Influence of diabetes and obesity on ten-year outcomes after coronary artery bypass grafting in the arterial revascularisation trial

AIMS

Diabetes and obesity are common conditions which can influence outcomes after coronary artery bypass graft (CABG) surgery. The aim of this study was to evaluate the influence of diabetes and obesity, and their interactions, on ten-year outcomes following CABG.

METHODS AND RESULTS

Patients enrolled in the Arterial Revascularisation Trial (ART) were stratified by diabetes and obesity at baseline. Diabetes was further stratified into insulin and non-insulin dependent. The primary outcome was all-cause mortality at 10 years of follow-up. Secondary outcomes were the composite of all-cause mortality, myocardial infarction or stroke at 10 years, and sternal wound complications at 6 months follow-up. A total of 3096 patients were included in the analysis (24% with diabetes, 30% with obesity). Patients in the "diabetes/no obesity" group had a higher risk of all-cause mortality following CABG (adjusted hazard ratio [aHR] 1.33, 95% confidence interval [CI] 1.08-1.64, p = 0.01) compared to the reference group of "no diabetes/no obesity". No excess risk was observed in the "no diabetes/obesity" or "diabetes/obesity" groups. Patients with insulin dependent diabetes had a significantly higher ten-year mortality risk compared to no diabetes (aHR 1.85, 95% CI 1.41-2.44, p = 0.00). Patients in the "diabetes/no obesity" and "diabetes/obesity groups" had a higher risk of sternal wound complications (HR 2.29, 95% CI 1.39-3.79, p < 0.001 and HR 3.21, 95% CI 1.89-5.45, p < 0.001 respectively). The composite outcome results were consistent with the mortality results.

CONCLUSION

Diabetes, especially insulin dependent diabetes, is associated with a higher ten-year mortality risk after CABG, in contrast to obesity which does not appear to increase long term mortality compared to non-obese. The interaction between diabetes and obesity shows an apparent "protective" effect of obesity irrespective of diabetes on mortality. Both conditions are associated with a higher risk of post-operative sternal wound infections.

Coronary artery bypass grafting using bilateral internal thoracic arteries in patients with diabetes and obesity: A systematic review and meta-analysis

Background

Patients with diabetes and obesity are at higher risk of adverse long-term outcomes following coronary artery bypass grafting. The use of bilateral internal thoracic arteries (BITA) can potentially offer survival benefit in higher risk patients compared to single internal thoracic artery (SITA), but BITA is not routinely used due to lack of clear evidence of efficacy and concerns over sternal wound complications.

Methods

Medline, Embase and the Cochrane Library were searched for studies comparing the efficacy and safety of BITA and SITA grafting in patients with diabetes and obesity. Meta-analysis of mortality and sternal wound complications was performed.

Results

We identified eight observational and ten propensity matched studies, and one RCT, comparing BITA and SITA which included patients with diabetes (n = 19,589); two propensity matched studies and one RCT which included patients with obesity (n = 6,972); mean follow up was 10.5 and 11.3 years respectively. Meta-analysis demonstrated a mortality reduction for BITA compared to SITA in patients with diabetes (risk ratio [RR] 0.79; 95% confidence interval [CI] 0.70-0.90; p = 0.0003). In patients with obesity there was a non-significant reduction in mortality in the BITA group (RR 0.73, 95% CI 0.47-1.12; p = 0.15). There was a significantly higher rate of sternal wound complications following BITA observed in patients with diabetes (RR 1.53, 95% CI 1.23-1.90; p = 0.0001) and obesity (RR 2.24, 95% CI 1.63-3.07; p < 0.00001).

Conclusions

BITA is associated with better long-term survival in patients with diabetes. The effects of BITA grafting in patients with obesity are uncertain. BITA is associated with higher rates of sternal wound complications compared to SITA in both patients with diabetes and obesity.

Heightened risks of cardiovascular disease in South Asian populations: causes and consequences

INTRODUCTION

South Asian individuals comprise almost a quarter of the world's population and have an excess risk of atherosclerotic cardiovascular disease (ASCVD) compared to other ethnicities. In part, this can be explained by higher prevalence, earlier onset, and suboptimal control of traditional cardiovascular risk factors, such as insulin resistance, metabolic syndrome, and dyslipidaemia. However, there remains a significant residual excess risk associated with South Asian ethnicity after controlling for traditional risk factors.

AREAS COVERED

In this review, we describe the epidemiology of ASCVD in both native and diaspora South Asian populations. We explore how traditional cardiovascular risk factors, novel cardiovascular risk factors, and social determinants of health may contribute to the excess ASCVD risk seen in South Asian populations.

EXPERT OPINION

There should be increased awareness of the relative importance of South Asian ethnicity and related social determinants of health, as risk factors for ASCVD. Systematic screening processes should be tailored to this population, and modifiable risk factors should be treated aggressively. Further research is required to quantify determinants of the excess ASCVD risk seen in South Asian populations and to develop targeted interventions to address these factors.

Therapeutic vs. prophylactic anticoagulation in COVID-19 patients: a systematic review and meta-analysis of real-world studies

INTRODUCTION

Coagulopathy, in the form of either venous or arterial thromboembolism, is one of the most severe sequelae of coronavirus disease (COVID-19) and has been associated with poorer outcomes. However, the role of therapeutic anticoagulation (tAC) or prophylactic anticoagulation (pAC) in COVID-19 patients has not been definitely established. Therefore, the aim of this systematic review and meta-analysis was to gather all the available real-world data in the field and to provide a reliable effect size of the effect on mortality of tAC compared to pAC in COVID-19 patients.

EVIDENCE ACQUISITION

Real-world studies (RWS) were identified by searching electronic databases from inception to 31st October, 2021. Randomized controlled trials were excluded. Mortality and bleedings were considered as primary and secondary outcomes, respectively.

EVIDENCE SYNTHESIS

10 RWS and 5541 patients were included in the analysis. Overall, tAC was associated with lower mortality (HR=0.62, 95% CI: 0.54-0.71). There was asymmetry at the funnel plot suggesting publication bias, that was not confirmed at the Egger test (P=0.07). For the secondary endpoint, there was a non-statistically significant tendency for more bleedings in patients treated with tAC compared to pAC (RR=1.75, 95% CI: 0.81-3.81).

CONCLUSIONS

Our meta-analysis, based on RWS and adjusted estimates of risk, suggests a survival benefit of tAC over pAC in COVID-19 patients in the real world.

Single versus multiple arterial grafting in diabetic patients at 10 years: the Arterial Revascularization Trial

AIMS

To evaluate the impact of multiple arterial grafting (MAG) vs. single arterial grafting (SAG) in a post hoc analysis of 10-year outcomes in patients with diabetes mellitus (DM) from the Arterial Revascularization Trial (ART).

METHODS AND RESULTS

The primary endpoint was all-cause mortality and the secondary endpoint was a composite of major adverse cardiac events (MACE) at 10-year follow-up. Patients were stratified by diabetes status (non-DM and DM) and grafting strategy (MAG vs. SAG). A total of 3020 patients were included in the analysis; 716 (23.7%) had DM. Overall, 55.8% non-DM patients received MAG and 44.2% received SAG, while 56.6% DM patients received MAG and 43.4% received SAG. The use of MAG compared with SAG was associated with lower 10-year mortality for both non-DM [17.7 vs. 21.0%, adjusted hazard ratio (HR) 0.87, 95% confidence interval (CI) 0.72-1.06] and DM patients (21.5 vs. 29.9%, adjusted HR 0.65, 95% CI 0.48-0.89; P for interaction = 0.12). For both groups, the rate of 10-year MACE was also lower for MAG vs. SAG. Overall, deep sternal wound infections (DSWIs) were uncommon but more frequent in the MAG vs. SAG group in both non-DM (3.3 vs. 2.1%) and DM patients (7.9 vs. 4.8%). The highest rates of DSWI were in insulin-treated patients receiving MAG (9.6 vs. 6.3%, when compared with SAG).

CONCLUSION

In this post hoc analysis of the ART, MAG was associated with substantially lower mortality rates at 10 years after coronary artery bypass grafting in patients with DM. Patients with DM receiving MAG had a higher incidence of DSWI, especially if insulin dependent.

Exercise and nutritional interventions on sarcopenia and frailty in heart failure: a narrative review of systematic reviews and meta-analyses

The purpose of this review is to describe the present evidence for exercise and nutritional interventions as potential contributors in the treatment of sarcopenia and frailty (i.e. muscle mass and physical function decline) and the risk of cardiorenal metabolic comorbidity in people with heart failure (HF). Evidence primarily from cross-sectional studies suggests that the prevalence of sarcopenia in people with HF is 37% for men and 33% for women, which contributes to cardiac cachexia, frailty, lower quality of life, and increased mortality rate. We explored the impact of resistance and aerobic exercise, and nutrition on measures of sarcopenia and frailty, and quality of life following the assessment of 35 systematic reviews and meta-analyses. The majority of clinical trials have focused on resistance, aerobic, and concurrent exercise to counteract the progressive loss of muscle mass and strength in people with HF, while promising effects have also been shown via utilization of vitamin D and iron supplementation by reducing tumour necrosis factor-alpha (TNF-a), c-reactive protein (CRP), and interleukin-6 (IL-6) levels. Experimental studies combining the concomitant effect of exercise and nutrition on measures of sarcopenia and frailty in people with HF are scarce. There is a pressing need for further research and well-designed clinical trials incorporating the anabolic and anti-catabolic effects of concurrent exercise and nutrition strategies in people with HF.

Effects of the Atrial fibrillation Better Care (ABC) pathway on outcomes among clinically complex chinese patients with atrial fibrillation with multimorbidity and polypharmacy

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patients with atrial fibrillation (AF) commonly have complex clinical backgrounds. In this ancillary analysis we assessed the adherence to and the effectiveness of the Atrial fibrillation Better Care (ABC) pathway in reducing adverse outcomes in Chinese AF patients with a complex clinical background of multimorbidity and/or polypharmacy.

Methods

The ChiOTEAF registry[1] is a prospective, multicentre nationwide study conducted from October 2014 to December 2018. The primary outcomes of interest were the composite endpoint of all-cause death and thromboembolic (TE) events, as well as individual endpoints of all-cause death, TE events, and major bleeding. ’Multimorbidity’ was defined as the presence of ≥2 co-morbidities, ’polypharmacy’ was defined as the concomitant use of ≥5 medications. The participants were assessed against the ABC pathway criteria: patients qualified for the ‘A’ criterion (Avoid stroke) if they were treated with oral anticoagulants according to their TE risk; ‘B’ criterion (Better symptom control) if they demonstrated optimal symptom control defined as European Heart Rhythm Association score of I/II at baseline; ‘C’ criterion (Cardiovascular risk factor and Comorbidity optimisation) if they received disease-specific treatment(s) according to current guidelines at baseline. Patients were considered as ABC-adherent if they fulfilled all three criteria.

Results

The eligible cohort included 4644 patients with multimorbidity and 2262 patients with polypharmacy (Fig 1.), of whom 56.2% (mean age 74.4±10.2; 42.8% female) and 58.7% (mean age 74.6±10.1; 43.3% female) respectively had available data to assess the ABC pathway utilisation. Adherence to the ABC pathway was associated with lower odds ratio (OR) of the primary composite outcome in the multimorbidy (OR: 0.48; 95% CI: 0.29-0.79) and polypharmacy (OR: 0.39; 95% CI: 0.19-0.78) groups (Table 1.). Adherence to the ABC pathway was associated with a lower risk of all-cause death in multimorbid patients (OR: 0.51; 95% CI: 0.27-0.95) and TE events in patients with polypharmacy (OR: 0.31; 95% CI: 0.10-0.95). In a subgroup of patients with concomitant multimorbidity and polypharmacy the risk of composite outcome (OR: 0.38; 95% CI: 0.18-0.79) and TE events (OR: 0.31; 95% CI: 0.10-0.94) were lower in the ABC-adherent patients. There were no significant differences in the incidence of major bleeding among patients with multimorbidity, polypharmacy or both in the ABC-adherent compared to the non-ABC adherent groups. Health-related quality of life (QoF) was lower in the non-ABC adherent compared to the ABC-adherent patients.

Conclusion

This study shows that adherence to the ABC pathway is associated with improved clinical outcomes and QoF in Chinese AF patients with multimorbidity and/or polypharmacy. There is no evidence to suggest that adhering to the ABC pathway is associated with a higher risk of major bleeding events compared to standard practice.

Effects of the Atrial Fibrillation Better Care Pathway on Outcomes Among Clinically Complex Chinese Patients With Atrial Fibrillation With Multimorbidity and Polypharmacy: A Report From the ChiOTEAF Registry

Background Patients with atrial fibrillation commonly have complex clinical backgrounds of multimorbidity and polypharmacy. The Atrial Fibrillation Better Care (ABC) pathway has been developed to help deliver integrated and holistic care for patients with atrial fibrillation. In this ancillary analysis, we assessed the adherence to and the effectiveness of the ABC pathway at reducing adverse outcomes in Chinese patients with atrial fibrillation with a complex clinical background of multimorbidity or polypharmacy. Methods and Results The ChiOTEAF (Optimal Thromboprophylaxis in Elderly Chinese Patients With Atrial Fibrillation) registry is a prospective, multicenter, nationwide study conducted from October 2014 to December 2018. The primary outcomes of interest were the composite end point of all-cause death and thromboembolic events, as well as individual end points of all-cause death, thromboembolic events, and major bleeding. Multimorbidity was defined as the presence of ≥2 comorbidities, and polypharmacy was defined as the concomitant use of ≥5 medications. The eligible cohort included 4644 patients with multimorbidity, of whom 2610 (56.2%) had available data to assess the ABC pathway usage (mean age, 74.4±10.2; 42.8% women). Among patients with polypharmacy (n=2262; mean age, 74.6±10.1; 43.3% women), 1328 (58.7%) had available data to assess the use of the ABC pathway. Adherence to the ABC pathway was associated with a lower risk of the primary composite outcome among patients with multimorbidity (odds ratio, 0.48; 95% CI, 0.29-0.79) and in the polypharmacy group (odds ratio, 0.39; 95% CI, 0.19-0.78). Health-related quality of life was lower in the non-ABC-adherent group compared with the ABC-treated patients. Conclusions This nationwide real-world registry shows that adherence to the ABC pathway is associated with improved clinical outcomes and health-related quality of life in clinically complex Chinese patients with atrial fibrillation with multimorbidity or polypharmacy.

Polypharmacy in Older People With Heart Failure: Roles of the Geriatrician and Pharmacist

Heart failure (HF) is a common health condition that typically affects older adults. Many people with HF are cared for on an inpatient basis, by noncardiologists, such as acute medical physicians, geriatricians and other physicians. Treatment options for HF are ever increasing, and adherence to guidelines for prognostic therapy contributes to polypharmacy, which is very familiar to clinicians who care for older people. This article explores the recent trials in both HF with reduced ejection fraction and HF with preserved ejection fraction and the limitations of international guidance in their management with respect to older people. In addition, this article discusses the challenge of managing polypharmacy in those with advanced age, and the importance of involving a geriatrician and pharmacist in the HF multidisciplinary team to provide a holistic and person-centred approach to optimisation of HF therapies.

Cardiovascular considerations in management of patients with Turner syndrome

Turner syndrome (TS) is a chromosomal disorder that affects 25-50 per 100,000 live born females. Patients with TS face a heavy burden of cardiovascular disease (congenital and acquired) with an increased risk of mortality and morbidity compared to the general population. Cardiovascular diseases are a major cause of death in females with TS. Approximately 50% of TS patients have a congenital heart abnormality, with a high incidence of bicuspid aortic valve (BAV), coarctation of the aorta (CoA) and generalised arteriopathy. Frequently, females with TS have systemic hypertension, which is also a risk factor for progressive cardiac dysfunction and aortopathy. This paper aims to provide an overview of the cardiovascular assessment, management and follow up strategies in this high-risk population of TS patients.

Renal Disease and Atrial Fibrillation

Incidence and prevalence of atrial fibrillation (AF) and chronic kidney disease are increasing, and the two conditions commonly coexist. Renal impairment further increases the risk of ischemic stroke and systemic thromboembolism in patients with AF but also paradoxically predisposes to bleeding. Renal function should be monitored closely in patients with AF requiring oral anticoagulation therapy, particularly those receiving direct oral anticoagulants. Vitamin K antagonists can be used as part of a dose-adjusted anticoagulation regimen in patients with mild to moderate renal dysfunction. Dialysis-dependent patients taking vitamin K antagonists are at increased risk of sustaining major hemorrhage.

Outcomes after coronary artery bypass graft surgery: systematic review and meta-analysis comparing bilateral versus single internal thoracic artery grafts

Background

Patients with diabetes and/or obesity are at higher risk of adverse outcomes following coronary artery bypass grafting (CABG). The use of bilateral internal thoracic arteries (BITA) can potentially offer survival benefit in higher risk patients compared to single internal thoracic artery (SITA) in patients undergoing CABG, but the overall evidence base for BITA has not influenced guidelines, and there are concerns over increased risk of sternal wound complications.

Methods

We conducted a systematic review of the literature to identify observational studies and randomised controlled trials (RCT) comparing the efficacy (mortality) and safety (sternal wound infection) of BITA and SITA in diabetic and obese patients.

Results

We identified 18 observational studies and one RCT to obtain data comparing BITA and SITA in 19,589 diabetic patients, and two observational studies and one RCT comparing BITA and SITA in 6972 obese patients. Pooled analysis demonstrated significant mortality benefit of BITA compared to SITA in diabetic patients (risk ratio [RR] 0.79; 95% confidence interval [CI] 0.70, 0.90; Z=3.62, p=0.0003; I2=88%) (Figure 1a). Pooled analysis in obese patients found no significant difference in mortality rates between BITA and SITA (RR 0.73, 95% CI 0.47, 1.12; Z=1.43, p=0.15; I2=78%) (Figure 1b). A significantly higher rate of sternal wound complications following BITA was observed in diabetic (RR 1.53, 95% CI 1.23, 1.90; Z=3.86, p=0.0001; I2=4%) and obese patients (RR 2.24, 95% CI 1.63, 3.07; Z=5.00, p&lt;0.00001; I2=0%).

Conclusions

BITA is associated with better long-term survival in diabetic patients, but most of the supportive data comes from observational studies. The effects of BITA grafting in patients who are obese is uncertain due to low numbers. BITA is associated with higher rates of sternal wound complications than SITA in both diabetic and obese patients. Further research is needed to understand if BITA has a role in higher risk patients undergoing CABG.

Figure 1. Pooled all-cause mortality

Funding Acknowledgement

Type of funding source: None

Effects of diabetes and obesity in patients undergoing coronary artery bypass graft surgery: ten-year results from the Arterial Revascularisation Trial

Background

Coronary artery bypass graft (CABG) surgery is an effective way to manage advanced coronary heart disease. Diabetes is associated with higher risk of mortality in patients undergoing CABG but the effects of obesity, and the interactions between diabetes and obesity in the context of CABG, have not been fully explored.

Methods

The Arterial Revascularisation Trial (ART) compared ten-year mortality in patients undergoing CABG randomised to single or bilateral internal thoracic arterial grafts. Effects of diabetes and obesity on mortality and risk (sternal wound complications) were explored. Diabetes was defined according to clinical history at baseline and combined insulin and non-insulin dependent patients, and obesity was defined as body mass index (BMI) ≥30kg/m2 at baseline.

Results

Information on diabetes, obesity and ten-year mortality were documented for 3094 patients who were included in the analysis. Mean age was 64 years, 86% male, mean weight 82kg and BMI 28. Diabetes was documented in 24% and obesity in 30% and as expected obese patients were more likely to be diabetic. The hazard ratios (95% confidence intervals) for ten-year mortality using the no diabetes, non-obese group as a reference were 1.33 (1.08, 1.64) (diabetes, non-obese), 0.93 (0.75, 1.16) (no diabetes, obese) and 1.18 (0.91, 1.54) (diabetes, obese) groups (Figure 1). Similar patterns of risk were observed whether patients were randomised to receive single or bilateral internal thoracic arteries and diabetes appeared to be the main driver of elevated risk of early sternal wound complications following CABG.

Conclusions

Obesity and diabetes are closely associated but our analysis shows that patterns of risk of death after CABG are not additive for these characteristics, and obesity may actually be associated with lower death rates in patients with and without diabetes. These findings will be explored further to understand mechanisms and interactions with other factors.

Figure 1. Hazard ratios at 10 years

Funding Acknowledgement

Type of funding source: None

Is it Time to Say Goodbye to Culture and Sensitivity? The Case for Culture-independent Urology

Next-generation sequencing has highlighted the limitations of conventional culture methods in the role of urology while discovering the intricate details of the role of microbiota in urologic health and disease. This review article explores: the utility and limitations of conventional culture methods; how culture-independent technologies are revolutionizing medicine; and how the implementation of these technologies may lead to improved patient outcomes. Finally, this article discusses the barriers to widespread adoption of culture-independent technologies, with suggestions for how these hurdles may be overcome.

New horizons in management of heart failure in older patients

Heart failure has a high prevalence in older populations, is a common and growing cause for hospital admission and carries a high risk of morbidity and mortality. Important co-morbidities in older patients with heart failure include atrial fibrillation, renal impairment, hypertension and anaemia. Diagnosing and managing heart failure in older patients are complicated due to atypical presentations, co-morbidities and a relative lack of evidence for commonly used treatments in younger patients. The growing epidemic of heart failure is also under-recognised and resourced in most health systems. Despite potential differences, we recommend that the basic approach to manage heart failure patients with an ejection fraction (EF) of <40% should be the same in older and younger. These treatments need to be started at low doses and titrated slowly along with the management of co-morbidities. Older patients with EF 40-49% can be treated in a similar manner to those with <40%, while the treatment of those with EF ≥50% is pragmatic in nature based on symptom control and management of co-morbidities although the evidence base for these recommendations is lacking. Overall management must be holistic and continuous based on the patient's social circumstances and ongoing needs. Finally, there is an urgent need for more research, evidence and resources directed towards older populations with heart failure to improve their care and the quality of life.

The human gastrointestinal microbiota and prostate cancer development and treatment

The human gastrointestinal microbiome contains commensal bacteria and other microbiota that have been gaining increasing attention in the context of cancer development and response to treatment. Microbiota play a role in the maintenance of host barrier surfaces that contribute to both local inflammation and other systemic metabolic functions. In the context of prostate cancer, the gastrointestinal microbiome may play a role through metabolism of estrogen, an increase of which has been linked to the induction of prostatic neoplasia. Specific microbiota such as Bacteroides, Streptococcus, Bacteroides massiliensis, Faecalibacterium prausnitzii, Eubacterium rectalie, and Mycoplasma genitalium have been associated with differing risks of prostate cancer development or extensiveness of prostate cancer disease. In this Review, we discuss gastrointestinal microbiota's effects on prostate cancer development, the ability of the microbiome to regulate chemotherapy for prostate cancer treatment, and the importance of using Next Generation Sequencing to further discern the microbiome's systemic influence on prostate cancer.

Metagenomics in diagnosis and improved targeted treatment of UTI

INTRODUCTION

The genomic revolution has transformed our understanding of urinary tract infection. There has been a paradigm shift from the dogmatic statement that urine is sterile in healthy people, as we are becoming forever more familiar with the knowledge that bacterial communities exist within the urinary tracts of healthy people. Metagenomics can investigate the broad populations of microbial communities, analysing all the DNA present within a sample, providing comprehensive data regarding the state of the microenvironment of a patient's urinary tract. This permits medical practitioners to more accurately target organisms that may be responsible for disease-a form of 'precision medicine'.

METHODS AND RESULTS

This paper is derived from an extensive review and analysis of the available literature on the topic of metagenomic sequencing in urological science, using the PubMed search engine. The search yielded a total of 406 results, and manual selection of appropriate papers was subsequently performed. Only one randomised clinical trial comparing metagenomic sequencing to standard culture and sensitivity in the arena of urinary tract infection was found.

CONCLUSION

Out of this process, this paper explores the limitations of traditional methods of culture and sensitivity and delves into the recent studies involving new high-throughput genomic technologies in urological basic and clinical research, demonstrating the advances made in the urinary microbiome in its entire spectrum of pathogens and the first attempts of clinical implementation in several areas of urology. Finally, this paper discusses the challenges that must be overcome for such technology to become widely used in clinical practice.