Both high and low HbA1c predict incident heart failure in type 2 diabetes mellitus

Long-term glycemic variability predicts compromised development of heart failure with improved ejection fraction: a cohort study

Background

A substantial portion of heart failure (HF) patients adherent to guideline-directed medical therapies have experienced improved ejection fraction (EF), termed HFimpEF. Glycemic variability (GV) has emerged as a critical cardiometabolic factor. However, the relation between long-term GV and the incidence of HFimpEF is still unclear.

Methods

A total of 591 hospitalized HF patients with reduced EF (HFrEF, EF≤ 40%) admitted from January 2013 to December 2020 were consecutively enrolled. Repeat echocardiograms were performed at baseline and after around 12 months. The incidence of HFimpEF, defined as (1) an absolute EF improvement ≥10% and (2) a second EF > 40% and its association with long-term fasting plasma glucose (FPG) variability were analyzed.

Results

During a mean follow-up of 12.2 ± 0.6 months, 218 (42.0%) patients developed HFimpEF. Multivariate analysis showed FPG variability was independently associated with the incidence of HFimpEF after adjustment for baseline HbA1c, mean FPG during follow-up and other traditional risk factors (odds ratio [OR] for highest vs. lowest quartile of CV of FPG: 0.487 [95% CI 0.257~0.910]). Evaluation of GV by alternative measures yielded similar results. Subgroup analysis revealed that long-term GV was associated with HFimpEF irrespective of glycemic levels and diabetic conditions.

Conclusions

This study reveals that greater FPG variability is associated with compromised development of HFimpEF. A more stable control of glycemic levels might provide favorable effects on myocardial functional recovery in HF patients even without diabetes.

Dynamic evolution and mechanism of myocardial glucose metabolism in different functional phenotypes of diabetic cardiomyopathy - a study based on 18 F-FDG microPET myocardial metabolic imaging

PURPOSE

To use ¹⁸ F-FDG microPET dynamic imaging to preliminarily identify the changes of myocardial glucose metabolism corresponding to different functional phenotypes of diabetic cardiomyopathy (DCM) in mice and elucidate their relationships.

METHODS

Left ventricular function was measured by echocardiography in C57BL/KsJ-db/db (db/db) mice and their controls at 8, 12, 16, and 20 weeks of age to divide DCM stages and functional phenotypes. Myocardial histopathology was used to verify the staging accuracy and list-mode microPET dynamic imaging was conducted. The myocardial metabolic rate of glucose (MRglu) and the glucose uptake rate constant (Ki) were derived via Patlak graphical analysis, and the differences in myocardial glucose metabolism levels in different DCM stages were compared. The key proteins involved in myocardial glucose metabolism signaling pathway were analyzed by Western blotting to elucidate the underlying mechanism of abnormal glucose metabolism in DCM.

RESULTS

Compared with the controls, the ratio of early diastolic transmitral flow velocity to early diastolic mitral annular tissue velocity (E/e') of db/db mice was significantly increased from the age of 12 weeks, while the left ventricular ejection fraction (LVEF) was significantly decreased from the age of 16 weeks (all P < 0.05). Based on the staging criteria, 8 and 12 weeks (8/12w) db/db mice were in DCM stage 1 (diastolic dysfunction with normal LVEF), and 16 and 20 weeks (16/20w) db/db mice were in DCM stage 2/3 (diastolic and systolic dysfunction). The degree of myocardial fibrosis, glycogen deposition and ultrastructural damage in 16/20w db/db mice were more obvious than those in 8/12w group. The myocardial MRglu, Ki of db/db mice in 8/12w group or 16/20w group were significantly lower than those in the control group (all P < 0.05), while the myocardial standard uptake value (SUV) was not significantly reduced in the 8/12w group compared with the control group (P > 0.05). MRglu and SUV were moderately negatively correlated with the E/e' ratio (r=-0.539 and - 0.512, P = 0.007 and 0.011), which were not significantly correlated with LVEF (P > 0.05). Meanwhile, Ki was not significantly correlated with LVEF or E/e' ratio. The decreased expression of glucose transporter (GLUT) -4 in db/db mice preceded GLUT-1 and was accompanied by decreased phosphorylated AMP-activated protein kinase (p-AMPK) expression. Myocardial MRglu, Ki and SUV were significantly positively correlated with the expression of GLUT-4 (MRglu: r = 0.537; Ki: r = 0.818; SUV: r = 0.491; P = 0.000 ~ 0.046), but there was no significant correlation with GLUT-1 expression (P = 0.238 ~ 0.780).

CONCLUSIONS

During the progression of DCM, with the changes of left ventricular functional phenotype, abnormal and dynamic changes of myocardial glucose metabolism can occur in the early stage.

Lipid Profile, Renal Function Tests and Inflammatory Markers in Algerian Type 2 Diabetic Patients

Background

Several studies show the relationship between chronic hyperglycemia and the appearance of macroangiopathy, microangiopathy and neuropathy. The major objective of this study was to investigate the serum lipids, renal function tests and inflammatory markersin type 2 diabetes patients.

Methods

The study lasted eight years between Feb-2013 and Mar-2021 (Mascara, Algeria). Overall,197 patients and 197 controls were selected during general medicine examinations; enzymatic and immunoturbidimetric colorimetric methods were used to determine the serum levels offasting glycaemia, total cholesterol, highdensity lipoprotein cholesterol, triglycerides, low-density lipoprotein cholesterol, fibrinogen, urea, acid uric, albumin and creatinine, C protein reactive; the glomerular filtration rate is calculated according to the MDRD equation; the glycatedhaemoglobin levels were determined by an ion-exchange resin separation method.

Results

Patients had 2.44 times higher fasting glycaemia, 1.71 times higher HbA1c, 1.23 times higher body mass index, 1.30 times higher waist circumference and 1.25times higher systolic blood pressure than control subjects; the findings of the present study also indicate that a significant differences between patients and controls were observed regarding triglycerides (P=0.008), LDL-cholesterol (P=0.011), HDL-cholesterol (P=0.009), urea (P=0.013), uric acid (P=0.015), creatinine (P=0.007), glomerular filtration rate (P=0.006), albumin (P=0.018), fibrinogen (P=0.023) and C protein reactive (P=0.019).

Conclusion

All this metabolic disordercould facilitate the appearance of serious complications in future.

Association of Baseline HbA1c With Cardiovascular and Renal Outcomes: Analyses From DECLARE-TIMI 58

OBJECTIVE

Current guidelines recommend prescribing SGLT2 inhibitors to patients with type 2 diabetes and established or at high risk for atherosclerotic cardiovascular disease (ASCVD), irrespective of HbA1c levels. We studied the association of HbA1c with cardiovascular and renal outcomes and whether the benefit of dapagliflozin varies by baseline HbA1c.

RESEARCH DESIGN AND METHODS

In the Dapagliflozin Effect on Cardiovascular Events trial (DECLARE-TIMI 58), 17,160 patients with type 2 diabetes were randomly assigned to dapagliflozin or placebo for a median follow-up of 4.2 years. Cardiovascular and renal outcomes by baseline HbA1c in the overall population and with dapagliflozin versus placebo in HbA1c subgroups were studied by Cox regression models.

RESULTS

In the overall population, higher baseline HbA1c was associated with a higher risk of cardiovascular death or hospitalization for heart failure (HHF); major adverse cardiovascular events (MACE), including cardiovascular death, myocardial infarction, and ischemic stroke; and cardiorenal outcomes (adjusted hazard ratios 1.12 [95% CI 1.06-1.19], 1.08 [1.04-1.13], and 1.17 [1.11-1.24] per 1% higher level, respectively). Elevated HbA1c was associated with a greater increased risk for MACE and cardiorenal outcomes in patients with multiple risk factors (MRF) than in established ASCVD (P-interaction = 0.0064 and 0.0093, respectively). Compared with placebo, dapagliflozin decreased the risk of cardiovascular death/HHF, HHF, and cardiorenal outcomes, with no heterogeneity by baseline HbA1c (P-interaction > 0.05).

CONCLUSIONS

Higher HbA1c levels were associated with greater cardiovascular and renal risk, particularly in the MRF population, yet the benefits of dapagliflozin were observed in all subgroups irrespective of baseline HbA1c, including patients with HbA1c <7%.

Management of Type 2 Diabetes in Stage C Heart Failure with Reduced Ejection Fraction

Type 2 diabetes is an increasingly common comorbidity of stage C heart failure with reduced ejection fraction (HFrEF). The two diseases are risk factors for each other and can bidirectionally independently worsen outcomes. The regulatory requirement of cardiovascular outcomes trials for antidiabetic agents has led to an emergence of novel therapies with robust benefits in heart failure, and clinicians must now ensure they are familiar with the management of patients with concurrent diabetes and stage C HFrEF. This review summarises the current evidence for the management of type 2 diabetes in stage C HFrEF, recapitulating data from landmark heart failure trials regarding the use of guideline-directed medical therapy for heart failure in patients with diabetes. It also provides a preview of upcoming clinical trials in these populations.

Increased risk of adverse cardiovascular events by strict glycemic control after percutaneous coronary intervention (HbA1c < 6.5% at 2 years) in type 2 diabetes mellitus combined with acute coronary syndrome: a 5-years follow-up study

OBJECTIVE

This study assessed the association between HbA1c level measured 2 years after percutaneous coronary intervention (PCI) and long-term clinical outcomes in type 2 diabetes mellitus combined with acute coronary syndrome (ACS) who underwent PCI.

METHODS

This prospective observational study analyzed 2877 ACS patients with type 2 diabetes mellitus whose baseline HbA1c ≥ 7.0% and underwent PCI. All patients were divided into 6 groups according to the HbA1c level at 2 years after PCI. The clinical outcome was major adverse cardiovascular events (MACEs), defined as all-cause death, all myocardial infarction, any revascularization, congestive heart failure, ischemic stroke. The median follow-up duration was 4.1 years.

RESULTS

All 2877 patients were divided into 6 groups: 2-year after PCI HbA1c < 6.0% (n = 219), 6.0-6.5% (n = 348), 6.5-7.0% (n = 882), 7.0-7.5% (n = 567), 7.5-8.0% (n = 441), ≥8.0% (n = 420). The 5-year incidence rate of MACEs in HbA1c <6.0% and 6.0-6.5% groups were similar to 7.5-8.0% and ≥8.0% groups, which were significantly higher than in 6.5-7.0% and 7.0-7.5% groups (p = .044). The cumulative incidence rate of MACEs significantly differed among the groups (p = .046). Multivariate Cox regression analysis revealed a U-shaped relationship between 2-year HbA1c level after PCI and risk of MACEs. 2-year HbA1c <6.5% after PCI was an independent risk factor for MACEs in type 2 diabetes mellitus combined with ACS who underwent PCI (p < .001).

CONCLUSIONS

The findings indicated an increased risk of MACEs by strict glycemic control after PCI (2-year HbA1c < 6.5% after PCI) in type 2 diabetes mellitus combined with ACS who underwent PCI.

Type 2 Diabetes, Metabolic Traits, and Risk of Heart Failure: A Mendelian Randomization Study

OBJECTIVE

The aim of this study was to use Mendelian randomization (MR) techniques to estimate the causal relationships between genetic liability to type 2 diabetes (T2D), glycemic traits, and risk of heart failure (HF).

RESEARCH DESIGN AND METHODS

Summary-level data were obtained from genome-wide association studies of T2D, insulin resistance (IR), glycated hemoglobin, fasting insulin and glucose, and HF. MR was conducted using the inverse-variance weighted method. Sensitivity analyses included the MR-Egger method, weighted median and mode methods, and multivariable MR conditioning on potential mediators.

RESULTS

Genetic liability to T2D was causally related to higher risk of HF (odds ratio [OR] 1.13 per 1-log unit higher risk of T2D; 95% CI 1.11-1.14; P < 0.001); however, sensitivity analysis revealed evidence of directional pleiotropy. The relationship between T2D and HF was attenuated when adjusted for coronary disease, BMI, LDL cholesterol, and blood pressure in multivariable MR. Genetically instrumented higher IR was associated with higher risk of HF (OR 1.19 per 1-log unit higher risk of IR; 95% CI 1.00-1.41; P = 0.041). There were no notable associations identified between fasting insulin, glucose, or glycated hemoglobin and risk of HF. Genetic liability to HF was causally linked to higher risk of T2D (OR 1.49; 95% CI 1.01-2.19; P = 0.042), although again with evidence of pleiotropy.

CONCLUSIONS

These findings suggest a possible causal role of T2D and IR in HF etiology, although the presence of both bidirectional effects and directional pleiotropy highlights potential sources of bias that must be considered.

Interdisciplinary assessment and diagnostic algorithm: The role of the diabetologist

In recent years, many studies have revealed the importance of heart failure (HF) development in type 2 diabetes (T2D), which increases the morbidity and mortality during the course of diabetes. In this context, it became important to emphasize the role of both cardiologists and diabetologists in the early diagnosis and further adequate treatment of HF in T2D. While HF appears in two major forms, with reduced or preserved ejection fraction (EF), namely HFrEF and HFpEF, it became important to define the optimal approach to the diagnostics. Regarding HFrEF, the role of cardiological methods remained dominant, while the complexity of early diagnosis requires nowadays more active participation of diabetologists. The absence of abundant symptoms and echocardiographic findings imposed the need for the use of risk markers based on metabolic variables and low-grade inflammation parameters. Following that unmet need, numerous studies have defined the possible relationship between metabolic variables in diabetes and the risk for HF. Moreover, attempts have been made to integrate biochemical and clinical parameters into risk score engines and some of them gave promising results. However, the follow-up studies in T2D subjects are needed to determine the clinical relevance of these new approaches.

Glucose-lowering pharmacotherapies in Chinese adults with type 2 diabetes and cardiovascular disease or chronic kidney disease. An expert consensus reported by the Chinese Diabetes Society and the Chinese Society of Endocrinology

Patients with type 2 diabetes mellitus (T2DM) are at risk of developing atherosclerotic cardiovascular disease (ASCVD) and chronic kidney disease (CKD), which are important causes of disabling and death in patients with T2DM. For the prevention and management of ASCVD or CKD, cardiovascular risk factors should be systematically evaluated, and ASCVD and CKD should be screened in patients with T2DM. In this consensus, we recommended that metformin should be used as the first-line therapy for patients with T2DM and ASCVD or very high cardiovascular risk, heart failure (HF) or CKD, and should be retained in the treatment regimen unless contraindicated or not tolerated. In patients with T2DM and established ASCVD or very high cardiovascular risk, addition of a glucagon-like peptide 1 receptor agonist (GLP-1RA) or sodium-glucose cotransporter type 2 (SGLT2) inhibitor with proven cardiovascular benefits should be considered independent of individualised glycated haemoglobin (HbA_1C ) targets. In patients with T2DM and HF, an SGLT2 inhibitor should be preferably added regardless of HbA_1C levels. In patients with T2DM and CKD, SGLT2 inhibitors should be preferred for the combination therapy independent of individualised HbA_1C targets, and GLP-1RAs with proven renal benefits would be alternative if SGLT2 inhibitors are contraindicated. Moreover, the prevention of hypoglycaemia and management of multiple risk factors by comprehensive regimen, including lifestyle intervention, antihypertensive therapies, lipid-lowering treatment and antiplatelet therapies, should be kept in mind in treating patients with T2DM and ASCVD, HF or CKD.

Association of Mean and Variability of HbA1c with Heart Failure in Patients with Type 2 Diabetes

Heart failure (HF) is a common presentation in patients with type 2 diabetes mellitus (T2DM). Previous studies revealed that the HbA1c level is significantly associated with HF. However, little is known about the association between HbA1c variability and HF. We aimed to evaluate the association of mean and variability of HbA1c with HF in patients with T2DM. Using Diabetes Share Care Program data, patients with T2DM who had mean HbA1c (HbA1c-Mean), and HbA1c variability (tertiles of HbA1c-SD and HbA1c-adjSD) within 12–24 months during 2001–2008 were included. The cutoffs of HbA1c-Mean were set at <7%, 7–7.9%, and ≥8%. Hazard ratios (HRs) for HF during 2008–2018 were estimated using Cox proportional hazard models. A total of 3824 patients were included, of whom 315 patients developed HF during the observation period of 11.72 years. The associated risk of HF increased with tertiles of HbA1c variability and cutoffs of HbA1c-Mean. In mutually adjusted models, HbA1c-Mean showed a consistent dose-response association with HF, while the association of HbA1c variability with HF disappeared. Among patients with HbA1c-Mean <7%, the associated risk of HF in patients with HbA1c variability in tertile 3 was comparable to patients with HbA1c-Mean ≥8%. In conclusion, mean HbA1c was an independent predictor of HF and not explained by HbA1c variability. In addition to absolute HbA1c level, targeting on stability of HbA1c in patients with good glycemic control was also important for the development of HF in patients with T2DM.

Effect of Flash Glucose Monitoring on Glycemic Control, Hypoglycemia, Diabetes-Related Distress, and Resource Utilization in the Association of British Clinical Diabetologists (ABCD) Nationwide Audit

OBJECTIVE

The FreeStyle Libre (FSL) flash glucose-monitoring device was made available on the U.K. National Health Service (NHS) drug tariff in 2017. This study aims to explore the U.K. real-world experience of FSL and the impact on glycemic control, hypoglycemia, diabetes-related distress, and hospital admissions.

RESEARCH DESIGN AND METHODS

Clinicians from 102 NHS hospitals in the U.K. submitted FSL user data, collected during routine clinical care, to a secure web-based tool held within the NHS N3 network. The t and Mann-Whitney U tests were used to compare the baseline and follow-up HbA_1c and other baseline demographic characteristics. Linear regression analysis was used to identify predictors of change in HbA_1c following the use of FSL. Within-person variations of HbA_1c were calculated using [Formula: see text].

RESULTS

Data were available for 10,370 FSL users (97% with type 1 diabetes), age 38.0 (±18.8) years, 51% female, diabetes duration 16.0 (±49.9) years, and BMI of 25.2 (±16.5) kg/m² (mean [±SD]). FSL users demonstrated a -5.2 mmol/mol change in HbA_1c, reducing from 67.5 (±20.9) mmol/mol (8.3%) at baseline to 62.3 (±18.5) mmol/mol (7.8%) after 7.5 (interquartile range 3.4-7.8) months of follow-up (n = 3,182) (P < 0.0001). HbA_1c reduction was greater in those with initial HbA_1c ≥69.5 mmol/mol (>8.5%), reducing from 85.5 (±16.1) mmol/mol (10%) to 73.1 (±15.8) mmol/mol (8.8%) (P < 0.0001). The baseline Gold score (score for hypoglycemic unawareness) was 2.7 (±1.8) and reduced to 2.4 (±1.7) (P < 0.0001) at follow-up. A total of 53% of those with a Gold score of ≥4 at baseline had a score <4 at follow-up. FSL use was also associated with a reduction in diabetes distress (P < 0.0001). FSL use was associated with a significant reduction in paramedic callouts and hospital admissions due to hypoglycemia and hyperglycemia/diabetic ketoacidosis.

CONCLUSIONS

We show that the use of FSL was associated with significantly improved glycemic control and hypoglycemia awareness and a reduction in hospital admissions.

Association of Long-term Change and Variability in Glycemia With Risk of Incident Heart Failure Among Patients With Type 2 Diabetes: A Secondary Analysis of the ACCORD Trial

OBJECTIVE

To evaluate the associations between long-term change and variability in glycemia with risk of heart failure (HF) among patients with type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

Among participants with T2DM enrolled in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, variability in HbA_1c was assessed from stabilization of HbA_1c following enrollment (8 months) to 3 years of follow-up as follows: average successive variability (ASV) (average absolute difference between successive values), coefficient of variation (SD/mean), and SD. Participants with HF at baseline or within 3 years of enrollment were excluded. Adjusted Cox models were used to evaluate the association of percent change (from baseline to 3 years of follow-up) and variability in HbA_1c over the first 3 years of enrollment and subsequent risk of HF.

RESULTS

The study included 8,576 patients. Over a median follow-up of 6.4 years from the end of variability measurements at year 3, 388 patients had an incident HF hospitalization. Substantial changes in HbA_1c were significantly associated with higher risk of HF (hazard ratio [HR] for ≥10% decrease 1.32 [95% CI 1.08-1.75] and for ≥10% increase 1.55 [1.19-2.04]; reference <10% change in HbA_1c). Greater long-term variability in HbA_1c was significantly associated with higher risk of HF (HR per 1 SD of ASV 1.34 [95% CI 1.17-1.54]) independent of baseline risk factors and interval changes in cardiometabolic parameters. Consistent patterns of association were observed with use of alternative measures of glycemic variability.

CONCLUSIONS

Substantial long-term changes and variability in HbA_1c were independently associated with risk of HF among patients with T2DM.

Risk stratification tools for heart failure in the diabetes clinic

The advent of Sodium Glucose Transporter 2-inhibitors (SGLT2-i) in recent years gave endocrinologists the opportunity to actively treat and prevent heart failure (HF) in patients with type 2 diabetes (T2DM). While the relationship between T2DM and HF has been extensively reviewed, previous works focused mostly on epidemiology, pathophysiology and treatment of HF in T2DM. The aim of our work was to aid health care professionals in identifying individuals at high risk for this dreadful complication. Recent guidelines recommend to use drugs with proven cardiovascular benefits (Glucagon-like peptide-1 receptor agonists (GLP1-RA) and SGLT2-i) in patients with previous cardiovascular disease (CVD) and to prefer SGLT2-i in patients with known HF. In everyday clinical practice, the choice between these two drug classes in patients without known HF or atherosclerotic CVD is mostly arbitrary and based on the side effect profile. Recently, risk stratification tools to estimate HF incidence have been developed in order to guide treatment with a view to bring precision medicine into diabetes care. With this purpose, we provide a review of the tools able to predict HF incidence for patients in primary CVD prevention as well as risk of future hospitalizations for patients with known HF.

Consensus document: management of heart failure in type 2 diabetes mellitus

Type 2 diabetes mellitus (T2DM) is a known predisposing factor for heart failure (HF). The growing burden of these two conditions and their impact on health of the individual and on society in general needs urgent attention from the health care professionals. Availability of multiple treatment choices for managing T2DM and HF may make therapeutic decisions more complex for clinicians. Recent cardiovascular outcome trials of antidiabetic drugs have added very robust evidence to effectively manage subjects with this dual condition. This consensus statement provides the prevalence trends and the impact of this dual burden on patients. In addition, it concisely narrates the types of HF, the different treatment algorithms, and recommendations for physicians to comprehensively manage such patients.

Genetics of diabetes mellitus and diabetes complications

Diabetes is one of the fastest growing diseases worldwide, projected to affect 693 million adults by 2045. Devastating macrovascular complications (cardiovascular disease) and microvascular complications (such as diabetic kidney disease, diabetic retinopathy and neuropathy) lead to increased mortality, blindness, kidney failure and an overall decreased quality of life in individuals with diabetes. Clinical risk factors and glycaemic control alone cannot predict the development of vascular complications; numerous genetic studies have demonstrated a clear genetic component to both diabetes and its complications. Early research aimed at identifying genetic determinants of diabetes complications relied on familial linkage analysis suited to strong-effect loci, candidate gene studies prone to false positives, and underpowered genome-wide association studies limited by sample size. The explosion of new genomic datasets, both in terms of biobanks and aggregation of worldwide cohorts, has more than doubled the number of genetic discoveries for both diabetes and diabetes complications. We focus herein on genetic discoveries for diabetes and diabetes complications, empowered primarily through genome-wide association studies, and emphasize the gaps in research for taking genomic discovery to the next level.

Microvascular disease and heart failure with reduced and preserved ejection fraction in type 2 diabetes

Aims

Identification of patients with type 2 diabetes (T2D) at increased risk of incident heart failure (HF) beyond traditional risk factors such as prior myocardial infarction (MI) might allow selection of patients who would benefit from preventative treatment. Microvascular disease (MiVD) is thought to play a pathophysiological role in the development of HF in T2D; however, its association with new‐onset HF with reduced or preserved ejection fraction has not been specifically defined.

Methods and results

Patients in the Genetics of Diabetes Audit and Research Tayside Scotland study were linked to echocardiography, prescriptions, and clinical outcomes. In total, 9141 patients with T2D were identified for analysis. Clinical variables and the presence of retinopathy, nephropathy, and neuropathy were assessed. Cumulative incidence was calculated for the association of both individual and the total number of MiVD states and incident HF. Median follow‐up was 9.3 years. In total, there were 900 HF events. The presence of any MiVD was independently associated with both HF with reduced ejection fraction (hazard ratio 1.40; 95% confidence interval 1.11–1.76, P = 0.004) and HF with preserved ejection fraction (hazard ratio 1.38; 95% confidence interval 1.10–1.72, P = 0.005), with a stepwise association between the number of MiVD states and risk of incident HF (P for trend <0.001). Similar associations were found in sensitivity analyses limited to patients without a prior MI, and using competing risks analysis.

Conclusions

Individuals with T2D and with MiVD are at risk of incident HF independent of a history of prior HF or MI. Patients with MiVD could benefit from screening for HF and individualized therapy with treatments that lower HF risk.

Effect of icariside II and metformin on penile erectile function, glucose metabolism, reaction oxygen species, superoxide dismutase, and mitochondrial autophagy in type 2 diabetic rats with erectile dysfunction

Background

Icariside II (ICAII) is a flavonoid isolated from herb Epimedium that has been shown to improve erectile function in rats. However, ICAII’s underlying mechanism remains unclear.

Methods

Type 2 diabetes mellitus erectile dysfunction (T2DMED) rats were induced by single intraperitoneal injection of 25 mg/kg streptozotocin (STZ) and fed a high-fat, high-sugar, and high-calorie diet for 8 weeks. In the control and T2DMED groups, rats were administered with normal saline; in the metformin (MET) group, rats were administered with MET at 0.2 g/kg/day; and in the ICAII + MET group, rats were administered with ICA II at 10 mg/kg/day and MET for 0.2 g/kg/day. The deposition of advanced glycation end products (AGEs), expression of receptor for AGEs (RAGEs), reactive oxygen species (ROS), and superoxide dismutase (SOD) activity, and corpus cavernosum smooth muscle cells (CCSMCs) mitochondrial autophagy were measured. We also evaluated the expression of LC3-II/I, Beclin-1, P70S6K, PI3K, AKT, mTOR, phospho-AKT, phospho-mTOR, and phospho-P70S6K.

Results

ICAII and MET can improve erectile function, and decrease the levels of fasting plasma glucose (FPG), hemoglobin A1c (HbA1c), and AGEs in rats with T2DMED. Furthermore, ICAII and MET can decrease excessive CCSMC mitochondrial autophagy and the level of RAGE and oxidant stress in rats with T2DMED. ICAII and MET may enhance signaling via the PI3K-AKT-mTOR pathway in order to reduce the excessive mitochondrial autophagy of CCSMCs.

Conclusions

ICAII may effectively improve penile erectile function via decreasing excessive CCSMCs mitochondrial autophagy, RAGE, and oxidant stress. Furthermore, ICAII may enhance signaling via the PI3K-AKT-mTOR pathway in order to reduce excessive CCSMC mitochondrial autophagy.

Increased risk of cardiovascular mortality by strict glycemic control (pre-procedural HbA1c < 6.5%) in Japanese medically-treated diabetic patients following percutaneous coronary intervention: a 10-year follow-up study

BACKGROUND

In the secondary prevention of cardiovascular (CV) disease in patients with diabetes, an optimal level of HbA1c, the most widely-used glycemic control indicator, for favorable clinical consequences still remains to be established. This study assessed the association between preprocedural HbA1c level and CV mortality in Japanese diabetic patients undergoing percutaneous coronary intervention (PCI).

METHODS

This is a retrospective observational study using a single-center prospective PCI database involving consecutive 4542 patients who underwent PCI between 2000 and 2016. Patients with any antidiabetic medication including insulin at PCI were included in the analysis (n = 1328). We divided the patients into 5 and 2 groups according to HbA1c level; HbA1c: < 6.5% (n = 267), 6.5-7.0% (n = 268), 7.0-7.5% (n = 262), 7.5-8.5% (n = 287) and ≥ 8.5% (n = 244), and 7.0% > and ≤ 7.0%, respectively. The primary outcome was CV mortality including sudden death. The median follow-up duration was 6.2 years.

RESULTS

In the follow-up period, CV and sudden death occurred in 81 and 23 patients, respectively. While unadjusted Kaplan-Meier analysis showed no difference in cumulative CV mortality rate between patients binarized by preprocedural HbA1c 7.0%, analysis of the 5 groups of HbA1c showed significantly higher cumulative CV death in patients with HbA1c < 6.5% compared with those with 7.0-7.5% (P = 0.042). Multivariate Cox hazard analysis revealed a U-shaped relationship between preprocedural HbA1c level and risk of CV death, and the lowest risk was in the HbA1c 7.0-7.5% group (Hazard ratio of HbA1c < 6.5% compared to 7.0-7.5%: 2.97, 95% confidence interval: 1.33-7.25, P = 0.007). Similarly, univariate analysis revealed the lowest risk of sudden death was in the HbA1c 7.0-7.5% group.

CONCLUSION

The findings indicate an increased risk of CV mortality by strict glycemic control (HbA1c < 6.5%) in the secondary prevention of CV disease in Japanese patients with medically-treated diabetes. Trial registration This study reports the retrospective analysis of a prospective registry database of patients who underwent PCI at Juntendo University Hospital, Tokyo, Japan (Juntendo Physicians' Alliance for Clinical Trials, J-PACT), which is publicly registered (University Medical Information Network Japan-Clinical Trials Registry UMIN-CTR 000035587).

Plasma kynurenines and prognosis in patients with heart failure

BACKGROUND

Metabolites of the kynurenine pathway (mKP) relate to important aspects of heart failure pathophysiology, such as inflammation, energy-homeostasis, apoptosis, and oxidative stress. We aimed to investigate whether mKP predict mortality in patients with heart failure.

METHODS

The study included 202 patients with heart failure (73.8% with coronary artery disease (CAD)), propensity score matched to 384 controls without heart disease, and 807 controls with CAD (71%). All underwent coronary angiography and ventriculography at baseline. Plasma mKP, pyridoxal 5'phosphate (PLP) and CRP were measured at baseline. Case-control differences were assessed by logistic regression and survival by Cox regression, adjusted for age, gender, smoking, diabetes, ejection fraction, PLP, eGFR and CRP. Effect measures are reported per standard deviation increments.

RESULTS

Higher plasma levels of kynurenine, 3- hydroxykynurenine (HK), quinolinic acid (QA), the kynurenine-tryptophan-ratio (KTR) and the ratio of HK to xanthurenic acid (HK/XA) were detected in heart failure compared to both control groups. The mortality rate per 1000 person-years was 55.5 in patients with heart failure, 14.6 in controls without heart disease and 22.2 in CAD controls. QA [HR 1.80, p = 0.013], HK [HR 1.77, p = 0.005], HK/XA [HR 1.67, p < 0.001] and KTR [HR 1.55, p = 0.009] were associated with increased mortality in patients with heart failure, while XA [HR 0.68-0.80, p = 0.013-0.037] were associated with lower mortality in all groups. HK and HK/XA had weak associations with increased mortality in CAD-controls.

CONCLUSION

Elevated plasma levels of mKP and metabolite ratios are associated with increased mortality, independent of CAD, in patients with heart failure.

An in-depth analysis of glycosylated haemoglobin level, body mass index and left ventricular diastolic dysfunction in patients with type 2 diabetes

BACKGROUND

Glycosylated hemoglobin (HbA1c) has a detrimental impact on the myocardium with left ventricular (LV) diastolic dysfunction. Obesity is a risk factor of type 2 diabetes. To understand the relationships between HbA1c, body mass index (BMI) and LV diastolic dysfunction, we performed this interaction analysis in patients with type 2 diabetes.

METHODS

Total 925 type 2 diabetes patients were selected from the patients who were diagnosed and treated at the First Affiliated Hospital of Shenzhen University. Patients' BMI levels were defined as normal (BMI < 24 kg/m²) and overweight /obese (BMI ≥ 24 kg/m²). Patients' HbA1c levels were grouped as HbA1c ≥ 9%、7% ≤ HbA1c < 9% and HbA1c < 7%. Logistic regression, stratified, interaction analysis, multivariate Cox regression and curve fitting analysis were performed to investigate the correlations and interactions between HbA1c and BMI with LV diastolic dysfunction.

RESULTS

The BMI levels were significantly associated with LV diastolic dysfunction in the patients with type 2 diabetes [adjusted model: 1.12 (1.05, 1.20), P = 0.001]. While HbA1c levels had association with LV diastolic dysfunction only in normal BMI group patients [adjusted model: 1.14 (1.01, 1.30), P = 0.0394] and curve correlation was observed. There was a significant interaction between BMI and HbA1c to affect LV diastolic dysfunction (P = 0.0335). Cox regression model analysis showed that the risk of LV diastolic dysfunction was a U type correlation with HbA1c levels in the normal weight group and the turning point was HbA1c at 10%. HbA1c level was not found to have a significant association with LV diastolic dysfunction in overweight/obese group.

CONCLUSIONS

In patients with type 2 diabetes, correlation between LV diastolic dysfunction and HbA1c was interactively affected by BMI. Glycemic control is beneficial to the heart function in normal body weight patients. For overweight/obese patients, the risk of LV diastolic dysfunction was not determined by the HbA1c level, indicating it may be affected by other confounding factors.

Type 2 Diabetes Mellitus and Heart Failure: A Scientific Statement From the American Heart Association and the Heart Failure Society of America: This statement does not represent an update of the 2017 ACC/AHA/HFSA heart failure guideline update

Type 2 diabetes mellitus is a risk factor for incident heart failure and increases the risk of morbidity and mortality in patients with established disease. Secular trends in the prevalence of diabetes mellitus and heart failure forecast a growing burden of disease and underscore the need for effective therapeutic strategies. Recent clinical trials have demonstrated the shared pathophysiology between diabetes mellitus and heart failure, the synergistic effect of managing both conditions, and the potential for diabetes mellitus therapies to modulate the risk of heart failure outcomes. This scientific statement on diabetes mellitus and heart failure summarizes the epidemiology, pathophysiology, and impact of diabetes mellitus and its control on outcomes in heart failure; reviews the approach to pharmacological therapy and lifestyle modification in patients with diabetes mellitus and heart failure; highlights the value of multidisciplinary interventions to improve clinical outcomes in this population; and outlines priorities for future research.

Type 2 Diabetes Mellitus and Heart Failure, A Scientific Statement From the American Heart Association and Heart Failure Society of America

Type 2 diabetes mellitus is a risk factor for incident heart failure and increases the risk of morbidity and mortality in patients with established disease. Secular trends in the prevalence of diabetes mellitus and heart failure forecast a growing burden of disease and underscore the need for effective therapeutic strategies. Recent clinical trials have demonstrated the shared pathophysiology between diabetes mellitus and heart failure, the synergistic effect of managing both conditions, and the potential for diabetes mellitus therapies to modulate the risk of heart failure outcomes. This scientific statement on diabetes mellitus and heart failure summarizes the epidemiology, pathophysiology, and impact of diabetes mellitus and its control on outcomes in heart failure; reviews the approach to pharmacological therapy and lifestyle modification in patients with diabetes mellitus and heart failure; highlights the value of multidisciplinary interventions to improve clinical outcomes in this population; and outlines priorities for future research.

Association of Low Fasting Glucose and HbA1c With Cardiovascular Disease and Mortality: The MESA Study

Trials of intensive glucose control have not improved cardiovascular disease (CVD) risk in populations with type 2 diabetes; however, in the general population, reports are inconsistent about the effects of maintaining lower glucose levels. Some speculate that low glycemic values are associated with increased glycemic variability, which is in turn associated with higher CVD risk. It has also been suggested that fasting glucose and hemoglobin A1c (HbA1c) in the lower ranges have a different relationship with CVD and mortality. In 4990 participants from the Multi-Ethnic Study of Atherosclerosis, we used logistic regression to investigate associations of low fasting glucose (<80 mg/dL) and HbA1c (<5.0%) from baseline and averaged across follow-up with incident CVD and mortality over 13 years. We used normal glycemic ranges (80 to <100 mg/dL and 5.0 to <5.7%) as references and analyzed glycemic levels with visit-matched covariates. We adjusted for potential confounding by age, sex, race/ethnicity, education, income, smoking status, body mass index, total cholesterol level, cholesterol medications, high-density lipoprotein cholesterol, and hypertension. Low baseline glucose and HbA1c were positively, but not significantly, associated with mortality, whereas low average fasting glucose and HbA1c were strongly and significantly associated with incident CVD [glucose OR, 2.04 (95% CI, 1.38-3.00); HbA1c OR, 2.01 (95% CI, 1.58-2.55)] and mortality [glucose OR, 1.93 (95% CI, 1.33-2.79); HbA1c OR, 2.51 (95% CI, 2.00-3.15)]. These results were not due to type 2 diabetes or medication use. Glucose variability did not explain CVD risk beyond average glucose levels. Chronic low fasting glucose and HbA1c may be better indicators of risk than a single low measurement.

Nonlinear model for the carotid artery disease 10-year risk prediction by fusing conventional cardiovascular factors to carotid ultrasound image phenotypes: A Japanese diabetes cohort study

MOTIVATION

This study presents a novel nonlinear model which can predict 10-year carotid ultrasound image-based phenotypes by fusing nine traditional cardiovascular risk factors (ethnicity, gender, age, artery type, body mass index, hemoglobin A1c, hypertension, low-density lipoprotein, and smoking) with five types of carotid automated image phenotypes (three types of carotid intima-media thickness (IMT), wall variability, and total plaque area).

METHODOLOGY

Two-step process was adapted: First, five baseline carotid image-based phenotypes were automatically measured using AtheroEdge^™ (AtheroPoint^™ , CA, USA) system by two operators (novice and experienced) and an expert. Second, based on the annual progression rates of cIMT due to nine traditional cardiovascular risk factors, a novel nonlinear model was adapted for 10-year predictions of carotid phenotypes.

RESULTS

Institute review board (IRB) approved 204 Japanese patients' left/right common carotid artery (407 ultrasound scans) was collected with a mean age of 69 ± 11 years. Age and hemoglobin were reported to have a high influence on the 10-year carotid phenotypes. Mean correlation coefficient (CC) between 10-year carotid image-based phenotype and age was improved by 39.35% in males and 25.38% in females. The area under the curves for the 10-year measurements of five phenotypes IMT_ave10yr , IMT_max10yr , IMT_min10yr , IMTV_10yr , and TPA_10yr were 0.96, 0.94, 0.90, 1.0, and 1.0. Inter-operator variability between two operators showed significant CC (P < 0.0001).

CONCLUSIONS

A nonlinear model was developed and validated by fusing nine conventional CV risk factors with current carotid image-based phenotypes for predicting the 10-year carotid ultrasound image-based phenotypes which may be used risk assessment.

The association between diabetes mellitus and reduction in myocardial glucose uptake: a population-based 18F-FDG PET/CT study

BACKGROUND

In diabetes, dysregulated substrate utilization and energy metabolism of myocardium can lead to heart failure. To examine the dynamic changes of myocardium, most of the previous studies conducted dynamic myocardial PET imaging following euglycemic-hyperinsulinemic clamp, which involves complicated procedures. In comparison, the whole-body 18F-FDG PET/CT scan is a simple and widely used method. Therefore, we hope to use this method to observe abnormal myocardial glucose metabolism in diabetes and determine the influencing factors.

METHODS

We retrospectively analyzed PET/CT images of 191 subjects from our medical examination center. The levels of FDG uptake in myocardium were visually divided into 4 grades (Grade 0-3, from low to high). The differences in clinical and metabolic parameters among diabetes mellitus (DM), impaired fasting glucose (IFG), and normal fasting glucose (NFG) groups were analyzed, as well as their associations with myocardial FDG uptake.

RESULTS

Compared with NFG and IFG groups, DM group had more cardiovascular-related risk factors. The degree of myocardial FDG uptake was significantly decreased in DM group; when myocardial FDG uptake ≤ Grade 1, the sensitivity of DM prediction was 84.0%, and the specificity was 58.4%. Univariate analysis showed that the myocardial FDG uptake was weakly and negatively correlated with multiple metabolic-related parameters (r = - 0.173~ - 0.365, P < 0.05). Multivariate logistic regression analysis showed that gender (male), HOMA-IR and nonalcoholic fatty liver disease (NAFLD) were independent risk factors for poor myocardial FDG uptake.

CONCLUSIONS

Diabetes is associated with decreased myocardial glucose metabolism, which is mediated by multiple metabolic abnormalities.

Poor Glycemic Control Is Associated With Increased Extracellular Volume Fraction in Diabetes

OBJECTIVE

We assessed whether poor glycemic control is associated with an increase in myocardial fibrosis among adults with diabetes.

RESEARCH DESIGN AND METHODS

We studied 47 adults with type 2 diabetes and stratified them into three groups according to their hemoglobin A1c (HbA_1c) level: <6.5% (group 1; n = 12), 6.5-7.5% (group 2; n = 20), and >7.5% (group 3; n = 15). Left ventricular (LV) mass was assessed using cardiac MRI. The extracellular volume fraction (ECVF), an index of myocardial fibrosis, was measured by using myocardial T1 mapping before and after the administration of a gadolinium-based contrast agent.

RESULTS

Mean HbA_1c was 5.84 ± 0.16%, 6.89 ± 0.14%, and 8.57 ± 0.2% in groups 1, 2, and 3, respectively. LV mass was not significantly different between the groups. The myocardial ECVF was significantly greater in groups 2 (mean 27.6% [95% CI 24.8-30.3]) and 3 (27.6% [24.4-30.8]) than in group 1 (21.1% [17.5-24.7]; P = 0.015). After adjusting for age, sex, BMI, blood pressure, and estimated glomerular filtration rate, the myocardial ECVF was significantly greater in groups 2 (27.4% [24.4-30.4]) and 3 (28% [24.5-31.5]) than in group 1 (20.9% [17.1-24.6]; P = 0.0156, ANCOVA).

CONCLUSIONS

An increased myocardial ECVF, suggesting myocardial fibrosis, is independently associated with poor glycemic control among adults with diabetes. Further research should assess whether tight glycemic control can revert fibrosis to healthy myocardium or ameliorate it and its adverse clinical consequences.

[The status of glycemic control and hypoglycemia in elderly patients visiting the outpatient department specializing in diabetes]

AIM

The Japan Diabetes Society (JDS)/Japan Geriatrics Society (JGS) Joint Committee reported 'Glycemic Targets for Elderly Patients with Diabetes' in 2016. Based on this recommendation, we aimed to clarify 1) the achievement status of glycemic targets in the elderly and 2) the presence of hypoglycemia in real life among elderly individuals with an HbA1c below the lower limit.

SUBJECTS AND METHODS

[Analysis I] In 326 elderly with diabetes ≥65 years of age visiting the outpatient department specializing in diabetes, the proportions of patients with HbA1c values below the lower limit and the use of drugs potentially associated with severe hypoglycemia (e.g. insulin formulations, sulfonylureas, glinides) were investigated. [Analysis II] Of the patients with HbA1c values below the lower limit, seven were tested for hypoglycemia in real life using a continuous glucose monitoring system (CGM).

RESULTS

[Analysis I] Among the 326 subjects, 235 (72.1%) were using drugs potentially associated with severe hypoglycemia, and 63 (19.3%) had an HbA1c value below the lower limit. [Analysis II] In the seven patients examined using CGM, hypoglycemia was detected in five, all of whom were unaware.

CONCLUSIONS

A considerable number of elderly patients were taking drugs associated with hypoglycemic risks and had an HbA1c value below the lower limit, some of whom actually had hypoglycemia as detected by CGM. Using tools such as CGM, preventive measures against hypoglycemia should be taken.

Left ventricular structural alterations are accompanied by subclinical systolic dysfunction in type 2 diabetes mellitus patients with concomitant hyperlipidemia: An analysis based on 3D speckle tracking echocardiography

AIMS

The aims of the current study were to analyze and compare the left ventricular (LV) structure and function in type 2 diabetes mellitus (T2DM) patients with or without hyperlipidemia using conventional echocardiography and real-time three-dimensional speckle tracking echocardiography (3DSTE) and to determine the variables that could affect LV strain values in these patients.

METHODS

Eighty-one T2DM patients with normal LVEF (≥55%) were included, 41 of whom had hyperlipidemia as comorbidity. Forty age- and gender-matched healthy volunteers were recruited as the control group. Conventional echocardiography and 3DSTE were performed, and LV global longitudinal strain (GLS), global circumferential strain (GCS), global area strain (GAS), and global radial strain (GRS) were measured.

RESULTS

Significant differences in two-dimensional LV geometry were found among three groups (P = .015). Compared with the control group, LV remodeling was more prevalent in the patients with T2DM, and LV hypertrophy was most prevalent in the T2DM patients with hyperlipidemia. GLS and GCS values decreased significantly in the T2DM patients without hyperlipidemia relative to the control group (P < .01 and P < .05). The GLS, GCS, GAS, and GRS values in the T2DM patients with hyperlipidemia were all significantly lower than those in the control group (all P < .001) and were also significantly lower than those in the T2DM patients without hyperlipidemia (P < .01 or P < .05). Both fasting plasma glucose (FPG) and hyperlipidemia were independently associated with all strain values in patients with T2DM.

CONCLUSIONS

The combination of conventional echocardiography and 3DSTE could detect subclinical LV abnormalities in T2DM patients with or without hyperlipidemia.

Hawthorn Leaf Flavonoids Protect against Diabetes-Induced Cardiomyopathy in Rats via PKC-α Signaling Pathway

Objectives

DCM has become one of the main reasons of death in diabetic patients. In this study, we aimed to explore the hawthorn leaf flavonoids (HLF) protective effect against diabetes-induced cardiac injury and the underlying mechanisms in experimental rats.

Methods

Experimental diabetic model was induced by intraperitoneal injection of streptozotocin (STZ, 40 mg/kg) in rats after feeding with high-fat diet for 8 weeks. The diabetic rats received a 16-week treatment of different doses of HLF (50, 100, and 200). The morphological changes of myocardial cells were observed by light microscope; the concentration of antioxidant indicator and TNF-α and the expression of PKC-α mRNA, PKC-α, and NF-κB proteins were assessed as well.

Results

STZ-induced diabetes mellitus prompted blood glucose, cardiac injury, oxidative stress, and inflammation, accompanied with suppressed body weight. On the contrary, HLF administration improved body weight and blood glucose and attenuated myocardial structural abnormalities in diabetic rats. In addition, HLF decreased MDA level and enhanced SOD activities, inhibited TNF-α expression, and downregulated PKC-α mRNA, PKC-α, and NF-κB which were induced by diabetes.

Conclusions

HLF has a protective effect against diabetic cardiomyopathy in rats. The mechanism may be involved in reducing oxidative stress and inflammation via inactivation of the PKC-α signaling pathway.

Contemporary risk estimates of three HbA1c variables in relation to heart failure following diagnosis of type 2 diabetes

BACKGROUND

We evaluated the association between glycaemic control and the risk of heart failure (HF) in a contemporary cohort of persons followed after diagnosis of type 2 diabetes (T2D).

METHODS AND RESULTS

Persons with T2D diagnosed between 1998 and 2012 were retrieved from the Clinical Practice Research Data Link in the UK and followed from diagnosis until the event of HF, mortality, drop out from the database due to any other reason, or the end of the study on 1 July 2015. The association between each of three different haemoglobin A_1C (HbA_1c) metrics and HF was estimated using adjusted proportional hazard models. In the overall cohort (n=94 332), the increased risk for HF per 1% (10 mmol/mol) increase in HbA_1c was 1.15 (95% CI 1.13 to 1.18) for updated mean HbA_1c, and 1.06 (1.04 to 1.07) and 1.06 (1.04 to 1.08) for baseline HbA_1c and updated latest HbA_1c, respectively. When categorised, the hazard risk (HR) for the updated mean HbA_1c in relation to HF became higher than for baseline and updated latest HbA_1c above HbA_1c levels of 9%, but did not differ at lower HbA_1c levels. The updated latest variable showed an increased risk for HbA_1c <6% (42 mmol/mol) of 1.16 (1.07 to 1.25), relative category 6-7%, while the HRs for updated mean and baseline HbA_1c showed no such J-shaped pattern.

CONCLUSIONS

Hyperglycaemia is still a risk factor for HF in persons with T2D of similar magnitude as in earlier cohorts. Such a relationship exists for current glycaemic levels, at diagnosis and the overall level but the pattern differs for these variables.

Post-translational modifications of the cardiac proteome in diabetes and heart failure

Cardiovascular complications are the leading cause of death in diabetic patients. Decades of research has focused on altered gene expression, altered cellular signaling, and altered metabolism. This work has led to better understanding of disease progression and treatments aimed at reversing or stopping this deadly process. However, one of the pieces needed to complete the puzzle and bridge the gap between altered gene expression and changes in signaling/metabolism is the proteome and its host of modifications. Defining the mechanisms of regulation includes examining protein levels, localization, and activity of the functional component of cellular machinery. Excess or misutilization of nutrients in obesity and diabetes may lead to PTMs contributing to cardiovascular disease progression. PTMs link regulation of metabolic changes in the healthy and diseased heart with regulation of gene expression itself (e.g. epigenetics), protein enzymatic activity (e.g. mitochondrial oxidative capacity), and function (e.g. contractile machinery). Although a number of PTMs are involved in each of these pathways, we will highlight the role of the serine and threonine O‐linked addition of β‐N‐acetyl‐glucosamine or O‐GlcNAcylation. This nexus of nutrient supply, utilization, and storage allows for the modification and translation of mitochondrial function to many other aspects of the cell.