Epidemiology of heart failure in diabetes: a disease in disguise.

Left ventricular diastolic dysfunction (LVDD) without symptoms, and heart failure (HF) with preserved ejection fraction (HFpEF) represent the most common phenotypes of HF in individuals with type 2 diabetes mellitus, and are more common than HF with reduced ejection fraction (HFrEF), HF with mildly reduced ejection fraction (HFmrEF) and left ventricular systolic dysfunction (LVSD) in these individuals. However, diagnostic criteria for HF have changed over the years, resulting in heterogeneity in the prevalence/incidence rates reported in different studies. We aimed to give an overview of the diagnosis and epidemiology of HF in type 2 diabetes, using both a narrative and systematic review approach; we focus narratively on diagnosing (using the 2021 European Society of Cardiology [ESC] guidelines) and screening for HF in type 2 diabetes. We performed an updated (2016-October 2022) systematic review and meta-analysis of studies reporting the prevalence and incidence of HF subtypes in adults ≥18 years with type 2 diabetes, using echocardiographic data. Embase and MEDLINE databases were searched and data were assessed using random-effects meta-analyses, with findings presented as forest plots. From the 5015 studies found, 209 were screened using the full-text article. In total, 57 studies were included, together with 29 studies that were identified in a prior meta-analysis; these studies reported on the prevalence of LVSD (n=25 studies, 24,460 individuals), LVDD (n=65 studies, 25,729 individuals), HFrEF (n=4 studies, 4090 individuals), HFmrEF (n=2 studies, 2442 individuals) and/or HFpEF (n=8 studies, 5292 individuals), and on HF incidence (n=7 studies, 17,935 individuals). Using Hoy et al's risk-of-bias tool, we found that the studies included generally had a high risk of bias. They showed a prevalence of 43% (95% CI 37%, 50%) for LVDD, 17% (95% CI 7%, 35%) for HFpEF, 6% (95% CI 3%, 10%) for LVSD, 7% (95% CI 3%, 15%) for HFrEF, and 12% (95% CI 7%, 22%) for HFmrEF. For LVDD, grade I was found to be most prevalent. Additionally, we reported a higher incidence rate of HFpEF (7% [95% CI 4%, 11%]) than HFrEF 4% [95% CI 3%, 7%]). The evidence is limited by the heterogeneity of the diagnostic criteria over the years. The systematic section of this review provides new insights on the prevalence/incidence of HF in type 2 diabetes, unveiling a large pre-clinical target group with LVDD/HFpEF in which disease progression could be halted by early recognition and treatment.Registration PROSPERO ID CRD42022368035.

Infective Endocarditis of the Aortic Valve with Anterior Mitral Valve Leaflet Aneurysm.

Mitral valve leaflet aneurysm is a rare and potentially devastating complication of aortic valve endocarditis. We report the case of a 48-year-old man who had endocarditis of the native aortic valve and a concomitant aneurysm of the anterior mitral valve leaflet. Severe mitral regurgitation occurred after the aneurysm perforated. The patient showed no signs of heart failure and completed a 6-week regimen of antibiotic therapy before undergoing successful aortic and mitral valve replacement. In addition to the patient's case, we review the relevant medical literature.

Predictors of outcome in patients undergoing MitraClip implantation: An aid to improve patient selection.

BACKGROUND: MitraClip implantation (MCI) reduces mitral regurgitation (MR) and symptoms in patients considered inoperable or with high-surgical risk. Data to determine the benefit from MCI for an individual patient are limited. The aim of this study is to determine predictors associated with the prognosis after MCI to improve the patient selection for this procedure. METHODS: We included 84 consecutive patients (age: 76 ± 10 years, 51% male) who underwent MCI in our institution for symptomatic severe MR. All patients underwent transthoracic echocardiography before MCI; clinical and echocardiographic follow-up was obtained after MCI. RESULTS: The 2-year survival was 81%. Predictors for two-year mortality in multi-variate analysis were baseline NT-proBNP ≥ 5000 µg/L (HR: 5.4, 95% CI: 1.8-16.2), previous valve surgery (HR: 4.5, 95% CI: 1.7-12.2), tricuspid regurgitation (TR)≥ grade 3 prior to MCI (HR: 2.8, 95% CI: 1.2-6.8) and absence of MR reduction after MCI (HR: 2.1, 95% CI: 1.2-3.8). The 2-year survival of patients with 0, 1 or ≥ 2 of these predictors was: 87%; 78% and 38% respectively (log-rank p < 0.001). The functional class at 1 month and mid-term follow-up was worse in patients with two or more of these predictors present at baseline compared to patients with zero or one of these predictors (1 month: p = 0.007 and mid-term: p < 0.001). CONCLUSION: Heart failure, previous valve surgery, co-presence of TR and the degree of MR reduction after MCI are the independent predictors of survival and functional status after MCI in high risk patients. The pre-procedural characteristics may be used to optimize patient selection, while maximal MR reduction should be attempted to optimize the outcome of MCI.

Hypertension control in a large multi-ethnic cohort in Amsterdam, The Netherlands: the HELIUS study.

OBJECTIVE: Hypertension is a major problem among European ethnic minority groups. We assessed the current situation of hypertension prevalence and its management among a multi-ethnic population in Amsterdam, The Netherlands. METHODS: Data from the HELIUS study were used including 12,974 participants (1871 Ghanaian, 2184 African Surinamese, 2278 South-Asian Surinamese, 2277 Turkish, 2222 Moroccan and 2142 Dutch origin people), aged 18-70 years. Comparisons among groups were made using proportions and age-adjusted prevalence ratios (PRs). RESULTS: Hypertension prevalence ranged from 24% and 16% in Moroccan men and women to 52% and 62% in Ghanaian men and women. Except for Moroccan women, age-adjusted PR of hypertension was higher in all the ethnic minority groups than in Dutch. Among hypertensives, ethnic minority groups generally had higher levels of hypertension awareness and BP lowering treatment than Dutch. Moreover, prevalence rates for the prescription of more than one BP lowering drug were generally higher in African and South-Asian origin groups compared with Dutch origin people. By contrast, BP control levels were lower in all the ethnic groups than in Dutch, with control rates being significantly lower in Ghanaian men (26%, PR=0.49; 95% CI, 0.37-0.66) and women (45%, PR=0.64; 0.52-0.77), African-Surinamese men (30%, PR=0.61; 0.46-0.81) and women (45%, PR=0.72; 0.51-0.77), and South-Asian Surinamese men (43%, PR=0.77; 0.61-0.97) and women (47%, PR=0.76; 0.63-0.92) compared with Dutch men (53%) and women (61%). CONCLUSION: Our findings indicate poor BP control in ethnic minority groups despite the high treatment levels. More work is needed to unravel the potential factors contributing to the poor control in order to improve BP control in ethnic minority groups, particularly among African and South-Asian origin groups.

Feasibility and quality of cardiovascular disease prevention within a community-based health insurance program in rural Nigeria: an operational cohort study.

OBJECTIVE: To assess the feasibility of providing guideline-based cardiovascular disease (CVD) prevention care within the context of a community-based health insurance program (CBHI) in rural Nigeria. METHODS: A prospective operational cohort study was conducted in a primary healthcare clinic in rural Nigeria, participating in a CBHI program. The insurance program provided access to care and improved the quality of the clinics participating in the program, including CVD prevention guideline implementation. Insured adults at risk of CVD were consecutively included upon clinic attendance. The primary outcome was quality of care determined by scoring of quality indicators on patient files of the cohort, 1.5 year after guideline implementation. RESULTS: Of the 368 screened patients, 349 were included and 323 (93%) completed 1 year of follow-up. The majority of patients (331, 95%) had hypertension. Process indicators showed that 114/115 (99%) new hypertension cases had a record of CVD risk assessment and 249/333 (75%) eligible cases a record of lifestyle advice. Outcome indicators showed that in 292/328 (64%) hypertension cases, blood pressure was on target. Barriers to care included limited human resources, limited affordability of diagnostic tests and multidrug regimes for the healthcare provider, frequent doctor's appointments, and inefficient drug supplies. CONCLUSION: Implementation of CVD prevention care within the context of a CBHI program resulted in high-quality care in rural sub-Saharan Africa, comparable to high-income countries. However, guideline implementation was resource-intense and specific recommendations were not feasible. Simple models of care delivery are needed for rapid scale-up of CVD prevention services in sub-Saharan Africa.

Aortic valve calcification as a predictor of location and severity of paravalvular regurgitation after transcatheter aortic valve implantation.

OBJECTIVES: To determine whether the location of aortic valve calcium (AVC) influences the location of paravalvular regurgitation (PR). PR is an adverse effect of transcatheter aortic valve implantation (TAVI) with a negative effect on long-term patient survival. The relationship between AVC and the occurrence of PR has been documented. However, the relationship between the distribution of AVC and the location of PR is still sparsely studied. The purpose of this study was to correlate severity and location of AVC with PR in patients treated with TAVI. METHODS: Fifty-six consecutive patients who underwent transaortic or transapical TAVI and had preoperative computed tomography scans were included in this retrospective study. The volume, mass and location of AVC was determined and compared between patients with and without PR using a non-parametric t-test. Postoperative echocardiography was performed to determine the presence and location of PR, which was associated with the cusp with highest AVC using a χ(2) test. RESULTS: Valve deployment was successful in all 56 patients. PR was present in 38 patients (68%) after TAVI. There was a non-significantly higher volume of AVC in the PR group [214 (70-418) vs 371 (254-606) cm(3), P = 0.15]. AVC mass was significantly higher in patients with PR than in patients without PR [282 (188-421) vs 142 (48-259) mg, respectively, P = 0.043]. The location of PR was determined in 36 of these patients. Of these 36 patients, PR occurred at the cusp with the highest AVC in 20 patients (56%, χ(2) P = 0.030). CONCLUSIONS: In our population, PR was associated with greater AVC mass. Moreover, the location of PR was associated with the cusp with the highest amount of AVC.

Mitral inflow patterns after MitraClip implantation at rest and during exercise.

BACKGROUND: MitraClip implantation reduces mitral regurgitation effectively but decreases mitral valve area, creating iatrogenic mitral stenosis. Evaluation with transesophageal echocardiography intraprocedurally is necessary to measure mitral regurgitation and mitral valve pressure gradient (MVPG) to determine whether it is necessary and safe to place more clips. The aim of this study was to investigate whether these intraprocedural hemodynamics represent postprocedural measurements and whether exercise is affected by the stenosis. METHODS: In this retrospective single-center study, 51 patients who underwent MitraClip implantation were included. Measurements were performed intraprocedurally using transesophageal echocardiography and postprocedurally using transthoracic echocardiography. In 23 of these patients, exercise echocardiography was performed at follow-up. RESULTS: Intraprocedural mean MVPG was 3.0 ± 1.6 mm Hg and increased to 4.3 ± 2.2 mm Hg postprocedurally (P < .001). During exercise, mean MVPG increased significantly compared with rest conditions (from 3.6 ± 1.7 to 6.3 ± 2.7 mm Hg, P < .001). Six patients had mean resting MVPGs ≥ 5 mm Hg at follow-up and had higher systolic pulmonary artery pressure (sPAPs) than patients with mean MVPGs < 5 mm Hg (47 ± 7 vs 35 ± 12 mm Hg, P = .035). Higher MVPG and sPAP did not lead to more symptoms of heart failure. Receiver operating characteristic curve analysis showed an estimated cutoff point for intraprocedural pressure half-time of 91 msec to identify patients with mitral stenosis and sPAP ≥ 50 mm Hg postprocedurally. CONCLUSIONS: Mean MVPG during MitraClip implantation measured by TEE underestimates the hemodynamics in daily life, of which operators should be aware when deciding on placing one or more clips. Pressure half-time seems to be the most robust parameter compared with mean and maximum MVPG and may contribute to this decision. Patients with higher mean MVPGs after MitraClip implantation have higher sPAPs at follow-up. However, more symptoms of heart failure were not detected at follow-up.

Target organ damage among hypertensive adults in rural Nigeria: a cross-sectional study.

OBJECTIVES: To study the prevalence of target organ damage (TOD) in hypertensive adults in a general population in rural Nigeria, to assess determinants of TOD and the contribution of TOD screening to assess eligibility for antihypertensive treatment. METHODS: All adults diagnosed with hypertension (n=387) and a random sample (n=540) out of all nonhypertensive adults, classified during a household survey in 2009, had a blood pressure measurement and were invited for TOD (myocardial infarction, left ventricular hypertrophy, angina pectoris, kidney disease) screening in 2011. RESULTS: Participation in TOD screening was 51% (n=196) in respondents with hypertension and 33% (n=179) in those without hypertension. TOD prevalence in hypertensive and nonhypertensive adults was 32 and 15%, respectively. Hypertension severity was a strong determinant for TOD [grade 1 odds ratio (OR) 2.66, 95% confidence interval (CI)1.04-6.84; grade 2 OR 3.82, 95% CI 1.41-10.36]. Out of 196 hypertensive patients, 151 were untreated, of whom all grade 2 hypertensive patients (n=71) were eligible for treatment. Screening revealed TOD in 19 out of 80 grade 1 hypertensive respondents (24%), therefore also classifying them as eligible for treatment. TOD screening hypertensive nonrespondents had more severe hypertension than hypertensive respondents, which may have resulted in an underestimation of the true prevalence of TOD among adults with hypertension. CONCLUSION: A high prevalence of 32% TOD in hypertensive adults in rural Nigeria was observed. Almost a quarter of respondents with grade 1 hypertension were eligible for antihypertensive treatment based on TOD screening findings. As TOD screening is mostly unavailable in sub-Saharan Africa, we propose antihypertensive treatment for all patients with hypertension.

Cardiovascular disease prevention in rural Nigeria in the context of a community based health insurance scheme: QUality Improvement Cardiovascular care Kwara-I (QUICK-I).

BACKGROUND: Cardiovascular diseases (CVD) are a leading contributor to the burden of disease in low- and middle-income countries. Guidelines for CVD prevention care in low resource settings have been developed but little information is available on strategies to implement this care. A community health insurance program might be used to improve patients' access to care. The operational research project "QUality Improvement Cardiovascular care Kwara - I (QUICK-I)" aims to assess the feasibility of CVD prevention care in rural Nigeria, according to international guidelines, in the context of a community based health insurance scheme. DESIGN: prospective observational hospital based cohort study. SETTING: a primary health care centre in rural Nigeria. STUDY POPULATION: 300 patients at risk for development of CVD (patients with hypertension, diabetes, renal disease or established CVD) who are enrolled in the Hygeia Community Health Plan. MEASUREMENTS: demographic and socio- economic data, physical and laboratory examination, CVD risk profile including screening for target organ damage. MEASUREMENTS will be done at 3 month intervals during 1 year. Direct and indirect costs of CVD prevention care will be estimated. OUTCOMES: 1) The adjusted cardiovascular quality of care indicator scores based on the "United Kingdom National Health Services Quality and Outcome Framework". 2) The average costs of CVD prevention and treatment per patient per year for patients, the clinic and the insurance company. 3) The estimated net health care costs of standard CVD prevention care per quality-adjusted life year gained. ANALYSIS: The primary outcomes, the score on CVD quality indicators and cost data will be descriptive. The quality scores and cost data will be used to describe the feasibility of CVD prevention care according to international guidelines. A cost-effectiveness analysis will be done using a Markov model. DISCUSSION: Results of QUICK-I can be used by policy makers and professionals who aim to implement CVD prevention programs in settings with limited resources. The context of the insurance program will provide insight in the opportunities community health insurance may offer to attain sustainable chronic disease management programs in low resource settings. TRIAL REGISTRATION: This protocol has been registered at ISRCTN, ID number: ISRCTN47894401.

Genome-wide association study identifies a susceptibility locus at 21q21 for ventricular fibrillation in acute myocardial infarction.

Sudden cardiac death from ventricular fibrillation during acute myocardial infarction is a leading cause of total and cardiovascular mortality. To our knowledge, we here report the first genome-wide association study for this trait, conducted in a set of 972 individuals with a first acute myocardial infarction, 515 of whom had ventricular fibrillation and 457 of whom did not, from the Arrhythmia Genetics in The Netherlands (AGNES) study. The most significant association to ventricular fibrillation was found at 21q21 (rs2824292, odds ratio = 1.78, 95% CI 1.47-2.13, P = 3.3 x 10(-10)). The association of rs2824292 with ventricular fibrillation was replicated in an independent case-control set consisting of 146 out-of-hospital cardiac arrest individuals with myocardial infarction complicated by ventricular fibrillation and 391 individuals who survived a myocardial infarction (controls) (odds ratio = 1.49, 95% CI 1.14-1.95, P = 0.004). The closest gene to this SNP is CXADR, which encodes a viral receptor previously implicated in myocarditis and dilated cardiomyopathy and which has recently been identified as a modulator of cardiac conduction. This locus has not previously been implicated in arrhythmia susceptibility.

Prevalence of diabetes mellitus and the performance of a risk score among Hindustani Surinamese, African Surinamese and ethnic Dutch: a cross-sectional population-based study.

BACKGROUND: While the prevalence of type 2 diabetes mellitus (DM) is high, tailored risk scores for screening among South Asian and African origin populations are lacking. The aim of this study was, first, to compare the prevalence of (known and newly detected) DM among Hindustani Surinamese, African Surinamese and ethnic Dutch (Dutch). Second, to develop a new risk score for DM. Third, to evaluate the performance of the risk score and to compare it to criteria derived from current guidelines. METHODS: We conducted a cross-sectional population based study among 336 Hindustani Surinamese, 593 African Surinamese and 486 Dutch, aged 35-60 years, in Amsterdam. Logistic regressing analyses were used to derive a risk score based on non-invasively determined characteristics. The diagnostic accuracy was assessed by the area under the Receiver-Operator Characteristic curve (AUC). RESULTS: Hindustani Surinamese had the highest prevalence of DM, followed by African Surinamese and Dutch: 16.7, 8.1, 4.2% (age 35-44) and 35.0, 19.0, 8.2% (age 45-60), respectively. The risk score included ethnicity, body mass index, waist circumference, resting heart rate, first-degree relative with DM, hypertension and history of cardiovascular disease. Selection based on age alone showed the lowest AUC: between 0.57-0.62. The AUC of our score (0.74-0.80) was higher than that of criteria from guidelines based solely on age and BMI and as high as criteria that required invasive specimen collection. CONCLUSION: In Hindustani Surinamese and African Surinamese populations, screening for DM should not be limited to those over 45 years, as is advocated in several guidelines. If selective screening is indicated, our ethnicity based risk score performs well as a screening test for DM among these groups, particularly compared to the criteria based on age and/or body mass index derived from current guidelines.

Creatine kinase activity is associated with blood pressure.

BACKGROUND: We previously hypothesized that high activity of creatine kinase, the central regulatory enzyme of energy metabolism, facilitates the development of high blood pressure. Creatine kinase rapidly provides adenosine triphosphate to highly energy-demanding processes, including cardiovascular contraction, and antagonizes nitric oxide-mediated functions. Relatively high activity of the enzyme, particularly in resistance arteries, is thought to enhance pressor responses and increase blood pressure. Tissue creatine kinase activity is reported to be high in black people, a population subgroup with greater hypertension risk; the proposed effects of high creatine kinase activity, however, are not "race dependent." We therefore assessed whether creatine kinase is associated with blood pressure in a multiethnic population. METHODS AND RESULTS: We analyzed a stratified random sample of the population of Amsterdam, The Netherlands, consisting of 1444 citizens (503 white European, 292 South Asian, 580 black, and 69 of other ethnicity) aged 34 to 60 years. We used linear regression analysis to investigate the association between blood pressure and normal serum creatine kinase after rest, as a substitute measure of tissue activity. Creatine kinase was independently associated with blood pressure, with an increase in systolic and diastolic pressure, respectively, of 8.0 (95% CI, 3.3 to 12.7) and 4.7 (95% CI, 1.9 to 7.5) mm Hg per log creatine kinase increase after adjustment for age, sex, body mass index, and ethnicity. CONCLUSIONS: Creatine kinase is associated with blood pressure. Further studies are needed to explore the nature of this association, including how variation in cardiovascular creatine kinase activity may affect pressor responses.

Prevalence, awareness, treatment, and control of hypertension among Black Surinamese, South Asian Surinamese and White Dutch in Amsterdam, The Netherlands: the SUNSET study.

OBJECTIVE: To assess ethnic differences in prevalence, levels of awareness, treatment and control of hypertension among Dutch ethnic groups and to determine whether these differences are consistent with the UK findings. DESIGN: Cross-sectional survey. SETTING: South-east Amsterdam, The Netherlands. PARTICIPANTS: A random sample of 1383 non-institutional adults aged 35-60 years. Of these, 36.7% were White, 42% were Black and 21.3% were South Asian people. MAIN OUTCOME MEASURES: Prevalence of hypertension, rates of awareness, treatment, and control of hypertension. RESULTS: The Black and South Asian subjects had a higher prevalence of hypertension compared with White people. After adjustments for age, the odds ratios (95% confidence interval) for being hypertensive were 2.2 (1.4-3.4; P < 0.0001) and 3.8 (2.6-5.7; P < 0.0001) for Black men and women, respectively, and 1.7 (1.0-2.6; P = 0.039) and 2.8 (1.8-4.5; P < 0.0001) for South Asian men and women, compared with White people. There were no differences in awareness and pharmacological treatment of hypertension between the groups. However, Black hypertensive men 0.3 (0.1-0.7; P < 0.01) and women 0.5 (0.3-0.9; P < 0.05) were less likely to have their blood pressure adequately controlled compared with White people. CONCLUSION: The higher prevalence of hypertension found among Black and South Asian people in The Netherlands is consistent with the UK studies. However, the lower control rates and the similar levels of awareness and treatment of hypertension in Black Surinamese contrast with the higher rates reported in African Caribbeans in the UK. The rates for the South Asians in The Netherlands were relatively favourable compared to similar South Asian groups in the UK. These findings underscore the urgent need to develop strategies aimed at improving the prevention and control of hypertension, especially among Black people, in The Netherlands.