The diagnostic approach and management of hypertension in the emergency department

Hypertension urgency and emergency represents a challenging condition in which clinicians should determine the assessment and/or treatment of these patients. Whether the elevation of blood pressure (BP) levels is temporary, in need of treatment, or reflects a chronic hypertensive state is not always easy to unravel. Unfortunately, current guidelines provide few recommendations concerning the diagnostic approach and treatment of emergency department patients presenting with severe hypertension. Target organ damage determines: the timeframe in which BP should be lowered, target BP levels as well as the drug of choice to use. It's important to distinguish hypertensive emergency from hypertensive urgency, usually a benign condition that requires more likely an outpatient visit and treatment.

ASSESSING SKIN MICROCIRCULATION IN PATIENTS AT CARDIOVASCULAR RISK BY USING LASER SPECKLE CONTRAST IMAGING. A NARRATIVE REVIEW

Skin tissue holds a prominent role in microcirculatory research as an easily accessible vascular bed for the non-invasive evaluation of microvascular function. Skin microvascular changes have been associated to alterations in distinct target organs and vascular beds, reinforcing the hypothesis that skin microcirculation can be used as a model of generalized microvascular function. In addition, skin microvascular dysfunction has been documented in cardiovascular disease and patients of increased cardiovascular risk where it has been associated with multiple cardiovascular risk factors, rendering it a candidate surrogate marker of vascular damage. Laser Speckle Contrast Imaging (LSCI) is a non-invasive, dynamic laser technique that allows assessment of skin microvascular function (SMF) by obtaining two-dimensional maps of the skin perfusion in real time with high spatial and temporal resolution and, most importantly, with the highest reproducibility as compared to other laser methods. An ever-increasing number of studies using LSCI is confirming evidence of impaired SMF in several cardiovascular risk groups, therefore expanding its application in microvascular research and showing its potential clinical utility. This review attempts to present the growing importance of SMF in cardiovascular research and the emergence of LSCI technique as a robust imaging modality with a promising role to explore skin microvascular physiology. After a short description of the relevant technique and its main principle of function, we have also opted to present the most up to date studies using LSCI for the investigation of SMF in patients with cardiovascular disease as well as various groups of increased cardiovascular risk. This article is protected by copyright. All rights reserved.

Effect of sodium-glucose co-transporter 2 inhibitors on left ventricular mass and left atrial volume indices assessed either by cardiovascular magnetic resonance or transthoracic echocardiography

Background

Sodium-glucose co-transporter 2 (SGLT-2) inhibitors are a novel class of antidiabetic regimens linked with a significant reduction in the risk for surrogate cardiovascular and renal outcomes. Specific patient populations, for example subjects with heart failure with reduced ejection fraction (HFrEF), also benefit from this drug class, regardless the presence of T2DM. Left ventricular (LV) hypertrophy is a strong, independent predictor of cardiovascular morbidity and mortality; left atrial volume index (LAVI), an indicator of severity of LV diastolic dysfunction and filling properties, has been shown to predict “hard” cardiovascular outcomes among patients with T2DM, while it might predict the recovery of left ventricular ejection fraction in patients with HFrEF.

Purpose

We sought to determine the effect of SGLT-2 inhibitors on the above indices, in order to evaluate additional cardioprotective mechanisms of this drug class.

Methods

We searched 2 major electronic databases (PubMed and Cochrane/CENTRAL) along with grey literature sources for parallel-group RCTs investigating the effect of SGLT-2 inhibitors compared to placebo or active control on LV mass, LV mass index (LVMI) and LAVI, evaluated either by TTE or CMR, on adult patients regardless the presence of T2DM or HF.

Results

After screening the potentially eligible records, 9 studies were included in our analysis with a total of 843 patients. Treatment with SGLT-2 inhibitors compared to placebo or active control leads to a statistically significant decrease in LV mass by 6.01 g (95% CI −11.33 to −0.69, I2=76%) (Figure 1a). A significant decrease in LVMI by 2.61 g/m2 was observed (MD=−2.61, 95% CI −4.94 to −0.29, I2=65%) (Figure 1b). Of note, the effect on LAVI was marginally non-significant (MD=−1.51 ml/m2, 95% CI −3.05 to 0.03, I2=0%) (Figure 1c). Subgroup analysis for patients with HFrEF demonstrated a non-significant reduction in LV mass (MD=−11.72 g, 95% CI −30.61 to 7.16, I2=90%) and in LVMI (MD=−6.28 g/m2, 95% CI −30.61 to 0.25, I2=80%) (Figure 2a and 2b).

Conclusions

SGLT-2 inhibitors demonstrate a clear benefit on LV mass and LVMI, regardless of diabetes status, while a marginally non-significant effect is observed on LAVI. These results provide further insights into the cardioprotective mechanisms mediated by this drug class, besides those already established.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Sodium-glucose co-transporter-2 inhibitors improve cardiovascular outcomes in heart failure with reduced ejection fraction regardless of ischemic etiology

Background

Coronary artery disease remains the main underlying cause of heart failure (HF), despite the progress in prevention, diagnosis and treatment. Sodium-glucose co-transporter-2 inhibitors have been shown to improve surrogate cardiovascular outcomes in patients with HF with reduced ejection fraction (HFrEF), regardless of diabetes status.

Purpose

We sought to determine the effect of SGLT-2 inhibitors on the primary composite endpoint (cardiovascular death or hospitalization for HF) across the two hallmark trials in the HFrEF population (EMPEROR Reduced and DAPA-HF), according to ischemic or non-ischemic etiology of HF.

Methods

We pooled data from EMPEROR reduced and DAPA-HF trials in a total of 8,474 patients with HFrEF, performing a sub-analysis according to the presence of ischemic cardiomyopathy as the underlying cause of HFrEF.

Results

Treatment with SGLT-2 inhibitors resulted in a significant decrease in the risk for the primary composite outcome in patients with HFrEF of ischemic etiology, equal to 18% (RR=0.82, 95% CI: 0.73–0.92, I2=0%). In patients with HFrEF of non-ischemic etiology, SGLT-2 inhibitors produced a significant decrease in the risk for the primary composite outcome equal to 18% (RR=0.72, 95% CI: 0.63–0.82, I2=0%). Despite the greater effect in patients with non-ischemic HFrEF, no subgroup difference was detected (p=0.16). Generated results are summarized in Figure 1.

Conclusions

SGLT-2 inhibitors improve surrogate cardiovascular outcomes both in patients with ischemic and non-ischemic HFrEF.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Impact of antidiabetic treatment with dipeptidyl peptidase-4 inhibitors on the risk of cardiac arrhythmias among patients with type 2 diabetes mellitus

Introduction

Type 2 diabetes mellitus (T2DM) is considered as a global pandemic, comprising a significant, independent cardiovascular risk factor. Besides major adverse cardiovascular events, patients with T2DM experience an increased risk of heart rhythm disorders, nevertheless the exact mechanisms of arrhythmogenesis in the context of diabetes mellitus are still being under investigation. Dipeptidyl peptidase-4 (DPP-4) inhibitors represent a novel class of antidiabetic regimens with proved safety and efficacy among patients with T2DM and a series of randomized controlled trials (RCTs) addressing cardiovascular outcomes with DPP-4 inhibitors have been published. The exact effect of DPP-4 inhibitors on the arrhythmic burden among diabetic individuals is yet to be identified.

Purpose

In the present meta-analysis, we sought to determine the impact of antidiabetic treatment with DPP-4 inhibitors on the risk of various cardiac arrhythmias.

Methods

We searched PubMed for all published RCTs assessing cardiovascular outcomes after antidiabetic treatment with DPP-4 inhibitors. We extracted data regarding the risk for the following cardiac arrhythmias: atrial fibrillation, atrial flutter, atrial tachycardia, ventricular fibrillation, ventricular tachycardia, ventricular extrasystoles, supraventricular tachycardia, sinus node dysfunction, second degree atrioventricular block, complete atrioventricular block.

Results

Following a meticulous assessment of the available literature, we pooled data from 6 trials in a total of 52,520 patients. Antidiabetic treatment with DPP-4 inhibitors did not significantly affect the risk for atrial fibrillation (RR=0.95, 95% CI: 0.78–1.17, I2=0%) (Figure 1a). Of note, DPP-4 inhibitors were associated with a significant increase in the risk for atrial flutter, equal to 52% (RR=1.52, 95% CI: 1.03–2.24, I2=0%), as shown in Figure 2. Finally, DPP-4 inhibitors did not have a significant impact on the risk for any of the rest assessed major cardiac arrhythmias.

Conclusions

DPP-4 inhibitors do not seem to be associated with a significant risk for any major cardiac arrhythmias, except for atrial flutter.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Risk of death with sodium-glucose co-transporter-2 inhibitors across the hallmark cardiovascular and renal outcome trials: an updated meta-analysis

Background

Patients with type 2 diabetes mellitus (T2DM) experience a 15% increase in the risk for death compared to the general population, with age less than 55 years, insufficient glycemic control and albuminuria representing the major risk factors for all-cause and cardiovascular mortality. Despite progression in diagnosis and treatment, mortality remains elevated among affected individuals. Sodium-glucose co-transporter 2 (SGLT-2) inhibitors are considered as the optimal treatment option for patients with T2DM and concomitant cardiovascular or renal disease, while these regimens demonstrated a clear benefit in all-cause and cardiovascular mortality compared to placebo.

Purpose

As we recently welcomed the publication of large-scale randomized controlled trials (RCTs) with SGLT-2 inhibitors addressing surrogate, hard endpoints, we sought to perform an updated meta-analysis, investigating the effect of SGLT-2 inhibitors on all-cause, cardiovascular and renal death among the high- or very-high risk patients enrolled in those trials.

Methods

We pooled data from the relevant, recent hallmark RCTs; 10 trials were included in our analysis encompassing a total of 71,533 enrolled participants, assigned either to SGLT-2 inhibitor treatment or placebo. We set cardiovascular death as the primary efficacy outcome, while we assessed all-cause death and renal death as secondary efficacy outcomes.

Results

Treatment with SGLT-2 inhibitors resulted in a significant decrease in the risk of cardiovascular death, equal to 14% (RR = 0.86, 95% CI; 0.80 to 0.93, I2=22%). Only canagliflozin produced a significant result, while dapagliflozin led to a marginally non-significant reduction in cardiovascular mortality (Figure 1). Notably, SGLT-2 inhibitors led to a significant decrease in the risk for all-cause death, equal to 14% (RR=0.86, 95% CI; 0.81 to 0.92, I2=34%) the result was significant only for canagliflozin and dapagliflozin, while none of the rest SGLT-2 inhibitors resulted in a significant decrease in the risk for all-cause death (Figure 1). SGLT-2 inhibitors also produced a non-significant decrease in the risk for renal death (RR=0.36, 95% CI; 0.12 to 1.14, I2=0%). Neither canagliflozin nor dapagliflozin had a significant impact on risk reduction for renal death, while no cases of renal death were reported in VERTIS CV trial. No subgroup differences were identified for any of the three comparisons (Figure 2).

Conclusions

Antidiabetic treatment with SGLT-2 inhibitors provides a clear benefit in terms of cardiovascular and all-cause mortality for the very high-risk patients enrolled in the cardiovascular and renal outcome trials. Canagliflozin seems to be associated with the greatest impact on risk reduction for all-cause and cardiovascular death, followed by dapagliflozin.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

How intravenous iron therapy affects arrhythmia burden and functional status in patients with advanced heart failure and implantable devices

Background

Heart failure with reduced ejection fraction (HFrEF) is a disease that confers significant morbidity and mortality to patients. Patients suffer from increased arrhythmia burden; lethal ventricular arrhythmias are frequent. Iron deficiency (ID) is increasingly recognized as a common comorbidity that constitutes a further detriment to patients' cardiorespiratory capacity and an independent prognosticator of mortality. ID treatment with intravenous ferric carboxymaltose (IV FCM) has proven beneficial, improving QoL and exercise capacity in HFrEF patients with ID. Iron depletion is linked to disturbed myocyte electromechanical balance, especially in HF. However, the role of IV FCM arrhythmic burden in HFrEF patients with ID has not been examined.

Purpose

Investigate the effect of IV FCM treatment on the functional capacity, QoL and arrhythmic burden of in HFrEF patients with ID and cardiac implantable electronic devices (CIED).

Methods

HFrEF patients with ID and CIEDs were recruited from our outpatient HF clinic. CIED telemetry revealed their arrhythmic burden for the 6 months preceding IV FCM administration. Patients underwent physical examination, blood testing, 6-minute walk testing, 24-hour Holter monitoring, QoL quantification with the KCCQ and EQ-5D-5L questionnaires and repeat CIED telemetry at study baseline (IV FCM administration) and 6-months. Microvolt T-wave alternans (MTWA) and heart rate turbulence (HRT) slope and onset were quantified through the 24-hour ECG recordings. HRT results are reported as HRT0, HRT1 or HRT2 based on the number of abnormal HRT parameters.

Results

So far, 83 (aged 68.3±8.7 years, 82% male) out of a total of 96 recruited patients have completed the 6-month follow-up (3 of 83 died before the 6-month mark). Picture 1 contains patients' baseline characteristics and 6-month results. Patients received a mean of 1.43±0.61g of IV FCM during the follow-up period, which significantly ameliorated iron status (Picture 1). The 6MWD increased by 32.4m (95% CI: 14.7–47.2, P<0.001), as did the KCCQ total score (P=0.008). Patients' CIEDs recorded significantly more nsVTs in the 6 months preceding IV FCM administration (2.2±15.7 per month) opposed to the subsequent period (0.06±3.1 per month, P=0.006). Patients' MTWA improved at 6-months over baseline (P=0.004), and a trend for improvement in HRT scores was observed (P=0.06). Hospitalization-free survival curves of these time periods reveal a non-significant trend for lower hospitalization risk following IV FCM (HR=1.9, P=0.09).

Conclusions

After 6 months of IV FCM treatment, HFrEF patients with ID had significantly better exercise capacity and quality of life. Regarding arrhythmias, a tentative improvement in CIED- and Holter-derived arrhythmic markers was observed. Extended follow-up of a larger sample size will provide further insight for the effect of IV FCM in these patients' arrhythmic burden.

Funding Acknowledgement

Type of funding sources: None. Baseline and 6-month resultsHospitalization curves pre-post IV FCM

Meta-analysis of cardiovascular outcome trials assessing the impact of glucagon-like peptide-1 receptor agonists on major cardiac arrhythmias

Background

Type 2 diabetes mellitus poses a significant health burden, whereas growing attention has been focused on the novel classes of antidiabetic drugs. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) constitute such a group of antidiabetic agents. In recent large, placebo-controlled randomized clinical trials (RCTs), GLP-1RAs have demonstrated beneficial cardiovascular effects. Nevertheless, the clear antiarrhythmic benefit has not been underlined yet.

Purpose

The purpose of the present analysis was to clarify the impact of antidiabetic treatment with GLP-1RAs on the several different types of cardiac arrhythmias, based on data extracted from relevant cardiovascular outcome trials.

Methods

We searched PubMed plus grey literature for all available cardiovascular and renal outcome, placebo-controlled RCTs utilizing GLP-1RAs versus placebo.

Results

We pooled data from 7 cardiovascular outcome trials with GLP-1RAs in a total of 55,943 randomized participants patients. When compared to placebo, treatment with GLP-1RAs did not provide a significant benefit in the risk for atrial fibrillation (RR = 0.81, 95% CI: 0.78–1.15, I2=51%) (Figure 1a), atrial flutter (RR=0.79, 95% CI: 0.53–1.16, I2=0%) (Figure 1b), ventricular fibrillation (RR=0.99, 95% CI: 0.48–2.04, I2=0%) (Figure 1c), ventricular tachycardia (RR=1.41, 95% CI: 0.87–2.28, I2=10%) (Figure 1d), atrial tachycardia (RR=0.63, 95% CI: 0.10–3.90, I2=24%) (Figure 2a), sinus node dysfunction (RR=0.70, 95% CI: 0.40–1.23, I2=0%) (Figure 2b), ventricular extrasystoles (RR=1.37, 95% CI: 0.56–3.30, I2=0%) (Figure 2c), second-degree atrioventricular block (RR=0.96, 95% CI: 0.52–1.74, I2=0%) (Figure 2d) or complete atrioventricular block (RR=0.78, 95% CI: 0.39–1.54, I2=38%) (Figure 2e).

Conclusions

In patients with type 2 diabetes mellitus, treatment with GLP-1RAs does not significantly affect the risk for major cardiac arrhythmias.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

The effect of glucagon-like peptide-1 receptor agonists on 24-hour ambulatory blood pressure: a meta-analysis

Background

Hypertension augments overall cardiovascular risk in patients with type 2 diabetes mellitus (T2DM), constituting a major additional burden for diabetic subjects; however, control rates of hypertension remain suboptimal. Glucagon-like peptide-1 receptor agonists (GLP-1RAs), second-line treatment option for diabetics, have revolutionized the field of T2DM therapeutic management due to their pleiotropic effects, while they seem to hold multiple cardiovascular benefits. A few randomized controlled trials (RCTs) evaluated the effect of GLP-1RAs on ambulatory blood pressure (ABP). Ambulatory blood pressure monitoring (ABPM) provides a better method to predict long-term cardiovascular outcomes than office blood pressure.

Purpose

We sought to determine the effect of GLP-1RAs on ABPM, pooling data from relevant randomized controlled trials (RCTs).

Methods

We searched 2 major electronic databases, namely PubMed and Cochrane/CENTRAL, along with grey literature sources, for RCTs assessing the effect of various GLP-1RAs on ABP in patients with T2DM.

Results

After screening of the potentially eligible records, 7 RCTs were finally included in our meta-analysis (4 parallel-group and 3 cross-over). GLP-1RA treatment compared to placebo or active control resulted in a nonsignificant decrease in 24-h systolic blood pressure (MD=−1.57 mm Hg, 95% CI: −4.12 to 0.98, I2=63%) (Figure 1) and in 24-h diastolic blood pressure (MD=1.28 mmHg, 95% CI: −0.31 to 2.87, I2=49%) (Figure 2). No subgroup differences between the various GLP-1RAs were identified. More specifically, it was demonstrated that liraglutide once daily produced a non-significant decrease in 24-h systolic blood pressure (MD=−1.43 mm Hg, 95% CI: −5.24 to 2.38, I2=72%) and a non-significant increase in 24-h diastolic blood pressure (MD=1.47 mm Hg, 95% CI: −1.12 to 4.05, I2=61%), while data concerning the effect of once weekly dulaglutide and twice daily exenatide on ABPM were pooled from one RCT respectively (Figures 1, 2).

Conclusions

Antidiabetic treatment with GLP-1RAs does not influence either systolic or diastolic ABP in patients with T2DM.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Meta-analysis assessing cardiovascular outcomes with febuxostat versus allopurinol for patients with gout

Background

Gout, the most common inflammatory arthritis in the USA, represents an established risk factor for cardiovascular disease and coronary artery disease mortality. In addition, patients with gout experience an increased risk for non-fatal myocardial infarction, while they might also feature increased risk for stroke. Recent real-world data also highlight the association between gout and atrial fibrillation, which inevitably augments cardiovascular burden. Allopurinol, a xanthine oxidase inhibitor, remains the uric acid-lowering treatment option of first choice, while febuxostat is prescribed, when allopurinol is contraindicated or not tolerated. Unfortunately, medication adherence among gout patients is poor, associated with age and related co-morbidities.

Purpose

We sought to determine the comparative efficacy of febuxostat versus allopurinol across surrogate cardiovascular outcomes of interest, by pooling data from the 2 dedicated cardiovascular outcome trials available so far. The motive for this analysis was the U.S. Food and Drug Administration (FDA) warning raised after the publication of the CARES trial, regarding the increased risk for cardiovascular and all-cause death with febuxostat compared to allopurinol.

Methods

We pooled data from the 2 dedicated cardiovascular outcome trials (CARES and FAST) and we assessed the following cardiovascular outcomes of interest: cardiovascular death, all-cause death, non-fatal myocardial infarction (MI), non-fatal stroke, fatal MI, fatal stroke, transient ischemic attack, hospitalization for heart failure, coronary revascularization, cerebrovascular revascularization and atrial fibrillation. Risk of bias was low across the included studies.

Results

Our analysis in a total of 12,318 patients with gout showed that febuxostat compared to allopurinol treatment does not confer significant risk reduction for any of the assessed, prespecified surrogate outcomes in a study population with significant cardiovascular co-morbidities (Figure 1). One third of patients enrolled in the FAST trial and 40% of the patients enrolled in the CARES trial had pre-existing cardiovascular disease, as depicted in Figure 2. Heterogeneity was low for the vast majority of the assessed outcomes, except for cardiovascular and all-cause death and fatal MI.

Conclusions

There is no significant difference across surrogate cardiovascular outcomes of interest between febuxostat and allopurinol in patients with gout and cardiovascular co-morbidities. Febuxostat seems to be a safe treatment alternative to allopurinol, despite initial concerns in terms of its cardiovascular safety.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Sodium-glucose co-transporter-2 inhibitors and the risk of major arrhythmias: a meta-analysis of the cardiovascular and renal outcome trials

Background

Type 2 diabetes mellitus is closely associated with cardiovascular disease and evidence already exists on its arrhythmogenic action. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are a unique class of oral antidiabetic medications which recently attracted attention for reducing the total risk of major adverse cardiovascular events in a series of recent, large placebo-controlled randomized clinical trials (RCTs). Dapagliflozin and empagliflozin additionally seem to improve survival and outcomes in patients with heart failure with reduced ejection fraction (HFrEF), irrespective of the presence of diabetes mellitus. Whether antidiabetic treatment with sodium-glucose co-transporter inhibitors could reduce the arrhythmic burden in diabetic patients still is to be clarified.

Purpose

The purpose of the present meta-analysis was to report the impact of SGLT2i on the risk for several types of cardiac arrhythmias, pooling data from all relevant cardiovascular and renal outcome, placebo-controlled, RCTs, comparing SGLT2i to placebo.

Methods

We searched PubMed for all available cardiovascular and renal outcome RCTs utilizing SGLT2i, along with grey literature sources. We sought to determine the risk of the following arrhythmias/cardiac disorders with the use of SGLT2i versus placebo: atrial fibrillation, atrial flutter, supraventricular tachycardia, ventricular tachycardia, ventricular fibrillation, ventricular extrasystoles, sinus bradycardia, sinus node dysfunction, second degree atrioventricular block, complete atrioventricular block.

Results

We extracted relevant data from 8 trials (5 dedicated cardiovascular outcome trials, 2 dedicated renal outcome trials, 1 trial enrolling patients with HFrEF), pooling data in a total of 55,966 patients. SGLT-2i treatment compared to placebo produced a significant reduction in the risk of atrial fibrillation equal to 21% (RR=0.79, 95% CI: 0.67–0.93, I2=0%) (Figure 1). A non-significant reduction in the risk of atrial flutter equal to 9% (RR=0.91, 95% CI: 0.64–1.29, I2=0%) was also observed with SGLT2i (Figure 2). No significant effect on the rest major arrhythmias was observed.

Conclusions

Antidiabetic therapy with SGLT2i seems to hold a significant impact on antiarrhythmic burden in type 2 diabetes mellitus, reducing the risk of atrial fibrillation development.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Meta-analysis of cardiovascular outcome trials assessing the cardiovascular efficacy and safety of dipeptidyl peptidase-4 inhibitors in patients with type 2 diabetes mellitus

Background

Type 2 diabetes mellitus (T2DM) represents an independent risk factor for the development of cardiovascular disease, which accounts for half of deaths among the affected patients. Patients with T2DM experience higher incidence of vascular interventions compared to high-risk patients without T2DM or cardiovascular disease at baseline, underscoring the necessity for targeted therapeutic interventions. Dipeptidyl peptidase-4 (DPP-4) inhibitors constitute a safe treatment option with fair glycemic efficacy in T2DM whose cardiovascular efficacy has been doubted over recent years. A series of randomized controlled trials (RCTs) addressing cardiovascular outcomes with DPP-4 inhibitors have been recently published, while previous meta-analyses failed to show any cardiovascular benefit with their use in patients with T2DM.

Purpose

The purpose of our analysis was to report the impact of antidiabetic treatment with DPP-4 inhibitors on different cardiovascular efficacy outcomes.

Methods

We searched PubMed for all published RCTs assessing cardiovascular outcomes after antidiabetic treatment with DPP-4 inhibitors. We extracted data related to the following efficacy outcomes: fatal and non-fatal myocardial infarction, fatal and non-fatal stroke, hospitalization for heart failure, hospitalization for unstable angina, hospitalization for coronary revascularization and cardiovascular death.

Results

We pooled data from a total of 6 trials in a total of 52,520 patients. Antidiabetic treatment with DPP-4 inhibitors did not significantly affect any of the prespecified cardiovascular efficacy outcomes. More specifically, DPP-4 inhibitors compared to control led to a non-significant increase in the risk for fatal and non-fatal myocardial infarction (RR=1.02, 95% CI: 0.94–1.11, I2=0%), hospitalization for heart failure (RR=1.09, 95% CI: 0.92–1.29, I2=65%) and cardiovascular death (RR=1.02, 95% CI: 0.93–1.11, I2=0%), as shown in figures 1a, 1c and 1f. In addition, DPP-4 inhibitors produced a non-significant decrease in the risk for fatal and non-fatal stroke (RR=0.96, 95% CI: 0.85–1.08, I2=0%) and coronary revascularization (RR=0.99, 95% CI: 0.90–1.09, I2=0%), as depicted in figures 1b and 1e. Finally, DPP-4 inhibitors demonstrated a neutral effect on the risk for hospitalization due to unstable angina (RR=1.00, 95% CI: 0.85–1.18, I2=0%), as shown in figure 1d.

Conclusions

Antidiabetic treatment with DPP-4 inhibitors does not seem to confer any significant cardiovascular benefit for patients with T2DM.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Meta-analysis evaluating the risk of respiratory tract infections and acute respiratory distress syndrome with glucagon-like peptide-1 receptor agonists in cardiovascular outcome trials: Useful implications for the COVID-19 pandemic

Patients with type 2 diabetes mellitus (T2DM) are at increased risk for severe coronavirus disease 2019 (COVID-19) and related mortality. Glucagon-like peptide-1 receptor agonists (GLP-1-RAs) have significant cardiovascular and renal benefits for patients with T2DM and related comorbidities. Their anti-inflammatory properties could be beneficial in these patients. This work provides less-biased estimates regarding the risk for respiratory tract infections and acute respiratory distress syndrome by performing the first significant meta-analysis of cardiovascular outcome trials in the literature. Notably, GLP-1-RAs do not seem to increase the risk for respiratory tract infection, pneumonia, or acute respiratory distress syndrome in patients with T2DM and cardiovascular comorbidities.

[Meta-analysis evaluating the risk of respiratory tract infections and acute respiratory distress syndrome with glucagon-like peptide-1 receptor agonists in cardiovascular outcome trials: useful implications for the COVID-19 pandemic]

Patients with type 2 diabetes mellitus (T2DM) are at increased risk for severe coronavirus disease 2019 (COVID-19) and related mortality. Glucagon-like peptide-1 receptor agonists (GLP-1-RAs) have significant cardiovascular and renal benefits for patients with T2DM and related comorbidities. Their anti-inflammatory properties could be beneficial in these patients. This work provides less-biased estimates regarding the risk for respiratory tract infections and acute respiratory distress syndrome by performing the first significant meta-analysis of cardiovascular outcome trials in the literature. Notably, GLP-1-RAs do not seem to increase the risk for respiratory tract infection, pneumonia, or acute respiratory distress syndrome in patients with T2DM and cardiovascular comorbidities.

Glucagon-like peptide-1 receptor agonists or sodium-glucose cotransporter-2 inhibitors as add-on therapy for patients with type 2 diabetes? A systematic review and meta-analysis of surrogate metabolic endpoints

OBJECTIVE

As sodium-glucose cotransporter-2 inhibitors (SGLT-2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) are second-line treatment options in type 2 diabetes mellitus (T2DM), our study sought to provide precise effect estimates regarding the role of GLP-1RAs vs SGLT-2is as add-on treatments in patients uncontrolled by metformin monotherapy.

RESEARCH DESIGN AND METHODS

PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL) and 'grey literature' were searched from their inception up to December 2019 for randomized controlled trials (RCTs) with durations≥12weeks to evaluate the safety and efficacy of adding a GLP-1RA vs an SGLT-2i in patients with T2DM.

RESULTS

Three eligible RCTs were identified. Administration of GLP-1RAs vs SGLT-2is resulted in significant decreases in HbA1c with no significant impact on either body weight or fasting plasma glucose. GLP-1RA treatment led to a significant increase in odds for achieving an HbA1c<7% compared with SGLT-2is, whereas no difference was detected in body weight reductions of>5%. Significantly greater risk for any hypoglycaemia, nausea and diarrhoea, and lower risk for genital infections, was also observed with GLP-1RAs, while no differences regarding severe hypoglycaemia, treatment discontinuation and impact on blood pressure levels were identified. No other major safety issues arose.

CONCLUSION

Our meta-analysis suggests that GLP-1RAs provide better glycaemic effects than SGLT-2is in patients with T2DM uncontrolled by metformin, albeit while increasing risk for hypoglycaemia and gastrointestinal adverse events.

Carotid baroreceptor stimulation: a promising approach for the management of resistant hypertension and heart failure

Many difficult-to-treat clinical entities in the cardiovascular field are characterized by pronounced sympathetic overactivity, including resistant hypertension and heart failure, underlining the need to explore therapeutic options beyond pharmacotherapy. Autonomic modulation via carotid baroreceptor activation has already been evaluated in clinical trials for resistant hypertension, and relevant outcomes with regard to safety and efficacy of the technique are critically presented. The pathophysiological background of heart failure renders carotid baroreceptor stimulation a potential treatment candidate for the disease. Available data from animal models with heart failure point towards significant cardioprotective benefits of this innovative technique. Accordingly, the effects of baroreceptor activation treatment (BAT) on cardiac parameters of hypertensive patients are well-promising, setting the basis for upcoming clinical trials with baroreflex activation on patients with heart failure. However, as the potential therapeutic of BAT unfolds and new perspectives are highlighted, several concerns are raised that should be meticulously addressed before the wide application of this invasive procedure is set in the limelight.

Renal nerve ablation for hypertensive patients with chronic kidney disease

Among current epidemics, chronic kidney disease (CKD) is accompanied with high morbidity and mortality rates inherently associated with the thriving comorbidities of hypertension and cardiovascular disease. In this mutually reinforcing triad, adequate control of high blood pressure emerges as extremely important for decreasing patients' complication rates and prolonging life expectancy. However, hypertension control in this particular group of patients is often proven an arduous task, presenting high rates of resistance. Sympathetic nervous system (SNS) overactivity is implicated not only in the pathophysiological basis of difficult-to-treat hypertension, but also in the development and progression of renal disease, thus rendering SNS a prime therapeutic target in CKD. As renal nerve ablation (RNA) is finding its place among other invasive procedures in the cardiovascular arena, the potential therapeutic impact of this innovative treatment modality is gradually expanding from resistant hypertension to other high blood pressure-related clinical conditions like CKD. Encouraging results of clinical trials testing efficacy and safety of renal nerve ablation in resistant hypertensives provide the opportunity to apply the procedure in other subgroups of hypertensive patients. Available data regarding renal function of study participants suggest the safe implementation of RNA in patients with renal disease, but both unexplored benefits as well as potential hazards should be taken into account and critically evaluated. While renal denervation has been tested in selected cases of patients with renal disease, the results of large, multicenter trials evaluating the effects of this procedure on large cohorts of patients with CKD are eagerly anticipated.

The Effect of Antihypertensive Drugs on Arterial Stiffness and Central Hemodynamics: Not All Fingers are Made the Same

Arterial stiffness and central hemodynamics attract increasing scientific interest within the hypertensive community during the last decade. Accumulating evidence indicates that aortic stiffness is a strong and independent predictor of cardiovascular events and all-cause mortality in hypertensive patients, and its predictive value extends beyond traditional risk factors. The role of central hemodynamics and augmentation index (a marker of reflected waves), remains less established and requires further investigation. Several lines of evidence indicate that antihypertensive therapy results in significant reductions of pulse wave velocity and central hemodynamics. However, beta-blockers seem to be the only exception with significant within-class differences. Conventional beta-blockers, although equally effective in reducing pulse wave velocity, seem to be less beneficial on central hemodynamics and augmentation index than the other antihypertensive drug categories, whereas the newer vasodilating beta-blockers seem to share the benefits of the other antihypertensive drugs. In conclusion, aortic stiffness seems ready for ‘prime-time’ in the management of essential hypertension, while further research is needed for central hemodynamics and augmentation index.

The pathophysiological basis of renal nerve ablation for the treatment of hypertension

Renal sympathetic innervation plays an important role in blood pressure regulation. Gradual activation of renal sympathetic efferent nerves enhances renin release, promotes sodium and water re-absorption, and reduces renal blood flow and glomerular filtration rate. On the other hand, activation of renal afferent sympathetic nerves induced by renal injury results in central sympathetic activation. This reciprocal relationship between the kidneys and the brain is involved in the pathogenesis of hypertension and other disease conditions characterized by sympathetic overactivity. Renal sympathetic nerve ablation has been recently introduced for the treatment of resistant hypertension. This review aims to provide the pathophysiological basis of renal nerve ablation for the attenuation of sympathetic overactivity.

Association of capillaroscopic microhaemorrhages with clinical and immunological antiphospholipid syndrome

OBJECTIVES

Patients with clinical signs of vasculopathy were screened with capillaroscopy for microangiopathy, and its presence was evaluated in the diagnosis of antiphospholipid syndrome (APS). For this purpose, autoantibody profiles in high risk patients with microhaemorrhages were correlated with thrombotic events.

METHODS

738 patients from a Rheumatology Outpatients cohort were consecutively screened with capillaroscopy. Patients with microhaemorrhages were selected from the total of individuals screened and tested for anticardiolipin (αCL) and anti-beta2 glycoprotein 1 (anti-β2GP1) Abs. Positive autoantibody profile was subsequently correlated with arterial and venous thrombotic events. Patients with scleroderma were excluded from the analysis.

RESULTS

149 patients with various rheumatologic conditions and capillary microhaemorrhages were included in the study. Antiphospholipid profile screening in these individuals revealed a 15.4% of newly diagnosed secondary laboratory APS. αCL antibodies and anti-β2-glycoprotein 1 (anti-β2GP1 Abs were both found to independently correlate significantly with thrombotic events. Subanalysis of the type of anti-β2GP1 Abs indicated that the correlation with thrombotic events was significant for IgG-type (p<0.001) and IgM-type (p=0.051), but not IgA-type Abs (p=0.292).

CONCLUSIONS

In patients with microhaemorrhages, αCL and anti-β2GP1 Abs were associated with thrombotic events. The observation that, although IgA type-anti-β2GP1 Abs were detected in patients with microangiopathy, they lacked any significant association with thrombotic complications, suggests, that either the type/conformation of the autoantibodies and/or additional factors may be critical for the development of thromboses. In conclusion, capillaroscopy can aid diagnostically to screen for or verify APS in combination with other parameters.

Neurofibromatosis type 1: should we screen for other genetic syndromes? A case report of co-existence with multiple endocrine neoplasia 2A

BACKGROUND

NF 1 is a genetic disorder with an autosomal dominant pattern of inheritence. It is associated with neoplastic disorders mainly derived from the neural seath. However, the co-existence of NF1 with the full spectrum of MEN 2A has rarely been reported. The aim of the study was to investigate the presence of secondary neoplasias in a patient with diagnosed NF1, and in particular the presence of hyperparathyroidism and the possible co-existence with another pheochromocytoma-related syndrome.

METHODS

We report a case of a 70 years old female patient who had NF1. The patient was referred to our center and was diagnosed with an isolated pheochromocytoma of the right adrenal gland for which she underwent right adrenalectomy. We further investigated for the presence of another pheochromocytoma-related syndrome and in particular for the presence of hyperparathyroidism and medullary thyroid cancer. Molecular screening for germline mutations of the genes NF1, RET and VHL has also been performed.

RESULTS

The patient was further diagnosed with hyperparathyroidism and medullary thyroid cancer, having the full spectrum of the clinical picture of the MEN2A syndrome. The genetic testing revealed the germline mutation for NF1 but not for the RET proto-oncogene which is generally found in MEN2A cases.

CONCLUSION

To our knowledge this is a rare case of co-existence of two pheochromocytoma-related genetic syndromes, and generates the question of whether all patients with these syndromes should undergo a thorough clinical and laboratory investigation for the possibility of another co-existing pheochromocytoma-related genetic syndrome.

Leptin induces the expression of functional tissue factor in human neutrophils and peripheral blood mononuclear cells through JAK2-dependent mechanisms and TNFalpha involvement

INTRODUCTION

Leptin is an adipocyte-derived cytokine primarily involved in the regulation of body weight and energy balance. In vivo studies suggest that leptin promotes platelet aggregation and thrombosis. Neutrophils are involved in the crosstalk between inflammation and thrombosis in clinical disorders. Leptin is also involved in the regulation of inflammation.

AIM

We examined the in vitro effects of leptin on the expression of tissue factor (TF), the primary initiator of coagulation, in healthy neutrophils.

MATERIALS AND METHODS/RESULTS

The effects on TF expression were assayed functionally using a modified prothrombin time (mPT), as well as at mRNA and protein levels. The same experiments were performed in parallel with PBMC. Leptin induced functional TF and increased TF mRNA and protein expression in both cell types, as determined by mPT, real-time RT-PCR, western blot, flow cytometry, immunocytochemistry. Inhibition studies revealed that the effect of leptin on TF expression is mediated, at least in part, by JAK2 and PI3K. Our findings, after neutralising TNFalpha in supernatants of leptin-treated cells, also suggest the involvement of TNFalpha in the leptin-induced TF expression in leukocytes.

CONCLUSIONS

This study indicates a novel link between inflammation, obesity and thrombosis by showing that leptin is able to trigger the extrinsic coagulation cascade. This work suggests a possible mechanism of the thrombotic effects of hyperleptinemic-associated clinical disorders.

MEFV alterations and population genetics analysis in a large cohort of Greek patients with familial Mediterranean fever

Familial Mediterranean fever (FMF) is a disease characterized by recurrent, self-limiting bouts of fever and serositis and caused by altered pyrin due to mutated MEFV gene. FMF is common in the Mediterranean Basin populations, although with varying genetic patterns. The spectrum and clinical significance of MEFV alterations in Greece has yet not been elucidated. The aim of this study was to analyze the spectrum of MEFV alterations in FMF patients and healthy individuals in Greece. A cohort of 152 Greek FMF patients along with 140 Greek healthy controls was enrolled. Non-isotopic RNase cleavage assay (NIRCA) and sequencing allowed mutational and haplotypic analysis of the entire coding sequence of MEFV. The ARLEQUIN 2.0, DNASP 4.0 and PHYLIP software were used for population genetics analysis. Among patients, 127 (83.6%) carried at least one known mutation. The most common mutations identified were M694V (38.1%), M680I (19.7%), V726A (12.2%), E148Q (10.9%) and E230K (6.1%). The total carrier rate among healthy individuals was 0.7%. The presence of R202Q homozygosity in 12 of the remaining 25 MEFV negative FMF patients might be considered as disease related in Greeks. Population genetics analysis revealed that Greeks rely closer to the eastern rather than western populations of the Mediterranean Basin.

Aortic calcification is associated with age and sex but not left ventricular mass in essential hypertension

The aim of this study was to investigate the prevalence of aortic calcification in patients with essential hypertension and its relationship with age, sex, and left ventricular hypertrophy. Two hundred ninety consecutive patients with essential hypertension were studied. A chest radiograph and an echocardiograph were performed. Aortic calcification was observed in 74/290 (25.5%) patients. Patients with calcification were mostly female (67.6%) and older (71.8+1.9 years), whereas patients without calcification were younger (59.0+0.79) and of both sexes (51.85% female). Left ventricular mass index in male patients with aortic calcification was 147.3+4.32 g/m(2) and without calcification was 132.7+2.28 g/(2) (p=0.023). Female patients' values were 131.9+4.32 g/m(2) with calcification and 121.2+2.85 g/m(2) without calcification (p=0.025). Left ventricular mass was independently associated with age and sex but not with aortic calcification. The prevalence of aortic calcification in essential hypertension is considerably higher compared to the general population. Essential hypertension and age seem to contribute to the concurrent appearance of aortic calcification and increased left ventricular mass.

Angiotensin converting enzyme gene polymorphism is not related to essential hypertension in a Greek population

Studies in various ethnic groups have shown contradictory evidence on the association of the angiotensin converting enzyme (ACE) insertion/ deletion (I/D) polymorphism with essential hypertension. In addition, mistyping of the insertion allele in heterozygotes has been reported. We analyzed the ACE genotype of 98 hypertensive and 84 normotensive subjects of Greek origin. Genomic DNA was extracted from blood samples and amplified by polymerase chain reaction (PCR). PCR primers were flanking the polymorphic region in intron 16 of the ACE gene. To avoid mistyping of heterozygotes, samples with the DD genotype were also amplified with primers that detect only the insertion allele. The distribution of the DD, ID, and II ACE genotypes was 30, 45, and 23 in hypertensive patients and 29, 40, and 15 in normotensive subjects, respectively. The estimated frequency of the insertion allele was 0.45 in hypertensive and 0.42 in normotensive subjects. The difference was not statistically significant. The results indicate a lack of association between ACE I/D polymorphism and essential hypertension in this Greek population, suggesting that other genes must contribute to the pathogenesis of hypertension.

Changes of plasma noradrenaline levels in the renal and systemic circulation after successful percutaneous transluminal angioplasty in renovascular hypertension

The sympathetic nervous system involvement in the pathogenesis of human renovascular hypertension was studied in 10 hypertensive patients with unilateral renal artery stenosis, who underwent percutaneous transluminal angioplasty (PTA). Before PTA, systolic/diastolic BP readings were 185.3 +/- 7.8/123.2 +/- 5.1 mmHg, peripheral PRA values were 8.63 +/- 2.27 ngAl/ml/h, the ratio RVRR was 2.15 +/- 0.27, the ratio V1-IVC/IVC was 1.00 +/- 0.23 (V1 = PRA from the renal vein of the stenotic side, IVC = PRA from the inferior vena cava) and the ratio V2-IVC/IVC was 0.04 +/- 0.02 (V2 = PRA from the renal vein of the non-stenotic side); 30 min after successful PTA the respective values of the above measured parameters were: 144.2 +/- 6.7/98.2 +/- 3.1 mmHg (p less than 0.01), 8.13 +/- 2.21 ngAl/ml/h (p less than 0.005), 1.79 +/- 0.19 (p less than 0.01), 0.68 +/- 0.18 (p less than 0.001) and 0.06 +/- 0.02 (p less than 0.005). Peripheral plasma noradrenaline levels (plNA) were 0.694 +/- 0.058 ng/ml, plNA levels from the renal vein of the stenotic side were 0.962 +/- 0.108 ng/ml and plNA levels from the renal vein of the non-stenotic side were 0.759 +/- 0.092 ng/ml; 30 min after successful PTA the respective values were 0.518 +/- 0.055 ng/ml (p less than 0.01), 0.681 +/- 0.078 ng/ml (p less than 0.005) and 0.510 +/- 0.063 ng/ml (p less than 0.005). It is suggested that the reversal of chronic renal ischaemia by PTA induced statistically significant changes in the sympathetic nervous system activity, parallel to the changes of renin secretion.