18.7 ± 2.7% vs. -18.6 ± 3.0%; p = 0.41). Estimated LV filling pressures increased in both the T2DM group (p = 0.001) and the non-T2DM group (p = 0.04). Metformin-treated patients with T2DM did not increase estimated LV filling pressure (E/e' baseline 8.9 ± 2.7 vs. follow-up 9.1 ± 2.7; p = 0.485) or change e' (7.6 ± 1.5 cm/s vs. 7.6 ± 1.8 cm/s; p = 0.88). After propensity matching, metformin was associated with a smaller change in e' (β = 0.58 [95% CI: 0.13 to 1.03]; p = 0.013) and E/e' (β = -0.96 [95% CI: -1.66 to -0.26]; p = 0.007) but was not associated with a change in GLS (p = 0.46). CONCLUSIONS Over 2 years, there is a worsening of GLS and LV filling pressures in asymptomatic diabetic patients with HF risk factors. Metformin use is associated with less deterioration of LV filling pressures and myocardial relaxation but had no association with systolic function.
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Affiliation(s)
- Amera Halabi
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Hilda Yang
- Menzies Institute for Medical Research, Imaging Research, Hobart, Tasmania, Australia
| | - Leah Wright
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Menzies Institute for Medical Research, Imaging Research, Hobart, Tasmania, Australia
| | - Elizabeth Potter
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Quan Huynh
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kazuaki Negishi
- Menzies Institute for Medical Research, Imaging Research, Hobart, Tasmania, Australia; Sydney Medical School Nepean, Charles Perkins Centre Nepean, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Thomas H Marwick
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Menzies Institute for Medical Research, Imaging Research, Hobart, Tasmania, Australia.
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7
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Bergmark BA, Bhatt DL, McGuire DK, Cahn A, Mosenzon O, Steg PG, Im K, Kanevsky E, Gurmu Y, Raz I, Braunwald E, Scirica BM. Metformin Use and Clinical Outcomes Among Patients With Diabetes Mellitus With or Without Heart Failure or Kidney Dysfunction. Circulation 2019; 140:1004-1014. [DOI: 10.1161/circulationaha.119.040144] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Metformin is first-line therapy for type 2 diabetes mellitus, although its effects on the cardiovascular system are unproved.
Methods:
In this post hoc analysis, patients in SAVOR-TIMI 53 (Saxagliptin and Cardiovascular Outcomes in Patients With Type 2 Diabetes Mellitus) with baseline biomarker samples (n=12 156) were classified as ever versus never taking metformin during the trial period. Associations between metformin exposure and outcomes were estimated with inverse probability of treatment weighting Cox modeling for the composite end point of cardiovascular death, myocardial infarction, or ischemic stroke, as well as cardiovascular death and all-cause mortality, with biomarkers included as covariates. Additional sensitivity analyses included propensity score matching and Cox multivariable models.
Results:
Of the 12 156 patients with baseline biomarker samples, 8971 (74%) had metformin exposure, 1611 (13%) had prior heart failure, and 1332 (11%) had at least moderate chronic kidney disease (estimated glomerular filtration rate ≤45 mL·min
−1
·1.73 m
−2
). Metformin use was associated with no difference in risk for the composite end point (hazard ratio for inverse probability of treatment weighting, 0.92 [95% CI, 0.76–1.11]) but lower risk of all-cause mortality (hazard ratio for inverse probability of treatment weighting, 0.75 [95% CI, 0.59–0.95]). There was no significant relationship between metformin use and these end points in patients with prior heart failure or moderate to severe chronic kidney disease.
Conclusions:
In a cohort of 12 156 patients with type 2 diabetes mellitus and high cardiovascular risk, metformin use was associated with lower rates of all-cause mortality, including after adjustment for clinical variables and biomarkers, but not lower rates of the composite end point of cardiovascular death, myocardial infarction, or ischemic stroke. This association was most apparent in patients without prior heart failure or moderate to severe chronic kidney disease.
Clinical Trial Registration:
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT01107886.
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Affiliation(s)
- Brian A. Bergmark
- Thrombolysis in Myocardial Infarction (TIMI) Study Group (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Cardiovascular Division, Heart and Vascular Center (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Deepak L. Bhatt
- Thrombolysis in Myocardial Infarction (TIMI) Study Group (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Cardiovascular Division, Heart and Vascular Center (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Darren K. McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.)
| | - Avivit Cahn
- Diabetes Unit, Division of Internal Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Israel (A.C., O.M., I.R.)
| | - Ofri Mosenzon
- Diabetes Unit, Division of Internal Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Israel (A.C., O.M., I.R.)
| | - Ph. Gabriel Steg
- FACT (French Alliance for Cardiovascular Clinical Trials), Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation, Remodelling), Université de Paris, Sorbonne Paris-Cité, France (P.G.S.)
- Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (P.G.S.)
- INSERM U-1148, Paris, France (P.G.S.)
- National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London, UK (P.G.S.)
| | - KyungAh Im
- Thrombolysis in Myocardial Infarction (TIMI) Study Group (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Cardiovascular Division, Heart and Vascular Center (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Estella Kanevsky
- Thrombolysis in Myocardial Infarction (TIMI) Study Group (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Cardiovascular Division, Heart and Vascular Center (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Yared Gurmu
- Thrombolysis in Myocardial Infarction (TIMI) Study Group (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Cardiovascular Division, Heart and Vascular Center (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Itamar Raz
- Diabetes Unit, Division of Internal Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Israel (A.C., O.M., I.R.)
| | - Eugene Braunwald
- Thrombolysis in Myocardial Infarction (TIMI) Study Group (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Cardiovascular Division, Heart and Vascular Center (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Benjamin M. Scirica
- Thrombolysis in Myocardial Infarction (TIMI) Study Group (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Cardiovascular Division, Heart and Vascular Center (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
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Avogaro A, Bonora E, Consoli A, Del Prato S, Genovese S, Giorgino F. Glucose-lowering therapy and cardiovascular outcomes in patients with type 2 diabetes mellitus and acute coronary syndrome. Diab Vasc Dis Res 2019; 16:399-414. [PMID: 31044622 DOI: 10.1177/1479164119845612] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Diabetes is a common comorbidity in patients hospitalized for an acute coronary syndrome event, and prevalence is increasing. Among patients hospitalized with acute myocardial infarction, diabetes can be an independent predictor of mortality and new cardiovascular events; both short- and long-term outcomes are worse for patients with diabetes relative to those without, and undiagnosed diabetes is associated with greater mortality. The impact of glycemic control on cardiovascular outcomes and the best approach to treat hyperglycemia upon hospital admission for acute coronary syndrome in patients with or without known diabetes remain open questions. This review assesses available evidence for hyperglycemia management at the time of admission for acute coronary syndrome and, thereafter, finds that (1) admission plasma glucose plays a role in predicting adverse events, especially in patients with unknown diabetes; (2) glycated haemoglobin is a likely predictor of events in patients with unknown diabetes; and (3) hypoglycemia at the time of acute myocardial infarction hospital admission is an important predictor for mortality in patients with and without diabetes. Whether glucose-targeted insulin and glucose infusion have advantages over glucose-insulin-potassium infusion remains controversial. Evidence for the effect of novel glucose-lowering agents used at the time of an acute cardiovascular event is limited and requires more dedicated studies.
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Affiliation(s)
- Angelo Avogaro
- 1 Unit of Metabolic Diseases, Department of Medicine, University of Padova, Padova, Italy
| | - Enzo Bonora
- 2 Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Hospital Trust of Verona, Verona, Italy
| | | | - Stefano Del Prato
- 4 Department of Clinical and Experimental Medicine, Section of Diabetes and Metabolic Diseases, University of Pisa, Pisa, Italy
| | - Stefano Genovese
- 5 Diabetes Endocrine and Metabolic Diseases Unit, Centro Cardiologico Monzino, Milan, Italy
| | - Francesco Giorgino
- 6 Department of Emergency and Organ Transplantation, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari, Italy
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9
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Han Y, Xie H, Liu Y, Gao P, Yang X, Shen Z. Effect of metformin on all-cause and cardiovascular mortality in patients with coronary artery diseases: a systematic review and an updated meta-analysis. Cardiovasc Diabetol 2019; 18:96. [PMID: 31362743 PMCID: PMC6668189 DOI: 10.1186/s12933-019-0900-7] [Citation(s) in RCA: 173] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 07/22/2019] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Metformin is the most widely prescribed drug to lower glucose and has a definitive effect on the cardiovascular system. The goal of this systematic review and meta-analysis is to assess the effects of metformin on mortality and cardiac function among patients with coronary artery disease (CAD). METHODS Relevant studies reported before October 2018 was retrieved from databases including PubMed, EMBASE, Cochrane Library and Web of Science. Hazard ratio (HR) was calculated to evaluate the all-cause mortality, cardiovascular mortality and incidence of cardiovascular events (CV events), to figure out the level of left ventricular ejection fraction (LVEF), creatine kinase MB (CK-MB), type B natriuretic peptide (BNP) and to compare the average level of low density lipoprotein (LDL). RESULTS In this meta-analysis were included 40 studies comprising 1,066,408 patients. The cardiovascular mortality, all-cause mortality and incidence of CV events were lowered to adjusted HR (aHR) = 0.81, aHR = 0.67 and aHR = 0. 83 respectively after the patients with CAD were given metformin. Subgroup analysis showed that metformin reduced all-cause mortality in myocardial infarction (MI) (aHR = 0.79) and heart failure (HF) patients (aHR = 0.84), the incidence of CV events in HF (aHR = 0.83) and type II diabetes mellitus (T2DM) patients (aHR = 0.83), but had no significant effect on MI (aHR = 0.87) and non-T2DM patients (aHR = 0.92). Metformin is superior to sulphonylurea (aHR = 0.81) in effects on lowering the incidence of CV events and in effects on patients who don't use medication. The CK-MB level in the metformin group was lower than that in the control group standard mean difference (SMD) = - 0.11). There was no significant evidence that metformin altered LVEF (MD = 2.91), BNP (MD = - 0.02) and LDL (MD = - 0.08). CONCLUSION Metformin reduces cardiovascular mortality, all-cause mortality and CV events in CAD patients. For MI patients and CAD patients without T2DM, metformin has no significant effect of reducing the incidence of CV events. Metformin has a better effect of reducing the incidence of CV events than sulfonylureas.
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Affiliation(s)
- Yechen Han
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.,Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100005, China
| | - Hongzhi Xie
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.,Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100005, China
| | - Yongtai Liu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.,Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100005, China
| | - Peng Gao
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.,Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100005, China
| | - Xufei Yang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.,Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100005, China
| | - Zhujun Shen
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China. .,Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100005, China.
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10
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Jong CB, Chen KY, Hsieh MY, Su FY, Wu CC, Voon WC, Hsieh IC, Shyu KG, Chong JT, Lin WS, Hsu CN, Ueng KC, Lai CL. Metformin was associated with lower all-cause mortality in type 2 diabetes with acute coronary syndrome: A Nationwide registry with propensity score-matched analysis. Int J Cardiol 2019; 291:152-157. [PMID: 30905518 DOI: 10.1016/j.ijcard.2019.03.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/20/2019] [Accepted: 03/12/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND No randomized controlled trials evaluating metformin therapy efficacy in patients with type 2 diabetes mellitus (DM) and acute coronary syndrome (ACS) have been reported. We aimed to examine the mortality benefit of metformin therapy in patients with type 2 DM and ACS, compared with non-metformin anti-diabetes agents users. METHODS Data were extracted from the prospective nationwide ACS-DM Taiwan Society of Cardiology registry. Propensity score (PS) matching on baseline characteristics and treatment measures was performed for metformin versus non-metformin users. The Cox proportional hazards model was used to compare mortality outcomes among the PS-matched cohort as the primary analysis. The Cox proportional hazards models adjusting for all pre-determined covariates and quintiles of the PS among the overall population were performed as the secondary analyses. RESULTS Of 1157 patients with type 2 DM and ACS receiving anti-diabetes agents, 78 patients (6.7%) died over the 2-year follow-up period. After PS matching, 318 metformin users were matched with 318 non-metformin users. Metformin users had a lower all-cause mortality rate (adjusted hazard ratio [aHR] 0.50, 95% confidence interval [CI] 0.26-0.95) in the primary analysis. The survival benefit of metformin therapy was consistent in the secondary analyses (aHR 0.30, 95% CI 0.17-0.54 while adjusting for all pre-determined covariates, and aHR 0.34, 95% CI 0.19-0.59 while adjusting for quintiles of the PS). CONCLUSIONS Among patients with type 2 DM and ACS, metformin was associated with lower all-cause mortality. However, a detrimental effect of any of the comparators could not be excluded.
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Affiliation(s)
- Chien-Boon Jong
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Kuan-Yu Chen
- Department of Internal Medicine, ANSN Clinic, Hsin-Chu, Taiwan
| | - Mu-Yang Hsieh
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Fang-Ying Su
- Biotechnology R&D Center, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Chih-Cheng Wu
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan; Cardiovascular Center, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan; Institute of Biomedical Engineering, National Tsing-Hua University, Hsin-Chu, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wen-Chol Voon
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan
| | - I-Chang Hsieh
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Kou-Gi Shyu
- Division of Cardiology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | | | - Wei-Shiang Lin
- Division of Cardiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
| | - Chih-Neng Hsu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan
| | - Kwo-Chang Ueng
- Department of Internal Medicine, Chung-Shan Medical University Hospital, Taichung, Taiwan
| | - Chao-Lun Lai
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.
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11
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Oikonomou E, Mourouzis K, Fountoulakis P, Papamikroulis GA, Siasos G, Antonopoulos A, Vogiatzi G, Tsalamadris S, Vavuranakis M, Tousoulis D. Interrelationship between diabetes mellitus and heart failure: the role of peroxisome proliferator-activated receptors in left ventricle performance. Heart Fail Rev 2019; 23:389-408. [PMID: 29453696 DOI: 10.1007/s10741-018-9682-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Heart failure (HF) is a common cardiac syndrome, whose pathophysiology involves complex mechanisms, some of which remain unknown. Diabetes mellitus (DM) constitutes not only a glucose metabolic disorder accompanied by insulin resistance but also a risk factor for cardiovascular disease and HF. During the last years though emerging data set up, a bidirectional interrelationship between these two entities. In the case of DM impaired calcium homeostasis, free fatty acid metabolism, redox state, and advance glycation end products may accelerate cardiac dysfunction. On the other hand, when HF exists, hypoperfusion of the liver and pancreas, b-blocker and diuretic treatment, and autonomic nervous system dysfunction may cause impairment of glucose metabolism. These molecular pathways may be used as therapeutic targets for novel antidiabetic agents. Peroxisome proliferator-activated receptors (PPARs) not only improve insulin resistance and glucose and lipid metabolism but also manifest a diversity of actions directly or indirectly associated with systolic or diastolic performance of left ventricle and symptoms of HF. Interestingly, they may beneficially affect remodeling of the left ventricle, fibrosis, and diastolic performance but they may cause impaired water handing, sodium retention, and decompensation of HF which should be taken into consideration in the management of patients with DM. In this review article, we present the pathophysiological data linking HF with DM and we focus on the molecular mechanisms of PPARs agonists in left ventricle systolic and diastolic performance providing useful insights in the molecular mechanism of this class of metabolically active regiments.
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Affiliation(s)
- Evangelos Oikonomou
- 1st Department of Cardiology, 'Hippokration' Hospital, National and Kapodistrian University of Athens Medical School, Vasilissis Sofias 114, TK, 115 28, Athens, Greece.
| | - Konstantinos Mourouzis
- 1st Department of Cardiology, 'Hippokration' Hospital, National and Kapodistrian University of Athens Medical School, Vasilissis Sofias 114, TK, 115 28, Athens, Greece
| | - Petros Fountoulakis
- 1st Department of Cardiology, 'Hippokration' Hospital, National and Kapodistrian University of Athens Medical School, Vasilissis Sofias 114, TK, 115 28, Athens, Greece
| | - Georgios Angelos Papamikroulis
- 1st Department of Cardiology, 'Hippokration' Hospital, National and Kapodistrian University of Athens Medical School, Vasilissis Sofias 114, TK, 115 28, Athens, Greece
| | - Gerasimos Siasos
- 1st Department of Cardiology, 'Hippokration' Hospital, National and Kapodistrian University of Athens Medical School, Vasilissis Sofias 114, TK, 115 28, Athens, Greece
| | - Alexis Antonopoulos
- 1st Department of Cardiology, 'Hippokration' Hospital, National and Kapodistrian University of Athens Medical School, Vasilissis Sofias 114, TK, 115 28, Athens, Greece
| | - Georgia Vogiatzi
- 1st Department of Cardiology, 'Hippokration' Hospital, National and Kapodistrian University of Athens Medical School, Vasilissis Sofias 114, TK, 115 28, Athens, Greece
| | - Sotiris Tsalamadris
- 1st Department of Cardiology, 'Hippokration' Hospital, National and Kapodistrian University of Athens Medical School, Vasilissis Sofias 114, TK, 115 28, Athens, Greece
| | - Manolis Vavuranakis
- 1st Department of Cardiology, 'Hippokration' Hospital, National and Kapodistrian University of Athens Medical School, Vasilissis Sofias 114, TK, 115 28, Athens, Greece
| | - Dimitris Tousoulis
- 1st Department of Cardiology, 'Hippokration' Hospital, National and Kapodistrian University of Athens Medical School, Vasilissis Sofias 114, TK, 115 28, Athens, Greece
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12
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Shah SR, Iqbal SM, Alweis R, Roark S. A closer look at heart failure in patients with concurrent diabetes mellitus using glucose lowering drugs. Expert Rev Clin Pharmacol 2018; 12:45-52. [PMID: 30488734 DOI: 10.1080/17512433.2019.1552830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Type 2 diabetes (T2D) is an independent risk factor for heart failure (HF). With concomitant T2D and HF, recent data suggests an incremental risk of cardiovascular death and hospitalization for HF, as compared to patients with HF without T2D. Areas covered: Management of these two diseases has been a challenge for physicians. The treatment goals for HF patients in T2D are very important. They serve as the endpoint in using a specific treatment for management and treatment of T2D patients hence, decreasing mortality rates. In this review, we examine the effects of oral antidiabetic drugs on HF patients, discussing current evidence-based up-to-date management strategies and guidelines in the general population with HF and T2D. Expert commentary: Future in the management of T2D in HF patients looks bright. Augmenting data on potential cardiovascular side effects of antidiabetic drugs is valuable since millions of people are treated over many years. Newer novel drugs targeting specific signaling pathways are approaching the stages of clinical investigation. They have been a highly attractive concept for the future in the management of these patients. However, while advances in technology elucidated many aspects of these diseases, many mysteries still remain.
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Affiliation(s)
- Syed Raza Shah
- a North Florida Regional Medical Center , University of Central Florida (Gainesville) , Gainesville , FL , USA
| | - Sana Muhammad Iqbal
- b Department of Medicine , Dow University of Health Sciences (DUHS) , Karachi , Pakistan
| | - Richard Alweis
- c Department of Medicine , Rochester Regional Health System , Rochester , NY , USA
| | - Steven Roark
- d North Florida Regional Medical Center, The Cardiac and Vascular Institute , University of Central Florida (Gainesville) , Gainesville , FL , USA
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13
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Varjabedian L, Bourji M, Pourafkari L, Nader ND. Cardioprotection by Metformin: Beneficial Effects Beyond Glucose Reduction. Am J Cardiovasc Drugs 2018; 18:181-193. [PMID: 29478240 DOI: 10.1007/s40256-018-0266-3] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Metformin is a biguanide that is widely used as an insulin-sparing agent to treat diabetes. When compared with the general population, diabetics are twice as likely to die from fatal myocardial infarction and congestive heart failure (CHF). There has been a significant concern regarding the use of metformin in patients with CHF because of their higher tendency to develop lactic acidosis. However, large epidemiological trials have reported better cardiovascular prognosis with metformin compared to other glucose-lowering agents among diabetics. Additionally, metformin has reduced the risk of reinfarction and all-cause mortality in patients with coronary artery disease and CHF, respectively. The protection against cardiovascular diseases appears to be independent of the anti-hyperglycemic effects of metformin. These effects are mediated through an increase in 5' adenosine monophosphate-activated protein kinase (AMPK) phosphorylation and by increased phosphorylation of endothelial nitric oxide synthase (eNOS) in cardiomyocytes with an increased production of nitric oxide (NO). Metformin preconditions the heart against ischemia-reperfusion injury and may improve myocardial remodeling after an ischemic insult. The preponderance of evidence currently suggests that metformin is safe in patients with CHF, prompting the Food and Drug Administration to remove CHF as a contraindication from the package insert of all generic metformin preparations. In this narrative, along with a limited meta-analysis of available studies, we have reviewed the pleiotropic (non-glucose-lowering) effects of metformin that potentially contribute to its cardioprotective properties. Additionally, we have reviewed issues surrounding the safety of metformin in patients with cardiac diseases.
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Affiliation(s)
| | - Mohammad Bourji
- Department of Medicine, University at Buffalo, Buffalo, NY, 14203, USA
| | - Leili Pourafkari
- Department of Anesthesiology, University at Buffalo, 77 Goodell Street # 550, Buffalo, NY, 14203, USA
| | - Nader D Nader
- Department of Anesthesiology, University at Buffalo, 77 Goodell Street # 550, Buffalo, NY, 14203, USA.
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14
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Ofstad AP, Atar D, Gullestad L, Langslet G, Johansen OE. The heart failure burden of type 2 diabetes mellitus-a review of pathophysiology and interventions. Heart Fail Rev 2018; 23:303-323. [PMID: 29516230 PMCID: PMC5937871 DOI: 10.1007/s10741-018-9685-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Diabetes and heart failure (HF) are both global epidemics with tremendous costs on society with increased rates of HF hospitalizations and worsened prognosis when co-existing, making it a significant "deadly duo." The evidence for pharmacological treatment of HF in patients with type 2 diabetes mellitus (T2DM) stems typically from either subgroup analyses of patients that were recruited to randomized controlled trials of HF interventions, usually in patients with reduced ejection fraction (EF), or from subgroup analyses of HF patients recruited to cardiovascular (CV) outcome trials (CVOT) of glucose lowering agents involving patients with T2DM. Studies in patients with HF with preserved EF are sparse. This review summarizes the literature on pathophysiology and interventions aiming to reduce the HF burden in T2DM and includes HF trials of ACEi, digoxin, β-blocker, ARB, If-blocker, MRA, and ARNI involving 38,600 patients, with or without prevalent diabetes, and CV outcome trials in T2DM involving 74,351 patients, with or without prevalent HF. In all HF trials, HF outcomes by prevalent diabetes were reported with an incremental risk of HF and death confessed by prevalent diabetes and a treatment effect similar to those without diabetes. All T2DM CVOTs reported on HF outcomes with heterogeneity between trials with two reporting benefits (empagliflozin and canagliflozin) and two reporting increased risk (saxagliptin, pioglitazone). In vulnerable T2DM patients with concomitant HF, guideline-recommended HF drugs are effective. When choosing glucose-lowering therapy, outcomes from available CVOTs should be considered.
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Affiliation(s)
- Anne Pernille Ofstad
- Bærum Hospital, Vestre Viken HF, Rud, Norway.
- Medical Department, Boehringer Ingelheim, Asker, Norway.
| | - Dan Atar
- Department of Cardiology B, Oslo University Hospital, Ullevål, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Lars Gullestad
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Gisle Langslet
- Rikshospitalet, Lipid Clinic, Oslo University Hospital, Oslo, Norway
| | - Odd Erik Johansen
- Bærum Hospital, Vestre Viken HF, Rud, Norway
- Medical Department, Boehringer Ingelheim, Asker, Norway
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15
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Gong TA, Hall SA. Targeting Other Modifiable Risk Factors for the Prevention of Heart Failure: Diabetes, Smoking, Obesity, and Inactivity. CURRENT CARDIOVASCULAR RISK REPORTS 2018. [DOI: 10.1007/s12170-018-0574-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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16
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De Broe M, Kajbaf F, Lalau JD. Renoprotective Effects of Metformin. Nephron Clin Pract 2017; 138:261-274. [DOI: 10.1159/000481951] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 10/03/2017] [Indexed: 12/18/2022] Open
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17
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Schlender L, Martinez YV, Adeniji C, Reeves D, Faller B, Sommerauer C, Al Qur'an T, Woodham A, Kunnamo I, Sönnichsen A, Renom-Guiteras A. Efficacy and safety of metformin in the management of type 2 diabetes mellitus in older adults: a systematic review for the development of recommendations to reduce potentially inappropriate prescribing. BMC Geriatr 2017; 17:227. [PMID: 29047344 PMCID: PMC5647555 DOI: 10.1186/s12877-017-0574-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Metformin is usually prescribed as first line therapy for type 2 diabetes mellitus (DM2). However, the benefits and risks of metformin may be different for older people. This systematic review examined the available evidence on the safety and efficacy of metformin in the management of DM2 in older adults. The findings were used to develop recommendations for the electronic decision support tool of the European project PRIMA-eDS. Methods The systematic review followed a staged approach, initially searching for systematic reviews and meta-analyses first, and then individual studies when prior searches were inconclusive. The target population was older people (≥65 years old) with DM2. Studies were included if they reported safety or efficacy outcomes with metformin (alone or in combination) for the management of DM2 compared to placebo, usual or no treatment, or other antidiabetics. Using the evidence identified, recommendations were developed using GRADE methodology. Results Fifteen studies were included (4 intervention and 11 observational studies). In ten studies at least 80% of participants were 65 years or older and 5 studies reported subgroup analyses by age. Comorbidities were reported by 9 studies, cognitive status was reported by 4 studies and functional status by 1 study. In general, metformin showed similar or better safety and efficacy than other specific or non-specific active treatments. However, these findings were mainly based on retrospective observational studies. Four recommendations were developed suggesting to discontinue the use of metformin for the management of DM2 in older adults with risk factors such as age > 80, gastrointestinal complaints during the last year and/or GFR ≤60 ml/min. Conclusions On the evidence available, the safety and efficacy profiles of metformin appear to be better, and certainly no worse, than other treatments for the management of DM2 in older adults. However, the quality and quantity of the evidence is low, with scarce data on adverse events such as gastrointestinal complaints or renal failure. Further studies are needed to more reliably assess the benefits and risks of metformin in very old (>80), cognitively and functionally impaired older people. Electronic supplementary material The online version of this article (doi:10.1186/s12877-017-0574-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lisa Schlender
- Institut für Allgemeinmedizin und Familienmedizin, UWH, Witten, Germany.
| | - Yolanda V Martinez
- NIHR School for Primary Care Research, University of Manchester, Manchester, UK
| | - Charles Adeniji
- NIHR School for Primary Care Research, University of Manchester, Manchester, UK
| | - David Reeves
- NIHR School for Primary Care Research, University of Manchester, Manchester, UK
| | - Barbara Faller
- Institut für Allgemeinmedizin und Familienmedizin, UWH, Witten, Germany
| | | | - Thekraiat Al Qur'an
- Institut für Allgemeinmedizin und Familienmedizin, UWH, Witten, Germany.,Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Adrine Woodham
- NIHR School for Primary Care Research, University of Manchester, Manchester, UK
| | - Ilkka Kunnamo
- Duodecim Medical Publications Ltd, Helsinki, Finland
| | | | - Anna Renom-Guiteras
- Institut für Allgemeinmedizin und Familienmedizin, UWH, Witten, Germany.,Department of Geriatrics, University Hospital Parc de Salut Mar, Barcelona, Spain
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18
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Roumie CL, Min JY, D'Agostino McGowan L, Presley C, Grijalva CG, Hackstadt AJ, Hung AM, Greevy RA, Elasy T, Griffin MR. Comparative Safety of Sulfonylurea and Metformin Monotherapy on the Risk of Heart Failure: A Cohort Study. J Am Heart Assoc 2017; 6:JAHA.116.005379. [PMID: 28424149 PMCID: PMC5533028 DOI: 10.1161/jaha.116.005379] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background Medications that impact insulin sensitivity or cause weight gain may increase heart failure risk. Our aim was to compare heart failure and cardiovascular death outcomes among patients initiating sulfonylureas for diabetes mellitus treatment versus metformin. Methods and Results National Veterans Health Administration databases were linked to Medicare, Medicaid, and National Death Index data. Veterans aged ≥18 years who initiated metformin or sulfonylureas between 2001 and 2011 and whose creatinine was <1.4 (females) or 1.5 mg/dL (males) were included. Each metformin patient was propensity score‐matched to a sulfonylurea initiator. The outcome was hospitalization for acute decompensated heart failure as the primary reason for admission or a cardiovascular death. There were 126 867 and 79 192 new users of metformin and sulfonylurea, respectively. Propensity score matching yielded 65 986 per group. Median age was 66 years, and 97% of patients were male; hemoglobin A1c 6.9% (6.3, 7.7); body mass index 30.7 kg/m2 (27.4, 34.6); and 6% had heart failure history. There were 1236 events (1184 heart failure hospitalizations and 52 cardiovascular deaths) among sulfonylurea initiators and 1078 events (1043 heart failure hospitalizations and 35 cardiovascular deaths) among metformin initiators. There were 12.4 versus 8.9 events per 1000 person‐years of use (adjusted hazard ratio 1.32, 95%CI 1.21, 1.43). The rate difference was 4 heart failure hospitalizations or cardiovascular deaths per 1000 users of sulfonylureas versus metformin annually. Conclusions Predominantly male patients initiating treatment for diabetes mellitus with sulfonylurea had a higher risk of heart failure and cardiovascular death compared to similar patients initiating metformin.
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Affiliation(s)
- Christianne L Roumie
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center (GRECC), HSR&D Center, Nashville, TN .,Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jea Young Min
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center (GRECC), HSR&D Center, Nashville, TN.,Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Lucy D'Agostino McGowan
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center (GRECC), HSR&D Center, Nashville, TN.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Caroline Presley
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center (GRECC), HSR&D Center, Nashville, TN.,Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Carlos G Grijalva
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center (GRECC), HSR&D Center, Nashville, TN.,Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
| | - Amber J Hackstadt
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center (GRECC), HSR&D Center, Nashville, TN.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Adriana M Hung
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center (GRECC), HSR&D Center, Nashville, TN.,Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Robert A Greevy
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center (GRECC), HSR&D Center, Nashville, TN.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Tom Elasy
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center (GRECC), HSR&D Center, Nashville, TN.,Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Marie R Griffin
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center (GRECC), HSR&D Center, Nashville, TN.,Department of Medicine, Vanderbilt University Medical Center, Nashville, TN.,Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
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19
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Chong CR, Clarke K, Levelt E. Metabolic Remodeling in Diabetic Cardiomyopathy. Cardiovasc Res 2017; 113:422-430. [PMID: 28177068 PMCID: PMC5412022 DOI: 10.1093/cvr/cvx018] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/02/2017] [Indexed: 02/07/2023] Open
Abstract
Diabetes is a risk factor for heart failure and cardiovascular mortality with specific changes to myocardial metabolism, energetics, structure, and function. The gradual impairment of insulin production and signalling in diabetes is associated with elevated plasma fatty acids and increased myocardial free fatty acid uptake and activation of the transcription factor PPARα. The increased free fatty acid uptake results in accumulation of toxic metabolites, such as ceramide and diacylglycerol, activation of protein kinase C, and elevation of uncoupling protein-3. Insulin signalling and glucose uptake/oxidation become further impaired, and mitochondrial function and ATP production become compromised. Increased oxidative stress also impairs mitochondrial function and disrupts metabolic pathways. The diabetic heart relies on free fatty acids (FFA) as the major substrate for oxidative phosphorylation and is unable to increase glucose oxidation during ischaemia or hypoxia, thereby increasing myocardial injury, especially in ageing female diabetic animals. Pharmacological activation of PPARγ in adipose tissue may lower plasma FFA and improve recovery from myocardial ischaemic injury in diabetes. Not only is the diabetic heart energetically-impaired, it also has early diastolic dysfunction and concentric remodelling. The contractile function of the diabetic myocardium negatively correlates with epicardial adipose tissue, which secretes proinflammatory cytokines, resulting in interstitial fibrosis. Novel pharmacological strategies targeting oxidative stress seem promising in preventing progression of diabetic cardiomyopathy, although clinical evidence is lacking. Metabolic agents that lower plasma FFA or glucose, including PPARγ agonism and SGLT2 inhibition, may therefore be promising options.
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Affiliation(s)
- Cher-Rin Chong
- 1 Department of Physiology, Anatomy and Genetics, University of Oxford
| | - Kieran Clarke
- 1 Department of Physiology, Anatomy and Genetics, University of Oxford
| | - Eylem Levelt
- 2 Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital
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Crowley MJ, Diamantidis CJ, McDuffie JR, Cameron CB, Stanifer JW, Mock CK, Wang X, Tang S, Nagi A, Kosinski AS, Williams JW. Clinical Outcomes of Metformin Use in Populations With Chronic Kidney Disease, Congestive Heart Failure, or Chronic Liver Disease: A Systematic Review. Ann Intern Med 2017; 166:191-200. [PMID: 28055049 PMCID: PMC5293600 DOI: 10.7326/m16-1901] [Citation(s) in RCA: 168] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Recent changes to the U.S. Food and Drug Administration boxed warning for metformin will increase its use in persons with historical contraindications or precautions. Prescribers must understand the clinical outcomes of metformin use in these populations. PURPOSE To synthesize data addressing outcomes of metformin use in populations with type 2 diabetes and moderate to severe chronic kidney disease (CKD), congestive heart failure (CHF), or chronic liver disease (CLD) with hepatic impairment. DATA SOURCES MEDLINE (via PubMed) from January 1994 to September 2016, and Cochrane Library, EMBASE, and International Pharmaceutical Abstracts from January 1994 to November 2015. STUDY SELECTION English-language studies that: 1) examined adults with type 2 diabetes and CKD (with estimated glomerular filtration rate less than 60 mL/min/1.73 m2), CHF, or CLD with hepatic impairment; 2) compared diabetes regimens that included metformin with those that did not; and 3) reported all-cause mortality, major adverse cardiovascular events, and other outcomes of interest. DATA EXTRACTION 2 reviewers abstracted data and independently rated study quality and strength of evidence. DATA SYNTHESIS On the basis of quantitative and qualitative syntheses involving 17 observational studies, metformin use is associated with reduced all-cause mortality in patients with CKD, CHF, or CLD with hepatic impairment, and with fewer heart failure readmissions in patients with CKD or CHF. LIMITATIONS Strength of evidence was low, and data on multiple outcomes of interest were sparse. Available studies were observational and varied in follow-up duration. CONCLUSION Metformin use in patients with moderate CKD, CHF, or CLD with hepatic impairment is associated with improvements in key clinical outcomes. Our findings support the recent changes in metformin labeling. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs. (PROSPERO: CRD42016027708).
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Affiliation(s)
- Matthew J. Crowley
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
- Division of Endocrinology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Clarissa J. Diamantidis
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Jennifer R. McDuffie
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - C. Blake Cameron
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - John W. Stanifer
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Clare K. Mock
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Xianwei Wang
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
| | - Shuang Tang
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
| | - Avishek Nagi
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
| | - Andrzej S. Kosinski
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - John W. Williams
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
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21
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Goltsman I, Khoury EE, Winaver J, Abassi Z. Does Thiazolidinedione therapy exacerbate fluid retention in congestive heart failure? Pharmacol Ther 2016; 168:75-97. [PMID: 27598860 DOI: 10.1016/j.pharmthera.2016.09.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The ever-growing global burden of congestive heart failure (CHF) and type 2 diabetes mellitus (T2DM) as well as their co-existence necessitate that anti-diabetic pharmacotherapy will modulate the cardiovascular risk inherent to T2DM while complying with the accompanying restrictions imposed by CHF. The thiazolidinedione (TZD) family of peroxisome proliferator-activated receptor γ (PPARγ) agonists initially provided a promising therapeutic option in T2DM owing to anti-diabetic efficacy combined with pleiotropic beneficial cardiovascular effects. However, the utility of TZDs in T2DM has declined in the past decade, largely due to concomitant adverse effects of fluid retention and edema formation attributed to salt-retaining effects of PPARγ activation on the nephron. Presumably, the latter effects are potentially deleterious in the context of pre-existing fluid retention in CHF. However, despite a considerable body of evidence on mechanisms responsible for TZD-induced fluid retention suggesting that this class of drugs is rightfully prohibited from use in CHF patients, there is a paucity of experimental and clinical studies that investigate the effects of TZDs on salt and water homeostasis in the CHF setting. In an attempt to elucidate whether TZDs actually exacerbate the pre-existing fluid retention in CHF, our review summarizes the pathophysiology of fluid retention in CHF. Moreover, we thoroughly review the available data on TZD-induced fluid retention and proposed mechanisms in animals and patients. Finally, we will present recent studies challenging the common notion that TZDs worsen renal salt and water retention in CHF.
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Affiliation(s)
- Ilia Goltsman
- Department of Physiology, Biophysics and Systems Biology, The Bruce Rappaport, Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Emad E Khoury
- Department of Physiology, Biophysics and Systems Biology, The Bruce Rappaport, Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Joseph Winaver
- Department of Physiology, Biophysics and Systems Biology, The Bruce Rappaport, Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Zaid Abassi
- Department of Physiology, Biophysics and Systems Biology, The Bruce Rappaport, Rappaport Faculty of Medicine, Technion, Haifa, Israel; Department of Laboratory Medicine, Rambam Human Health Care Campus, Haifa, Israel.
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22
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Abstract
Individuals with diabetes are not only at high risk of developing heart failure but are also at increased risk of dying from it. Fortunately, antiheart failure therapies such as angiotensin-converting-enzyme inhibitors, β blockers and mineralocorticoid-receptor antagonists work similarly well in individuals with diabetes as in individuals without the disease. Response to intensive glycaemic control and the various classes of antihyperglycaemic agent therapy is substantially less well understood. Insulin, for example, induces sodium retention and thiazolidinediones increase the risk of heart failure. The need for new glucose-lowering drugs to show cardiovascular safety has led to the unexpected finding of an increase in the risk of admission to hospital for heart failure in patients treated with the dipeptidylpeptidase-4 (DPP4) inhibitor, saxagliptin, compared with placebo. Here we review the relation between glycaemic control and heart failure risk, focusing on the state of knowledge for the various types of antihyperglycaemic drugs that are used at present.
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Affiliation(s)
- Richard E Gilbert
- Division of Endocrinology, St Michael's Hospital, University of Toronto, On, Canada.
| | - Henry Krum
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia
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23
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Patorno E, Garry EM, Patrick AR, Schneeweiss S, Gillet VG, Zorina O, Bartels DB, Seeger JD. Addressing Limitations in Observational Studies of the Association Between Glucose-Lowering Medications and All-Cause Mortality: A Review. Drug Saf 2015; 38:295-310. [DOI: 10.1007/s40264-015-0280-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Patorno E, Patrick AR, Garry EM, Schneeweiss S, Gillet VG, Bartels DB, Masso-Gonzalez E, Seeger JD. Observational studies of the association between glucose-lowering medications and cardiovascular outcomes: addressing methodological limitations. Diabetologia 2014; 57:2237-50. [PMID: 25212258 DOI: 10.1007/s00125-014-3364-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 08/06/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Recent years have witnessed a growing body of observational literature on the association between glucose-lowering treatments and cardiovascular disease. However, many of the studies are based on designs or analyses that inadequately address the methodological challenges involved. METHODS We reviewed recent observational literature on the association between glucose-lowering medications and cardiovascular outcomes and assessed the design and analysis methods used, with a focus on their ability to address specific methodological challenges. We describe and illustrate these methodological issues and their impact on observed associations, providing examples from the reviewed literature. We suggest approaches that may be employed to manage these methodological challenges. RESULTS From the evaluation of 81 publications of observational investigations assessing the association between glucose-lowering treatments and cardiovascular outcomes, we identified the following methodological challenges: 1) handling of temporality in administrative databases; 2) handling of risks that vary with time and treatment duration; 3) definitions of the exposure risk window; 4) handling of exposures that change over time; and 5) handling of confounding by indication. Most of these methodological challenges may be suitably addressed through application of appropriate methods. CONCLUSIONS/INTERPRETATION Observational research plays an increasingly important role in the evaluation of the clinical effects of diabetes treatment. Implementation of appropriate research methods holds the promise of reducing the potential for spurious findings and the risk that the spurious findings will mislead the medical community about risks and benefits of diabetes medications.
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Affiliation(s)
- Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street (Suite 3030), Boston, MA, 02120, USA,
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25
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Impact of diabetes mellitus on the clinical response to cardiac resynchronization therapy in elderly people. J Cardiovasc Transl Res 2014; 7:362-8. [PMID: 24500410 DOI: 10.1007/s12265-014-9545-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Accepted: 01/19/2014] [Indexed: 10/25/2022]
Abstract
Heart failure (HF) and type 2 diabetes mellitus (T2DM) exhibit a well-established interrelationship and a growing prevalence, in particular in elderly people. Cardiac resynchronization therapy (CRT) has been shown to improve myocardial function in patients with HF and cardiac dyssynchrony. However, reports on CRT in diabetic elderly patients are limited and controversial. Therefore, the aim of the present study was to investigate the functional role of T2DM on the effectiveness of CRT at advanced age. In this single-center prospective study, we enrolled 72 HF patients over 75 years old with and without T2DM who underwent CRT implant. Detailed clinical and instrumental data, including cardiac ultrasound analysis, 6-min walk test, and quality-of-life evaluation, were collected at baseline and at 1-year follow-up. At the time of implantation, 44.4 % of patients had T2DM, of which 62.5 % were well controlled with diet and hypoglycemic drugs and 37.5 % were treated by insulin therapy. After 1 year, CRT improved myocardial ventricular geometry and functional capacity in a comparable proportion of diabetic and non-diabetic patients alongside with a similar amelioration in the functional status. Taken together, our findings demonstrate that diabetic patients >75 years old exhibit a response to CRT that is comparable to non-diabetic subjects.
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26
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Abstract
High-density lipoprotein (HDL) is a complex mixture of lipoproteins that is associated with many minor proteins and lipids that influence the function of HDL. Although HDL is a promising marker and potential therapeutic target based on its epidemiological data and the effects of healthy HDL in vitro in endothelial cells and macrophages, as well as based on infusion studies of reconstituted HDL in patients with hypercholesterolemia, it remains still uncertain whether or not HDL cholesterol–raising drugs will improve outcomes. Recent studies suggest that HDL becomes modified in patients with coronary artery disease or acute coronary syndrome because of oxidative processes that result in alterations in its proteome composition (proteome remodelling) leading to HDL dysfunction.
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Affiliation(s)
- Thomas F. Lüscher
- From Department of Cardiology, University Heart Center (T.F.L., U.L.), and Department of Clinical Chemistry (A.v.E.), University Hospital Zurich, Zurich, Switzerland; Division of Cardiovascular Research, Institute of Physiology, University of Zurich, Zurich, Switzerland (T.F.L., U.L.); and Department of Medicine, University of California, Los Angeles, CA (A.M.F.)
| | - Ulf Landmesser
- From Department of Cardiology, University Heart Center (T.F.L., U.L.), and Department of Clinical Chemistry (A.v.E.), University Hospital Zurich, Zurich, Switzerland; Division of Cardiovascular Research, Institute of Physiology, University of Zurich, Zurich, Switzerland (T.F.L., U.L.); and Department of Medicine, University of California, Los Angeles, CA (A.M.F.)
| | - Arnold von Eckardstein
- From Department of Cardiology, University Heart Center (T.F.L., U.L.), and Department of Clinical Chemistry (A.v.E.), University Hospital Zurich, Zurich, Switzerland; Division of Cardiovascular Research, Institute of Physiology, University of Zurich, Zurich, Switzerland (T.F.L., U.L.); and Department of Medicine, University of California, Los Angeles, CA (A.M.F.)
| | - Alan M. Fogelman
- From Department of Cardiology, University Heart Center (T.F.L., U.L.), and Department of Clinical Chemistry (A.v.E.), University Hospital Zurich, Zurich, Switzerland; Division of Cardiovascular Research, Institute of Physiology, University of Zurich, Zurich, Switzerland (T.F.L., U.L.); and Department of Medicine, University of California, Los Angeles, CA (A.M.F.)
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27
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Taegtmeyer H, Beauloye C, Harmancey R, Hue L. Insulin resistance protects the heart from fuel overload in dysregulated metabolic states. Am J Physiol Heart Circ Physiol 2013; 305:H1693-7. [PMID: 24097426 DOI: 10.1152/ajpheart.00854.2012] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Reversing impaired insulin sensitivity has been suggested as treatment for heart failure. However, recent clinical evidence suggests the opposite. Here we present a line of reasoning in support of the hypothesis that insulin resistance protects the heart from the consequences of fuel overload in the dysregulated metabolic state of obesity and diabetes. We discuss pathways of myocardial fuel toxicity, as well as several layers of defense against fuel overload. Our reassessment of the literature suggests that in the heart, insulin-sensitizing agents result in an elimination of some of the defenses, leading to cytotoxic damage. In contrast, a normalization of fuel supply should either prevent or reverse the process. Taken together, we offer a new perspective on insulin resistance of the heart.
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Affiliation(s)
- Heinrich Taegtmeyer
- Division of Cardiology, Department of Internal Medicine, The University of Texas School of Medicine at Houston, Houston, Texas
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28
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Punthakee Z, Bosch J, Gerstein HC. Setting the record straight on TIDE: a lost opportunity for patients with diabetes. Diabetologia 2013; 56:1884-7. [PMID: 23740195 DOI: 10.1007/s00125-013-2959-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 05/16/2013] [Indexed: 10/26/2022]
Abstract
Much has been written regarding the recently discontinued Thiazolidinedione Intervention with Vitamin D Evaluation (TIDE) trial (ClinicalTrials.gov NCT00879970; Diabetologia 55: 36-45) and a variety of opinions have been advanced regarding its purpose, context and design (N Engl J Med 397: 959-964). As such, we deemed it appropriate to clarify TIDE's objectives, research questions and design and the clinical equipoise regarding its research questions.
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Affiliation(s)
- Zubin Punthakee
- Population Health Research Institute, McMaster University, 1280 Main Street West, HSC 3V51 Hamilton, ON, Canada L8S 4K1.
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29
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Scheen AJ, Paquot N. Metformin revisited: a critical review of the benefit-risk balance in at-risk patients with type 2 diabetes. DIABETES & METABOLISM 2013; 39:179-90. [PMID: 23528671 DOI: 10.1016/j.diabet.2013.02.006] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Accepted: 02/12/2013] [Indexed: 12/18/2022]
Abstract
Metformin is unanimously considered a first-line glucose-lowering agent. Theoretically, however, it cannot be prescribed in a large proportion of patients with type 2 diabetes because of numerous contraindications that could lead to an increased risk of lactic acidosis. Various observational data from real-life have shown that many diabetic patients considered to be at risk still receive metformin and often without appropriate dose adjustment, yet apparently with no harm done and particularly no increased risk of lactic acidosis. More interestingly, recent data have suggested that type 2 diabetes patients considered at risk because of the presence of traditional contraindications may still derive benefit from metformin therapy with reductions in morbidity and mortality compared with other glucose-lowering agents, especially sulphonylureas. The present review analyzes the benefit-risk balance of metformin therapy in special populations, namely, patients with stable coronary artery disease, acute coronary syndrome or myocardial infarction, congestive heart failure, renal impairment or chronic kidney disease, hepatic dysfunction and chronic respiratory insufficiency, all conditions that could in theory increase the risk of lactic acidosis. Special attention is also paid to elderly patients with type 2 diabetes, a population that is growing rapidly, as older patients can accumulate several comorbidities classically considered contraindications to the use of metformin. A review of the recent scientific literature suggests that reassessment of the contraindications of metformin is now urgently needed to prevent physicians from prescribing the most popular glucose-lowering therapy in everyday clinical practice outside of the official recommendations.
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Affiliation(s)
- A J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders and Division of Clinical Pharmacology, Department of Medicine, CHU Sart-Tilman (B35), University of Liège, 4000 Liège, Belgium.
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30
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Eurich DT, Weir DL, Majumdar SR, Tsuyuki RT, Johnson JA, Tjosvold L, Vanderloo SE, McAlister FA. Comparative safety and effectiveness of metformin in patients with diabetes mellitus and heart failure: systematic review of observational studies involving 34,000 patients. Circ Heart Fail 2013; 6:395-402. [PMID: 23508758 DOI: 10.1161/circheartfailure.112.000162] [Citation(s) in RCA: 241] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is an ongoing controversy regarding the safety and effectiveness of metformin in the setting of heart failure (HF). Therefore, we undertook a systematic review of the trial and nontrial evidence for metformin in patients with diabetes mellitus and HF. METHODS AND RESULTS We conducted a comprehensive search for controlled studies, evaluating the association between metformin and morbidity and mortality in people with diabetes mellitus and HF. Two reviewers independently identified citations, extracted data, and evaluated quality. Risk estimates were abstracted and pooled where appropriate. As measures of overall safety, we examined all-cause mortality and all-cause hospitalizations. Nine cohort studies were included; no randomized controlled trials were identified. Most (5 of 9) studies were published in 2010 and were of good quality. Metformin was associated with reduced mortality compared with controls (mostly sulfonylurea therapy): 23% versus 37% (pooled adjusted risk estimates: 0.80; 0.74-0.87; I(2)=15%; P<0.001). No increased risk was observed for metformin in those with reduced left ventricular ejection fraction (mortality pooled adjusted risk estimate: 0.91; 0.72-1.14; I(2)=0%; P=0.34), nor in those with HF and chronic kidney disease (pooled adjusted risk estimate: 0.81; 0.64-1.02; P=0.08). Metformin was associated with a small reduction in all-cause hospitalizations (pooled adjusted risk estimate: 0.93; 0.89-0.98; I(2)=0%; P=0.01). Metformin was not associated with increased risk of lactic acidosis. CONCLUSIONS The totality of evidence indicates that metformin is at least as safe as other glucose-lowering treatments in patients with diabetes mellitus and HF and even in those with reduced left ventricular ejection fraction or concomitant chronic kidney disease. Until trial data become available, metformin should be considered the treatment of choice for patients with diabetes mellitus and HF.
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Affiliation(s)
- Dean T Eurich
- Department of Public Health Sciences, School of Public Health, Li Ka Shing Center, University of Alberta, Edmonton, Alberta, Canada.
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31
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Wong AKF, Struthers AD, Choy AMJ, Lang CC. Insulin sensitization therapy and the heart: focus on metformin and thiazolidinediones. Heart Fail Clin 2012; 8:539-50. [PMID: 22999238 DOI: 10.1016/j.hfc.2012.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Chronic heart failure (CHF) is an insulin-resistant (IR) state and the degree of IR is related to disease severity and poor clinical outcome in CHF. IR may be pathophysiologically linked with CHF. Therefore, IR may represent a new target for treatment in CHF. Metformin and thiazolidinediones (TZDs) are effective diabetic therapies that are insulin sensitizers. TZDs are contraindicated in CHF because their use is associated with increased incidence of CHF as a result of their effects on renal sodium reabsorption and vascular permeability. There is evidence to suggest that metformin may be both safe and useful in CHF.
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Affiliation(s)
- Aaron K F Wong
- Division of Cardiovascular and Diabetes Medicine, Medical Research Institute, Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom
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32
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Teupe C, Rosak C. Diabetic cardiomyopathy and diastolic heart failure -- difficulties with relaxation. Diabetes Res Clin Pract 2012; 97:185-94. [PMID: 22502812 DOI: 10.1016/j.diabres.2012.03.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2012] [Revised: 03/11/2012] [Accepted: 03/15/2012] [Indexed: 01/14/2023]
Abstract
Diabetic patients carry a four- to five-fold increased risk of heart failure. Hyperglycaemia plays a central role in the pathogenesis of diabetic cardiomyopathy. Diabetic cardiomyopathy represents a distinct structural and functional disorder of the myocardium characterized by cardiac hypertrophy and an increased myocardial stiffness. At an early stage, diabetic cardiomyopathy is manifested by diastolic heart failure with preserved ejection fraction. In some patients, diastolic dysfunction may progress to heart failure with reduced ejection fraction and result in overt systolic heart failure. Diastolic dysfunction can accurately be diagnosed by echocardiography and BNP measurement in daily clinical practice. Early treatment is prognostically important. Optimal control of blood glucose levels and blood pressure is beneficial. So far metformin is the only antidiabetic agent not associated with harm in diabetic patients with heart failure. Incretin-based therapies potentially provide cardiovascular benefits. ACE inhibitors, angiotensin-1 receptor antagonists and beta-blockers should be preferred in heart failure therapy.
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Affiliation(s)
- C Teupe
- Department of Internal Medicine and Cardiology, Krankenhaus Sachsenhausen, Teaching Hospital, Goethe University, Frankfurt, Germany.
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Papanas N, Maltezos E, Mikhailidis DP. Metformin and heart failure: never say never again. Expert Opin Pharmacother 2012; 13:1-8. [PMID: 22149365 DOI: 10.1517/14656566.2012.638283] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Metformin represents the cornerstone of treatment for type 2 diabetes mellitus. Traditionally, heart failure (HF) was considered a contraindication to its use. However, more recent evidence has shown that this should no longer be the case. Indeed, studies have demonstrated that metformin may even reduce the risk of incident HF and mortality in diabetic patients, while improving up to 2-year survival rates in those with HF. In addition, it appears to exert cardioprotective actions. Although longer follow-up data and more explicit information about the situation in patients with very advanced HF are needed, the cardiac safety of metformin has profound clinical implications and may be anticipated to further encourage its widespread use.
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von Bibra H, St John Sutton M. Impact of diabetes on postinfarction heart failure and left ventricular remodeling. Curr Heart Fail Rep 2012; 8:242-51. [PMID: 21842146 PMCID: PMC3208100 DOI: 10.1007/s11897-011-0070-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Diabetes mellitus, the metabolic syndrome, and the underlying insulin resistance are increasingly associated with diastolic dysfunction and reduced stress tolerance. The poor prognosis associated with heart failure in patients with diabetes after myocardial infarction is likely attributable to many factors, important among which is the metabolic impact from insulin resistance and hyperglycemia on the regulation of microvascular perfusion and energy generation in the cardiac myocyte. This review summarizes epidemiologic, pathophysiologic, diagnostic, and therapeutic data related to diabetes and heart failure in acute myocardial infarction and discusses novel perceptions and strategies that hold promise for the future and deserve further investigation.
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Affiliation(s)
- Helene von Bibra
- Klinic for Endocrinology, Diabetes and Vascular Medicine, Klinikum Bogenhausen, Städtische Klinikum München GmbH, Englschalkingerstrasse 77, 81925, München, Germany.
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35
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Punthakee Z, Bosch J, Dagenais G, Diaz R, Holman R, Probstfield JL, Ramachandran A, Riddle MC, Rydén LE, Zinman B, Afzal R, Yusuf S, Gerstein HC. Design, history and results of the Thiazolidinedione Intervention with vitamin D Evaluation (TIDE) randomised controlled trial. Diabetologia 2012; 55:36-45. [PMID: 22038523 DOI: 10.1007/s00125-011-2357-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Accepted: 10/06/2011] [Indexed: 11/26/2022]
Abstract
AIMS/OBJECTIVE Conflicting data regarding cardiovascular effects of thiazolidinediones (TZDs) and extra-skeletal effects of vitamin D supported the need for a definitive trial. The Thiazolidinedione Intervention with vitamin D Evaluation (TIDE) trial aimed to assess the effects of TZDs (rosiglitazone and pioglitazone) on cardiovascular outcomes and the effects of vitamin D (cholecalciferol) on cancers and mortality. METHODS A large multicentre 3 × 2 factorial double-blind placebo-controlled randomised trial recruited from outpatient primary care and specialty clinics in 33 countries. From June 2009 to July 2010, 1,332 people with type 2 diabetes and other cardiovascular risk factors aged ≥ 50 years whose HbA(1c) was 6.5-9.5% (48-80 mmol/mol) when using two or fewer glucose-lowering drugs were randomised by a central computer system to placebo (n = 541), rosiglitazone 4-8 mg/day (n = 399) or pioglitazone 30-45 mg/day (n = 392); 1,221 participants were randomised to placebo (n = 614) or vitamin D 1,000 IU/day (n = 607). Participants and all study personnel were blind to treatment allocation. The primary outcome for the TZD arm was the composite of myocardial infarction, stroke or cardiovascular death, and for the vitamin D arm it was cancer or all-cause death. All randomised participants were included in the primary analysis. RESULTS From the study design, 16,000 people were to be followed for approximately 5.5 years. However, the trial was stopped prematurely because of regulatory concerns after a mean of 162 days without consideration of the accrued data. In the TZD arm, the cardiovascular outcome occurred in five participants (0.9%) in the placebo groups and three participants (0.4%) in the TZD groups (two allocated to pioglitazone, one to rosiglitazone). In the vitamin D arm, the primary outcome occurred in three participants (0.5%) in the placebo group and in two participants (0.3%) receiving vitamin D. Adverse events were comparable in all groups. CONCLUSIONS/INTERPRETATION Uncertainty persists regarding the clinically relevant risks and benefits of TZDs and vitamin D because of the early cancellation of this comprehensive trial.
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Affiliation(s)
- Z Punthakee
- Population Health Research Institute, McMaster University, 237 Barton St E., Hamilton, ON, Canada, L8L 2X2.
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Eurich DT, McAlister FA. Wrongfully accused: metformin use in heart failure. Expert Rev Cardiovasc Ther 2011; 9:147-50. [PMID: 21453211 DOI: 10.1586/erc.10.186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Evaluation of: Aguilar D, Chan W, Bozkurt B, Ramasubbu K, Deswal A. Metformin use and mortality in ambulatory patients with diabetes and heart failure. Circ. Heart Fail. 4(1), 53-58 (2010). Metformin has long been the cornerstone of therapy for glycemic control in patients with Type 2 diabetes worldwide. It is recommended as first-line therapy by all major diabetes clinical practice guidelines owing to its efficacy, favorable tolerability profile and beneficial effects in limiting weight gain. Moreover, metformin is the only oral anthyperglycemic agent shown in randomized controlled trials to reduce mortality in newly diagnosed patients with Type 2 diabetes. However, the use of metformin has not been without controversy, in particular in patients with heart failure. This article will review a recent observational study by Aguilar et al. published in Circulation - Heart Failure that reported improved outcomes associated with metformin therapy in patients with diabetes and heart failure.
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Affiliation(s)
- Dean T Eurich
- School of Public Health, University of Alberta, Edmonton, AL, T6G 2T4, Canada.
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Lebovitz HE. Insulin: potential negative consequences of early routine use in patients with type 2 diabetes. Diabetes Care 2011; 34 Suppl 2:S225-30. [PMID: 21525460 PMCID: PMC3632184 DOI: 10.2337/dc11-s225] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Harold E Lebovitz
- Department of Medicine, Division of Endocrinology, State University of New York Health Science Center at Brooklyn, Brooklyn, New York, USA.
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Affiliation(s)
- Zachary T. Bloomgarden
- Zachary T. Bloomgarden, MD, is a practicing endocrinologist in New York, New York, and is affiliated with the Division of Endocrinology, Mount Sinai School of Medicine, New York, New York
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Saha SA, Tuttle KR. Influence of glycemic control on the development of diabetic cardiovascular and kidney disease. Cardiol Clin 2010; 28:497-516. [PMID: 20621253 DOI: 10.1016/j.ccl.2010.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Diabetes mellitus leads to the development of a host of micro- and macrovascular complications, which collectively lead to substantial morbidity and mortality. Among the microvascular complications of diabetes, diabetic kidney disease is the most common. Macrovascular complications from diabetes lead to a 2- to 4-fold increase in the incidence of cardiovascular disease and up to twice the mortality from cardiovascular causes as compared with nondiabetic individuals. This article discusses the various drug classes used to treat diabetes mellitus, and reviews the current clinical evidence linking glycemic control using these drug classes on diabetic kidney and cardiovascular disease.
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Affiliation(s)
- Sandeep A Saha
- Providence Medical Research Center, Spokane, WA 99204, USA.
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Abstract
Heart failure is a common complication of type 2 diabetes and bears a poor prognosis. For patients with diabetes and heart failure the commonly accepted standards for diagnosis and treatment of heart failure are to be applied, although prospective diabetes- specific trials are lacking. The optimum HbA(1c) target value as well as the optimum blood glucoselowering treatment are not known. Due to an absence of prospective randomized trials the treatment should follow general therapeutic principles (low incidence of side effects, combination therapy, patient-friendly dosage, costs).
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Giamouzis G, Triposkiadis F, Butler J. Metformin Use in Patients With Diabetes Mellitus and Heart Failure: Friend or Foe? J Card Fail 2010; 16:207-10. [DOI: 10.1016/j.cardfail.2009.12.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Indexed: 12/25/2022]
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Chaitman BR, Hardison RM, Adler D, Gebhart S, Grogan M, Ocampo S, Sopko G, Ramires JA, Schneider D, Frye RL. The Bypass Angioplasty Revascularization Investigation 2 Diabetes randomized trial of different treatment strategies in type 2 diabetes mellitus with stable ischemic heart disease: impact of treatment strategy on cardiac mortality and myocardial infarction. Circulation 2009; 120:2529-40. [PMID: 19920001 PMCID: PMC2830563 DOI: 10.1161/circulationaha.109.913111] [Citation(s) in RCA: 203] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial in 2368 patients with stable ischemic heart disease assigned before randomization to percutaneous coronary intervention or coronary artery bypass grafting strata reported similar 5-year all-cause mortality rates with insulin sensitization versus insulin provision therapy and with a strategy of prompt initial coronary revascularization and intensive medical therapy or intensive medical therapy alone with revascularization reserved for clinical indication(s). In this report, we examine the predefined secondary end points of cardiac death and myocardial infarction (MI). METHODS AND RESULTS Outcome data were analyzed by intention to treat; the Kaplan-Meier method was used to assess 5-year event rates. Nominal P values are presented. During an average 5.3-year follow-up, there were 316 deaths (43% were attributed to cardiac causes) and 279 first MI events. Five-year cardiac mortality did not differ between revascularization plus intensive medical therapy (5.9%) and intensive medical therapy alone groups (5.7%; P=0.38) or between insulin sensitization (5.7%) and insulin provision therapy (6%; P=0.76). In the coronary artery bypass grafting stratum (n=763), MI events were significantly less frequent in revascularization plus intensive medical therapy versus intensive medical therapy alone groups (10.0% versus 17.6%; P=0.003), and the composite end points of all-cause death or MI (21.1% versus 29.2%; P=0.010) and cardiac death or MI (P=0.03) were also less frequent. Reduction in MI (P=0.001) and cardiac death/MI (P=0.002) was significant only in the insulin sensitization group. CONCLUSIONS In many patients with type 2 diabetes mellitus and stable ischemic coronary disease in whom angina symptoms are controlled, similar to those enrolled in the percutaneous coronary intervention stratum, intensive medical therapy alone should be the first-line strategy. In patients with more extensive coronary disease, similar to those enrolled in the coronary artery bypass grafting stratum, prompt coronary artery bypass grafting, in the absence of contraindications, intensive medical therapy, and an insulin sensitization strategy appears to be a preferred therapeutic strategy to reduce the incidence of MI.
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Affiliation(s)
- Bernard R Chaitman
- St Louis University School of Medicine, 1034 S Brentwood Blvd., St Louis, MO 63117, USA.
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Anselmino M. Cardiovascular prevention in type 2 diabetes mellitus patients: the role of oral glucose-lowering agents. J Diabetes Complications 2009; 23:427-33. [PMID: 18768334 DOI: 10.1016/j.jdiacomp.2008.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2007] [Accepted: 07/12/2008] [Indexed: 01/10/2023]
Abstract
Diabetes mellitus (DM) is a metabolic disorder that requires medical diagnosis and treatment. Type 2 DM is due to a combination of defective secretion of and responsiveness to insulin. In early stages, the predominant abnormality is reduced insulin sensitivity, and hyperglycemia can be reversed by a variety of measures and medications. In this stage, the cornerstone of glucose-lowering therapy is lifestyle modification, but when counseling does not adequately achieve the recommended glycemic targets, at least five classes of oral drugs are available. In general, alpha-glucosidase inhibitors delay carbohydrate absorption, metiglinides and sulfonylureas increase insulin supply, and biguanides and thiazolidinediones enhance insulin action. Given the high cardiovascular morbidity and mortality in type 2 DM patients, the attempt to reduce cardiovascular complications, beyond the glucose lowering itself, is an extremely relevant task. Indeed, the role of oral glucose-lowering agents concerning hyperglycemia reduction is defined; however, they have not clearly demonstrated to reduce micro- and macrovascular disease, and hitherto, no firm evidence favors one pharmacological treatment over another. The aim of this update is to describe the existing experiences with oral glucose-lowering agents for type 2 DM treatment with respect to cardiovascular prevention.
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Affiliation(s)
- Matteo Anselmino
- Cardiology Unit, San Giovanni Battista Hospital, University of Turin, Italy.
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Abstract
As the diabetic population has significant morbidity and mortality from cardiovascular disease (CVD), much of its medical care focuses on CVD prevention and treatment. Some medications used to treat hyperglycemia may have beneficial effects on CV outcomes, others may have negative effects, while still others seem to have no direct effect. Although past epidemiological studies have shown a relationship between glycated hemoglobin levels and CV events in patients with type 2 diabetes, recent large randomized clinical trials (ACCORD, ADVANCE, and VADT) lasting 3.5 to 5.6 years have found that intensive glycemic control either has no impact on CV outcomes or even worsens them. Results of the 10-year follow-up of the UKPDS suggest that tight glycemic control of younger, newly diagnosed patients with type 2 diabetes may have CV benefits many years later. Because the pathogenesis of atherosclerosis spans decades, it may be that beneficial effects of tight glycemic control on CV outcomes are mainly in younger patients without established macrovascular disease. There is an emerging notion that tight glycemic control may be beneficial in primary prevention of CVD in younger patients with diabetes, but may become deleterious in older patients with established or subclinical CVD. Thus, while tight control may lessen microvascular disease, it may increase the risk of hypoglycemia and possibly of adverse CV events. In each patient, the goals of glycemic control need to be individualized based on age, overall prognosis, presence of macrovascular disease, and risk of hypoglycemia.
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Cheng JWM, Bhatt SH, Goldman-Levine JD. The Benefit and Risk of Antidiabetic Agents Used in Patients With Heart Disease. J Pharm Pract 2009. [DOI: 10.1177/0897190008326104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Diabetes increases the risk of cardiovascular diseases. While improving glycemic control has been demonstrated to reduce microvascular complications, the benefits in reducing macrovascular complications have been controversial. This article reviews the published evidence assessing the benefits and risk of antidiabetic agents as related to cardiovascular outcomes. Current literature revealed that metformin and α-glucosidase inhibitors are the two agents that have not been associated with any harm in diabetic patients in terms of cardiovascular events. Clinical studies have demonstrated controversial results in the use of insulin, sulfonylureas, and thiazolidinediones and cardiovascular outcomes. However, the results may be affected by other unknown confounders, the comparative agents, and the degree of control of other cardiovascular risk factors. Clinicians should choose antidiabetic therapy based on patient specific parameters such as current glycemic control, and other concurrent disease states such as heart failure.
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Affiliation(s)
- Judy W. M. Cheng
- Massachusetts College of Pharmacy and Health Sciences, , Brigham and Women's Hospital
| | - Snehal H. Bhatt
- Massachusetts College of Pharmacy and Health Sciences, Beth Israel Deaconess Medical Center Boston, Massachusetts
| | - Jennifer D. Goldman-Levine
- Massachusetts College of Pharmacy and Health Sciences, Tufts University Family Medicine Residency at Cambridge Health Alliance, Malden, Massachusetts
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Abstract
Although a clear relationship exists between glycosylated hemoglobin and cardiovascular (CV) disease in individuals with type 2 diabetes mellitus (T2DM) in epidemiologic studies, data from prospective studies are less clear. Earlier prospective studies examining intensive glucose lowering suffered from a lack of statistical power to show CV event reduction, as well as a lack of durable glycemic control and relatively poor control of associated CV risk factors. Although recent CV outcome trials comparing intensive glycemic compared with standard glycemic control have been disappointing, CV event rates appear to be declining substantially in T2DM individuals in the setting of aggressive global CV risk factor modification. No single hypoglycemic agent or combination of agents was associated with increased CV events or mortality. A comprehensive strategy of multifactorial intervention including aggressive and durable glycemic blood pressure, and lipid lowering, aspirin usage, and lifestyle modifications is beneficial in reducing macrovascular and microvascular events in T2DM individuals.
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Affiliation(s)
- Stuart W Zarich
- Division of Cardiovascular Medicine, Bridgeport Hospital, 267 Grant Street, Bridgeport, CT 06610, USA.
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Abstract
Rosiglitazone is an effective therapy for type 2 diabetes although concerns have grown about the incidence of oedema and cardiovascular adverse events in patients treated with the drug. The following review was conducted to evaluate further and complement the evidence linking rosiglitazone with an increased risk for cardiovascular adverse events by examining trials and case reports not included in recent meta-analyses. Rosiglitazone-related publications describing case reports and prospective and retrospective cohort analyses were identified using MEDLINE and EMBASE, from July 1999 to July 2007. Relevant reports cited in these publications were also obtained. A recently-published meta-analysis and a double-blind, randomized, placebo-controlled trial were also reviewed. This review of 20 case reports and 10 uncontrolled studies supports the need for added vigilance when prescribing rosiglitazone to patients for the treatment of type 2 diabetes who may be at risk for congestive heart failure. Clinical data from numerous case reports and uncontrolled studies suggested that patients receiving rosiglitazone should be monitored for the development of weight gain or oedema. Prudence should be observed in patients with a history or risk factors for congestive heart failure as they may be poor candidates for rosiglitazone therapy.
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Affiliation(s)
- Javier C Waksman
- Division of Clinical Pharmacology and Toxicology, Division of General Internal Medicine, University of Colorado Denver, Rocky Mountain Poison and Drug Center, Denver, CO, USA.
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Zinn A, Felson S, Fisher E, Schwartzbard A. Reassessing the cardiovascular risks and benefits of thiazolidinediones. Clin Cardiol 2009; 31:397-403. [PMID: 18781598 DOI: 10.1002/clc.20312] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This article is designed for the general cardiologist, endocrinologist, and internist caring for patients with diabetes and coronary artery disease. Despite the burden of coronary disease in diabetics, little is known about the impact of commonly used oral hypoglycemic agents on cardiovascular outcomes. As the untoward effects of insulin resistance (IR) are increasingly recognized, there is interest in targeting this defect. Insulin resistance contributes to dyslipidemia, hypertension, inflammation, hypercoagulability, and endothelial dysfunction. The aggregate impact of this process is progression of systemic atherosclerosis and an increased risk of adverse cardiovascular outcomes. As such, much attention has been paid to the peroxisome-proliferator-activated receptor gamma (PPARg) agonists rosiglitazone and pioglitazone (thiazolidinediones [TZDs]). Many studies have demonstrated a beneficial effect on the atherosclerotic process; specifically, these agents have been shown to reduce markers of inflammation, retard progression of carotid intimal thickness, prevent restenosis after coronary stenting, and prevent cardiovascular death and myocardial infarction in 1 large trial. Such benefits come at the risk of fluid retention and heart failure (HF) exacerbation, and the net effect on plasma lipids is still poorly understood. Thus, the aggregate risk-benefit ratio is poorly defined. A recent meta-analysis has raised significant concerns regarding the overall cardiovascular safety of 1 particular PPARg agonist (rosiglitazone), prompting international debate and regulatory changes. This review scrutinizes the clinical evidence regarding the cardiovascular risks and benefits of PPARg agonists. Future studies of PPARg agonists, and other emerging drugs that treat IR and diabetes, must be designed to look at cardiovascular outcomes.
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Affiliation(s)
- Andrew Zinn
- The Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY 10016, USA.
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