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Magri CJ, Xuereb S, Xuereb RA, Xuereb RG, Fava S, Galea J. Response to: Letter to the editor: Sleep measures and cardiovascular disease in type 2 diabetes mellitus. Clin Med (Lond) 2024; 24:100023. [PMID: 38331387 PMCID: PMC11024838 DOI: 10.1016/j.clinme.2024.100023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Affiliation(s)
- Caroline J Magri
- Mater Dei Hospital, Msida, Malta; University of Malta, Faculty of Medicine & Surgery, Msida, Malta
| | | | | | - Robert G Xuereb
- Mater Dei Hospital, Msida, Malta; University of Malta, Faculty of Medicine & Surgery, Msida, Malta
| | - Stephen Fava
- Mater Dei Hospital, Msida, Malta; University of Malta, Faculty of Medicine & Surgery, Msida, Malta.
| | - Joseph Galea
- Mater Dei Hospital, Msida, Malta; University of Malta, Faculty of Medicine & Surgery, Msida, Malta
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Magri CJ, Xuereb S, Xuereb RA, Fava S. Metabolic Health and Carotid Intima-Media Thickness: Association of Different Definitions in Women. Am J Cardiol 2023; 206:35-39. [PMID: 37677881 DOI: 10.1016/j.amjcard.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 07/28/2023] [Accepted: 08/01/2023] [Indexed: 09/09/2023]
Abstract
The concept of metabolic health and the metabolic syndrome is to identify subjects at a higher cardiovascular risk. However, many definitions are currently in use, and it is uncertain which is the best in identifying at-risk subjects. We performed a cross-sectional study whereby women were invited to participate and were assessed for several anthropometric and biochemical parameters. Carotid intima-media thickness (CIMT) was measured in both common carotid arteries in each participant. The study cohort consisted of 203 white premenopausal women with a mean age of 38.3 ± 5.4 years. The prevalence of the metabolically unhealthy varied from 7.3% to 61.6%, according to the definition used. The prevalence of the metabolic syndrome, as defined by the International Diabetes Federation, was 20.7%. Women with a metabolically unhealthy phenotype had a higher referent CIMT for all definitions of metabolic health. Defining metabolically unhealthy phenotype as having <2 abnormalities using the National Cholesterol Education Program Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (NCEP-ATPIII) cutoffs had the highest odds ratio for an abnormal CIMT. In conclusion, we found that in a contemporary cohort of middle-aged women, the NCEP-ATPIII definition of the metabolic syndrome was more strongly associated with atherosclerosis as determined by the CIMT than the International Diabetes Federation definition or other definitions of metabolic health; it was also more strongly associated than body mass index or waist circumference. Our results need to be validated by other investigators in other populations.
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Affiliation(s)
- Caroline Jane Magri
- University of Malta Medical School, Msida, Malta; Department of Cardiology, Mater Dei Hospital, Msida, Malta
| | - Sara Xuereb
- Department of Cardiology, Mater Dei Hospital, Msida, Malta
| | - Rachel-Anne Xuereb
- University of Malta Medical School, Msida, Malta; Department of Cardiology, Mater Dei Hospital, Msida, Malta
| | - Stephen Fava
- University of Malta Medical School, Msida, Malta; Department of Medicine, Mater Dei Hospital, Msida, Malta.
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Abstract
OBJECTIVE The objective of this study was to assess whether poor sleep is independently associated with cardiovascular disease in people with type 2 diabetes mellitus (T2DM). METHODS A cross-sectional study was performed in subjects with T2DM aged between 40 and 80 years. Sleep assessment was achieved by actigraphy and Pittsburgh Sleep Quality Index (PSQI) score. RESULTS The study population comprised 108 subjects with T2DM. The mean age was 64.9 years, the median diabetes duration was 6 years and 73.1% were men. No association was shown between sleep parameters as assessed by actigraphy and T2DM-associated micro- and macrovascular complications. However, sleep quality as assessed by PSQI was significantly associated with macrovascular disease in univariate analysis. Multivariate logistic regression analysis showed red blood cell distribution width (RDW) (odds ratio (OR) 1.79, p=0.018) and good sleep quality (OR 0.35, p=0.017) to be independently associated. Binary logistic regression analysis revealed that body mass index (BMI) (OR 1.11, p=0.024), RDW (OR 1.95, p=0.007) and Center for Epidemiologic Studies Depression score (OR 1.06, p=0.012] were independently associated with abnormal carotid intima-media thickness (CIMT). CONCLUSIONS Poor sleep quality and higher RDW levels are associated with macrovascular disease in a T2DM population. Increased BMI as well as depression also appear to have an independent role in subclinical atherosclerosis, as assessed by CIMT.
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Affiliation(s)
| | - Sara Xuereb
- Mater Dei Hospital, Malta; University of Malta, Malta
| | | | | | - Stephen Fava
- Mater Dei Hospital, Malta; University of Malta, Malta.
| | - Joseph Galea
- Mater Dei Hospital, Malta; University of Malta, Malta
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Magri CJ, Xuereb S, Xuereb RA, Xuereb RG, Fava S, Galea J. Sleep measures and cardiovascular disease in type 2 diabetes mellitus. Clin Med (Lond) 2023; 22:clinmed2022-0442. [PMID: 37353307 DOI: 10.7861/clinmed2022-0442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2023]
Abstract
OBJECTIVE The objective of this study was to assess whether poor sleep is independently associated with cardiovascular disease in people with type 2 diabetes mellitus (T2DM). METHODS A cross-sectional study was performed in subjects with T2DM aged between 40 and 80 years. Sleep assessment was achieved by actigraphy and Pittsburgh Sleep Quality Index (PSQI) score. RESULTS The study population comprised 108 subjects with T2DM. The mean age was 64.9 years, the median diabetes duration was 6 years and 73.1% were men. No association was shown between sleep parameters as assessed by actigraphy and T2DM-associated micro- and macrovascular complications. However, sleep quality as assessed by PSQI was significantly associated with macrovascular disease in univariate analysis. Multivariate logistic regression analysis showed red blood cell distribution width (RDW) (odds ratio (OR) 1.79, p=0.018) and good sleep quality (OR 0.35, p=0.017) to be independently associated. Binary logistic regression analysis revealed that body mass index (BMI) (OR 1.11, p=0.024), RDW (OR 1.95, p=0.007) and Center for Epidemiologic Studies Depression score (OR 1.06, p=0.012] were independently associated with abnormal carotid intima-media thickness (CIMT). CONCLUSIONS Poor sleep quality and higher RDW levels are associated with macrovascular disease in a T2DM population. Increased BMI as well as depression also appear to have an independent role in subclinical atherosclerosis, as assessed by CIMT.
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Affiliation(s)
| | | | | | | | - Stephen Fava
- University of Malta, Malta, and consultant endocrinologist, Mater Dei Hospital, Malta
| | - Joseph Galea
- University of Malta, Malta, and consultant cardiac surgeon, Mater Dei Hospital, Malta
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Xuereb RA, Borg M, Vella K, Gatt A, Xuereb RG, Barbara C, Fava S, Magri CJ. LONG COVID SYNDROME: A CASE-CONTROL STUDY. Am J Med 2023:S0002-9343(23)00299-1. [PMID: 37169323 PMCID: PMC10168190 DOI: 10.1016/j.amjmed.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 03/11/2023] [Accepted: 04/06/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Acute coronavirus disease 2019 (COVID-19) causes various cardiovascular complications. However, it is unknown if there are cardiovascular sequelae in the medium and long-term. The aim of this study was dual. Firstly, we wanted to investigate symptomology and health-related quality of life (HRQoL) at medium-term follow-up (6 months post-COVID). Secondly, we wanted to assess whether history of COVID-19 and persistent shortness of breath at medium-term follow-up are associated with ongoing inflammation, endothelial dysfunction and cardiac injury. METHODS A case-control study was performed. Virologically proven COVID-19 cases and age- and gender-matched controls were interviewed to assess symptoms and HRQoL. Biochemical tests were also performed. RESULTS The study comprised 174 cases and 75 controls. The mean participants' age was 46.1±13.8 years. The median follow-up was of 173.5 days (IQR 129-193.25 days). There was no significant difference in the demographics between cases and controls. At follow-up, cases had a higher frequency of shortness of breath, fatigue, arthralgia, abnormal taste of food (p<0.001) and anosmia. Cases also exhibited worse scores in the general health and role physical domains of the Short Form Survey-36. hsCRP was significantly higher in cases and there was a positive correlation of hsCRP with time. Significant determinants of shortness of breath were age, female gender and white cell count, troponin I and lower haemoglobin levels at follow-up. CONCLUSION Post-COVID-19 patients have persistent symptomatology at medium-term follow-up. Higher hsCRP in cases and the positive association of hsCRP with time suggest ongoing systemic inflammation in patients persisting for months after COVID-19.
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Affiliation(s)
- Rachel-Anne Xuereb
- Mater Dei Hospital, Msida, Malta; University of Malta Medical School, Msida, Malta
| | | | | | - Alex Gatt
- Mater Dei Hospital, Msida, Malta; University of Malta Medical School, Msida, Malta
| | - Robert G Xuereb
- Mater Dei Hospital, Msida, Malta; University of Malta Medical School, Msida, Malta
| | - Christopher Barbara
- Mater Dei Hospital, Msida, Malta; University of Malta Medical School, Msida, Malta
| | - Stephen Fava
- Mater Dei Hospital, Msida, Malta; University of Malta Medical School, Msida, Malta.
| | - Caroline J Magri
- Mater Dei Hospital, Msida, Malta; University of Malta Medical School, Msida, Malta
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Xuereb RA, Gatt A, Vella K, Xuereb RG, Barbara CJ, Fava S, Magri CJ. Long COVID syndrome: a case-control study. Eur Heart J 2022. [PMCID: PMC9619596 DOI: 10.1093/eurheartj/ehac544.2836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Cardiovascular complications are rapidly emerging as a major threat in COVID-19 infection. Nonetheless, the mechanisms underlying the disproportionate effect of SARS-CoV-2 infection on patients with cardiovascular comorbidities remain incompletely understood. Purpose To assess whether COVID-19 infection has an adverse clinical outcome at medium-term follow-up. Methods A case-control study was performed. Cases were subjects who were diagnosed with COVID-19 infection following nasopharyhngeal swabbing. Controls were age- and gender-matched subjects who were not found to be infected with COVID-19 following swabbing and were negative on testing for COVID-19 IgG antibodies. All participants were submitted a standardised questionnaire regarding past medical history. Baseline blood investigations were taken including N-terminal pro–B-type natriuretic peptide (NT-proBNP) and troponin levels. High-sensitivity C-reactive protein (hsCRP) was taken as marker of inflammation and von Willebrand factor (vWF) was taken as marker of endothelial dysfunction. Results 270 subjects were recruited, comprising 174 cases and 96 controls. Of the latter, 21 were found to be COVID-19 IgG positive and were excluded from the analysis. Hence, the study cohort comprised 174 cases and 75 controls. The mean age of the participants was 46.1±13.8 years. The median follow-up was of 173.5 days (IQR 129–193.25 days). There was no statistically significant difference in the baseline demographics between cases and controls with regards age, gender as well as cardiovascular risk factors and underlying medical conditions. Regarding symptomatology at follow-up, there was a statistically significant difference between the groups in deterioration in general condition (p<0.001), shortness of breath (SOB) (p=0.008), fatigue (p=0.044), arthralgia (p<0.001), abnormal taste (p<0.001) and anosmia (p<0.001), all being more frequent in subjects with prior COVID-19 infection. At follow-up, the blood investigations showed that only hsCRP was statistically significantly higher in the cases as compared to the controls (p=0.03, Figure 1). Correlation analysis consequently revealed a negative correlation in both troponin (p=0.013, r=−0.19) and vWF levels (p=0.026, r=−0.169) with time. Finally, the association between the cases experiencing dyspnoea and the blood investigations at follow-up was assessed. Multivariate analysis revealed that COVID-19 positive cases experiencing dyspnoea have significantly higher white cell count (WCC) (OR 1.22, 95% CI 1.02–1.46, p=0.029) and troponin levels (OR 1.15, 95% CI 1.02–1.29, p=0.015) and lower haemoglobin levels at follow-up (OR 0.66, 95% CI 0.5–0.86, p<0.002), Figure 2. Conclusion Patients previously infected with COVID-19 have persistent symptomatology at medium-term follow-up. The role of troponin, together with markers of inflammation and endothelial dysfunction at long-term follow-up merit further investigation. Funding Acknowledgement Type of funding sources: None.
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Affiliation(s)
- R A Xuereb
- Mater Dei Hospital of Malta, Department of Cardiology , Msida , Malta
| | - A Gatt
- Mater Dei Hospital of Malta, Department of Haematology , Msida , Malta
| | - K Vella
- Mater Dei Hospital of Malta, Department of Pathology , Msida , Malta
| | - R G Xuereb
- Mater Dei Hospital of Malta, Department of Cardiology , Msida , Malta
| | - C J Barbara
- Mater Dei Hospital of Malta, Department of Pathology , Msida , Malta
| | - S Fava
- Mater Dei Hospital of Malta, Department of Medicine , Msida , Malta
| | - C J Magri
- Mater Dei Hospital of Malta, Department of Cardiology , Msida , Malta
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Xuereb RA, Xuereb RG, Barbara C, Fava S, Magri CJ. COVID-19 and the autonomic nervous system. Eur Heart J 2022. [PMCID: PMC9619640 DOI: 10.1093/eurheartj/ehac544.2422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background COVID-19 infection has been shown to have an adverse impact on the cardiovascular system. Cardiac injury, as indicated by elevated cardiac troponin and NT-proBNP levels have been confirmed in COVID-19 cases. There is still ambivalent data on the effect of left ventricular function. Cases of left ventricular impairment, persistent hypotension, acute myopericarditis, myocarditis, arrhythmia and heart failure have been reported in the short term, but there is a significant lacuna when it comes to medium and long-term follow-up of subjects previously infected with COVID-19. Purpose To assess any residual myocardial and autonomic injury in subjects previously infected with COVID-19 at a median follow-up of 5 months. Methods A case-control study was performed. Cases were randomly selected subjects who were previously diagnosed with COVID-19 infection following nasopharyngeal swabbing. Controls were subjects who had not been found to be infected with COVID-19 following swabbing and were negative for COVID-19 IgG antibodies. All participants were submitted a standardised questionnaire regarding past medical history. Blood investigations were taken including NT-proBNP and troponin I levels. In addition, all participants underwent 24-hour ambulatory blood pressure monitoring (ABPM) and 24-hour ECG monitoring. The latter was used to assess both for underlying arrhythmias as well as heart rate variability (HRV), a measure of autonomic regulation of the heart. All data was analysed using SPSS version 23.0. Results The study comprised 259 subjects, whereby cases included 174 participants while 75 subjects were age- and gender-matched controls. The study cohort was relatively young with a mean age of 46.1±13.8 years. The median follow-up was of approximately 5 months (median 173.5 days, IQR 129–193.25 days). There was no statistically significant difference between cases and controls with regards cardiovascular risk factors and underlying medical conditions. Likewise, there was no difference in blood investigations, including troponin I and NT-proBNP levels at 5-months follow-up. No difference was noted between the two groups in both awake and asleep blood pressure (BP) readings, as well as dipping BP status. No significant arrhythmias were noted in both groups on 24-hour ECG monitoring. However, when assessing for heart rate variability, it was shown that subjects who had been previously infected with COVID-19 exhibited lower root-mean square differences of successive R-R intervals (RMSSD), p=0.028. This indicates poor vagus nerve-mediated autonomic control of the heart. Conclusion Subjects previously infected with COVID-19 exhibited lower HRV as exhibited by low RMSSD as compared to controls. Reduced HRV is a known biomarker for mortality and sudden death in cardiac disease. The possible long-term implications of reduced HRV in subjects previously infected with COVID-19 merits further investigation. Funding Acknowledgement Type of funding sources: None.
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Affiliation(s)
- R A Xuereb
- Mater Dei Hospital of Malta, Department of Cardiology , Msida , Malta
| | - R G Xuereb
- Mater Dei Hospital of Malta, Department of Cardiology , Msida , Malta
| | - C Barbara
- Mater Dei Hospital of Malta, Department of Pathology , Msida , Malta
| | - S Fava
- Mater Dei Hospital of Malta, Department of Medicine , Msida , Malta
| | - C J Magri
- Mater Dei Hospital of Malta, Department of Cardiology , Msida , Malta
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Barbara JM, Gatt J, Xuereb RA, Tabone Adami N, Darmanin J, Erasmi R, G Xuereb R, Barbara C, Stephen F, Jane Magri C. Clinical outcomes at medium-term follow-up of COVID-19. J R Coll Physicians Edinb 2022; 52:220-227. [PMCID: PMC9478632 DOI: 10.1177/14782715221124617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background: The long coronavirus disease 2019 (COVID-19) syndrome is defined as persistent physical, cognitive and/or psychological symptoms that continue for more than 12 weeks following the acute illness. Methods: In all, 2,646 patients were randomly selected from all individuals who were diagnosed with COVID-19. They were interviewed so as to assess the persistence of symptoms and health-related quality of life. Blood investigations were also taken. Results: The median (interquartile range (IQR)) age was 44 (31–55) years and 48.6% were males. Five per cent had been hospitalised. Follow-up was for a median of 142 days (IQR: 128–161). Twenty-two per cent of the participants claimed that they were feeling worse than they felt before COVID-19. The most common symptoms were anosmia, ageusia, fatigue, shortness of breath, headaches and myalgia. The Short Form-36 questionnaire revealed that 16.4% felt that they were somewhat worse than in the previous year and that hospitalised patients fared worse in all domains except for role-emotional. New-onset diabetes was similar to the rate of undiagnosed diabetes in the background population. Hospitalised patients had significantly higher liver transaminases, fasting plasma glucose, glycated haemoglobin, uric acid, red cell distribution width, mean platelet volume, triglyceride levels and troponin levels but lower estimated glomerular filtration rate and high-density lipoprotein-cholesterol at follow-up. Conclusions: A significant proportion of patients were symptomatic at a median follow-up of 142 days and felt worse than 1 year previously. Hospitalised patients had more biochemical and haematological abnormalities compared to non-hospitalised ones, suggesting ongoing inflammation in subjects who were more severely affected by the disease.
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Affiliation(s)
| | | | - Rachel-Anne Xuereb
- Mater Dei Hospital, Msida, Malta
- University of Malta Medical School, Msida, Malta
| | | | | | | | - Robert G Xuereb
- Mater Dei Hospital, Msida, Malta
- University of Malta Medical School, Msida, Malta
| | - Christopher Barbara
- Mater Dei Hospital, Msida, Malta
- University of Malta Medical School, Msida, Malta
| | - Fava Stephen
- Mater Dei Hospital, Msida, Malta
- University of Malta Medical School, Msida, Malta
| | - Caroline Jane Magri
- Mater Dei Hospital, Msida, Malta
- University of Malta Medical School, Msida, Malta
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Xuereb S, Magri CJ, Xuereb RA, Xuereb RG, Galea J, Fava S. P1525Assessment of subclinical atherosclerosis in premenopausal women who were previously investigated for gestational diabetes mellitus. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p1525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- S Xuereb
- Mater Dei Hospital, Msida, Malta
| | | | | | | | - J Galea
- Mater Dei Hospital, Msida, Malta
| | - S Fava
- Mater Dei Hospital, Msida, Malta
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