Cardiac Events In Diabetic Patients Research Articles

Relation between myocardial blood flow and cardiac events in diabetic patients with suspected coronary artery disease and normal myocardial perfusion imaging

BackgroundWe assessed the prognostic value of structural abnormalities and coronary vasodilator function in diabetic patients referred to a PET/CT for suspected coronary artery disease (CAD). MethodsWe studied 451 diabetics and 451 nondiabetics without overt CAD and normal myocardial perfusion. Myocardial blood flow (MBF) was computed from the dynamic rest and stress imaging. Myocardial flow reserve (MFR) was defined as ratio of hyperemic to baseline MBF and was considered reduced when < 2. ResultsDuring a mean follow-up of 44 months 33 events occurred. Annualized event rate (AER) was higher in diabetic than nondiabetic patients (1.4% vs 0.3%, P < .001). Diabetic patients with reduced MFR had higher AER compared to those with preserved MFR (3.3% vs 0.4%, P < .001). At Cox analysis, age, BMI and reduced MFR were independent predictors of events in diabetic patients. Patients with diabetes and reduced MFR had lower event-free survival compared to nondiabetic patients and MFR < 2 (P < .001). Event-free survival was similar in patients with diabetes and normal MFR and those without diabetes and reduced MFR. ConclusionsDiabetic patients with reduced MFR had higher AER and lower event-free survival compared to those with preserved MFR and to nondiabetic patients.

The effects of insulin therapy on mortality in diabetic patients undergoing percutaneous coronary intervention.

BackgroundA growing number of studies have reported insulin therapy to be associated with a higher incidence of major adverse cardiac events in diabetic patients with coronary artery disease. However, the relationship between insulin use and the clinical outcomes of patients with diabetes who undergoing percutaneous coronary intervention (PCI) has not been fully clarified.MethodsA total of 1,069 consecutive patients with diabetes who underwent PCI were enrolled and divided into 2groups: oral hypoglycemic agents (OHA) group (709 patients) and insulin therapy group (360 patients). The primary and secondary endpoints of this study were all-cause death and cardiac death, respectively.ResultsAt baseline, the maximum creatine kinase-MB (CK-MB), plasma glucose, hemoglobin A1c, high-sensitivity C-reactive protein (CRP), and creatinine levels were higher, while the left ventricular ejection fraction (LVEF) was lower, in the insulin therapy group than in the OHA group. After propensity score matching of baseline characteristics, for patients treated with insulin, the odds ratios of death from any cause in hospital, within 1 year of surgery, and within 2 years of surgery were 12.03 (95% CI: 1.486–97.33, P=0.020), 10.33 (95% CI: 1.21–88.12, P=0.033), and 2.99 (95% CI: 1.22–7.31, P=0.016), respectively, and the odds ratios of cardiac death were 10.33 (95% CI: 1.21-88.12, P=0.033), 6.49 (95% CI: 1.33–31.59, P=0.021), and 5.27 (95% CI: 1.45–19.13, P=0.011), respectively. Generalized estimating equations analysis showed the odds ratios of all-cause death and cardiac death for insulin-treated patients to be 4.77 (95% CI: 1.76–12.95, P=0.002) and 5.38 (95% CI: 1.29–22.96, P=0.023), respectively.ConclusionsCompared with OHA, insulin therapy significantly increases the risk of in-hospital all-cause and cardiac death in patients with diabetes undergoing PCI, and the risk remains significantly at least 2 years after surgery.

Correlation between myocardial perfusion imaging findings and future cardiac events in patients with type 2 diabetes mellitus

Introduction/Objective. Myocardial perfusion imaging (MPI) is clinically useful for the evaluation of coronary artery disease in patients with diabetes mellitus. However, the prevalence of ischemia and its ability to predict future cardiac events is less clear. The aim was to determine the incidence of cardiac events in diabetic patients and the relationship between them and MPI findings. Methods. Two cohorts of patients, 98 diabetics and 100 non-diabetics, with medium- to high-risk of coronary artery disease without previous coronary revascularization, were studied prospectively. All of them were outpatients who underwent 99mTc-sestamibi MPI with dipyridamole. The data about cardiac events were collected during a follow-up period of two years. Results. Cardiac events occurred in 17.3% diabetics and in 8% non-diabetics (p = 0.048). Diabetics had shorter estimated event-free time of 24.7 months (95% CI 23.2?26.2) versus non-diabetics? estimated event-free time of 28.5 months (95% CI 27.4?29.5) (p = 0.046). The independent predictors of cardiac events were male sex (p = 0.010), previous myocardial infarction (p &lt; 0.001), presence of the symptoms of angina (p = 0.014), and all variables derived from MPI findings. After adjustment for variables derived from MPI findings, the significant predictors in diabetics were the size of stress perfusion defect (p = 0.022), summed stress score (p = 0.011), and summed difference score (p = 0.044). Conclusion. In diabetic patients, the cumulative rate of cardiac events was higher and the event-free survival was worse. MPI could help in prediction of cardiac events in diabetics and the most important predictors were size of stress perfusion defect, summed stress score, and summed difference score.

Cost-utility of ticagrelor plus aspirin in diabetic patients with stable coronary artery disease.

Ticagrelor plus aspirin could reduce the risks of major adverse cardiac events in diabetic patients with stable coronary artery disease (SCD), and yet it also increases bleeding risk. This study would compare the cost and effectiveness of aspirin and ticagrelor plus aspirin therapies in diabetic patients with SCD from a US healthcare sector perspective. A state-transition Markov model was developed to project probabilities of myocardial infarction, ischaemic stroke, bleeding, and death with and without ticagrelor among all diabetic patients with SCD as the overall population, and those with a history of previous percutaneous coronary intervention (PCI) as a sub-population. Model inputs were extracted from published sources. Lifetime costs and quality-adjusted life-years (QALYs) were measured. The clinical benefits and bleeding risk of ticagrelor added to aspirin were translated into additional 0.08 QALYs at incremental costs of $19 580 in the overall population, yielding an incremental cost-utility ratio (ICUR) of $260 032/QALY. In the sub-population with an additional 0.43 QALYs at an incremental cost of $20 189, the ICUR was $46 426/QALY. Two-way sensitivity showed the clinical benefits of ticagrelor plus aspirin was counterbalanced by its risk of major bleeding. One-way sensitivity and probabilistic sensitivity analysis demonstrated that the results were generally robust except the all-cause death reduction. The results indicated that ticagrelor plus aspirin is likely to be a cost-effective option in the diabetic patients with a history of PCI. Diabetes management can be improved by carefully prescribing ticagrelor to individuals with low risk of bleeding and high risk of ischaemic events.

Coronary Plaque Assessment By Coronary Ct Angiography May Predict Cardiac Events In Diabetic Patients: A Long-term Follow-up Study

Coronary Plaque Assessment By Coronary Ct Angiography May Predict Cardiac Events In Diabetic Patients: A Long-term Follow-up Study

Empagliflozin, an SGLT2 Inhibitor, Reduced the Mortality Rate after Acute Myocardial Infarction with Modification of Cardiac Metabolomes and Antioxidants in Diabetic Rats

The mechanism by which SGLT2 inhibitors reduce cardiac events in diabetic patients remains unclear. Here, we examined the effects of an SGLT2 inhibitor on the acute survival rate after myocardial infarction (MI) in an animal model of type 2 diabetes mellitus (DM) and the possible involvement of modification of cardiac metabolomes and antioxidative proteins. MI was induced in DM Otsuka Long-Evans Tokushima Fatty (OLETF) rats and Long-Evans Tokushima Otsuka (LETO) control rats. Treatment with empagliflozin (10 mg/kg per day, 14 days) before MI reduced blood glucose and increased blood and myocardial β-hydroxybutyrate (βOHB) levels in OLETF. Survival rate at 48 hours after MI was significantly lower in OLETF rats than in LETO rats (40% vs. 84%), and empagliflozin significantly improved the survival rate in OLETF rats to 70%, although the sizes of MI were comparable. Patterns of metabolomes and gene expression in the noninfarcted myocardium of OLETF rats were consistent with increased fatty acid oxidation and decreased glucose oxidation. The patterns were modified by empagliflozin, suggesting both increased glucose oxidation and ketone utilization in OLETF rats. Empagliflozin prevented reduction of ATP level in the noninfarcted myocardium after MI and significantly increased myocardial levels of Sirt3 and superoxide dismutase 2 in OLETF rats. Administration of βOHB partially mimicked the effects of empagliflozin in OLETF rats. The results suggest that empagliflozin prevents DM-induced increase in post-MI mortality, possibly by protective modification of cardiac energy metabolism and antioxidant proteins.

The correlation between glucose fluctuation from self-monitored blood glucose and the major adverse cardiac events in diabetic patients with acute coronary syndrome during a 6-month follow-up by WeChat application.

Background This study aimed to investigate the correlation between glucose fluctuation from self-monitored blood glucose (SMBG) and the major adverse cardiac events (MACE) in diabetic patients with acute coronary syndrome (ACS) during a 6-month follow-up period using the WeChat application. Methods From November 2016 to June 2017, 262 patients with ACS were discharged in a stable condition and completed a 6-month follow-up period. SMBG was recorded using the WeChat application. The patients were divided to a high glucose fluctuation group (H group; n=92) and a low glucose fluctuation group (L group; n=170). The 6-month incidence of MACE, lost-to-follow-up rate and satisfaction rate were measured through the WeChat follow-up. Results MACE occurred in 17.4% of patients in the H group and in 8.2% of patients in the L group (p=0.04). Multivariable analysis suggested that high glucose fluctuation conferred an 87% risk increment of MACE in the 6-month follow-up period (odds ratio: 2.1, 95% confidence interval 1.95-4.85; p=0.03). The lost-to-follow-up rate was lower and the satisfaction rate was higher in the patients using the WeChat application during follow-up than those of the regular outpatient follow-up during the same period (p<0.05). Conclusions The trial demonstrates that higher glucose fluctuation from SMBG after discharge was correlated with a higher incidence of MACE in diabetic patients with ACS. WeChat follow-up might have the potential to promote a good physician-patient relationship.

Usefulness of Highly Sensitive Troponin as a Predictor of Short-Term Outcome in Patients With Diabetes Mellitus and Stable Coronary Artery Disease (from the ARTEMIS Study)

The aim of this study was to test the hypothesis that novel biomarkers may predict cardiac events in diabetic patients with stable coronary artery disease (CAD). Serum levels of highly sensitive troponin T (hs-TnT), B-type natriuretic peptide, highly sensitive C-reactive protein (hs-CRP), galectin-3, and soluble suppressor of tumorigenicity-2 (sST2) were analyzed in 1,137 patients with CAD and with type 2 diabetes, impaired glucose tolerance, or fasting glycaemia (diabetic group) and in 649 patients with normal glucose state. Cardiac death or hospitalization for congestive heart failure was the major end point during the follow-up of 2 years. Forty patients in the diabetic group (3.5%) and 9 patients in the nondiabetic group (1.4%) reached the primary end point. High hs-TnT level (≥14 ng/l) was the strongest predictor of the primary end point with hazard ratio of 24.5 (95% confidence interval 8.7 to 69.0; p <0.001) and remained so when adjusted for clinical variables, ejection fraction, renal, lipid, and glycemic status and other biomarkers (hazard ratio 9.9, 95% confidence interval 3.2 to 30.8; p <0.001). In the multivariate model, hs-CRP, B-type natriuretic peptide, and sST2 also predicted the primary end point in the diabetic group (p <0.01 for all). Only sST2 (p <0.001) and hs-CRP (p = 0.02) predicted the primary end point in nondiabetic group. The inclusion of hs-TnT in the model significantly improved discrimination (integrated discrimination improvement 0.050) and reclassification of the patients (net reclassification index 0.21). In conclusion, hs-TnT is a strong predictor of cardiac death or hospitalization for heart failure independently from traditional risk markers or other biomarkers in diabetic patients with stable CAD.

Effects of Clopidogrel and Proton Pump Inhibitors on Cardiovascular Events in Patients with Type 2 Diabetes Mellitus after Drug-Eluting Stent Implantation: A Nationwide Cohort Study.

ObjectiveTo investigate whether there is an increased risk of cardiac events in diabetic patients with a combined therapy of clopidogrel (CLO) and proton pump inhibitors (PPIs) after drug-eluting stent (DES) deployment.MethodsBy using National Health Insurance Research Database, all patients who received CLO with or without PPI therapy within 90 days after undergoing DES (limus-eluting or paclitaxel-eluting stents) deployment were enrolled. Endpoints were acute coronary syndrome (ACS) and readmission for revascularization (percutaneous coronary intervention or coronary artery bypass graft surgery) after 3, 6, and 12 months.ResultsA total of 6,603 diabetic patients received LESs (5,933 in the CLO subgroup and 670 in the CLO plus PPIs subgroup), and 3,202 patients received PESs (2,923 in the CLO subgroup and 279 in the CLO plus PPIs subgroup). The patients who received CLO plus PPIs were at higher risk of ACS than those receiving CLO within 1 year after DES deployment (LESs: 6-month hazard ratio [HR] = 1.63, and 1-year HR = 1.37; PESs: 3-month HR = 1.72). Patients with a history of ACS who received CLO plus PPIs were at higher risk of ACS after LES implantation (HR = 1.55) than those in the CLO group.ConclusionIn “real-world” diabetic patients with LES deployment, the combination of PPIs and CLO is associated with higher rates of ACS after 6 months and 1 year. Even after correction for confounding factors, concomitant PPI use remained an independent predictor of cardiac events, emphasizing the clinical importance of this drug—drug interaction.

Prognostic value of normal stress myocardial perfusion imaging in diabetic patients: A meta-analysis

BackgroundThe prognostic value of normal stress myocardial perfusion single-photon emission computed tomography (MPS) in patients with diabetes has only been evaluated in single-center studies of relatively limited sample size. We performed a meta-analysis of published studies, including diabetic patients with known or suspected coronary artery disease (CAD), to assess the predictive value for adverse cardiac ischemic events of normal stress MPS. Methods and ResultsStudies published between January 1990 and December 2013 were identified by database search. We included studies using stress MPS to evaluate diabetic patients with known or suspected CAD and providing data on clinical outcomes of non-fatal myocardial infarction or cardiac death with a follow-up time ≥12 months. A total of 14 studies were finally included, recruiting 13,493 patients. The negative predictive value (NPV) for non-fatal myocardial infarction and cardiac death of normal MPS was 94.92% (95% confidence interval 93.67-96.05), during a weighted mean follow-up of 36.24 months, resulting in estimated event rate after a negative test equal to 5.08% (95% confidence interval 3.95-6.33). The corresponding annualized event rate after a negative test was 1.60% (95% confidence interval 1.21-2.04). ConclusionsStress MPS has a high NPV for adverse cardiac events in diabetic patients with known or suspected CAD leading to define a “relatively low-risk” patients category.

Second- versus first-generation drug-eluting stents for diabetic patients: a meta-analysis.

IntroductionThe issue of whether various drug-eluting stents (DES) provide similar benefit in diabetic patients with coronary artery disease remains unclear. The purpose of the study is to assess the clinical utility of the second-generation and first-generation DES in patients with diabetes mellitus by a meta-analysis.Material and methodsA systematic literature search of PubMed, EMBASE, and Cochrane databases was conducted. We included randomized trials involving head-to-head comparison of clinical outcomes of second- versus first-generation DES in patients with a diagnosis of diabetes with at least 6-month follow-up data. Summary statistics were calculated using random-effects models.ResultsA total of 10 trials with 4503 patients were available for analysis. The pooled analyses showed that the second-generation everolimus-eluting stent (EES) significantly lowered all-cause mortality (risk ratio (RR) = 0.58, 95% CI: 0.37–0.90; p = 0.01) and the risk of stent thrombosis (RR = 0.46, 95% CI: 0.22–0.95; p = 0.03) compared with the first-generation sirolimus-eluting stents (SES) and the overall first-generation DES, respectively. Moreover, the EES showed a tendency toward reducing the incidence of recurrent myocardial infarction when compared with paclitaxel-eluting stents (PES) (RR = 0.58, p = 0.08). In contrast, the second-generation zotarolimus-eluting stents (ZES) were associated with increased rates of stent thrombosis and risk of target lesion revascularization in comparison with the SES (both p < 0.05) or the overall first-generation DES (both p < 0.05).ConclusionsThe second-generation EES are highly effective in reducing the risk of major cardiac events in diabetic patients with coronary artery disease.

Reclassification of cardiovascular risk by myocardial perfusion imaging in diabetic patients with abnormal resting electrocardiogram

Background and aimsDespite an extensive use of stress myocardial perfusion single-photon emission computed tomography (MPS), no study addressed the role of perfusion imaging in diabetic patients with abnormal resting electrocardiogram (ECG). We compared analytical approaches to assess the added value of stress MPS variables in estimating coronary heart disease outcomes in diabetic patients with abnormal resting ECG. Methods and resultsA total of 416 patients with diabetes and abnormal resting ECG who underwent stress MPS were prospectively followed up after the index study. The end point was the occurrence of a major cardiac event, including cardiac death and nonfatal myocardial infarction. At the end of follow-up (median 58 months), 42 patients experienced events. MPS data increased the predictive value of a model including traditional cardiovascular risk factors and left ventricular (LV) ejection fraction (likelihood ratio χ2 from 17.54 to 24.15, p < 0.05, with a C statistic of 0.72, 95% confidence interval: 0.65–0.79). The addition of MPS data resulted in reclassification of 25% of the sample with a net reclassification improvement of 0.20 (95% confidence interval: 0.05–0.36). Overall, 63 patients were reclassified to a lower risk category, with a 5-year event rate of 3.5%, and 40 patients were reclassified to a higher risk category, with a 5-year event rate of 20%. ConclusionThe addition of MPS findings to a model based on traditional cardiovascular risk factors and LV ejection fraction improves risk classification for incident cardiac events in diabetic patients with abnormal resting ECG.

Post-stress left ventricular ejection fraction drop in patients with diabetes: a gated myocardial perfusion imaging study

BackgroundTo evaluate the relevance of stress-induced decrease in left ventricular ejection fraction (LVEF) in patients with type-2 diabetes.MethodsA total of 684 diabetic patients with available rest and post-stress gated myocardial perfusion single-photon emission computed tomography (MPS) data were enrolled. An automated algorithm was used to determine the perfusion scores using a 17-segment model. LVEF drop was considered significant if the post-stress LVEF was ≥5% below the rest value. Follow-up data were available in 587 patients that were followed for the occurrence of cardiac death, nonfatal myocardial infarction, or unstable angina requiring revascularization.ResultsA post-stress LVEF drop ≥5% was observed in 167 (24%) patients. Patients with LVEF drop had higher summed stress score (p < 0.05), summed difference score (p < 0.001), and rest LVEF (p < 0.001) compared to patients without. Conversely, summed rest score, a measure of infarct size, was comparable between the two groups. At multivariable analysis, summed difference score and rest LVEF were independent predictors (both p < 0.001) of post-stress LVEF drop. Myocardial perfusion was abnormal in 106 (63%) patients with post-stress LVEF drop and in 296 (57%) of those without (p = 0.16). The overall event-free survival was lower in patients with post-stress LVEF drop than in those without (log rank χ2 7.7, p < 0.005). After adjusting for clinical data and MPS variables, the hazard ratio for cardiac events for post-stress LVEF drop was 1.52 (p < 0.01).ConclusionsIn diabetic patients stress-induced ischemia is an independent predictor of post-stress LVEF drop; however, a reduction in LVEF is detectable also in patients with normal perfusion. Finally, post-stress LVEF drop increases the risk of subsequent cardiac events in diabetic patients.

Prognostic Value of Normal Perfusion but Impaired Left Ventricular Function in the Diabetic Heart on Quantitative Gated Myocardial Perfusion SPECT.

This study aimed at identifying the predictive parameters on quantitative gated myocardial perfusion single-photon emission computed tomography (QG-SPECT) in diabetic patients with normal perfusion but impaired function. Among the 533 consecutive diabetic patients, 379 patients with normal perfusion on rest Tl-201/dipyridamole-stress Tc-99m sestamibi Gated SPECT were enrolled. Patients were grouped into those with normal post-stress left ventricular function (Group I) and those with impaired function (EF <50 or impaired regional wall motion, Group II). We investigated cardiac events and cause of death by chart review and telephone interview. Survival analysis and Cox proportional hazard model analysis were performed. Between the Group I and II, cardiac events as well as chest pain symptoms, smoking, diabetic complications were significantly different (P < 0.05). On survival analysis, event free survival rate in Group II was significantly lower than in Group I (P = 0.016). In univariate Cox proportional hazard analysis on overall cardiac event, Group (II over I), diabetic nephropathy, summed motion score (SMS), summed systolic thickening score (STS), numbers of abnormal segmental wall motion and systolic thickening predicted more cardiac events (P < 0.05). Multivariate analysis showed that STS was the only independent predictor cardiac event. The functional parameter, especially summed systolic thickening score on QG-SPECT had prognostic values, despite normal perfusion, in predicting cardiac events in diabetic patients, and QG-SPECT provides clinically useful risk stratification in diabetic patients with normal perfusion.

Long-Term Prognostic Value of Dobutamine Stress Echocardiography in Diabetic Patients With Limited Exercise Capability

OBJECTIVETo determine the incremental prognostic value of dobutamine stress echocardiography (DSE) at 13-year follow-up (SD 3.2 years) for predicting mortality and cardiac events in diabetic patients.RESEARCH DESIGN AND METHODSA total of 396 diabetic patients (mean age 61 ± 11 years; 252 men [64%]) with limited exercise capacity who underwent DSE for evaluation of ischemia were studied. End points were all causes of mortality, cardiac death, and hard cardiac events (cardiac death and nonfatal myocardial infarction).RESULTSDuring a mean follow-up of 13 years, 230 patients (58%) died (121 cardiac deaths), and 30 patients had nonfatal myocardial infarction. Cumulative survival in patients with an abnormal DSE at 5, 10, and 15 years was 68, 49, and 41%, respectively. In patients with a normal DSE, these respective numbers were 74, 57, and 44%. Multivariate analyses showed that DSE provided incremental value over clinical characteristics and stress test parameters for prediction of mortality and cardiac events. Survival analysis showed that DSE provided optimal risk stratification up to 7 years after initial testing; after that period, the risk of adverse outcome increased comparably in both normal and abnormal DSE patients.CONCLUSIONSDSE provided restricted predictive value of adverse outcome in patients with diabetes who were unable to perform an adequate exercise stress test. DSE provided optimal risk stratification up to 7 years after initial testing. Repeated DSE at that time might add to its prognostic value.

Myocardial perfusion imaging: a plus for coronary risk classification in diabetics

Type 2 diabetes mellitus is the most common form of diabetes worldwide (>90%). Long-term complications of diabetes include microvascular and macrovascular damage. Life expectancy of patients with diabetes remains substantially shorter than that of individuals without diabetes, mainly because of coronary heart disease (CHD) [1]. However, CHD risk in patients with diabetes is highly variable and difficult to stratify by conventional clinical markers [2, 3]. Moreover, the early identification of CHD in diabetics is difficult due to its often silent or atypical presentation in this population. As a result, CHD in diabetics may be diagnosed several years after its onset, when the disease is in an advanced stage, frequently in the form ofmyocardial infarction (MI) or sudden cardiac death. To improve outcomes, common CHD risk factors should be assessed at least annually, along with the presence of microor macroalbuminuria, and be actively managed [4, 5]. The increasing prevalence of diabetes and the associated high CHD risk raises the question as to the need to develop noninvasive approaches to detect the patients with diabetes at the highest risk of CHD. This strategy could identify higher risk diabetics in whom coronary revascularization may improve the outcome beyond that achieved by currently recommended medical management. Stress/rest myocardial perfusion imaging (MPI) is effective in detecting CHD and predicting adverse cardiac events in diabetic patients [6, 7]. Nevertheless, the clinical utility of MPI in diabetics is debated due to the small number of prospective and outcome studies, along with some epidemiological and cost-effectiveness data. It has been reported that routine screening of asymptomatic diabetics who have a normal ECG does not have clinical benefit and that cardiac outcomes are essentially equal (and very low) in screened and unscreened patients (despite abnormal MPI in >20% of these patients) [8]. In addition, according to the large multicentre Bypass Angioplasty Revascularization Investigation 2 Diabetes trial (BARI 2D), optimal intensive medical therapy provides equal outcomes to revascularization in patients with diabetes [9]. In this randomized trial, only patients who had undergone coronary bypass surgery had significantly reduced major cardiac events, compared with those assigned in the intensive medical therapy group, but no difference in mortality was recorded. Therefore, only those diabetics with evidence of myocardial ischaemia and extensive multivessel disease would benefit from prompt surgical revascularization, mainly because of a lower rate of nonfatal MI. It is noteworthy that the majority of the patients enrolled had symptoms and all of them had stable CHD [9]. There is also some evidence that silent myocardial ischaemia may reverse over time with optimized medical treatment, adding to the controversy concerning aggressive screening strategies [10]. Finally, it has been reported that even asymptomatic diabetics with intermediate/high CHD risk have a low annual cardiac event rate (<1%), which is not affected by routine screening for inducible ischaemia [11]. Since screening for CHD in asymptomatic patients does not improve outcomes as long as CHD risk factors are treated, it is not routinely recommended by professional organizations or guidelines for appropriate use of cardiac A. Flotats Nuclear Medicine Department, Universitat Autonoma de Barcelona, Barcelona, Spain

Rosuvastatin in Diabetic Hemodialysis Patients

A randomized, placebo-controlled trial in diabetic patients receiving hemodialysis showed no effect of atorvastatin on a composite cardiovascular endpoint, but analysis of the component cardiac endpoints suggested that atorvastatin may significantly reduce risk. Because the AURORA (A Study to Evaluate the Use of Rosuvastatin in Subjects on Regular Hemodialysis: An Assessment of Survival and Cardiovascular Events) trial included patients with and without diabetes, we conducted a post hoc analysis to determine whether rosuvastatin might reduce the risk of cardiac events in diabetic patients receiving hemodialysis. Among the 731 participants with diabetes, traditional risk factors such as LDL-C, smoking, and BP did not associate with cardiac events (cardiac death and nonfatal myocardial infarction). At baseline, only age and high-sensitivity C-reactive protein were independent risk factors for cardiac events. Assignment to rosuvastatin associated with a nonsignificant 16.2% reduction in risk for the AURORA trial's composite primary endpoint of cardiac death, nonfatal MI, or fatal or nonfatal stroke (HR 0.84; 95% CI 0.65 to 1.07). There was no difference in overall stroke, but the rosuvastatin group had more hemorrhagic strokes than the placebo group (12 versus two strokes, respectively; HR, 5.21; 95% CI 1.17 to 23.27). Rosuvastatin treatment significantly reduced the rates of cardiac events by 32% among patients with diabetes (HR 0.68; 95% CI 0.51 to 0.90). In conclusion, among hemodialysis patients with diabetes mellitus, rosuvastatin might reduce the risk of fatal and nonfatal cardiac events.

Prognostic Value of Hemoglobin A1C Levels in Patients With Diabetes Mellitus Undergoing Percutaneous Coronary Intervention With Stent Implantation

The optimal glycosylated hemoglobin (HbA1C) target in diabetic patients is a subject of ongoing controversy that may be especially pertinent in diabetic patients with coronary artery disease. This study aimed to determine the prognostic value of preprocedural HbA1C levels in diabetic patients undergoing percutaneous coronary intervention (PCI) with stent implantation. From 2002 to 2007, a cohort of 952 consecutive diabetic patients underwent PCI with stent implantation in our center. We compared patients with a normal preprocedural HbA1C (< or = 7%, n = 429) with patients with an increased HbA1C (>7%, n = 523). One-year rate of major adverse cardiovascular events (MACEs) including death, myocardial infarction, and target vessel revascularization was indexed. Baseline characteristics were similar between groups, except for body mass index, which was higher in the high HbA1C group (32.2 vs 31.2 kg/m(2), p = 0.03). Patients in the high HbA1C group were more likely insulin dependent (45.5% vs 26.3%, p <0.001). Rates of MACEs were similar (23.7% vs 20.8%) in the high HbA1C and low HbA1C groups (p = 0.45). By multivariate analysis, age, renal failure, clinical presentation as myocardial infarction, and history of congestive heart failure were independently associated with MACEs. In contrast, HbA1C was not associated with patient outcome. In conclusion, this study suggests that HbA1C is not a predictor of cardiac events in diabetic patients with advanced coronary artery disease. These results could explain, at least in part, recent findings of randomized clinical trials that suggest the absence of benefit in macrovascular complications of a strict glycemia control.

Prognostic value of exercise echocardiography in diabetic patients

BackgroundCoronary artery disease (CAD) is the leading cause of death in diabetic patients. Although exercise echocardiography (EE) is established as a useful method for diagnosis and stratification of risk for CAD in the general population, there are few studies on its value as a prognostic tool in diabetic patients. The purpose of this investigation was to evaluate the value of EE in predicting cardiac events in diabetics.Methods193 diabetic patients, 97 males, 59.8 ± 9.3 yrs (mean ± SD) were submitted to EE between 2001 and 2006 and followed from 7 to 65 months with median of 29 months by phone calls and personal interviews with patients and their primary physician, and reviewing medical records and death certificates. The end points were cardiac events, defined as non-fatal myocardial infarction, late myocardial revascularization and cardiac death. Sudden death without another explanation was considered cardiac death. Survival free of end points was estimated by the Kaplan-Meier method.ResultsTwenty-six cardiac events were registered in 24 individuals during the follow-up. The rates of cardiac events were 20.6 and 7% in patients with positive and negative EE, respectively (p < 0.001). Predictors of cardiac events included sedentary lifestyle, with RR of 2.57 95%CI [1.09 to 6.02] (P = 0.03) and positive EE, with RR 3.63, 95%CI [1.44 to 9.16] (P = 0.01). Patients with positive EE presented higher rates of cardiac events at 12 months (6.8% vs. 2.2%), p = 0.004.ConclusionEE is a useful method to predict cardiac events in diabetic patients with suspected or known CAD.

Nuclear Factor-kB Inhibitor Attenuates Hypoxia-Induced Left Ventricular Remodeling in Diabetic Rats

Background: Intermittent hypoxia relevant to sleep apnea might increase cardiac events in diabetic patients. The aim of this study was to examine the role of nuclear factor-kB (NF-kB) in the development of left ventricular (LV) remodeling in diabetic rats exposed to intermittent hypoxia.