Diabetic autonomic neuropathy

OBJECTIVES\nWe sought to compare 10-year clinical outcomes in the BARI (Bypass Angioplasty Revascularization Investigation) trial patients who were randomly assigned to percutaneous transluminal coronary balloon angioplasty (PTCA) versus coronary artery bypass grafting (CABG).\n\n\nBACKGROUND\nAngioplasty and bypass surgery have been compared in numerous studies, but long-term clinical outcomes are limited.\n\n\nMETHODS\nSymptomatic patients with multivessel coronary artery disease (n = 1,829) were randomly assigned to initial treatment with PTCA or CABG and followed up for an average of 10.4 years. Analyses were conducted on an intention-to-treat basis.\n\n\nRESULTS\nThe 10-year survival was 71.0% for PTCA and 73.5% for CABG (p = 0.18). At 10 years, the PTCA group had substantially higher subsequent revascularization rates than the CABG group (76.8% vs. 20.3%, p < 0.001), but angina rates for the 2 groups were similar. In the subgroup of patients with no treated diabetes, survival rates were nearly identical by randomization (PTCA 77.0% vs. CABG 77.3%, p = 0.59). In the subgroup with treated diabetes, the CABG assigned group had higher survival than the PTCA assigned group (PTCA 45.5% vs. CABG 57.8%, p = 0.025).\n\n\nCONCLUSIONS\nThere was no significant long-term disadvantage regarding mortality or myocardial infarction associated with an initial strategy of PTCA compared with CABG. Among patients with treated diabetes, CABG conferred long-term survival benefit, whereas the 2 initial strategies were equivalent regarding survival for patients without diabetes.

The Final 10-Year Follow-up Results from the BARI Randomized Trial

Glucagon-like peptide-1 (GLP-1) receptor agonists result in greater improvements in glycemic control than placebo and promote weight loss with minimal hypoglycemia in patients with type 2 diabetes mellitus. A number of case reports show an association of GLP-1 receptor agonists, mainly exenatide, with the development of acute kidney injury. The present review aims to present the available data regarding the effects of GLP-1 receptor agonists on renal function, their use in subjects with chronic renal failure and their possible association with acute kidney injury. Based on the current evidence, exenatide is eliminated by renal mechanisms and should not be given in patients with severe renal impairment or end stage renal disease. Liraglutide is not eliminated by renal or hepatic mechanisms, but it should be used with caution since there are only limited data in patients with renal or hepatic impairment. There is evidence from animal studies that GLP-1 receptor agonists exert protective role in diabetic nephropathy with mechanisms that seem to be independent of their glucose-lowering effect. Additionally, there is evidence that GLP-1 receptor agonists influence water and electrolyte balance. These effects may represent new ways to improve or even prevent diabetic nephropathy.

Effects of glucagon-like peptide-1 receptor agonists on renal function

Sodium-glucose co-transporter 2 (SGLT2) inhibitors inhibit glucose re-absorption in the proximal renal tubules. Two trials have shown significant reductions of cardiovascular (CV) events with empagliflozin and canagliflozin, which could not be attributed solely to their antidiabetic effects. The aim of the review is the critical presentation of suggested mechanisms/hypotheses for the SGLT2 inhibitors' cardioprotection. The search of the literature revealed many possible cardioprotective mechanisms, because SGLT2 inhibitors (i) increase natriuresis and act as diuretics with unique properties leading to a reduction in preload and myocardial stretch (the diuretic hypothesis); (ii) decrease blood pressure and afterload (the blood pressure lowering hypothesis), (iii) favor the production of ketones, which can act as a 'superfuel' in the cardiac and renal tissue (the 'thrifty substrate' hypothesis), (iv) improve many metabolic variables (the metabolic effects hypothesis), (v) exert many anti-inflammatory effects (the anti-inflammatory effects hypothesis), (vi) can act through the angiotensin II type II receptors in the context of simultaneous renin-angiotensin-aldosterone-system (RAAS) blockade leading to vasodilation and positive inotropic effects (the RAAS hypothesis), (vii) directly decrease the activity of the upregulated in heart failure Na+-H+ exchanger in myocardial cells leading to restoration of mitochondrial calcium handling in cardiomyocytes (the sodium hypothesis). Additionally, some SGLT2 inhibitors exhibit also SGLT1 inhibitory action possibly resulting in an attenuation of oxidative stress in ischemic myocardium (the SGLT1 inhibition hypothesis). Thus, many mechanisms have been suggested (and possibly act cumulatively) for the cardioprotective effects of SGLT2 inhibitors.

SGLT2 inhibitors and cardioprotection: a matter of debate and multiple hypotheses.

Objectives: The purpose of this analysis was to assess in patients with type 2 diabetes and stable coronary artery disease, (CAD) whether the risk of all-cause mortality and cardiovascular events varied according to the presence or absence, of angina and angina equivalent symptoms.

Background: Data on the prognostic value of symptoms in these patients are limited. Methods Post-hoc analysis was performed in 2,364 patients with type 2 diabetes and documented CAD enrolled in the, BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial to determine the occurrence of, death and composite of death, myocardial infarction, and stroke during a 5-year follow-up according to cardiac symptoms at baseline.

Results: There were 1,434 patients with angina (A), 506 with angina equivalents (E), and 424 with neither of these (N). The cumulative death rates (total 316) were 12% in A, 14% in E, and 10% in N (p 0.3), and cardiovascular composite rates (total 548) were 24% in A, 24% in E, and 21% in N (p 0.5). Compared with N, the hazard ratios adjusted for confounders were not different for death in A (1.11; 99% CI: 0.81 to 1.53) and E (1.17; 99% CI: 0.81 to 1.68) or for cardiovascular events in A (1.17; 99% CI: 0.92 to 1.50) and E (1.11; 99% CI: 0.84 to 1.48).

Conclusions: Whatever their symptom status, patients with type 2 diabetes and stable CAD were at similar risk of cardiovascular events and death. These findings suggest that these patients may be similarly managed in terms of risk stratification and preventive therapies. (Bypass Angioplasty Revascularization Investigation 2 Diabetes [BARI 2D]; {"type":"clinical-trial","attrs":{"text":"NCT00006305","term_id":"NCT00006305"}}NCT00006305) (J Am Coll Cardiol 2013;61:702–11) © 2013 by the American College of Cardiology Foundation

Diabetes mellitus (DM) is a global epidemic. Accelerated atherosclerosis in DM leads to high incidence of Cardiovascular Disease (CVD). Coronary Artery Disease (CAD) accounts for large fraction of morbidity, mortality and cost of DM.

In Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial, it was analyzed whether symptoms affect prognosis or not in Type 2 DM and CAD with documented ischemia.

A total of 2368 patients with Type 2DM and stable CAD with documented ischemia were followed up for 5.3 years. Patients were divided into those with angina, angina equivalent (dyspnea, palpitation or diaphoresis on exertion) or no cardiac symptom.

Stable CAD and Type 2DM had similar long term prognosis across a variety of cardiovascular outcome irrespective of their symptomatic status. Five-year death rate was 12% with angina, 14% with angina equivalent, and 10% in asymptomatic patient. Cumulative 5-year composite outcome rate were 24%, 24% and 21%, respectively. Asymptomatic patients were at the same relative high risk for all cause mortality, the composite outcome, CVD death, nonfatal myocardial infarction (MI) and nonfatal stroke, compared to patients with angina or angina equivalent. These were independent of baseline characteristics, severity of CAD and coronary revascularization. In separate analysis of optimized medical therapy and revascularization, the outcome remained unchanged. Left ventricular systolic function was normal in all three groups. Exercise induced ischemia causing diastolic dysfunction could be responsible for exertional dyspnea qualifying angina equivalent.

Summarizing, the take home message of this study is that Type 2DM, stable CAD with documented ischemia and no symptoms are at the same high risk for all cause mortality and major cardiovascular outcomes compared to those with angina or angina equivalent. These patients should be similarly managed in terms of risk stratification and preventive therapy.

Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D).

Coronary artery disease (CAD) in patients with type 2 diabetes mellitus (T2DM) is associated with increased immediate and long–term mortality compared with patients without T2DM. The amplified incidence of CAD stems partly from the aggregation of multiple risk factors, such as obesity, dyslipidemia, and hypertension, which occur in this population. In addition, there appear to be increased forces at play at the molecular and vascular levels in these individuals, which is evidenced by the increased thrombosis and inflammation that is seen in those with diabetic atherosclerosis. Hence, there is a growing need to emphasize early and vigilant risk factor management in patients with T2DM to help reduce their burden of cardiovascular–related mortality. In this article, we review the primary and secondary prevention measures as well as the management of CAD in patients with T2DM.

Medical management and strategies to prevent coronary artery disease in patients with type 2 diabetes mellitus.

Patients are avoiding hospitals for fear of contracting severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). We are witnessing a re-emergence of rare complications of myocardial infarctions (MI) due to delayed revascularization. Herein, we describe a case of hemorrhagic pericarditis from thrombolytics administered to a patient with late presenting MI. (Level of Difficulty: Beginner.).

Complication of Late Presenting STEMI Due to Avoidance of Medical Care During the COVID-19 Pandemic

Femoral arterial closure using ProGlide® is more efficacious and cost-effective when ambulating early following cardiac catheterization.

The Changing Face of Interventional Cardiology Training: A Fellow's Perspective.

The 12-lead ECG plays a central role in the evaluation of patients with chest pain in the emergency department as it is rapid, reliable, noninvasive and inexpensive, and identifies cases that need early intervention. Although most physicians are well trained in recognizing STEMI in an ECG, other ominous signs such as Wellens’ syndrome are not well recognized. We present a review of the literature over the past three decades since the seminal publication characterizing these changes, with an illustrative case.

Prafull Raheja

Papers

Medical management and strategies to prevent coronary artery disease in patients with type 2 diabetes mellitus.

Complication of Late Presenting STEMI Due to Avoidance of Medical Care During the COVID-19 Pandemic

Femoral arterial closure using ProGlide® is more efficacious and cost-effective when ambulating early following cardiac catheterization.

The Changing Face of Interventional Cardiology Training: A Fellow's Perspective.

Wellens' syndrome over the past three decades.