Strategy In Diabetic Patients Research Articles

Comparison of endovascular infrapopliteal revascularisation strategies based on the angiosome model in diabetics with CLTI.

Background: Infrapopliteal endovascular interventions (EVT) strategies in diabetic patients are still in debate because the lesions are more likely to be diffuse with a different pattern of collateral arteries ranging from reduced to normal caliber. The aim of this all-comers study was to analyse the outcome of two different infrapopliteal EVT strategies (Group I: angiosome-based direct revascularization - DR vs. Group II: complete (direct + indirect) revascularization strategy - CR) in diabetic patients with chronic limb-threatening ischemia (CLTI) in 2 time-periods. Furthermore we analysed the outcome if DR or CR failed and only indirect revascularization (IR) or no revascularization was possible. Both groups were differentiated in patients with collaterals, defined as an intact pedal arch (immediate or after pedal PTA). Patients and methods: The database includes 91 consecutive EVT with two intrapopliteal interventional strategies performed in 68 diabetic patients (pts. 24 female, 44 male, mean age 73±10 years) between 2013-2016 and 2017-2022. Positive clinical outcome was defined as wound healing with or w/o minor amputation, combined with a symptom improvement to Rutherford category 0 or 1 after 6 months. The clinical outcome proportions were compared using the Fisher's exact test. Results: Successful DR (59%) and successful CR (47%) strategy demonstrated a similar positive clinical outcome (92.6% vs. 90.5%; p=0.594). Indirect revascularization (Group I: 26%; Group II: 44%) showed a significantly lower positive outcome in comparison to a successful DR as well as CR strategy (33.3% vs. 92.6%, p=0.0003; 40% vs 90.5%, p=0.001). IR outcome improved by the presence of collaterals (66.7% vs. 30.8%). Conclusions: In case of successful intervention, both strategies (DR and CR) yielded a similarly high proportion of positive clinical outcome. The role of collaterals and the pedal arch on the clinical outcome are important in patients in whom only IR was possible.

Hypertension in Diabetes: An Update of Basic Mechanisms and Clinical Disease.

Epidemiological studies have documented that insulin resistance and diabetes not only constitute metabolic abnormalities but also predispose to hypertension, vascular stiffness, and associated cardiovascular disease. Meanwhile, excessive arterial stiffness and impaired vasorelaxation, in turn, contribute to worsening insulin resistance and the development of diabetes. Molecular mechanisms promoting hypertension in diabetes include inappropriate activation of the renin-angiotensin-aldosterone system and sympathetic nervous system, mitochondria dysfunction, excessive oxidative stress, and systemic inflammation. This review highlights recent studies which have uncovered new underlying mechanisms for the increased propensity for the development of hypertension in association with diabetes. These include enhanced activation of epithelial sodium channels, alterations in extracellular vesicles and their microRNAs, abnormal gut microbiota, and increased renal sodium-glucose cotransporter activity, which collectively predispose to hypertension in association with diabetes. This review also covers socioeconomic factors and currently recommended blood pressure targets and related treatment strategies in diabetic patients with hypertension.

Diabetes and COVID-19: Mechanism of pneumonia, treatment strategy and vaccine

As of August 5, 2021, there were about 200,000,000 global confirmed patients of COVID-19, with more than 4,250,000 deaths. The COVID-19 disease which is a tremendous public health threat, jumps unpredictably and outbreaks very quickly. The overall mortality rate of COVID-19 infection is 1%–15% but reaches up to 17–38% in older cases with chronic disorders and in intensive care unit (ICU) subjects. Diabetic patients, particularly those whose disease is not well controlled can be more susceptible to COVID-19. Although diabetes was present in 5.3%–42.3% of fatalities from COVID-19, the underlying pathophysiological mechanisms of action of novel coronavirus in diabetic patients are unknown. Based on the elevating of global prevalence, diabetes is the main medical problem associated with COVID-19. It is plausible that diabetes can forecast elevated severity of pneumonia. The mortality of lung infection among diabetes is remarkably higher compared with non-diabetic patients. Mechanisms responsible for severe pneumonia in the diabetic patients as well as treatment of diabetic patients infected with COVID-19 are largely speculative. Hence, this paper will summarize the recent findings related to the mechanisms of pneumonia and treatment strategies in diabetic patients.

Протизапальний ефект нефропротекторної терапії у хворих на діабетичну нефропатію

Diabetic kidney disease develops in approximately 40% of patients who are diabetic and is the leading cause of chronic kidney disease worldwide. The majority of patients actually die from cardiovascular diseases and infections before needing kidney replacement therapy. The progression of fibrotic processes in the diabetic kidneys occurs with the participation of universal mediators of inflammation. Given the clinical and social significance of diabetic kidney damage, the determination of interleukin-1β and interleukin-6 in blood serum may expand the understanding of this problem, as well as help in the development of individualized therapeutic approaches. The purpose of the study is to investigate interleukin-1β and interleukin-6 levels in the serum of patients with type 2 diabetes mellitus, depending on kidney functional state in the dynamics of therapy and with additional prescription of dapagliflozin. Materials and methods. 72 patients with type 2 diabetes were examined. The control group consisted of 20 healthy individuals. The patients were divided into the following groups: group I – type 2 diabetic patients with normal glomerular filtration rate and without albuminuria (n = 25); group II – patients with type 2 diabetes with normal glomerular filtration rate and albuminuria (n = 23); group III – patients with type 2 diabetes with decreased glomerular filtration rate and albuminuria (n = 24). The complex pathogenetic therapy of patients of group 1 included renin-angiotensin-aldosterone system blockers, metformin and hypolipidemic agents. Patients of group 2 were additionally prescribed dapagliflozin. The control was carried out after 6 months. Results and discussion. According to the results of the study, the development of diabetic nephropathy in patients with type 2 diabetes is accompanied by a significant increase in the level of interleukin-1β and interleukin-6 in the blood plasma compared with the control and in patients with diabetes without signs of nephropathy. Nephroprotective therapy contributed to a significant decrease of interleukin-1β and interleukin-6 levels in the blood serum in all groups of patients. The highest response to treatment was observed in patients with diabetic nephropathy and albuminuria. Most significant decrease of albuminuria, normalization of blood pressure and lipid spectrum improvement were observed in patients with the initial stages of the disease. Additional using of dapagliflozin leads to a more significant decrease in the content of proinflammatory cytokines in the blood serum of patients with type 2 diabetes mellitus with diabetic nephropathy. Conclusion. The results of the study indicate the advisability of using interleukin-1β and interleukin-6 as a diagnostic marker of cardiac disorders, assessment of prognosis, and improvement of the cardionephroprotective strategy in diabetic patients. The therapeutic potential of dapagliflozin in the treatment of diabetic nephropathy and the prevention of cardiovascular events in patients with diabetes is of great scientific interest and requires further research

Renal denervation as a new nephroprotective strategy in diabetic patients with resistant hypertension

Background. Diabetic patients with resistant hypertension (RHT) are characterized by a high rate of annual decline in estimated glomerular filtration rate (eGFR) (up to 14 mL/min/1.73 m 2 ). The distal approach to sympathetic renal denervation (RD) reduces blood pressure (BP) to a greater extent compared with standard RD. However, the long-term effect of distal RD on the renal function remains unknown. Aim . The purpose of this study was to evaluate the long-term safety and nephroprotective efficacy profile of distal RD compared to conventional intervention in RHT patients with type 2 diabetes mellitus (T2DM) during a three-year follow-up. Material and Methods. Twenty seven patients (eight men) with true RHT and T2DM were included in a single-arm prospective interventional study (number NCT01499810 at ClinicalTrials.gov) (mean age of 61.6 ± 7.3 years; mean office (systolic/diastolic) BP of 171.8 ± 21.9/87.7 ± 17.7 mmHg; mean eGFR of 72.1 ± 19.9 mL/min/1.73 m²; and glycosylated hemoglobin level (HbA1c) of 6.3 ± 1.1%). Patients were randomized into two comparable groups of distant ( n = 13) and standard RD ( n = 14). Office BP, ABPM, renal Doppler ultrasound, renal function (eGFR (CKD-EPI) and 24-hour urinary albumin excretion (UAE)), and kidney MRI were assessed at baseline and annually during a three-year follow-up. Nineteen patients completed a 36-month follow-up (8 patients were treated by distal RD and 11 patients received the conventional procedure). Results. The change in eGFR during three-year follow-up was insignificant in group of distal RD (-5.3 ± 0.4 mL/min/1.73 m 2 , p = 0.63) and was comparable with the corresponding value in conventional RD group (–6.7 ± 4.2 mL/min/1.73 m 2 , p = 0.3), ( p = 0.7 for intergroup comparison) despite a more powerful decrease in 24-h systolic BP in the distal RD group relative to that in conventional RD group (–25.3 ± 15.3 vs. 4.4 ± 22 mmHg, p = 0.04). The degrees of annual decline in GFR did not differ between the distal RD group and conventional RD group ( p = 0.9) and were –2.7 ± 2.4 mL/min/1.73 m 2 /year and –2.7 ± 4.0 mL/min/1.73 m 2 /year, respectively. No significant changes in renal blood flow, albuminuria, MRI-based kidney size, and the number of patients with albuminuria and renal dysfunction were found during the study. Conclusions. Distal RDN in diabetic patients with RHT had a three-year safety profile and nephroprotective efficacy similar to those when the standard method was used despite a more significant reduction of blood pressure. Both modes of RD are likely to slow the progression of renal dysfunction in these patients.

Self-Care Management Practices of Diabetic Patients Type 2 in Saudi Arabia

Background & Aim: Patients’ self-care management practice in diabetes is considered a critical element to keep diabetes under control and the disease management is usually conducted by the patients themselves and/or their families. The main aim of this study is to assess the level of self-care management practices of diabetic patients type 2 in Saudi Arabia. Materials & Methods: A cross-sectional study design was utilized in the Prince Sultan Military Medical City in Riyadh on a convenience sampling method consisted of 377 diabetic patients type 2. The researcher used a self-administered questionnaire (Summery of Diabetes Self-care Activities) which was adopted from Toobert et al. (2000). Results: The study results revealed that the level of self-care management practices among patients with type 2 DM is not satisfactory, except in the medication domain. Conclusion & Recommendations: Policymakers should revise the education strategy for diabetic patients and develop health education campaigns that focus on the patient’s family as well as the individual with type-2 DM.

Percutaneous Coronary Intervention of Chronic Total Occlusions in Patients with Diabetes Mellitus: a Treatment-Risk Paradox.

Diabetes mellitus (DM) is highly prevalent among patients undergoing percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs). This review aims to summarize the available evidence on CTO recanalization in patients with DM. Coronary artery bypass grafting (CABG) surgery is the recommended revascularization modality for patients with DM and multivessel coronary artery disease (CAD). However, the optimal management strategy in diabetic patients with CTO and single-vessel disease or prior CABG remains a clinical dilemma. Contemporary, large-scale, observational registries support the notion that CTO PCI, if performed at high-volume CTO PCI centers by highly experienced operators, conveys similar high procedural success and low complication rates in patients with and without DM. Although DM patients have more frequently CTOs and may derive greater benefit from complete revascularization, they are less frequently exposed to CTO PCI than non-DM patients (treatment-risk paradox). CTO PCI performed by highly experienced operators constitutes a safe and effective treatment option for selected diabetic CTO patients who are not candidates for CABG. Randomized studies are warranted to compare long-term outcomes of CTO PCI and medical therapy in this high-risk subset.

Hydroxytyrosol nicotinate, a new multifunctional hypolipidemic and hypoglycemic agent

Hydroxytyrosol (HT) is a natural polyphenol antioxidant that exists in olive oil. In the study of multifunctional hypolipidemic of nicotinic derivatives, we found that hydroxytyrosol nicotinate (HT-N) incorporation of niacin with HT displayed α-glucosidase inhibitory activities in vitro, such as yeast α-glucosidase (IC50 = 117.72 μM) and rat intestinal α-glucosidases maltase (IC50 = 31.86 μM) and sucrase (IC50 = 22.99 μM), and had a good control of postprandial blood glucose (PBG). HT-N shown significantly hypoglycemic action by 16.9% and protection of pancreatic tissue in type 2 diabetic mellitus (T2DM) mouse model. HT-N also shown a potent antioxidant activity and property of anti-glycation in vitro, which were benefit for ameliorating diabetic complications. Moreover, HT-N exhibited much significant hypolipidemia, lowering plasma triglyceride (TG), total cholesterol (TC), and malonaldehyde (MDA) by 34.6%, 45.8% and 32.1% respectively, in hyperlipidemic mice induced by Triton WR 1339. The results indicated that HT-N has hypolipidemic, hypoglycemic and antioxidant actions. All these properties could be conducive to amelioration of oxidative stress, hyperlipidemia, and diabetes that HT-N may serve as a multifunctional potential therapeutic strategy in diabetic patients with hyperlipidemia.

Diabetes Mellitus in Patients Presenting with Cardiovascular Events: Descriptive Analysis from a Tertiary Heart Hospital Over a 22-year Period.

Diabetes mellitus (DM) remains a health care challenge worldwide. We evaluated the trends and outcome of DM in patients presenting with cardiovascular diseases (CVD) over a 22-year period in Qatar. A retrospective analysis was performed between 1991 and 2012, including 48,803 patients admitted to the tertiary Heart Hospital (HH). The average CVD hospitalization rate was 37 admissions per 10,000 people, of which, 2 out of 5 patients had DM. Diabetic males were 6 years younger than females. DM was more prevalent in Arabs (68 vs. 32%), but its burden showed a decreasing trend over time compared with South Asians. More diabetics presented with ST-elevation myocardial infarction (47.5 vs. 22.7%), which tended to occur 8 years earlier compared with heart failure. Over the study period, beta-blocker use increased substantially (from 10 to 71%). However, angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARBs) were underutilized (from 30 to 56%). There were 4.4 deaths per 100 CVD admissions, which is equivalent to 97 deaths per year. Of this, 52% had DM (2.3 deaths per 100 CVD admissions). The overall case fatality rate (CFR) of DM was 5.6%. Diabetic Asian patients died 9 years earlier than diabetic Arabs at the HH. Multivariate regression analysis revealed that predictors of mortality in DM patients in the HH included lack of beta-blocker use (OR 4.35; 95% CI: 0.20 - 0.27), lack of ACEI/ARBs use (OR 3.58; 95% CI: 0.23 - 0.32), myocardial infarction (OR 3.20; 95% CI: 2.77 - 3.68), lack of aspirin use (OR 2.56; 95% CI: 0.34 - 0.45), congestive heart failure (OR 1.75; 95% CI: 1.50 - 2.04) and age (OR 1.03; 95% CI: 1.02 - 1.04) (P=0.001 for all). DM remains a healthcare challenge in Qatar. Although the admission rate of diabetic patients is increasing at the HH, the mortality rate is decreasing. The use of evidence-based medication is still far from the guideline recommendation; however, it has substantially improved. The lack of evidence-based CVD medications in diabetic patients was associated with an increased mortality up to 4-fold in the HH. Moreover, there is a need to enhance public awareness regarding CVD risk factors and DM through education programs for the adoption of healthier lifestyles and nutrition. Great efforts are needed for more efficient primary and secondary prevention strategies in diabetic patients.

Surgical Revascularization versus Percutaneous Coronary Intervention and Optimal Medical Therapy in Diabetic Patients with Multi-Vessel Coronary Artery Disease

Coronary artery disease (CAD) is the leading cause of death in patients with diabetes mellitus (DM). Patients with DM and CAD undergoing revascularization with either a surgical or a percutaneous approach are at higher risk of adverse outcomes and mortality compared with non-DM patients. It is within this background that the optimal choice of revascularization is of critical importance in this high-risk population. The large FREEDOM trial randomized 1900 patients with DM and multivessel CAD to either revascularization with coronary artery by-pass graft (CABG) surgery or percutaneous coronary intervention (PCI). Compared with PCI, CABG significantly reduced the rates of death and myocardial infarction but was associated with a higher risk of stroke. In a real-world setting the decision-making process for the optimal revascularization strategy in these patients is challenging as many clinical factors may influence the decision to either pursue a surgical or a percutaneous revascularization. However, the current consensus is that CABG should be the preferred revascularization strategy in diabetic patients with extensive multivessel CAD.

The dual targeting of EGFR and ErbB2 with the inhibitor Lapatinib corrects high glucose-induced apoptosis and vascular dysfunction by opposing multiple diabetes-induced signaling changes

The epidermal growth factor receptors, EGFR and EGFR2 (ErbB2), appear important mediators of diabetes-induced vascular dysfunction. We investigated whether targeted dual inhibition of EGFR and ErbB2 with Lapatinib would be effective in treating diabetes-induced vascular dysfunction in a rat model of type 1 diabetes. In streptozotocin-induced diabetes, chronic 4-week oral or acute, ex vivo, administration of Lapatinib prevented the development of vascular dysfunction as indicated by the attenuation of the hyper-reactivity of the diabetic mesenteric vascular bed (MVB) to norephinephrine without correcting hyperglycemia. Chronic in vivo or acute ex vivo Lapatinib treatment also significantly attenuated diabetes-induced increases in phosphorylation of EGFR, ErbB2, ERK1/2, AKT, ROCK2 and IkB-alpha as well as normalized the reduced levels of phosphorylated FOXO3A, and eNOS (Ser1177) in the diabetic MVB. Similar results were observed in vascular smooth muscle cells (VSMCs) cultured in high glucose (25 mM) treated with Lapatinib or small interfering RNA (siRNA) targeting the ErbB2 receptor. Lapatinib also prevented high glucose-induced apoptosis in VSMC. Thus, Lapatinib corrects hyperglycemia-induced apoptosis and vascular dysfunction with concomitant reversal of diabetes or high glucose-induced signaling changes in EGFR/ErbB2 and downstream signaling pathways implying that targeted dual inhibition of EGFR/ErbB2 might be an effective vasculoprotective treatment strategy in diabetic patients.

Intensive Versus Conventional Glycemic Control in Patients with Diabetes During Enteral Nutrition After Gastrectomy

BackgroundThis study compared intensive and conventional glycemic management strategies in diabetic patients receiving enteral nutrition after gastrectomy. MethodsDiabetic patients (n = 212) who underwent gastrectomy between September 2006 and March 2014 were randomized to intensive glycemic (IG) management with continuous insulin infusion (target glucose 4.4–6.1 mmol/l (80–110 mg/dl)) or conventional glycemic (CG) management with intermittent bolus insulin (target glucose <11.1 mmol/l (<200 mg/dl)). Outcomes included blood glucose concentrations, insulin administration, and postoperative morbidity and mortality. ResultsBlood glucose levels were lower (5.4±1.2 vs. 9.5±1.8 mmol/l, P < 0.001) and mean insulin dose was higher (55 ± 15 vs.32 ± 16 units/day, P < 0.001) in the IG than in the CG group. Rates of severe hypoglycemia (7.5 vs. 0.9 %, P = 0.035) and achievement of target blood glucose (86.3 vs. 72.6 %, P = 0.023) were higher, while severe hyperglycemia rate was lower (1.9 vs. 11.3 %, P = 0.010), in the IG group. Surgical site infection rate was lower in the IG group (4.7 vs. 13.2 %, P < 0.030). Rates of other infective complications, bleeding, delayed gastric emptying, obstruction, hepatic dysfunction, renal dysfunction, and circulatory insufficiency were similar in the two groups. ConclusionsIntensive glycemic control in diabetic patients receiving enteral nutrition after gastrectomy was associated with a lower surgical site infection rate but a higher hypoglycemia rate.

MiR33 inhibition overcomes deleterious effects of diabetes mellitus on atherosclerosis plaque regression in mice.

Diabetes mellitus increases cardiovascular disease risk in humans and remains elevated despite cholesterol-lowering therapy with statins. Consistent with this, in mouse models, diabetes mellitus impairs atherosclerosis plaque regression after aggressive cholesterol lowering. MicroRNA 33 (miR33) is a key negative regulator of the reverse cholesterol transport factors, ATP-binding cassette transporter A1 and high-density lipoprotein, which suggested that its inhibition may overcome this impairment. To assess the effects of miR33 inhibition on atherosclerosis regression in diabetic mice. Reversa mice, which are deficient in the low-density lipoprotein receptor and in which hypercholesterolemia is reversed by conditional inactivation of the microsomal triglyceride transfer protein gene, were placed on an atherogenic diet for 16 weeks, then either made diabetic by streptozotocin injection or kept normoglycemic. Lipid-lowering was induced by microsomal triglyceride transfer protein gene inactivation, and mice were treated with anti-miR33 or control oligonucleotides. Although regression was impaired in diabetic mice treated with control oligonucleotides, anti-miR33 treatment decreased plaque macrophage content and inflammatory gene expression in these mice. The decreased macrophage content in anti-miR33 treated diabetic mice was associated with a blunting of hyperglycemia-induced monocytosis and reduced monocyte recruitment to the plaque, which was traced to an inhibition of the proliferation of bone marrow monocyte precursors associated with the upregulation of their Abca1. miR33 inhibition overcomes deleterious effects of diabetes mellitus in atherosclerosis regression in mice, which suggests a therapeutic strategy in diabetic patients, who remain at elevated cardiovascular disease risk, despite plasma cholesterol lowering.

Uso de estrategia invasiva precoz en pacientes diabéticos con síndrome coronario agudo sin elevación del ST

In the management of non-ST-segment elevation acute coronary syndromes (NSTE-ACS), several studies have shown a reduction in mortality with the use of an invasive strategy in high-risk patients, including diabetic patients. Paradoxically, other studies have shown an under-utilization of this invasive strategy in these patients. The aim of this study is to determine the characteristics of patients managed conservatively and identify determinants of the use of invasive or conservative strategy.Retrospective cohort study conducted in diabetic patients with NSTE-ACS included in the ARIAM-SEMICYUC registry (n=531) in 2010 and 2011. We performed crude and adjusted unconditional logistic regression.We analyzed 531 diabetic patients, 264 (49.7%) of which received invasive strategy. Patients managed conservatively were a subgroup characterized by older age and cardiovascular comorbidity, increased risk of bleeding and the absence of high-risk electrocardiogram (ECG). In diabetic patients with NSTE-ACS, independent predictors associated with conservative strategy were low-risk ECG, initial Killip class>1, high risk of bleeding and pretreatment with clopidogrel.The fear of bleeding complications or advanced coronary lesions could be the cause of the underutilization of an invasive strategy in diabetic patients with NSTE-ACS.

Early or Selective Invasive Strategy in Patients with Non-ST-segment Elevation Acute Coronary Syndrome According to the Risk Factors at Presentation? An Outcome Study

Aims: Patients with acute coronary syndrome without ST segment elevation are a heterogeneous group with respect to the risk of having a major adverse cardiac event (MACE). History of diabetes mellitus (DM), chronic kidney disease (CKD) and elevated GRACE risk score are all factors defining a higher risk of MACE. We aimed to compare the outcome of patients with early vs selective invasive strategy according to the risk factors at presentation. Methodology: We enrolled 178 patients with unstable angina or non-ST elevation myocardial infarction (UA/NSTEMI), 52 (29.2%) had DM, 32 (19.7%)-CKD, defined when MDRD measured glomerular filtration rate (GFR) was <60ml/min/1.73m and 28 (15.7%) had GRACE≥140. The study had two arms: an early invasive strategy one (coronary arteriography and percutaneous coronary intervention within 24 hours after admission), Original Research Article Dimitrov et al.; CA, 2(4): 205-222, 2014; Article no. CA.2014.4.006 206 and a selective invasive strategy arm (medical stabilization, with coronary arteriography required only in case of angina recurrence and/or evidence of inducible myocardial ischemia). Follow-up was 22.8±14 months. Results: For the whole group MACE occurred less often and the event free period was longer in the early invasive strategy group compared to selective invasive one (p=0.001). Early invasive strategy in diabetic patients, those with CKD and with GRACE ≥140 was associated with a reduced MACE rate (p=0.008, 0.016 and 0.006, respectively) and longer time to MACE occurrence compared with the selective invasive strategy. When we evaluated separately non-diabetics, patients with normal renal function and those with GRACE <140 we found no significant difference in MACE rate between the patients allocated to early invasive strategy and those assigned to selective invasive strategy. Early invasive strategy, however, showed some advantage over the selective one also in the subgroup analysis-the time to occurrence of MACE was prolonged in patients with lower risk at presentation. Conclusions: Early invasive strategy in UA/NSTEMI is associated with a reduced MACE rate and longer event-free period compared with selective invasive strategy. This benefit is clearly evident in higher risk subsets (patients with DM, CKD and GRACE ≥140).

Chronic Metformin Treatment is Associated with Reduced Myocardial Infarct Size in Diabetic Patients with ST-segment Elevation Myocardial Infarction

Increased myocardial infarct (MI) size is associated with higher risk of developing left ventricular dysfunction, heart failure and mortality. Experimental studies have suggested that metformin treatment reduces MI size after induced ischaemia but human data is lacking. We aimed to investigate the effect of metformin on MI size in patients presenting with an acute MI. All consecutive patients (n = 3,288) presenting to our hospital with ST-segment elevation myocardial infarction (STEMI) undergoing primary PCI between January 2004 and December 2010 were included in this retrospective analysis. Patients with diabetes were divided according to metformin versus non-metformin based pharmacotherapy. MI size was estimated using peak values of serum creatine kinase (CK), myocardial band of CK (CK-MB), and troponin-T. We identified 677 (20.6%) patients with diabetes, of whom 189 (27.9%) were treated with metformin. Chronic metformin treatment was associated with lower peak levels of CK (1,101 vs. 1,422 U/L, P = 0.005), CK-MB (152 vs. 182 U/L, P = 0.018) and troponin-T (2.5 vs. 4.0ng/L, P = 0.021) compared to non-metformin using diabetics. After adjustment for age, sex, TIMI flow post PCI, and previous MI, the use of metformin treatment remained an independent predictor of smaller MI size. Patient with diabetes treated with metformin had even smaller MI size than patients without diabetes. Chronic metformin treatment is associated with reduced MI size compared to non-metformin based strategies in diabetic patients presenting with STEMI. Metformin might have additional beneficial effects beyond glucose lowering efficacy.

Timing of Invasive Strategy in Diabetic and Non-Diabetic Patients with Non-St-Segment Elevation Acute Coronary Syndrome

Patients with acute coronary syndrome without ST segment elevation are a heterogeneous group with respect to the risk of having a major adverse cardiac event (MACE). A history of diabetes mellitus (DM) is no doubt one of the factors that define a patient as being at a higher risk of having the syndrome. To compare early invasive strategy with selective invasive strategy indicated for patients with and without DM. The study enrolled 178 patients with unstable angina or non-ST elevation myocardial infarction (UA/NSTEMI), and of these 52 (29.2%) had DM. Patients were randomly assigned to an early invasive strategy (these were scheduled to undergo coronary arteriography and percutaneous coronary intervention within 24 hours after admission) or to a selective invasive strategy (at first these were medically stabilized, with coronary arteriography required only in case of angina recurrence and/or evidence of inducible myocardial ischemia). The patients were followed up for a mean period of 22.8 +/- 14 months. In the follow up the diabetics allocated to an early invasive strategy were found to have a significantly lower angina recurrence incidence (p = 0.005), rehospitalization rate (p = 0.001), fewer arteriographies (p = 0.001) and coronary interventions (p = 0.001) and low cumulative incidence of MACE (p = 0.008) in comparison with the diabetics assigned to selective invasive strategy. We also found, using the Kaplan-Meier curves survival analysis, that the time to MACE in patients assigned to an early invasive strategy was significantly longer than that in the group of selective invasive strategy. In the follow-up of non-diabetics we found no significant difference in MACE rate between the patients allocated to early invasive strategy and those assigned to selective invasive strategy. In the selective invasive strategy group, however, the cardiovascular adverse events tended to occur earlier than in the early invasive strategy group. Early invasive strategy in diabetic patients with non-ST-segment elevation acute coronary syndrome is associated with a reduced MACE rate compared with the selective invasive strategy used in these patients. Early invasive strategy applied in diabetic patients is also associated with a significantly longer time to MACE. In non-diabetics the advantages of early over selective invasive strategy are not so clearly differentiated.

Percutaneous coronary intervention in diabetic patients: should choice of stents be influenced?

Patients with diabetes mellitus are prone to a diffuse and rapidly progressive form of coronary artery disease. As a result, diabetic patients undergoing coronary revascularization are at higher risk of cardiovascular events compared with nondiabetic patients. Due to marked advances of stent device technology and adjunctive pharmacology, percutaneous coronary intervention has been regarded as an efficient revascularization strategy in diabetic patients. Numerous randomized trials and large observational registries have compared the efficacy and safety of bare-metal stents and drug-eluting stents, as well as several DE platforms. This article systematically reviews the cumulative evidence from key clinical studies and tries to help guide the physician in making informed decisions on the optimal stent type for patients with diabetes mellitus.

Optimal choice of coronary revascularization and stent type in diabetic patients with coronary artery disease.

Patients with diabetes mellitus (DM) are prone to a diffuse and accelerated form of coronary artery disease (CAD), which in turn is a major cause of cardiac-related morbidity and mortality. Compared with patients without diabetes, patients with diabetes undergoing coronary revascularization are at higher risk of procedural, short-, and long-term cardiovascular events and mortality. Although coronary artery bypass grafting (CABG) has been regarded as the primary revascularization strategy in diabetic patients with complex CAD, percutaneous coronary intervention (PCI) is an effective revascularization alternative, due to remarkable advances in stent devices and adjunctive drug therapies. Outcomes data, from subgroup analyses and small-sized clinical trials and large registries, have suggested that PCI with current stent technology showed comparable long-term risks of mortality and hard endpoints, but higher risk of repeat revascularization for the diabetic population compared to CABG. However, the recent landmark International Future REvascularization Evaluation in patients with diabetes mellitus: optimal management of Multivessel disease (FREEDOM) trial provides compelling evidence of the superiority of CABG over PCI in reducing the rates of death, myocardial infarction, at the expense of stroke, in patients with diabetes with advanced CAD. When opting for PCI in patients with diabetes, currently used drug-eluting stents (DES) are more efficient in reducing the risk of repeat revascularization without compromising safety outcomes, compared to bare-metal stents. The selection of a specific type of DES in patients with diabetes is controversial and therefore more data comparing second- and newer-generation DES for patients with diabetes are currently needed. Also, efforts to make more advanced DES platforms suitable for patients with diabetes with complicated angiographic features are still ongoing.

A comparison of efficacy and safety of an ezetimibe/simvastatin combination compared with other intensified lipid-lowering treatment strategies in diabetic patients with symptomatic cardiovascular disease

The low-density lipoprotein cholesterol (LDL-C) lowering efficacy of switching to ezetimibe/simvastatin (EZ/S) 10/20 mg versus doubling the run-in statin dose (to simvastatin 40 mg or atorvastatin 20 mg) or switching to rosuvastatin 10 mg in subjects with cardiovascular disease (CVD) and diabetes was assessed. Endpoints included percentage change in LDL-C and percentage of patients achieving LDL-C <70 mg/dL. Significantly greater reductions in LDL-C occurred when switching to EZ/S versus statin doubling in the overall population and in subjects treated with simvastatin 20 mg or atorvastatin 10 mg (all p < 0.001). The LDL-C reduction was numerically greater when switching to EZ/S versus switching to rosuvastatin (p = 0.060). Significantly more subjects reached LDL-C <70 mg/dL with EZ/S (54.5%) versus statin doubling (27.0%) or rosuvastatin (42.5%) in the overall population (all p < 0.001) and within each stratum (all p < 0.001). Switching to EZ/S provided significantly greater reductions in LDL-C versus statin doubling and significantly greater achievement of LDL-C targets versus statin doubling or switching to rosuvastatin.