Effects of Liraglutide, Empagliflozin and Their Combination on Left Atrial Strain and Arterial Function

Background and Objectives: Glucagon-like peptide-1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter-2 inhibitors (SGLT-2i) are cardioprotective drugs. We investigated their effects on left atrial function, a major determinant of cardiac diastolic dysfunction in type 2 diabetes mellitus. We also explored the association of changes in arterial stiffness with those of the LA strain after treatment. Materials and Methods: A total of 200 patients (59.5 ± 9.1 year old, 151 male) with type 2 diabetes mellitus treated with metformin were randomized to insulin (n = 50 served as controls), liraglutide (n = 50), empagliflozin (n = 50) or their combination (liraglutide + empagliflozin) (n = 50). We measured at baseline and 6 months post-treatment: (a) left atrial and global left ventricular longitudinal strain by speckle tracking echocardiography; (b) pulse wave velocity (PWV) and central systolic blood pressure. Results: At baseline, there was a correlation of the LA reservoir strain with PWV (r = -0.209, p = 0.008), central SBP (r = -0.151, p = 0.030), EF (r = 0.214, p = 0.004) and GLS (r = -0.279, p = 0.009). The LA reservoir change 6 months post-treatment was correlated with the PWV change in all groups (r = -0.242, p = 0.028). The LA reservoir change 6 months post-treatment was correlated with the GLS change in all groups (r = -0.322, p = 0.004). Six months after intervention, patients treated with liraglutide, empagliflozin and their combination improved the left atrial reservoir strain (GLP1RA 30.7 ± 9.3 vs. 33.9 ± 9.7%, p = 0.011, SGLT2i 30 ± 8.3 vs. 32.3 ± 7.3%, p = 0.04, GLP1&SGLT2i 29.1 ± 8.7 vs. 31.3 ± 8.2, p = 0.007) compared to those treated with insulin (33 ± 8.3% vs. 32.8 ± 7.4, p = 0.829). Also, patients treated with liraglutide and the combination liraglutide and empagliflozin had improved left atrial conduction strain (p < 0.05). Empagliflozin or the combination liraglutide and empagliflozin showed a greater decrease of PWV and central and brachial systolic blood pressure than insulin or GLP-1RA. (p < 0.05). Conclusions: Impaired aortic elastic properties are associated with a decreased LA strain in type 2 diabetics. Treatment with liraglutide, empagliflozin and their combination for 6 months showed a greater improvement of left atrial function compared to insulin treatment in parallel with the improvement of arterial and myocardial functions.

Familial Partial Lipodystrophy: Clinical Features, Genetics and Treatment in a Greek Referral Center

Familial partial lipodystrophy (FPLD) is a rare syndrome in which a patient's phenotype is not merely dependent on the specific genetic mutation, but it is also defined by a combination of other demographic, environmental and genetic factors. In this prospective observational study in a Greek referral center, we enrolled 39 patients who fulfilled the clinical criteria of FPLD. A genetic analysis was conducted, which included sequence and deletion/duplication analyses of the LMNA and PPRARG genes, along with anthropometric and metabolic parameters. The treatment responses of patients who were eligible for treatment with metreleptin were evaluated at 3 and 12 months. In most of the patients, no significant changes were detected at the exon level, and any mutations that led to changes at the protein level were not associated with the lipodystrophic phenotype. On the contrary, various changes were detected at the intron level, especially in introns 7 and 10, whose clinical significance is considered unknown. In addition, treatment with metreleptin in specific FPLD patients significantly improved glycemic and lipidemic control, an effect which was sustained at the 12-month follow-up. More large-scale studies are necessary to clarify the genetic and allelic heterogeneity of the disease, along with other parameters which could predict treatment response.

Endothelial dysfunction due to decreased nitric oxide bioavailability in dysglycaemic subjects and first-degree relatives of type 2 diabetic patients

Background/Introduction

Oxidative stress plays an important role in the pathogenesis of type 2 diabetes mellitus.

Purpose

We aimed to investigate oxidative stress and nitrites/nitrates concentrations at baseline and during postprandial hyperglycaemia in 40 first-degree relatives (FDR) of type 2 diabetic patients with normal oral glucose test (OGTT), 40 subjects with abnormal OGTT (dysglycaemic) and 20 subjects with normal OGTT without parental history of diabetes (normoglycaemic).

Methods

Perfused boundary region (PBR) of the sublingual microvessels with a diameter 5–25μm (Microscan, Glycocheck), a marker of endothelial glycocalyx integrity, coronary flow reserve (CFR) in the distal left anterior descending coronary artery, left ventricular global longitudinal strain (GLS), malondialdehyde (MDA), protein carbonyls (PC) and nitrites/nitrates plasma levels were assessed at 0 and 120 min of a 2-hour OGTT. Insulin sensitivity was evaluated using Matsuda and insulin sensitivity index (ISI).

Results

In all subjects, there were no significant changes in MDA and PC at 120 min after OGTT (p&gt;0.05). Compared with normoglycaemic subjects, in FDR and dysglycaemic subjects, nitrites/nitrates levels were significantly decreased at 120 min (−24% versus −30% versus −3%, respectively) with a parallel increase in PBR (+7% versus +10% versus −3%) and a reduction in CFR (−11% versus −14% versus −6%) and GLS (−4% versus −4% versus +0.1%) (p&lt;0.05 for all comparisons). The percent reduction of nitrites/nitrates levels was associated with abnormal values of Matsuda and ISI, reversely related with the percent increase of PBR (r=−0.60, p=0.001) and positively related with the percent decrease of CFR (r=0.39, p=0.038) and GLS (r=0.48, p=0.008).

Conclusion

Insulin resistance determines acute endothelial responses during OGTT leading to reduced nitric oxide production with resultant coronary and myocardial dysfunction in FDR and dysglycaemic subjects.

Funding Acknowledgement

Type of funding sources: None.

The additive predictive value of arterial stiffness for outcome to endothelial glycocalyx and SCORE in middle age individuals: 6 years follow-up

Background/Aim

Arterial stiffness is involved in the clinical course of atherogenesis. We have previously shown that PBR, a marker of glycocalyx integrity is predictor of cardiovascular events in patients without established cardiovascular disease. The purpose of this study was to investigate whether altered arterial properties of the vessels confers predictively and additively to estimation of cardiovascular risk.

Methods

Pulse wave velocity carotid-femoral (PWVc-f), the gold standard method to assess arterial stiffness, was measured non-invasively by Complior device. Increased PWV(c-f), especially above 10 m/s, indicates increased arterial stiffness. We measured baseline PWV(c-f) in 600 apparently healthy subjects (47.61±13.84 years old, 50.1% males), without established cardiovascular disease. We prospectively monitored the occurrence of major cardiovascular events (MACE-death, myocardial infarction, stroke and heart failure hospitalization) during a 6-year follow-up period using electronic records and clinic visits.

Results

Fifty-seven MACEs were documented during follow-up. In univariate analysis, subjects with increased PWV were found to exert greater risk for MACEs (hazard ratio (HR): 1.09, 95% CI: 1.02–1.17, p=0.01). In all subjects, PWV predicted higher risk for MACEs in a model including PBR, sex, age, hyperlipidemia, diabetes, hypertension, current smoking, family history of coronary artery disease and treatment with ACEi/ARBs or lipid lowering agents (HR: 1.12; 95% CI: 1.04–1.17, p=0.029,net reclassification improvement (NRI): 23%; C-statistic: from 0.644 to 0.697). However, only in participants older than 50 years old, PWV was an independent and additive predictor of outcome when added in a model including PBR, SCORE, those risk factors not included in SCORE (diabetes, family history of CAD) and medication (HR: 1.09; 95% CI: 1.02–1.13, NRI: 23.8%, C-statistic increase from 0.703 to 0.762, p&lt;0.01).

Conclusion

Arterial stiffness is an independent and additive predictor to endothelial glycocalyx and SCORE for adverse outcome at 6 years follow-up in individuals over 50 years old.

Funding Acknowledgement

Type of funding sources: None.

Impaired Endothelial Glycocalyx Predicts Adverse Outcome in Subjects Without Overt Cardiovascular Disease: a 6-Year Follow-up Study

We investigated whether disturbance of glycocalyx integrity is related with increased cardiovascular risk. In 600 healthy subjects, we measured perfused boundary region (PBR), a marker of glycocalyx integrity, in sublingual microvessels with diameter ranging 5-25 µm using a dedicated camera (Sideview Darkfield Imaging). Increased PBR indicates reduced glycocalyx thickness. We prospectively monitored the occurrence of cardiovascular events (MACE-death, myocardial infarction, and stroke) during a 6-year follow-up. Fifty-seven MACE were documented. Increased values of PBR5-25 predicted higher risk for MACE in a model including sex, age, hyperlipidemia, diabetes, hypertension, smoking, family history of coronary disease, treatment with ACEi/ARBs, or lipid-lowering agents (hazard ratio (HR), 6.44, p = 0.011; net reclassification improvement (NRI), 28%; C-statistic: 0.761). PBR5-25 was an independent and additive predictor of outcome when added in a model including the European Heart SCORE, diabetes, family history of CAD, and medication (HR, 4.71; NRI: 39.7%, C-statistic from 0.653 to 0.693; p < 0.01).Glycocalyx integrity is an independent and additive predictor to risk factors for MACE at 6-year follow-up in individuals without cardiovascular disease. ClinicalTrials.govIdentifier:NCT04646252. PBR5-25 was an independent and additive predictor of adverse cardiovascular events in a model including the European Heart SCORE, diabetes, family history of coronary disease, and medication (HR: 4.71, NRI: 39.7%, C-statistic from 0.653 to 0.693; p < 0.01, NRI:37.9%).

Endothelial Dysfunction Is Associated with Decreased Nitric Oxide Bioavailability in Dysglycaemic Subjects and First-Degree Relatives of Type 2 Diabetic Patients

Oxidative stress plays an important role in the pathogenesis of diabetes. We investigated oxidative stress and nitrite/nitrate concentrations at baseline and during postprandial hyperglycaemia in 40 first-degree relatives (FDRs) of diabetic patients with normal oral glucose tolerance test (OGTT) results, 40 subjects with abnormal OGTT results (dysglycaemic) and 20 subjects with normal OGTT results (normoglycaemic). Malondialdehyde (MDA), protein carbonyls (PCs), nitrite/nitrate plasma levels, the perfused boundary region (PBR—Glycocheck) of the sublingual microvessels, a marker of glycocalyx integrity, coronary flow reserve (CFR) and left ventricular global longitudinal strain (GLS) were assessed at 0 and 120 min of the OGTT. Insulin sensitivity was evaluated using Matsuda and the insulin sensitivity index (ISI). In all subjects, there were no significant changes in MDA or PC after the OGTT (p > 0.05). Compared with normoglycaemic subjects, FDRs and dysglycaemic subjects had significantly decreased nitrite/nitrate levels (−3% vs. −24% vs. −30%, respectively), an increased PBR and reduced CFR and GLS at 120 min (p < 0.05). The percent reduction in nitrite/nitrate was associated with abnormal Matsuda and ISI results, reversely related with the percent increase in PBR (r = −0.60) and positively related with the percent decrease in CFR (r = 0.39) and GLS (r = 0.48) (p < 0.05). Insulin resistance is associated with reduced nitric oxide bioavailability and coronary and myocardial dysfunction in FDRs and dysglycaemic subjects.

The combination of dulaglutide and dapagliflozin improves arterial stiffness, endothelial glycocalyx and albuminuria vs DPP-4 inhibitors independently of glycemic control

Background

Studies in recent years have shown that dulaglutide, a glucagon-like peptide-1 receptor agonist (GLP-1RA), and dapagliflozin, a sodium-glucose cotransporter-2 inhibitor (SGLT-2i), improve or prevent diabetic nephropathy and macrovascular complications in patients with type 2 diabetes mellitus (T2DM).

Purpose

The aim of this study is to determine whether the combination of dulaglutide and dapagliflozin exerts improves arterial stiffness, endothelial glycocalyx and albuminuria in T2DM compared to dipeptidyl-peptidase 4 inhibitors (DPP-4is).

Methods

Overall 37 patients with T2DM were included in our study. 21 patients were transitioned from DPP-4is to dulaglutide and dapagliflozin (treatment group) and were followed immediately prior (baseline) and 4 months after the initiation of treatment. 16 patients, matched for sex, age and glycemic control, remained on treatment with DPP-4is (control group). In each visit we measured a) Carotid-femoral PWV b) central systolic blood pressure (cSBP) c) perfused boundary region (PBR) of the sublingual arterial microvessels, d) urinary albumin-to-creatinine ratio (UACR), e) glycosylated hemoglobin (HbA1c).

Results

There were no statistically significant differences in cardiovascular markers, UACR and HbA1c at baseline (p&gt;0.05). After 4 months, patients on dulaglutide and dapagliflozin combination improved HbA1c (7.9±1.5% vs 6.59±0.6%, p&lt;0.001), PBR (2.3±0.3 vs. 2.1±0.2 μm, p&lt;0.05), PWV (11.9±0.3.5 vs. 10.9±2.2m/s, p&lt;0.05), cSBP (128.5±23.6 vs. 121.1±15.7 mmHg, p&lt;0.05) and UACR (413.66±352.57 vs. 248.06±203.5 mg/g, p&lt;0.001). There were no statistically significant differences in PBR (2.1±0.3 vs. 2.2±0.3 μm, p&gt;0.05), PWV (10.7±3.4 vs. 12±3.3m/s, p&gt;0.05), cSBP (125.4±21.2 vs. 127±20.1 mmHg, p&gt;0.05) and UACR (240.8±103.6 vs. 204.9±119.6 mg/g), in the control group, despite a statistically significant improvement of HbA1c (8.2±1.9% vs 7.3±1.3%, p&lt;0.01).

Conclusions

The combination of dulaglutide and dapagliflozin improves arterial stiffness, endothelial glycocalyx and albuminuria compared to DPP-4is in patients with T2DM.

Funding Acknowledgement

Type of funding sources: None.

First-degree relatives of type-2 diabetic patients and dysglycaemic patients have impaired endothelial function due to decreased bioavailability of nitric oxide

Background/Introduction

Oxidative stress plays an important role in the pathogenesis of type 2 diabetes.

Purpose

We investigated oxidative stress in first-degree relatives of type-2 diabetes patients (FDR) since they are more prone to develop type-2 diabetes, at baseline and during postprandial hyperglycemia in comparison with dysglycaemic or normoglycaemic subjects. We evaluated these results in relation to vascular function.

Methods

We studied 40 FDR with normal oral glucose test (OGTT), 40 subjects with abnormal OGTT (dysglycaemic) and 20 subjects with normal OGTT without parental history of diabetes (normoglycaemic) with similar demographical and clinical characteristics. Glucose and insulin levels, pulse wave velocity (PWV-Complior, ALAM), central systolic blood pressure (cSBP) and augmentation index (AI) were measured at baseline, 30, 60, 90 and 120min during OGTT. Perfused boundary region (PBR-Microscan, Glycocheck) of the sublingual arterial microvessels (high PBR values represent reduced glycocalyx thickness), plasma concentrations of malondialdehyde (MDA) and protein carbonyls (PCs) as markers of lipid peroxidation and protein oxidation, respectively, and nitrite/nitrates levels as markers for NO biosynthesis, were assessed at baseline and at 120min of OGTT. Insulin sensitivity was evaluated using Matsuda and insulin sensitivity index (ISI).

Results

FDR and dysglycaemics patients had higher fasting insulin, reduced ISI, Matsuda index as well as increased PBR (2.5±0.5 vs. 2.5±0.6 vs. 2.4±0.3μm), increased PWV (8.9±1.1 vs. 10.3±2.4 vs. 8.0±1.5m/s), AI, MDA, PCs and nitrite/nitrate than normoglycaemic subjects (p&lt;0.05 for all comparisons). ISI was negatively related with PBR and MDA (r=−0.35 and r=−0.34, p&lt;0.05) at baseline in FDR and dysglycaemics. During OGTT, AI was similarly reduced in both normoglycaemics and FDR whereas AI was significantly increased in dysglycaemics at 120min (p&lt;0.05). PBR was increased by 7.5% and 4% at 120min in dysglycaemics and FDR, respectively, while remained unchanged in normoglycaemics (p&lt;0.05). In dysglycaemics and FDR, nitrite/nitrate levels were significantly decreased at 120min (52.85±8.22 vs. 36.31±4.36 and 48.23±7.20 vs. 34.70±4.71nmol/ml, respectively, p&lt;0.05) while they were remained unchanged in normoglycaemics likely leading to a greater decrease of MDA (−83% vs. −40% vs. −48%) and of PCs (−28% vs. −7% vs. −16%) in normoglycaemics compared with dysglycaemics and FDR (p&lt;0.05).

Conclusions

Insulin resistance determines acute endothelial responses during postprandial hyperglycemia leading to reduced NO production and thus facilitating augmentation of oxidative stress during postprandial hyperglycemia in dysglycaemic patients and FDR of diabetic patients.

Funding Acknowledgement

Type of funding sources: None.

The effect of one year treatment with GLP1-RA, SGLT2i and their combination on plasma levels of oxidative and antioxidative biomarkers

Background/Introduction

Biomarkers of oxidative stress burden are found increased in Type-2 diabetes mellitus (T2DM) patients. An imbalance between oxidative and antioxidative plasma factors is implicated in the pathway of cardiovascular disease in diabetics. Novel antidiabetic agents with cardioprotective effects are glucagon like peptide-1 receptor agonists (GLP1-RA) and sodium-glucose cotransporter-2 inhibitors (SGLT-2i).

Purpose

We investigated the effect of liraglutide (GLP1-RA),empagliflozin (SGLT-2i) and their combination on plasma levels of oxidative and antioxidative factors.

Methods

A hundred-sixty T2DM patients were randomly assigned and received: a) insulin (n=40), b) liraglutide (n=40), c) empagliflozin (n=40) and d) the combination liraglutide and empagliflozin (n=40) for 1 year. We measured at baseline and after 1 year of treatment the following antioxidative markers: a) Reducing Power (RP), b) 2,2'-azino-bis(3-ethylbenzothiazoline-6-sulfonic acid (ABTS), c) Total Antioxidant Capacity (TAC) and also Thiobarbituric acid reactive substances (TBARS) as a marker of oxidative burden.

Results

After 1 year of treatment all subjects achieved successful glycemic regulation, as estimated by Hemoglobin A1c (HbA1c) levels (8±0.5 vs 6.65±0.5, p&lt;0.05). Patients on the combination GLP1-RA + SGLT2i displayed greater reduction of TBARS (8.66±0.42 μmol/l vs 7.92±0.35 μmol/l, p&lt;0.05) and increase of ABTS (17.49 ±0.63 mmol/l vs 19.14 ±0.64 mmol/l, p&lt;0.05) compared with insulin-treated participants (8.85±0.41 μmol/l vs 8.83±0.44 μmol/l and 17.07 ±0.58 mmol/l vs 17.22 ±0.49 mmol/l, p=NS respectively). Patients treated on GLP1-RA or SGLT2i separately showed the same improving trend with the combination group in the abovementioned biomarkers but the changes were not so prominent. In the insulin group worsening of TAC was also noticed (0.92±0.02 mmol/l vs 0.89±0.01 mmol/l, p&lt;0.05). In the other biomarkers nonsignificant changes were observed for all groups. Furthermore the absolute change of HbA1c was correlated with the relative change of TBARS (r=0.419, p&lt;0.05)

Conclusion

One year treatment with the GLP1-RA liraglutide and SGLT2i empagliflozin resulted in improvement of plasma levels of oxidative and antioxidative biomarkers compared to administration of insulin and the changes were more outstanding in patients that received the combination of GLP1-RA and SGLT2i, despite similar glycemic regulation in all participants. Thus the favorable cardiovascular effects of these novel factors may be partly explained by alterations in equilibrium between oxidative and antioxidative circulating biomarkers.

Funding Acknowledgement

Type of funding sources: None.

Effect ofglucagon-like peptide-1 receptor agonists, sodium-glucose cotransporter-2 inhibitors and their combination on left atrial strain and arterial function

Background

We investigated the effects of insulin, glucagon-like peptide-1 receptor agonists (GLP-1RA), sodium-glucose cotransporter-2 inhibitors (SGLT-2i) and their combination on left atrial function of patients with type 2 diabetes mellitus and we searched for a relation with arterial function.

Methods

A total of 213 patients (59,5±9,1 year old, 161 male) with type 2 diabetes mellitus treated with metformin were randomized to insulin (n=46 served as controls), liraglutide (n=40), empagliflozin (n=46) or their combination (GLP-1RA + SGLT-2i) (n=50) as add-on. We measured at baseline and 6 months posttreatment: (a) perfused boundary region of the sublingual arterial microvessels (marker of endothelial glycocalyx thickness), (b) pulse wave velocity (PWV) and central systolic blood pressure, (c) global left ventricular Longitudinal strain, (d) left atrial strain.

Results

Six months after intervention, all patients improved left atrial reservoir strain (GLP1RA 30,7±9,3 vs 33,9±9,7%, p=0,011 / SGLT2i 30±8,3 vs 32,3±7,3%, p=0,04 / GLP1 & SGLT2i 29,1±8,7 vs 31,3±8,2, p=0,007) in comparison with controls (33±8,3% vs 32,8±7,4, p=0,829). Also, patients treated with GLP1RA and their combination improved left atrial conduction strain (p&lt;0.05). GLP-1RA or GLP-1RA + SGLT-2i provided a greater improvement in GLS compared with insulin or SGLT-2i (controls −18,5±3,9% vs −19,1±3%, p=0,202 / GLP1RA −18,2±4,1% vs −19,1±3,5%, p=0,03 / SGLT2i −19±4,1% vs −19,1±3,8%, p=0,764 / GLP1 & SGLT2i −16,7±3,9% vs −17,5±4,3%, p=0,026). SGLT-2i or GLP-1RA and SGLT-2i showed a greater decrease of PWV (Controls 12,06±3,02 vs 11,62±2,79 m/sec, p=0,142 / GLP1 11,54±2,91 vs 11,45±2,52 m/sec, p=0,822 / SGLT2 11,86±2,51 vs 11,33±2,28 m/sec, p=0,047 / GLP1 & SGLT2 12,01±2,46 vs 10,85±1,79 m/sec, p=0,021) and central and brachial systolic blood pressure than insulin or GLP-1RA. At baseline, there was a correlation of LA reservoir strain with PWV (r=−0,209, p=0,008), central SBP (r=−0,151, p=0,030), EF (r=0,214, p=0,004), GLS (r=−0,279, p=0,009). At 6 months follow up, there was a correlation of LA reservoir strain with PWV (r=0,217, p=0,003), central SBP (r=0,214, p=0,004), EF (r=−0,221, p=0,049), GLS (r=0,275, p=0,014).

Conclusions

Treatment with GLP-1RA, SGLT-2i, and their combination for 6 months showed a greater improvement of left atrial function compared to insulin treatment in parallel with improvement arterial and myocardial function.

Funding Acknowledgement

Type of funding sources: None.

Effects of Treatment With Continuous Subcutaneous Insulin Infusion on Arterial Stiffness and Endothelial Glycocalyx Compared to MDI Intensification in Patients With Type 1 Diabetes: Improvement After a Six-Month Pump Treatment

Patients with type 1 diabetes mellitus (T1DM) present signs of atherosclerosis and endothelial dysfunction earlier compared to healthy individuals. The evidence regarding the efficacy of continuous subcutaneous insulin infusion (CSII) in vascular function in T1DM are scarce. The aim of this study is to determine whether insulin intensification with CSII improves arterial stiffness and endothelial function in T1DM compared to multiple daily insulin (MDI) injections. Thirty patients with T1DM were included in our study. Fifteen patients with poor glycemic control were transitioned from MDI to CSII and were reviewed immediately prior (baseline) and six months after the initiation of CSII. Fifteen patients, matched for sex, age and glycemic control, remained on intensified treatment with MDI (control group). In all patients at each visit we measure a) Carotid-femoral PWV b) central systolic blood pressure (cSBP) c) perfused boundary region (PBR) of the sublingual arterial microvessels. Both groups had similar cardiovascular markers and HbA1c at baseline (p>0.05). After a six month treatment period, patients on CSII improved HbA1c (7.9±1.5% vs 7.35±0.7%, p<0.05), PBR (2.1±0.2 vs. 2±0.2 μm, p<0.05), PWV (7.5±0.3 vs. 7.4±1.1m/s, p<0,05) and cSBP (114.6±12.5 vs. 112±5.4 mmHg, p<0.05). There were no statistically significant differences in PBR (2±0.3 vs. 2±0.3 μm, p>0.05), PWV (8±2.3 vs. 8±1.9m/s, p>0.05) and cSBP (115±15.2 vs. 115.7±15.4 mmHg, p>0.05) in patients who remained on MDI, despite improvement of HbA1c (8±1.1% vs 7.36±0.8%, p<0.05). The use of CSII improves the thickness of endothelial glycocalyx and decreases arterial stiffness after six months treatment in patients with T1DM.

The association of bullous pemphigoid with dipeptidyl-peptidase 4 inhibitors: a ten-year prospective observational study

BACKGROUND

Bullous pemphigoid is the most common bullous chronic autoimmune skin disease. Recent studies have suggested dipeptidyl-peptidase 4 inhibitors as possible predisposing agents of bullous pemphigoid. The objective of our study was to prospectively estimate the association between gliptins and the development of bullous pemphigoid.

METHODS

We conducted a prospective study which included all patients diagnosed with biopsy-proven bullous pemphigoid in the Dermatology Department of our hospital between April 1, 2009 and December 31,2019. The diagnosis of bullous pemphigoid was based on specific clinical, histological and immunological features.

RESULTS

Overall 113 consecutive patients (age 75 ± 13 years, 62 females) with the diagnosis of bullous pemphigoid were enrolled. Seventy-six patients (67.3%) suffered from type 2 Diabetes and 52 (46%) were treated with dipeptidyl-peptidase 4 inhibitors. The most frequent prescribed gliptin was vildagliptin, being administered to 45 cases (39.8% of total patients enrolled, 86.5% of the patients treated with gliptins). Gliptins were withdrawn immediately after the diagnosis of bullous pemphigoid, which together with steroid administration led to remission of the rash.

CONCLUSIONS

This study revealed that treatment with dipeptidyl-peptidase 4 inhibitors, especially vildagliptin, is significantly associated with an increased risk of bullous pemphigoid development.

Effects of glucagon like peptide-1 receptor agonists and their combination with sodium-glucose cotransporter-2 inhibitors on myocardial deformation and work index in type 2 diabetes: 1 year follow up

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction:

Type-2 diabetes mellitus (T2DM) exacerbates mechanisms of atherosclerosis and heart failure.

Purpose

We investigated the effect of novel antidiabetic drugs, glucagon like peptide-1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter-2 inhibitors (SGLT-2i) and their combination on myocardial function.

Methods

A hundred-sixty T2DM patients (age: 58 ± 10years) were randomized to insulin (n = 40), liraglutide (n = 40), empagliflozin (n = 40) or their combination (GLP-1RA + SGLT-2i) (n = 40) as add-on to metformin. We measured at baseline and 1 year post-treatment: a) global LV longitudinal strain (GLS), systolic (GLSR) and diastolic (GLSR E) strain rate, global circumferential (GCS) and radial (GRS) strain, peak twisting (pTw), peak twisting velocity (pTwVel) and peak untwisting velocity (pUtwVel), b) global myocardial work index (GWI), global constructive (GCW) and global wasted work (GWW) derived by pressure-myocardial strain loops using speckle tracking imaging.

Results

After 1 year of treatment, all patients improved GLS, GCS, GRS and pUtwVel (p &lt; 0.05). GLP-1RA or GLP-1RA + SGLT-2i provided a greater increase of GLS (11.5% and 13% vs. 6.8% and 2.3%), GWI (12.7% and 17.4% vs. 3.1% and 2%), GCW (12.3% and 15% vs. 2.2% and 7.8%) and a greater reduction of GWW (38.7% and 41.6% vs. 13.5% and 4.9%) compared with insulin or SGLT-2i, despite a similar HbA1c reduction (p &lt; 0.05 for all comparisons) (Table). Patients under combined treatment with GLP-1RA + SGLT-2i achieved a 2-fold reduction of pTw and a 2-fold increase of pUtwVel than those under each one regimen or insulin (p &lt; 0.05). The dual therapy showed the greatest effect on measured myocardial markers in LVEF &lt; 55% (p &lt; 0.05).

Conclusions

One year treatment with GLP-1RA or combination of GLP-1RA and SGLT-2i resulted in a greater improvement of myocardial deformation and effective cardiac work than insulin or SGLT-2i treatment, independently of glycemic control in T2DM.

All patients (n = 160) Insulin (n = 40) GLP-1RA (n = 40) SGLT-2i (n = 40) GLP-1RA + SGLT-2i (n = 40) p-value GLS, % Baseline -16.4 ± 3.7 -16.4 ± 3.5 -16.2 ± 3.5 -17 ± 4 -16 ± 4 0.139 1 year -17.9 ± 3.9 -17.6 ± 4.2 -18.3 ± 3.5 -17.4 ± 3.4 -18.4 ± 4.7 0.003 GWI, mmHg% Baseline 1538 ± 430 1644 ± 416 1510 ± 403 1536 ± 535 1463 ± 362 0.116 1 year 1692 ± 412 1696 ± 377 1730 ± 318 1568 ± 456 1772 ± 499 0.006 pTw, deg Baseline 15.7 ± 6 16 ± 5.1 15.6 ± 5 15.2 ± 6 16.1 ± 8 0.910 1 year 14.6 ± 5.1 15.4 ± 5.4 14.4 ± 5.4 14.7 ± 4.6 14 ± 5 0.034 pUtwVel, deg/s Baseline -104 ± 42 -100 ± 44 -107 ± 41 -101 ± 28 -111 ± 54 0.550 1 year -116 ± 49 -107 ± 55 -114 ± 45 -108 ± 38 -134 ± 61 0.017 Table

The effects of empagliflozin on arterial stiffness, endothelial function and ventriculoarterial coupling in type 2 diabetes mellitus: 1 year follow up

Introduction

Sodium glucose cotransporters inhibitors (SGLT2i) are currently used in the treatment of patients with type 2 diabetes mellitus (T2DM) who pose high cardiovascular risk. However their effects on arterial stiffness, endothelial function and ventriculoarterial coupling have not been described.

Methods

We recruited 120 patients with T2DM. They received either the SGLT2i empagliflozin (n=60) or insulin (n=60). We measured at baseline and after 1 year of treatment: 1) Perfused Boundary Region (PBR 5–25μm) to evaluate endothelial glycocalyx integrity via Glycocheck, 2) Pulse wave Velocity (PWVc-f), 3)central systolic blood pressure (cSBP), 4) central Pulse Pressure (cPP) via Complior,5) the ratio PWV/GLS by echocardiography to assess ventriculoarterial coupling (VA coupling).

Results

The patients were matched for age, gender, smoking, hypertension and hyperlipidemia (p=NS). Hemoglobin A1c was deteriorated in both groups (8.1% vs 8.2%, p=NS). The baseline measurements of aforementioned markers did not differ between the 2 groups (p=NS). PWV was correlated with cSBP (r=0.4.p&lt;0.05) and cPP (r=0.35, p&lt;0.05) for all participants at baseline. After 1 year of treatment both groups achieved significant reduction of HbA1c. Patients treated with insulin showed an increase of PWV in contrary with empagliflogin group (11.4±0.5 to 12.6±0.4 vs 11.7±0.5 to 10.9±0.4, correspondingly, p&lt;0.05). cSBP declined considerably in empagliflozin group (135±10 to 129±10 vs 134±9 to 136±9 respectively, p&lt;0.05) and cPP remained approximately steady (47±8 to 48±8 vs 49±6 to 55±6 respectively, p&lt;0.05) compared with insulin group. PBR dropped in SGLT2i group (2.20±0.2 to 1.98±0.2, p&lt;0.05) whereas PBR fluctuated at the same level in insulin group (2.18±0.2 to 2.15±0.3, p=NS).PWV/GLS fell in both groups but the reduction was more prominent in empagliflozin group (−0.72±0.1 to −0.67±0.1 vs −0.72±0.1 to −0.60±0.1 respectively, p&lt;0.05).

Conclusion

1 year treatment with empagliflozin resulted in improved markers of arterial stiffness, ventriculoarterial coupling and endothelial function, independently of glycemic control.

Funding Acknowledgement

Type of funding source: None

Effects of glucagon like peptide-1 receptor agonists, sodium-glucose cotransporter-2 inhibitors and their combination on vascular function and myocardial work index in patient with type-2 diabetes

Background/Introduction

Type-2 diabetes mellitus (T2DM) is associated with endothelial and myocardial dysfunction.

Purpose

We investigated the effects of insulin, glucagon like peptide-1 receptor agonists (GLP-1RA), sodium-glucose cotransporter-2 inhibitors (SGLT-2i) and their combination on vascular and cardiac function of T2DM patients.

Methods

A hundred-sixty T2DM patients were randomized to insulin (n=40), liraglutide (n=40), empagliflozin (n=40) or their combination (GLP-1RA+SGLT-2i) (n=40) as add-on to metformin. We measured at baseline, 4 and 12 months post-treatment: a) perfused boundary region (PBR) of the sublingual arterial microvessels (marker of glycocalyx thickness), b) pulse wave velocity (PWV), central systolic blood pressure (cSBP), c) global LV longitudinal (GLS), circumferential (GCS) and radial (GRS) strain, d) the ratio PWV/GLS, as an index of ventricular-arterial interaction, e) myocardial work index (GWI) using speckle tracking imaging.

Results

Twelve months post-treatment, all patients improved PBR, PWV, GLS, GCS and GRS (p&lt;0.05). GLP-1RA, SGLT-2i and their combination showed a greater reduction of PBR, PWV and cSBP than insulin, despite a similar HbA1c reduction (p&lt;0.05). GLP-1RA or GLP-1RA+SGLT-2i provided a greater decrease of PWV/GLS (28.1% and 31% vs. 11.1% and 14.5%) and a greater increase of GWI (12.7% and 17.4% vs. 3.1% and 2%) compared with insulin or SGLT-2i. SGLT-2i or GLP-1RA+SGLT-2i showed a greater decrease of PWV (10.1% and 13%), cSBP than insulin or GLP-1RA (PWV: 3.6% and 8.6%) (p&lt;0.05 for all comparisons) (Table 1). The dual therapy showed the greatest effect on measured markers in patients with LVEF &lt;55% (p&lt;0.05).

Conclusions

Twelve-month treatment with GLP-1RA, SGLT-2i and their combination showed a greater improvement of vascular markers and effective cardiac work than insulin in T2DM. The combined therapy was superior to either insulin, or GLP-1RA and SGLT-2i separately.

Funding Acknowledgement

Type of funding source: None

Beta-amyloid and mitochondrial-derived peptide-c are additive predictors of adverse outcome to high-on-treatment platelet reactivity in type 2 diabetics with revascularized coronary artery disease

Background and aims

Increased b-amyloid and decreased Mitochondrial-derived peptide (MOTS-c), are reported in diabetes. We investigated their additive value to high on-clopidogrel platelet reactivity (HPR) for adverse outcome in type 2 diabetics after recent revascularization.

Patients and methods

In 121 type II diabetics, treated with clopidogrel and aspirin, (93 males, mean age 67.2 years) we measured: a). maximum platelet aggregation to adenosine diphosphate (ADP) by Light Transmission Aggregometry (LTAmax), b) Malondialdehyde (MDA), as oxidative stress marker, c) MOTS-c, d) b-amyloid blood levels. Cardiac death and acute coronary syndromes (MACE) were recorded during 2 years of follow-up.

Results

Out of 121 patients, 32 showed HPR (LTAmax &gt;48%,). At baseline, HPR was associated with b-amyloid &gt;51 pg/ml (p=0.006) after adjusting clinical variables, HbA1c, MOTS-c, MDA and medication. During follow-up, 22 patients suffered a MACE. HPR, b-amyloid &gt;51 pg/ml and MOTS-c&lt;167 ng/ml were predictors of MACE (relative risk 3.1, 3.5 and 3.8 respectively, p&lt;0.05) after adjusting for confounders and medication. There was significant interaction between HPR and b-amyloid or MOTS-c for the prediction of MACE (p&lt;0.05). Patients with HPR and b-amyloid&gt;51mg/dl or HPR and MOTS-c concentration&lt;167 ng/ml had a 4-fold higher risk for MACE than patients without these predictors (relative risk 4.694 and 4.447 respectively p&lt;0.01). The above results were confirmed in an external validation cohort of 90 patients with diabetes and CAD.

Conclusions

Increased b-amyloid or low MOTS-c are additive predictors to high on-clopidogrel platelet reactivity for adverse outcome in diabetics with CAD during 2-years follow- up.

Funding Acknowledgement

Type of funding source: None

Glucagon like peptide-1 receptor agonists and their combination with sodium-glucose cotransporter-2 inhibitors improve myocardial deformation and work index in type-2 diabetes after 12-month treatment

Background/Introduction

Type-2 diabetes mellitus (T2DM) exacerbates mechanisms of atherosclerosis and heart failure.

Purpose

We investigated the effects of insulin, glucagon like peptide-1 receptor agonists (GLP-1RA), sodium-glucose cotransporter-2 inhibitors (SGLT-2i) and their combination on LV myocardial function of T2DM patients.

Methods

A hundred-sixty T2DM patients (age: 58±10 years) were randomized to insulin (n=40), liraglutide (n=40), empagliflozin (n=40) or their combination (GLP-1RA+SGLT-2i) (n=40) as add-on to metformin. We measured at baseline, 4 and 12 months post-treatment: a) global LV longitudinal strain (GLS), systolic (LongSr) and diastolic (LongSrE) strain rate, global circumferential (GCS) and radial (GRS) strain, peak twisting (pTw), peak twisting velocity (pTwVel) and peak untwisting velocity (pUtwVel), b) global myocardial global work index (GWI), global constructive (GCW) and global wasted myocardial work (GWW) derived by pressure-myocardial strain loops using speckle tracking imaging.

Results

At 4 and 12 months post-treatment, all patients improved GLS, GCS, GRS and pUtwVel (p&lt;0.05). At 12 months, GLP-1RA or GLP-1RA+SGLT-2i provided a greater increase of GLS (11.5% and 13% vs. 6.8% and 2.3%), GCS (11.9% and 14.6% vs. 7.3% and 3.4%), GRS (3.8% and 4.3% vs. 2.2% and 1.6%), GWI (12.7% and 17.4% vs. 3.1% and 2%), GCW (12.3% and 15% vs. 2.2% and 7.8%) and a greater reduction of GWW (38.7% and 41.6% vs. 13.5% and 4.9%) compared with insulin or SGLT-2i, despite a similar HbA1c reduction (p&lt;0.05 for all comparisons) (Table). Patients under combined treatment with GLP-1RA+SGLT-2i achieved a 2-fold reduction of pTw and a 2-fold increase of pUtwVel than those under each one regimen or insulin (p&lt;0.05). The dual therapy showed the greatest effect on measured myocardial markers in patients with LVEF &lt;55% (p&lt;0.05).

Conclusions

Twelve-month treatment with GLP-1RA or combination of GLP-1RA and SGLT-2i showed a greater improvement of myocardial deformation and effective cardiac work than insulin or SGLT-2i treatment in T2DM. The combined therapy as second line was superior to either insulin, or GLP-1RA and SGLT-2i separately.

Funding Acknowledgement

Type of funding source: None

Sodium-glucose cotransporter-2 inhibitors and their combination with glucagon like peptide-1 receptor agonists improve endothelial glycocalyx and arterial stiffness in type-2 diabetes

Background/Introduction

Type-2 diabetes mellitus (T2DM) is associated with endothelial and arterial dysfunction.

Purpose

We investigated the effects of insulin, glucagon like peptide-1 receptor agonists (GLP-1RA), sodium-glucose cotransporter-2 inhibitors (SGLT-2i)and their combination on endothelial and arterial function of T2DM patients.

Methods

A hundred-sixty T2DM patients (age: 58±10 years) were randomized to insulin (n=40), liraglutide (n=40), empagliflozin (n=40) or their combination (GLP-1RA+SGLT-2i) (n=40)as add-on to metformin. We measured at baseline, 4 and 12 months post-treatment: a) perfused boundary region (PBR) of the sublingual arterial microvessels (ranged from 5 to 25μm) using Sideview Darkfield imaging. Increased PBR indicates reduced glucocalyx thickness, b) pulse wave velocity (PWV-Complior), central systolic blood pressure (cSBP) and augmentation index (AI) of the aortic pulse wave.

Results

Twelve months post-treatment, all patients improved PBR, PWV and AI (p&lt;0.05). GLP-1RA, SGLT-2i and their combination showed a greater reduction of PBR, PWV and cSBP than insulin, despite a similar HbA1c reduction (p&lt;0.05). SGLT-2i or combined therapy with GLP-1RA and SGLT-2i showed a greater decrease of PWV (−10.1% and −13% vs. −3.6% and −8.6%) and cSBP (−3% and −5.5% vs. −0.8% and −1.5%)than insulin or GLP-1RA (p&lt;0.05 for all comparisons). GLP-1RA or GLP-1RA+SGLT-2i provided a greater decrease of AI (−42.7% and −48.6% vs. +6.2% vs. −3.8%) compared with insulin or SGLT-2i (Table). The dual therapy showed the greatest effect on measured markers in patients with LVEF &lt;55% (p&lt;0.05).

Conclusions

Twelve-month treatment with SGLT-2i and its combination with GLP-1RA, showed a greater improvement on arterial elastic properties than GLP1RA or insulin treatment in T2DM. The combined therapy as second line was superior to either insulin, or GLP-1RA and SGLT-2i separately.

Funding Acknowledgement

Type of funding source: None

Obesity and COVID-19: immune and metabolic derangement as a possible link to adverse clinical outcomes

Recent reports have shown a strong association between obesity and the severity of COVID-19 infection, even in the absence of other comorbidities. After infecting the host cells, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may cause a hyperinflammatory reaction through the excessive release of cytokines, a condition known as "cytokine storm," while inducing lymphopenia and a disrupted immune response. Obesity is associated with chronic low-grade inflammation and immune dysregulation, but the exact mechanisms through which it exacerbates COVID-19 infection are not fully clarified. The production of increased amounts of cytokines such as TNFα, IL-1, IL-6, and monocyte chemoattractant protein (MCP-1) lead to oxidative stress and defective function of innate and adaptive immunity, whereas the activation of NOD-like receptor family pyrin domain containing 3 (NLRP3) inflammasome seems to play a crucial role in the pathogenesis of the infection. Endothelial dysfunction and arterial stiffness could favor the recently discovered infection of the endothelium by SARS-CoV-2, whereas alterations in cardiac structure and function and the prothrombotic microenvironment in obesity could provide a link for the increased cardiovascular events in these patients. The successful use of anti-inflammatory agents such as IL-1 and IL-6 blockers in similar hyperinflammatory settings, like that of rheumatoid arthritis, has triggered the discussion of whether such agents could be administrated in selected patients with COVID-19 disease.

Effects of Glucagon-Like Peptide-1 Receptor Agonists, Sodium-Glucose Cotransporter-2 Inhibitors, and Their Combination on Endothelial Glycocalyx, Arterial Function, and Myocardial Work Index in Patients With Type 2 Diabetes Mellitus After 12-Month Treatment

Background We investigated the effects of insulin, glucagon-like peptide-1 receptor agonists (GLP-1RA), sodium-glucose cotransporter-2 inhibitors (SGLT-2i), and their combination on vascular and cardiac function of patients with type 2 diabetes mellitus. Methods and Results A total of 160 patients with type 2 diabetes mellitus were randomized to insulin (n=40), liraglutide (n=40), empagliflozin (n=40), or their combination (GLP-1RA+SGLT-2i) (n=40) as add-on to metformin. We measured at baseline and 4 and 12 months posttreatment: (a) perfused boundary region of the sublingual arterial microvessels (marker of endothelial glycocalyx thickness), (b) pulse wave velocity (PWV) and central systolic blood pressure, (c) global left ventricular longitudinal, circumferential, and radial strain, (d) myocardial work index (global work index) derived by pressure-myocardial strain loops using speckle tracking imaging. Twelve months posttreatment, all patients improved perfused boundary region, PWV, global longitudinal strain, global circumferential strain, and global radial strain (P<0.05). GLP-1RA, SGLT-2i, and their combination showed a greater reduction of perfused boundary region, PWV, and central systolic blood pressure than insulin, despite a similar glycosylated hemoglobin reduction (P<0.05). GLP-1RA or GLP-1RA+SGLT-2i provided a greater increase of global work index (12.7% and 17.4%) compared with insulin or SGLT-2i (3.1% and 2%). SGLT-2i or GLP-1RA and SGLT-2i showed a greater decrease of PWV (10.1% and 13%) and central and brachial systolic blood pressure than insulin or GLP-1RA (PWV, 3.6% and 8.6%) (P<0.05 for all comparisons). The dual therapy showed the greatest effect on measured markers in patients with left ventricular ejection fraction <55% (P<0.05). Conclusions Twelve-month treatment with GLP-1RA, SGLT-2i, and their combination showed a greater improvement of vascular markers and effective cardiac work than insulin treatment in type 2 diabetes mellitus. The combined therapy as second line was superior to either insulin or GLP-1RA and SGLT-2i separately. Registration URL: https://www.clini​caltr​ials.gov. Unique identifier: NCT03878706.

β-Amyloid and mitochondrial-derived peptide-c are additive predictors of adverse outcome to high-on-treatment platelet reactivity in type 2 diabetics with revascularized coronary artery disease

BACKGROUND AND AIMS

Increased β-amyloid and decreased mitochondrial-derived peptide (MOTS-c), are reported in diabetes. We investigated their additive value to high on-clopidogrel platelet reactivity (HPR) for adverse outcome in type 2 diabetics after recent revascularization.

PATIENTS AND METHODS

In 121 type II diabetics, treated with clopidogrel and aspirin, (93 males, mean age 67.2 years) we measured: (a) maximum platelet aggregation to adenosine diphosphate (ADP) by light transmission aggregometry (LTAmax), (b) malondialdehyde (MDA), as oxidative stress marker, (c) MOTS-c, (d) β-amyloid blood levels. Cardiac death and acute coronary syndromes (MACE) were recorded during 2 years of follow-up.

RESULTS

Out of 121 patients, 32 showed HPR (LTAmax > 48%,). At baseline, HPR was associated with β-amyloid > 51 pg/ml (p = 0.006) after adjusting clinical variables, HbA1c, MOTS-c, MDA and medication. During follow-up, 22 patients suffered a MACE. HPR, β-amyloid > 51 pg/ml and MOTS-c < 167 ng/ml were predictors of MACE (relative risk 3.1, 3.5 and 3.8 respectively, p < 0.05) after adjusting for confounders and medication. There was significant interaction between HPR and β-amyloid or MOTS-c for the prediction of MACE (p < 0.05). Patients with HPR and β-amyloid > 51 mg/dl or HPR and MOTS-c concentration < 167 ng/ml had a fourfold higher risk for MACE than patients without these predictors (relative risk 4.694 and 4.447 respectively p < 0.01). The above results were confirmed in an external validation cohort of 90 patients with diabetes and CAD.

CONCLUSIONS

Increased β-amyloid or low MOTS-c are additive predictors to high on-clopidogrel platelet reactivity for adverse outcome in diabetics with CAD during 2-years follow-up. Clinical Trial Registration-URL: https://www.clinicaltrials.gov. Unique identifier: NCT04027712.

P4991Effects of the glucagon like peptide-1 receptor analogue, sodium-glucose co-transporter 2 and their combination on myocardial work index and vascular function in diabetes after 3-month treatment

Methods

A hundred twenty, patients with type 2 diabetes were randomized to receive the insulin +/− metformin (n=30), GLP-1A, liraglutide (n=30), the SGLT-2, empagliflozin (n=30) or their combination (GLP-1R+SGLT-2) for 3 months (n=30). We measured at baseline and after treatment a) pulse wave velocity (PWV), central systolic blood pressure (cSBP) b) the perfusion boundary region (PBR-micrometers) of the sublingual arterial microvessels, as a marker of endothelial glycocalyx thickness. c) global LV longitundinal strain (GLS), peak LV untwisting velocity and global myocardial work index (GWI) derived by pressure–myocardial strain loops using speckle tracking imaging and PWV to GLS ratio, as a marker of ventricular-arterial coupling

Results

All treatment groups had similar vascular and cardiac markers, glucose levels and HbA1 at inclusion (p>0.05). After treatment, all patients had improved GLS, PWV and increased LV twisting-untwisting velocities (p<0.05). Patients under GLP-1R, SGLT-2 and their combination achieved a significant reduction of PBR, PWV, central SBP and a greater increase of GWI (30%, 25% and 50% respectively) and LV untwisting velocities (p<0.05) than those under insulin (15% reduction of GWI), despite a similar reduction of HbA1 (p<0.05). The combination of GLP-1A and SGLT-2 showed a greater improvement of the measured markers than each treatment alone (table, p<0.05). The reduction of PBR (indicating improvement of glycocalyx thickness) was related with the changes in central SBP (r=0.40) and PWV (r=0.35) (p<0.05).

N=120 Insulin GLP-1A SGLT-2 GLP-1A + SGLT-2 P 3-months N=30 N=30 N=30 N=30 PBR, μm 2.27±0.3 2.17±0.3 2.17±0.3 1.99±0.2 <0.05 Central SBP, mmHg 136±20 127±16 126±11 124±10 <0.05 PWV, m/sec 11.7±0.5 9.5±0.5 9.3±0.5 9.2±0.5 <0.05 HbA1 7.1±1.5 6.6±0.3 6.7±0.6 6.2±0.6 0.8 Myocardial work index (GWI), mmHg% 1343±394 1579±245 1364±431 1784±593 <0.05 LV untwisting velocity, deg/sec −116±36 −123±36 −122±36 −130±36 <0.05 PWV/GLS ratio −0.77±0.2 −0.57±0.2 −0.66±0.3 −0.55±0.3 <0.05

Conclusion

Three-month treatment with GLP-1A, SGLT-2 and their combination showed a greater improvement of vascular markers, ventricular-arterial coupling and effective cardiac work than insulin treatment in type 2 diabetes.

Effects of Different Antidiabetic Medications on Endothelial Glycocalyx, Myocardial Function, and Vascular Function in Type 2 Diabetic Patients: One Year Follow-Up Study

Background: Poor glycaemic control affects myocardial function. We investigated changes in endothelial function and left ventricular (LV) myocardial deformation in poorly controlled type 2 diabetics before and after glycaemic control intensification. Methods: In 100 poorly-controlled diabetic patients (age: 51 ± 12 years), we measured at baseline and at 12 months after intensified glycaemic control: (a) Pulse wave velocity (PWV, Complior); (b) flow-mediated dilatation (FMD, %) of the brachial artery; (c) perfused boundary region (PBR) of the sublingual arterial micro-vessels (side-view dark-field imaging, Glycocheck); (d) LV global longitudinal strain (GLS), peak twisting (pTw), peak twisting velocity (pTwVel), and peak untwisting velocity (pUtwVel) using speckle tracking echocardiography, where the ratio of PWV/GLS was used as a marker of ventricular-arterial interaction; and (e) Malondialdehyde (MDA) and protein carbonyls (PCs) plasma levels. Results: Intensified 12-month antidiabetic treatment reduced HbA1c (8.9 ± 1.8% (74 ± 24 mmol/mol) versus 7.1 ± 1.2% (54 ± 14 mmol/mol), p = 0.001), PWV (12 ± 3 versus 10.8 ± 2 m/s), PBR (2.12 ± 0.3 versus 1.98 ± 0.2 μm), MDA, and PCs; meanwhile, the treatment improved GLS (−15.2 versus −16.9%), PWV/GLS, and FMD% (p < 0.05). By multi-variate analysis, incretin-based agents were associated with improved PWV (p = 0.029), GLS (p = 0.037), PBR (p = 0.047), and FMD% (p = 0.034), in addition to a reduction of HbA1c. The patients with a final HbA1c ≤ 7% (≤ 53 mmol/mol) had greater reduction in PWV, PBR, and markers of oxidative stress, with a parallel increase in FMD and GLS, compared to those who had HbA1c > 7% (> 53 mmol/mol). Conclusions: Intensified glycaemic control, in addition to incretin-based treatment, improves arterial stiffness, endothelial glycocalyx, and myocardial deformation in type 2 diabetes after one year of treatment.

Laboratory Assessment of the Anticoagulant Activity of Apixaban in Patients With Nonvalvular Atrial Fibrillation

Our aim is to determine the most appropriate laboratory tests, besides anti-factor Xa (anti-FXa) chromogenic assays, to estimate the degree of anticoagulation with apixaban and compare it with that of rivaroxaban in real-world patients. Twenty patients with nonvalvular atrial fibrillation treated with apixaban 5 mg twice daily and 20 patients on rivaroxaban 20 mg once daily were studied. Conventional coagulation tests, thrombin generation assay (TGA), and thromboelastometry (nonactivated TEM [NATEM] assay) were performed in the 40 patients and 20 controls. The anti-FXa chromogenic assays were used to measure apixaban and rivaroxaban plasma levels. The NATEM measurements showed no significant difference between the 2 groups of patients. Concerning TGA, endogenous thrombin potential (ETP) was significantly decreased in patients on rivaroxaban as compared to those treated with apixaban (P < .003). A statistically significant, strong inverse correlation between apixaban plasma concentrations and ETP (P < .001) was observed. Apixaban significantly reduces ETP compared to controls, but to a lesser extent than rivaroxaban. Thrombin generation assay might provide additional information on apixaban exposure, which is required in order to individualize treatment especially for patients with a high bleeding risk. Our findings have to be further investigated in studies with larger sample sizes, in the entire range of apixaban exposure, with other direct oral anticoagulants, and in relation to clinical outcomes.

Effects of 6-month treatment with the glucagon like peptide-1 analogue liraglutide on arterial stiffness, left ventricular myocardial deformation and oxidative stress in subjects with newly diagnosed type 2 diabetes

Background

Incretin-based therapies are used in the treatment of type 2 diabetes mellitus (T2DM) and obesity. We investigated the changes in arterial stiffness and left ventricular (LV) myocardial deformation after 6-month treatment with the GLP-1 analogue liraglutide in subjects with newly diagnosed T2DM.

Methods

We randomized 60 patients with newly diagnosed and treatment-naive T2DM to receive either liraglutide (n = 30) or metformin (n = 30) for 6 months. We measured at baseline and after 6-month treatment: (a) carotid-femoral pulse wave velocity (PWV) (b) LV longitudinal strain (GLS), and strain rate (GLSR), peak twisting (pTw), peak twisting velocity (pTwVel) and peak untwisting velocity (pUtwVel) using speckle tracking echocardiography. LV untwisting was calculated as the percentage difference between peak twisting and untwisting at MVO (%dpTw–Utw_MVO), at peak (%dpTw–Utw_PEF) and end of early LV diastolic filling (%dpTw–Utw_EDF) (c) Flow mediated dilatation (FMD) of the brachial artery and percentage difference of FMD (FMD%) (d) malondialdehyde (MDA), protein carbonyls (PCs) and NT-proBNP.

Results

After 6-months treatment, subjects that received liraglutide presented with a reduced PWV (11.8 ± 2.5 vs. 10.3 ± 3.3 m/s), MDA (0.92 [0.45–2.45] vs. 0.68 [0.43–2.08] nM/L) and NT-proBNP (p < 0.05) in parallel with an increase in GLS (− 15.4 ± 3 vs. − 16.6 ± 2.7), GLSR (0.77 ± 0.2 vs. 0.89 ± 0.2), pUtwVel (− 97 ± 49 vs. − 112 ± 52°, p < 0.05), %dpTw–Utw_MVO (31 ± 10 vs. 40 ± 14), %dpTw–Utw_PEF (43 ± 19 vs. 53 ± 22) and FMD% (8.9 ± 3 vs. 13.2 ± 6, p < 0.01). There were no statistically significant differences of the measured markers in subjects that received metformin except for an improvement in FMD. In all subjects, PCs levels at baseline were negatively related to the difference of GLS (r = − 0.53) post-treatment and the difference of MDA was associated with the difference of PWV (r = 0.52) (p < 0.05 for all associations) after 6-month treatment.

Conclusions

Six-month treatment with liraglutide improves arterial stiffness, LV myocardial strain, LV twisting and untwisting and NT-proBNP by reducing oxidative stress in subjects with newly diagnosed T2DM.

ClinicalTrials.gov Identifier NCT03010683

Defective production of interleukin-1 beta in patients with type 2 diabetes mellitus: Restoration by proper glycemic control

The underlying immune defect of susceptibility in diabetes mellitus type 2 to infections remains unknown. The qualitative changes in cytokine biosynthesis by circulating mononuclear cells (PBMCs) and its modulation by glycemic control were investigated. PBMCs were isolated from 39 patients and 25 controls. They were stimulated with purified ligands and heat-killed bacteria in the absence/presence of glucose and NLPR3 inflammasome ligands. Experiments were repeated after 3 and 6months. Cytokine production was measured in cell supernatants; pro-interleukin(IL)-1 β was measured in cell lysates. Gene expression of IL-1β and activity of caspase-1 were measured as well. Adequate release of interleukin (IL)-1β was found in 42.9% of patients compared to 90% of controls (p: 0.0001). This was related with down-regulation of the NLRP3 inflammasome since gene expression of IL-1β remained unaltered whereas both the ratio of IL-1β to the intracellular pro-IL-1β and the activity of caspase-1 was lower in patients than controls. Addition of glucose did not modify defective IL-1β production. IL-6 production was increased after stimulation with Pam3Cys, phytohemagglutinin and C. albicans. After proper glycemic control, release of IL-1β was increased and of IL-6 decreased; cells of patients with improved glycemic control responded better to LPS stimulation under increased concentrations of glucose. It is concluded that diabetes type 2 is characterized by defective production of IL-1β from circulating monocytes due to impaired activation of the NLRP3 inflammasome and increased production of the anti-inflammatory IL-6. Defects are restored with proper glycemic control.

P673Improvement of arterial stiffness and myocardial deformation in patients with poorly controlled diabetes mellitus type 2 after optimization of antidiabetic medication

Background

Arterial stiffness is associated with increased risk for cardiovascular disease. The purpose of this study is to investigate the arterial stiffness and myocardial deformation in patients with poorly controlled diabetes mellitus type 2 before and after glycemic control by optimal medication.

Methods

In 50 patients with uncontrolled type 2 diabetes(age:52±10years)and 25 controls of similar age and sex and no atherosclerotic risk factors we measured at baseline and 6 months after glycemic control a) carotid-femoral pulse wave velocity(PWVc m/sec-Complior SP ALAM),central systolic blood pressure(cSBP -mmHg),augmentation index(AI%), of the aortic pulse wave(ArteriographTensioMed) b)S',E'(m/sec)andE'/A'of mitral annulus by Tissue Doppler c)LV longitudinal strain(GLS-%),systolic(LongSr-l/sec)and diastolic(LongSrE-l/sec)strain rate, twisting(Tw-deg),peak twisting(Tw)and untwisting(unTw-deg/sec)velocity using speckle tracking echocardiography.The degree of LV untwisting was calculated as the percentage difference between peak twisting and untwisting at MVO(%dp PeakTw-UntwMVO)and between peak twisting and untwisting at peak and end of the mitral inflow E wave d)perfusion boundary region(PBR- micrometers)of the sublingual arterial microvessels(ranged from 5-25 micrometers)using Sideview,Darkfield imaging(Microscan,Glycocheck).Increased PBR is considered an accurate index of reduced endothelial glucocalyx thickness because of a deeper RBC penetration in the glucocalyx e) Flow mediated dilatation(FMD) of the brachial artery and percentage difference of FMD (FMD%).

Results

Compared to controls,diabetics had higher PWVa(10.3±2.2 vs. 8.1±1.9), AI(27.9±15 vs. 19.4±14.7), PWVc(11.8±3.2 vs. 8.8±1.3),cSBP(136±20 vs. 119±18),PBR (2.1±0.2 vs 1.89±0.1)and lower GLS(-15±3 vs. -18±3),LongSr(-0.78±0.1 vs. -0.96±0.2),LongSrE(0.77±0.29 vs. 1.2±0.3),S',E' and E/A(p<0.05 for all comparisons). Baseline FMD was related with Untw at peak E%(r=0,65, p<0.05). Six months after the modification of antidiabetic medication all patients achieved glycaemic control and there was a reduction of PWVc(12.3±2.9 vs. 11.3±3.2,p<0.05) in parallel with a increase of Untw velocity (-73±27 vs. -98±43,p<0.05),Untw MVO%(20±9 vs. 30±2),Untw peak E% (40±14 vs. 50±16)and FMD%(7.8±3 vs. 13.6±11,p<0.01).Reduced PWVc was related with reduced SBP(r=0.62),cSBP(r=0.55)and increased LongsrE(r=-0.50), Untw at end E(r=-0.56)respectively(p<0.05 for all associations).

Conclusion

Glycaemic control after optimizing medical treatment improves arterial stiffness, LV myocardial strain, twisting and untwisting velocity in diabetics.

Legal, cultural and ethical considerations on the informing of the cancer patient: a perspective from Greece

PURPOSE

To discuss the current official legal position of the Greek Council and the official international statement on the subject, as well as the emerging cultural and moral aspects on the issue of informing the cancer patient.

METHODS

Perusal of national and international legal and ethics sources, under a multidisciplinary perspective.

RESULTS

According to the Council of State of Greece the violation of informing the patient by the physician constitutes urban liability and disciplinary offence. The Greek Code of Medical Ethics declares that the physician is obliged to inform his patient about his health and respect the desire of the patient who decides not to be informed. The UNESCO declaration does not seem to clarify the subject. In Greece, physicians have the tendency to tell the truth more often today than in the past, reflecting the global tendency, although the majority still discloses the truth to the next of kin. The difference in the tactics of informing in several nations reflects huge cultural, social, economic and religious differences in each society.

CONCLUSION

Well informed and knowledgeable health-care and legal professionals, alongside with patients and ethical directors, should sit at the same table in order to productively discuss the most sensitive matters of the contemporary medical practice.