•Microvascular and endothelial dysfunction is present in the non-culprit territory in up to 93% of patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease.•Whether an ...impaired coronary physiology in the non-culprit territory correlates with long-term prognosis is yet to be determined.•At a median follow-up of 4 years, we found that cardiovascular events and death occurred more frequently in patients with a low coronary flow reserve (CFR) in the non-culprit artery.•Other parameters such as the index of microvascular resistance (IMR) or endothelial dysfunction were not independent predictors of adverse outcomes.
Endothelial and microvascular dysfunction are frequently found in the non-culprit territory in patients with acute myocardial infarction (AMI). We aimed to determine whether an impaired coronary physiology of the non-culprit territory impacts long-term prognosis.
FISIOIAM was an observational single-center study which included patients with AMI and another coronary artery lesion in a different territory. Intracoronary physiology of the non-culprit artery was analyzed early after primary percutaneous coronary intervention of the culprit artery, using fractional flow reserve (FFR), index of microcirculatory resistance (IMR), coronary flow reserve (CFR), endothelium-dependent CFR (eCFR) and macrovascular endothelial function . Patients were followed for a composite outcome of cardiovascular death, non-fatal myocardial infarction, coronary revascularization, and hospitalization due to heart failure or unstable angina.
A total of 84 patients (mean age: 62 ± 10 years) were included and functional abnormalities were detected in 93% of them. During follow-up (median of 1422 days; interquartile range, 1287–1634), 13.1% of the patients experienced at least one adverse cardiovascular event. Kaplan-Meier analysis revealed that patients with a CFR < 2 had a higher risk of events (Hazard Ratio, HR: 4.97, 95% Confidence Interval, CI, 1.32–18.75), whereas other parameters such as FFR, IMR, eCFR, and macrovascular endothelial function had no effect. A low CFR was an independent predictor of cardiovascular events, even after adjustment for age and traditional cardiovascular risk factors (adjusted HR: 6.62, 95% CI, 1.30–33.70).
The presence of abnormal coronary microvascular function as measured by a CFR < 2 in the non-culprit territory predicts future risk of adverse cardiovascular events.
Background
Concern exists regarding adequacy of visualization of stress echocardiograms performed without intravenous contrast in persons with Class III obesity (body mass index ≥ 40 kg/m2).
Methods
...Dobutamine stress echocardiography (DSE) was performed on 128 candidates for bariatric surgery with class III obesity without chest pain or pre‐existent coronary artery disease (CAD). DSE without intravenous contrast was initially performed on 62 patients with class III obesity, then was subsequently was performed with intravenous contrast on 66 patients with class III obesity. Left ventricular (LV) regional wall motion was assessed at baseline and peak stress using the 16‐segment model.
Results
In the intravenous contrast group, 1046 of 1056 LV segments studied (99.1%) were well‐visualized and interpretable at baseline and 1044 of 1056 LV segments studied (98.9%) were well‐visualized and interpretable at peak stress. In the non‐contrast group, 905 of 992 segments studied (91.2%) were well‐visualized and interpretable at baseline and 886 of 992 segments studied (89.3%) were well‐visualized and interpretable at peak stress. A significantly greater number of LV segments were well‐visualized and interpretable in the intravenous contrast group than in the group compared to the non‐contrast group, at baseline and at peak stress (p < 0.00001 for both). DSE was positive for ischemia in one patient. All patients underwent bariatric surgery without cardiovascular complications. Six months after surgery, all patients were alive; none developed cardiovascular events.
Conclusion
The use of intravenous contrast during DSE significantly improves visualization and interpretability of LV segments in patients with class III obesity.
Cardiac allograft vasculopathy (CAV) remains the major cause of late graft-related death after heart transplantation (HT). Identification of patients at risk of cardiovascular events has relevant ...implications in appropriately guiding resources and intensity of follow-up. In this context, the prognostic relevance of serial coronary imaging long-term after HT is unexplored.
Recipients with intravascular ultrasound (IVUS) and coronary angiography performed 1 and 5 years after HT were monitored for subsequent 1 to 10 years to analyze the association of serial coronary imaging with cardiovascular death and major cardiovascular events (MACEs).
Included were 131 patients. The MACE incidence was 31.8 per 1,000 patient-years, and cardiovascular mortality was 17.4 per 1,000 patient-years. Progression of coronary lesions detected by angiography and changes in IVUS-defined parameters, including an increase in maximal intimal thickness (MIT) ≥0.35 mm and vascular remodeling, predicted MACE occurrence. However, only MIT change ≥0.35 mm also predicted cardiovascular mortality. Among patients with normal or stable angiography, an MIT change ≥0.35 mm identified those with a significantly higher MACE rate (80 vs 13 events/1,000 patient-years). Worsening metabolic parameters appeared associated with the increasing severity of CAV development.
Combined imaging analysis of progression of angiographic lesions and IVUS-detected MIT between 1 and 5 years post-HT allows discriminating patients at high, intermediate, and low risk for adverse long-term cardiovascular outcomes. The metabolic syndrome milieu is confirmed as a key risk factor for long-term CAV progression and adverse prognosis.
The link between influenza and medical complications is well stablished and plays a role in the high mortality rates of this disease. Available scientific evidence suggests that influenza vaccination ...might reduce the risk of cardiovascular events. This setting for cardiovascular prevention beyond immunoprotection has been studied in several clinical trials. Most of them include populations with coronary artery disease. However, differences in clinical design, population included, and vaccination strategies might explain divergent results and should be interpreted with caution. The present article summarizes available literature in a manner that aids physicians in a better interpretation and encourages the implementation of influenza vaccination in cardiovascular prevention programmes.
Background:
Obstructive sleep apnea (OSA) is highly common in patients with coronary artery disease (CAD) and it is a strong predictor of subsequent cardiovascular events. However, whether treatment ...with continuous positive airway pressure (CPAP) can decrease this risk remains controversial.
Methods:
PubMed, EMBASE, the Cochrane Library, and
ClinicalTrials.gov
were systematically searched to identify randomized clinical trials reporting cardiovascular events from database inception to February 12, 2022.
Results
: Four trials with 3043 participants were included. The median follow-up duration ranged from 3 to 4.75 years. Compared with usual care alone, CPAP was not associated with decreased MACCE risk (RR 0.96, 95% CI 0.77–1.21, P = 0.75), and the results were consistent regardless of CPAP adherence (≥4 hours/night vs. <4 hours/night, RR 0.48, 95% CI 0.20–1.16). Similarly, no significant differences were observed between groups in the risks of all-cause death (RR 0.81, 95% CI 0.52–1.26), cardiovascular death (RR 0.70, 95% CI 0.36–1.33), myocardial infarction (RR 1.08, 95% CI 0.73–1.60), revascularization (RR 1.03, 95% CI 0.77–1.38), and cerebrovascular events (RR 0.77, 95% CI 0.23–2.61).
Conclusion:
Existing evidence does not support an association between CPAP treatment and decreased risk of recurrent cardiovascular events in patients with CAD and OSA, regardless of adherence to CPAP.
What is known and objective
People with type 2 diabetes (T2D) are at increased risk of cardiovascular disease (CVD), which in turn is associated with increased morbidity and mortality. The impact of ...glucagon‐like peptide‐1 receptor agonists (GLP‐1 RAs) on cardiovascular (CV) outcomes has been investigated in CV outcomes trials (CVOTs). This review aims to help pharmacists and other healthcare professionals (HCPs) gain a better understanding of such CVOTs in T2D with a primary focus on the once‐weekly (QW) GLP‐1 RAs.
Methods
This narrative review mainly focuses on the evaluation of the similarities and differences in the design and results of CVOTs involving currently approved and marketed QW GLP‐1 RAs—semaglutide subcutaneous, exenatide extended‐release (ER) and dulaglutide. Results from CVOTs of dipeptidyl peptidase‐4 inhibitors (DPP4is) and sodium‐glucose cotransporter‐2 inhibitors (SGLT2is) are also included.
Results and discussion
Three CVOTs of QW GLP‐1 RAs were identified for inclusion in this review: SUSTAIN 6 (semaglutide), EXSCEL (exenatide ER) and REWIND (dulaglutide), all of which varied in terms of trial design, patient demographics and other baseline characteristics. Results from these CVOTs demonstrated the CV safety of QW GLP‐1 RAs compared with standard of care. Additionally, CV and renal benefits were demonstrated for semaglutide and dulaglutide, but not for exenatide ER. The CV safety of four DPP4is and three SGLT2is was demonstrated. None of the DPP4is had a CV or renal benefit, whereas all three SGLT2is were associated with CV and renal benefits.
What is new and conclusion
This article provides an overview of the results from QW GLP‐1 RA CVOTs, including the recently published results for dulaglutide, and places them within the broader T2D treatment landscape to help HCPs make informed decisions in daily practice. The QW GLP‐1 RAs with benefits reaching beyond glycaemic control can provide a comprehensive treatment option for people with T2D at high risk of CVD, with CVD or chronic kidney disease.
This study investigated the effects of weight loss during follow-up on cardiovascular outcomes in a type 2 diabetes cohort and tested interactions with clinical and laboratory variables, particularly ...physical activity, that could impact the associations.
Relative weight changes were assessed in 651 individuals with type 2 diabetes and categorized as ≥5% loss, <5% loss, or gain. Associations between weight loss categories and incident cardiovascular outcomes (total cardiovascular events CVEs, major adverse cardiovascular events MACEs, and cardiovascular mortality) were assessed using multivariable Cox regression with interaction analyses.
During the initial 2 years, 125 individuals (19.2%) lost ≥5% of their weight, 180 (27.6%) lost <5%, and 346 (53.1%) gained weight. Over a median additional follow-up of 9.3 years, 188 patients had CVEs (150 MACEs) and 106 patients died from cardiovascular causes. Patients with ≥5% weight loss had a significantly lower risk of total CVEs (hazard ratio HR, 0.52; 95% confidence interval, 0.33 to 0.89; P=0.011) than those who gained weight, but non-significant lower risks of MACEs or cardiovascular deaths. Patients with <5% weight loss had risks similar to those with weight gain. There were interactions between weight loss and physical activity. In active individuals, ≥5% weight loss was associated with significantly lower risks for total CVEs (HR, 0.20; P=0.004) and MACEs (HR, 0.21; P=0.010), whereas in sedentary individuals, no cardiovascular protective effect of weight loss was evidenced.
Weight loss ≥5% may be beneficial for cardiovascular disease prevention, particularly when achieved with regular physical activity, even in high-risk individuals with long-standing type 2 diabetes.
Non-alcoholic fatty liver disease (NAFLD), identified by the Fatty Liver Index (FLI), is associated with increased mortality and cardiovascular (CV) outcomes. Whether this also applies to type 1 ...diabetes (T1D) has not been yet reported.
We prospectively observed 774 subjects with type 1 diabetes (males 52%, 30.3 ± 11.1 years old, diabetes duration (DD) 18.5 ± 11.6 years, HbA1c 7.8 ± 1.2%) to assess the associations between FLI (based on BMI, waist circumference, gamma-glutamyl transferase and triglycerides) and all-cause death and first CV events.
Over a median 11-year follow-up, 57 subjects died (7.4%) and 49 CV events (6.7%) occurred among 736 individuals with retrievable incidence data. At baseline, FLI was < 30 in 515 subjects (66.5%), 30-59 in 169 (21.8%), and ≥ 60 in 90 (11.6%). Mortality increased steeply with FLI: 3.9, 10.1, 22.2% (p < 0.0001). In unadjusted Cox analysis, compared to FLI < 30, risk of death increased in FLI 30-59 (HR 2.85, 95% CI 1.49-5.45, p = 0.002) and FLI ≥ 60 (6.07, 3.27-11.29, p < 0.0001). Adjusting for Steno Type 1 Risk Engine (ST1-RE; based on age, sex, DD, systolic BP, LDL cholesterol, HbA1c, albuminuria, eGFR, smoking and exercise), HR was 1.52 (0.78-2.97) for FLI 30-59 and 3.04 (1.59-5.82, p = 0.001) for FLI ≥ 60. Inclusion of prior CV events slightly modified HRs. FLI impact was confirmed upon adjustment for EURODIAB Risk Engine (EURO-RE; based on age, HbA1c, waist-to-hip ratio, albuminuria and HDL cholesterol): FLI 30-59: HR 1.24, 0.62-2.48; FLI ≥ 60: 2.54, 1.30-4.95, p = 0.007), even after inclusion of prior CVD. CV events incidence increased with FLI: 3.5, 10.5, 17.2% (p < 0.0001). In unadjusted Cox, HR was 3.24 (1.65-6.34, p = 0.001) for FLI 30-59 and 5.41 (2.70-10.83, p < 0.0001) for FLI ≥ 60. After adjustment for ST1-RE or EURO-RE, FLI ≥ 60 remained statistically associated with risk of incident CV events, with trivial modification with prior CVD inclusion.
This observational prospective study shows that FLI is associated with higher all-cause mortality and increased risk of incident CV events in type 1 diabetes.
To provide an update on the connection between obstructive sleep apnea (OSA) and cardiovascular disease.
Large prospective studies have established that OSA is associated with an increased incidence ...of hypertension and, in men, of coronary disease, stroke, and heart failure. Advances in understanding the pathophysiologic basis for these associations include identification of a role for OSA in inducing abnormalities in hepatic lipid-metabolizing enzymes, endothelial dysfunction, and upregulation of pro-inflammatory and pro-thrombotic mediators. A large body of data implicates OSA as playing a significant role in the occurrence and resistance to treatment of atrial fibrillation. Clinical trials have shown small-to-modest improvements in blood pressure associated with continuous positive airway pressure (CPAP) use, with smaller or uncontrolled studies suggesting that CPAP may improve cardiovascular outcomes or intermediate markers.
OSA and cardiovascular disease commonly co-aggregate. Multiple studies indicate that OSA contributes to or exacerbates cardiovascular disease, and thus may be a novel target for cardiovascular risk reduction. Although the evidence supports screening and treatment of OSA in patients at risk for cardiovascular disease, it also underscores a need for well powered clinical trials to examine the role of CPAP and other therapies in these populations.
Adults with type 2 diabetes mellitus can benefit from pharmacotherapies that lower their risk for cardiovascular disease. This review describes the salient findings from sodium-glucose ...cotransporter-2 (SGLT2) inhibitor cardiovascular outcome trials that serendipitously revealed the cardiorenal benefits of SGLT2 inhibitors in adults with type 2 diabetes mellitus who either have established cardiovascular disease or multiple cardiovascular risk factors. It also summarizes the findings from other phase 3 clinical studies that measured the cardiovascular effects of SGLT2 inhibitors and real-world evidence reports that compared the cardiovascular impact of SGLT2 inhibitors with other antihyperglycemic agents. The collective data indicate that SGLT2 inhibitors are pleiotropic agents that offer important cardiovascular, metabolic and renal benefits beyond glucose lowering with low incidences of hypoglycemia. Specifically, the placebo-controlled SGLT2 inhibitor cardiovascular outcome trials documented either fewer major adverse cardiac events (nonfatal myocardial infarction, nonfatal stroke and cardiovascular death) or a reduction in the composite endpoint of cardiovascular death or hospitalization for heart failure in participants with type 2 diabetes mellitus and established cardiovascular disease. Amongst those with type 2 diabetes mellitus who did not have established cardiovascular disease but did present with multiple risk factors, SGLT2 inhibitors lowered the combined endpoint of cardiovascular death or hospitalization for heart failure but had little impact on the occurrence of major adverse cardiac events. Ongoing clinical trials and subanalyses of the trials that have been reported should shed further light on the clinical benefits and utility of SGLT2 inhibitors.
Adultes atteints du diabète sucré de type 2 peuvent bénéficier des pharmacothérapies qui abaissent leur risque de maladies cardiovasculaires. La présente revue décrit les principaux résultats des essais sur les résultats cardiovasculaires des inhibiteurs du cotransporteur sodium-glucose de type 2 (SGLT2) qui ont fortuitement révélé les bénéfices cardio-rénaux des inhibiteurs du SGLT2 chez les adultes atteints du diabète sucré de type 2 ayant soit une maladie cardiovasculaire établie ou de multiples facteurs de risque cardiovasculaire. De plus, elle récapitule les résultats d’autres études cliniques de phase III qui portaient sur la mesure des effets cardiovasculaires des inhibiteurs du SGLT2 et fait la synthèse des données probantes du monde réel sur la comparaison des répercussions cardiovasculaires des inhibiteurs du SGLT2 aux autres antihyperglycémiants. L’ensemble des données indiquent que les inhibiteurs du SGLT2 sont des agents à effets pléiotropiques qui, outre la réduction de la glycémie, apportent des bénéfices cardiovasculaires, métaboliques et rénaux, et entraînent un faible risque d’hypoglycémie. Particulièrement, les essais sur les résultats cardiovasculaires des inhibiteurs du SGLT2 contre placebo ont démontré soit une moindre survenue d’événements cardiaques indésirables majeurs (infarctus du myocarde non fatal, accident vasculaire cérébral non fatal et décès d’origine cardiovasculaire) soit une diminution de la survenue du critère combiné de décès d’origine cardiovasculaire ou d’hospitalisation pour insuffisance cardiaque chez les participants atteints de diabète sucré de type 2 et d’une maladie cardiovasculaire établie. Parmi les individus atteints du diabète sucré de type 2 qui n’avaient pas de maladie cardiovasculaire établie, mais présentaient de multiples facteurs de risque, les inhibiteurs du SGLT2 ont fait réduire les critères combinés de décès d’origine cardiovasculaire ou d’hospitalisation pour insuffisance cardiaque, mais avaient peu de répercussions sur la survenue d’événements cardiaques indésirables majeurs. Les essais cliniques et les sous-analyses d’essais en cours rapportées devraient davantage élucider les avantages cliniques et l’utilité des inhibiteurs du SGLT2.
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