European journal of preventive cardiology最新文献

Aims: This study aims to assess pharmacological treatment patterns and outcomes according to the coexistence of heart failure (HF) and Type 2 diabetes (T2DM).

Methods and results: Two cohorts were derived: HF patients with/without T2DM and T2DM patients with/without HF, by linking the Swedish HF Registry, the National Diabetes Registry, and other national registries in 2017-2021. In 37 903 patients with HF (35% females, median age 74), T2DM was independently associated with a 10-fold higher use of sodium-glucose cotransporter-2 inhibitors (SGLT2is) and less likely use of mineralocorticoid receptor antagonists (MRAs) irrespective of ejection fraction (EF), and of renin-angiotensin inhibitors (RASis)/angiotensin receptor-neprilysin inhibitors (ARNis) in HF with reduced and mildly reduced EF. Over a median follow-up of 1.8 years, T2DM was independently associated with higher risk of first HF hospitalization (HHF)/cardiovascular (CV) death, first HHF, and all-cause death, but not with CV death alone. In 16 266 patients with T2DM (29% females, median age 76), HF was independently associated with more likely use of SGLT2i but less likely use of metformin. Over a median follow-up of 2.2 years, HF was independently associated with higher risk of CV death, all-cause death, and myocardial infarction.

Conclusion: In HF, T2DM was associated with higher use of SGLT2i and lower use of MRA and RASi/ARNI despite being linked with a higher risk of death and HHF. In T2DM, presence of HF was linked with higher SGLT2i use and an independent higher risk of death and myocardial infarction. Heart failure was associated with comparatively greater risk increase than T2DM.

Aims: Circadian heart rate (HR) fluctuations are associated with cardiovascular health. We examined their relationship with microvascular disease and long-term survival in patients with diabetes.

Methods and results: In this secondary analysis from the CHAMP1ON cohort of 497 adults with metabolic disease, 349 participants who had type 1 or type 2 diabetes, baseline 24-h ambulatory blood pressure and HR monitoring (ABPM), and survival data over a 21-year observational follow-up were included. Clinical features, microvascular complications, and mortality rates were examined in participants with low circadian HR fluctuations [24-h HR standard deviation (SD) below the median of 30.4] and blunted nocturnal HR dip (<10%). Low 24-h HR SD and blunted nocturnal HR dip were associated with an adverse cardiometabolic risk profile and 12-23% higher prevalence of cardiac autonomic neuropathy and nephropathy. After 6251 person-year follow-up [21.0 (14.0-21.0) years], a total of 136 (39%) deaths occurred, of which 100 (68%) of cardiovascular cause. The low 24-h HR SD group had a higher risk for both cardiovascular [adjusted hazard ratio (aHR) 2.00, 95% confidence interval (CI) 1.30-3.08, P = 0.002] and all-cause mortality (aHR 1.61, 95% CI 1.13-2.29, P = 0.009), compared with high 24-h HR SD. Similarly, patients with blunted nocturnal HR dip had a higher risk for cardiovascular (aHR 1.63, 95% CI 1.08-2.46, P = 0.019) and all-cause mortality (aHR 1.69, 95% CI 1.20-2.38, P = 0.003), compared with those with preserved nocturnal HR dip.

Conclusion: Impaired circadian HR fluctuations are associated with microvascular disease and long-term cardiovascular and all-cause mortality in diabetes. The ABPM-derived HR measures may provide a widely available and inexpensive risk stratification tool in this high-risk population.

Aims: Evidence is limited as to who benefit the most from sodium-glucose cotransporter 2 inhibitors (SGLT2i), especially among people without elevated cardiovascular disease (CVD) risk. To address this knowledge gap, we investigated the heterogeneity in the effect of SGLT2i across CVD risk profiles.

Methods and results: Using a target trial emulation framework, we compared SGLT2i vs. dipeptidyl peptidase 4 inhibitors (DPP4i) in a nationwide insurer-based database of working-age Japanese citizens in 2015-23. The primary outcome was a composite of all-cause death, myocardial infarction, stroke, or heart failure over 3 years. Machine learning causal forest was applied to assess heterogeneity by predicting individual-level risk reduction in primary outcomes by SGLT2i and its correlation with CVD risk score. Overall, among 150 830 individuals included in this study (mean age, 54 years; female, 13.3%), SGLT2i was associated with decreased risk of primary outcomes {3-year risk difference, +0.38 [95% confidence interval (CI): 0.16-0.61] percentage points}. The causal forest model revealed heterogeneity in the effectiveness of SGLT2i, with estimated benefit correlating weakly with CVD risk score (r = 0.287, P < 0.001). In particular, among 107 425 individuals with low CVD risk, 97 757 (91.0%) were predicted to benefit from SGLT2i. This subpopulation was characterized as individuals with higher blood pressure, body mass index, and fasting plasma glucose levels even with low CVD risk score.

Conclusion: The cardioprotective effect of SGLT2i was heterogeneous and more strongly predicted by individual patient characteristics than by overall CVD risk score, highlighting the importance of considering its benefit beyond the conventional risk stratification approach.

Aims: To quantify the productivity burden of cardiovascular disease (CVD) in type 2 diabetes and the potential benefits of improved CVD risk factor control.

Methods and results: We designed models to quantify the productivity burden (using the productivity-adjusted life-year; PALY) of CVD in Australians with type 2 diabetes aged 40-69 years from 2023-2032. PALYs were ascribed a financial value equivalent to gross domestic product (GDP) per full-time worker (AU$204 167 (€124 542)). The base-case model was designed to quantify the productivity burden of CVD in the target population. Then, other hypothetical scenarios were simulated to estimate the potential productivity gains resulting from improved control of risk factors. These scenarios included reductions in systolic blood pressure (SBP), number of smokers, total cholesterol, and incidence of type 2 diabetes. All future costs and outcomes were discounted at an annual rate of 5%. In the base-case (i.e. current projections), the estimated total PALYs lost due to CVD in type 2 diabetes were 1.21 million [95%CI (1.10-1.29 million)], contributing to an AU$258.93 (€157.94) billion [95%CI (AU$258.73-261.69 (€157.83-159.63) billion)] lost in the country's GDP. If there were reductions in SBP, number of smokers, total cholesterol, and incidence of type 2 diabetes, there would be gains of 7,889, 28,971, 7,117, and 320 124 PALYs, respectively. These improvements would also lead to economic gains of AU$1.72 (€1.05) billion, AU$6.21 (€3.79) billion, AU$1.55 billion (€947.33 million), and AU$68.34 (€41.69) billion, respectively.

Conclusion: Targeted 'early lifestyle' strategies that can prevent CVD in Australians with type 2 diabetes are likely to positively impact Australian health and work productivity.

Chronic kidney disease (CKD) is a complex and progressive condition ultimately leading to premature death. Diabetes is the leading cause of end-stage kidney disease worldwide. Up till 2024, international clinical guidelines have established three therapeutic pillars to delay CKD progression in people with type 2 diabetes (T2D): renin-angiotensin system inhibitors, sodium-glucose cotransporter 2 inhibitors, and the non-steroidal mineralocorticoid receptor antagonist finerenone. With the recent results from the Evaluate Renal Function with Semaglutide Once Weekly study, the glucagon-like peptide-l receptor agonist (GLP-1 RA) class is now considered a new therapeutic pillar in reducing CKD complications in this patient population. In this expert opinion, we identify patient populations at risk of developing new onset or worsening pre-existing CKD to explore optimal therapeutic strategies, introducing GLP-1 RAs. We highlight the important challenges that remain in optimising, sequencing, and combining these four therapeutic pillars. Even though the conventional approach of combining the pillars has been based on the historical emergence of evidence, we discuss the factors that would influence physicians' decision for preferring one pillar over another, and for selecting a certain combination, whether performed simultaneously or sequentially. These factors include the grade of CKD and the level of albuminuria; diabetic control (glycaemia); comorbidities: atherosclerotic cardiovascular disease, heart failure, obesity; concomitant medications; biological variables: potassium serum levels. The efficacy and safety profiles of each pillar, as demonstrated in landmark trials that have clearly shown the nephroprotective effects, along with real-world data, should also be carefully considered when selecting the most appropriate therapeutic option.