Erythropoiesis in Cushing syndrome: sex-related and subtype-specific differences. Results from a monocentric study

CONTEXT

Cushing syndrome (CS) is associated with different hematological abnormalities. Nevertheless, conflicting data about erythropoiesis in CS have been reported. Furthermore, it is unclear whether CS sex and subtype-specific alterations in red blood cells (RBC) parameters are present.

OBJECTIVE

To investigate sex and subtype-specific changes in RBC in patients with CS at initial diagnosis and after remission.

DESIGN

Retrospective, monocentric study including 210 patients with CS (women, n = 162) matched 1:1 for sex and age to patients with pituitary microadenomas or adrenal incidentalomas (both hormonally inactive). RBC parameters were evaluated at initial diagnosis and after remission.

RESULTS

Women with CS had higher hematocrit (median 42.2 vs 39.7%), hemoglobin (14.1 vs 13.4 g/dl) and mean corpuscular volume (MCV) (91.2 vs 87.9 fl) compared to the controls (all p < 0.0001). Women with Cushing disease (CD) showed higher hematocrit, RBC and hemoglobin levels than those with ectopic Cushing (ECS) (all p < 0.005). Men with CS had lower hematocrit (42.9 vs 44.7%), RBC count (4.8 vs 5.1n*106/µl) and hemoglobin (14.2 vs 15.4 g/dl), but higher MCV (90.8 vs 87.5 fl) than controls (all p < 0.05). In men with CS, no subtype-specific differences were identified. Three months after remission hemoglobin decreased in both sexes.

CONCLUSION

CS is characterized by sexual and subtype-specific differences in RBC parameters. Compared to controls, women with CS showed higher hematocrit/hemoglobin levels, whereas men had lower hematocrit/hemoglobin, which further decreased directly after remission. Therefore, anemia should be considered as complication of CS in men. In women, differences in RBC parameters may help to differentiate CD from ECS.

Performance of high-sensitivity cardiac troponin T in predicting major cardiovascular events in patients admitted to the emergency department for syncope with normal ECG: An observational prospective study

INTRODUCTION

History of syncope, clinical examination and electrocardiographic (ECG) findings are fundamental to assess the risk of major cardiovascular events (MACE) in patients attending the emergency department (ED) for syncope. However, in the absence of abnormal clinical examination findings or an abnormal ECG in the ED, transient rhythm or conduction disorders may not be safely excluded, hence predicting MACE remains challenging. High-sensitivity cardiac troponin T (hs-cTnT) may be a useful tool in this context.

AIM

The primary objective was to evaluate the performance of hs-cTnT in the diagnosis of MACE at 30 days in patients attending the ED for syncope with a normal initial ECG.

METHODS

This was a prospective observational cohort study that took place in the ED of a French university hospital between June 2018 and June 2019. Patients≥18 years admitted to the ED for syncope with a normal ECG were eligible. After receiving verbal consent from patients, the ED physician collected clinical and ECG data and all patients had a blood sample taken that included hs-cTnT measurement. The primary outcome was MACE within 30 days after the ED visit. MACE were evaluated by consulting the patient's medical records and telephoning patients or their general practitioners. Sensitivity, specificity, positive and negative predictive values were calculated with their 95% confidence intervals (CI) for different hs-cTnT thresholds.

RESULTS

Data from 246 patients were analysed, including 21 (9%) with MACE. Hs-cTnT had an area under the curve of 0.917 (CI: 0.872-0.962). Hs-cTnT with a threshold of 19ng/L had a sensitivity of 86% (CI: 64-97) and a specificity of 86% (CI: 81-90) for predicting MACE.

CONCLUSION

Hs-cTnT may be a relevant tool for assessing MACE risk in patients with syncope and normal ECG results.

SGLT2-inhibition increases total, LDL, and HDL cholesterol and lowers triglycerides: Meta-analyses of 60 randomized trials, overall and by dose, ethnicity, and drug type

BACKGROUND AND AIMS

Sodium glucose co-transporter 2 (SGLT2)-inhibitors were developed as glucose-lowering drugs. Surprisingly, SGLT2-inhibitors also reduced risk of cardiovascular disease. The impact of SGLT2-inhibitors on lipids and lipoproteins is unclear, but an effect might contribute to the observed lower cardiovascular risk. We conducted a meta-analysis to examine this, overall and by dose, ethnicity, and drug type.

METHODS

PubMed, EMBASE and Web of Science were searched for randomized controlled trials examining all available SGLT2-inhibitors. Studies with available lipid measurements were included. Quantitative data synthesis was performed using random and fixed effects models.

RESULTS

We identified 60 randomized trials, including 147,130 individuals. Overall, using random effects models, SGLT2-inhibitor treatment increased total cholesterol by 0.09 mmol/L (95% CI: 0.06, 0.13), low-density lipoprotein (LDL) cholesterol by 0.08 mmol/L (0.05, 0.10), and high-density lipoprotein (HDL) cholesterol by 0.06 mmol/L (0.05, 0.07), while it reduced triglycerides by 0.10 mmol/L (0.06, 0.14). Fixed effects estimates were similar but with smaller effect sizes for HDL cholesterol and triglycerides. For higher SGLT2-inhibitor doses, there was a nominally higher non-significant effect on lipids and lipoproteins. In Asian compared to non-Asian populations, a slightly larger increase in HDL cholesterol and a decrease in triglycerides were observed, but with similar results for total and LDL cholesterol. Treatment effects on lipids and lipoproteins were generally robust across different SGLT2-inhibitor drugs.

CONCLUSION

In meta-analyses, SGLT2-inhibition increased total, LDL, and HDL cholesterol and decreased triglycerides. Effect sizes varied slightly by drug dose and ethnicity but were generally robust by drug type.

Risk of cardiovascular disease, death, and renal progression in diabetes according to albuminuria and estimated glomerular filtration rate

AIM

We aimed to examine risks of major cardiovascular events (MACEs), renal outcomes, and all-cause mortality in type 2 diabetes mellitus (T2DM) patients with different diabetic kidney disease (DKD) subtypes.

METHODS

A total of 36,509 participants with T2DM recruited from 20 community sites across mainland China were followed up during 2011-2016. DKD subtypes were categorized based on albuminuria (urinary albumin-to-creatinine ratio, UACR ≥ 30 mg/g) and reduced estimated glomerular filtration rate (eGFR < 60 ml/min/1.73 m²) as Alb^-/eGFR^-, Alb⁺/eGFR^-, Alb^-/eGFR⁺, and Alb⁺/eGFR⁺. Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs) of developing clinical outcomes in DKD subtypes.

RESULTS

More than half (53.5%) of participants with diabetes and reduced eGFR had normal UACR levels (Alb^-/eGFR⁺), termed as non-albuminuria DKD. These patients had a modest increase in the risks of MACEs (hazard ratio, HR 1.42 [95% CI 1.08;1.88]) and mortality (HR 1.42 [1.04;1.92]) compared with patients without DKD, whereas CKD progression was not significantly increased (HR 0.97 [0.60;1.57]). Participants with albuminuria (Alb⁺/eGFR^- or Alb⁺/eGFR⁺) had higher risks of clinical outcomes. Subgroup analysis revealed that the associations between non-albuminuria DKD and risks of MACEs and mortality were more evident in those aged <65 years.

CONCLUSION

Non-albuminuria DKD accounts for more than half of DKD cases with low eGFR in Chinese diabetes patients. Diabetes patients with albuminuria are at higher risks of developing clinical outcomes and warrant early intervention, as well as patients with non-albuminuria DKD with age < 65 years.

NT-proBNP as predictor of major cardiac events after renal transplantation in patients with preserved left ventricular ejection fraction

BACKGROUND

For the improvement of outcome after renal transplantation it is important to predict future risk of major adverse cardiac events as well as all-cause mortality. We aimed to determine the relationship of pre-transplant NT-proBNP with major adverse cardiac events and all-cause mortality after transplant in patients on the waiting-list with preserved left ventricular ejection fraction.

PATIENTS AND METHODS

We included 176 patients with end-stage renal disease and preserved left ventricular ejection fraction who received a kidney transplant. MACE was defined as myocardial infarction (ST-segment elevation [STEMI] or non-ST-segment elevation [NSTEMI]), stroke or transient ischemic attack), coronary artery disease requiring intervention or bypass or death from cardiovascular causes.

RESULTS

MACE occurred in 28/176 patients. Patients with NT-proBNP levels above 4350 pg/ml had 1- and 5-year survival rates of 90.67% and 68.20%, whereas patients with NT-proBNP levels below 4350 pg/ml had 1- and 5-year survival rates of 100% and 90.48% (p < 0.01). 1- and 5-year MACE-free survival rates were calculated as 78.82% and 74.68% for patients with NT-proBNP > 4350 pg/ml and 93.33% and 91.21% for patients with NT-proBNP < 4350 pg/ml (p < 0.01).

CONCLUSIONS

Pre-transplant NT-proBNP might identify renal transplant candidates at risk for MACE after transplant.

Clinical Efficacy and Safety of Reduced-Dose Prasugrel versus Clopidogrel in Patients Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

This systematic review and meta-analysis of randomized controlled trials (RCTs) compared the clinical efficacy and safety of reduced-dose prasugrel (loading dose: 20 mg; daily maintenance dose: 3.75 mg) and clopidogrel in patients undergoing percutaneous coronary intervention (PCI).

METHODS

PubMed, Embase, and the Cochrane Library database were searched for relevant articles from inception to March 8, 2021. Only RCTs that compared the clinical efficacy and safety of reduced-dose prasugrel and clopidogrel treatment in adult patients undergoing PCI were included. The primary outcome was the risk of major cardiovascular events (MACEs).

RESULTS

Four RCTs involving 2464 patients were included. The overall risk of MACEs was 8.3% (102/1235) in the study group (reduced-dose prasugrel) and 9.8% (121/1229) in the control group (clopidogrel). No significant difference was observed in the risk of MACEs between the study and control groups (risk ratio: 0.84, 95% confidence interval: 0.65-1.08, I ² = 0%). In addition, cardiovascular-related death, all-cause death, nonfatal myocardial infarction, nonfatal stroke, revascularization, and stent thrombosis did not differ significantly between the two groups. Apart from a higher risk of minor bleeding in the study group, reduced-dose prasugrel had a similar bleeding risk to clopidogrel.

CONCLUSIONS

The clinical efficacy of reduced-dose prasugrel is comparable to that of clopidogrel; however, the risk of minor bleeding should be considered when prescribing this regimen for patients undergoing PCI.

Incidence and Predictors of Sudden Cardiac Death After a Major Non-Fatal Cardiovascular Event

BACKGROUND

Sudden cardiac death (SCD) still accounts for the majority of deaths from the four major cardiovascular events (myocardial infarction (MI), heart failure (HF), atrial fibrillation (AF), and stroke) despite substantial progress on prevention.

METHODS

Four separate cohorts (one for each of the four major cardiovascular conditions) were captured through person-linked hospital morbidity and mortality data collections between 2000 and 2009 and followed-up for 11.5 years. The incidence rate for each cohort was total SCD cases divided by sum of follow-up time for each individual alive. Kaplan-Meier survival curve was used to calculate unadjusted risk of SCD. Predictors of SCD were identified by fitting multivariable adjusted Cox regression models in each of the cohorts.

RESULTS

There were 1,174 cases of SCD from 53,614 total CVD events across the cohorts (35.6% for MI, 15.6% for HF, 22.4% for AF, 26.4% for stroke). The incidence rate and unadjusted risk of SCD were both highest after incident hospitalisation for HF, followed by MI, stroke and AF. The elevated risk of SCD was independently associated with MI, HF, arrhythmias, peripheral artery disease, diabetes, chronic kidney disease, and prior coronary heart disease (hazard ratios ranging from 1.1 to 2.8). Early revascularisation is protective in 28-day survivors after an incident MI event.

CONCLUSIONS

An appreciable incidence of SCD following an incident event of MI, HF, AF and stroke deserves greater prevention efforts. Major medical conditions such as MI, HF, peripheral artery disease, and arrhythmias are risk markers of SCD and coronary revascularisation is protective.

Prediction of future cardiovascular disease with an equation to estimate apolipoprotein B in patients with high cardiovascular risk: an analysis from the TNT and IDEAL study

BACKGROUND

Apolipoprotein B (apoB) is known to be a more powerful predictor of cardiovascular disease than conventional lipids. We aimed to determine the clinical relevance of a newly developed equation to estimate serum apoB levels based on total cholesterol, HDL cholesterol, and triglycerides in patients with high cardiovascular risk.

METHODS

The occurrence of a major cardiovascular event (MCVE) was assessed using the data from the Treating to New Targets (TNT) and Incremental Decrease in End points through Aggressive Lipid lowering (IDEAL) trials.

RESULTS

Pooled analysis of these two data sets showed that both directly-measured apoB (HR per 1-SD (95% CI): 1.16 (1.11-1.21), P < 0.001) and apoB estimated from the eq. (HR per 1-SD (95% CI): 1.14 (1.09-1.19), P < 0.001) were significantly associated with the development of a future MCVE. Prediction of MCVEs by the apoB eq. (C statistic 0.650) was nearly identical to that of directly-measured apoB (0.651). In addition, the net reclassification indices indicated no difference in the prediction of MCVEs between models including the apoB equation and directly-measured apoB (1% (-1.3-4.0), P = 0.31).

CONCLUSIONS

Our equation to predict apoB levels showed MCVE risk prediction comparable to directly-measured apoB in high risk patients with previous coronary heart disease.

Red blood cell distribution width predicts long term cardiovascular event after on-pump beating coronary artery bypass grafting

Background

Reports investigating the predictive value of red cell distribution width (RDW) on major cardiac and cardiovascular event (MACCE) following coronary artery bypass grafting (CABG) have major limitations, including lack of elimination of common factors affecting RDW levels, such as anemia. The purpose of this study is to identify the real effect of higher RDW level, free from the other factors, on MACCE following CABG.

Methods

Data of 500 consecutive, non-anemic patients (77.2 % male and mean age 63.05 ± 9.24) undergoing ONBHCAB between January 2007 and January 2010, were analyzed retrospectively.

Results

Overall MACCE was 7.8 % of all cases. Mean follow-up was 66.5 ± 9.96 months. In multivariate Cox regression analysis, RDW (P = 0.022) remained the only independent predictor of MACCE and the ROC analyze revealed an RDW cut-off value of 13.95 % predicting MACCE. Therefore, patients were grouped on this cut-off value. There were 238 patients in the lower RDW group (Group 1) and 262 patients in the higher RDW group (Group 2). Kaplan–Meier survival analysis of freedom from MACCE revealed significantly lower event free survival in Group 2 (P < 0.001 by the log-rank test). Group 2 showed a higher MACCE incidence in 1 year (P = 0.030), in 3 years (P < 0.001) and in 6 years (P < 0.001). The long-term follow-up was similar regarding noncardiovascular mortality.

Conclusion

An RDW level greater than 13.95 % in hospital admission is independently associated with an increased incidence of MACCE after CABG. Physicians should be more aggressive in the management of these patients.