Cardiovascular Safety and Benefits of Noninsulin Antihyperglycemic Drugs for the Treatment of Type 2 Diabetes Mellitus-Part 1.

Cardiovascular disease (CVD) is a major contributor to the morbidity and mortality associated with type 2 diabetes mellitus (T2DM). With T2DM growing in pandemic proportions, there will be profound healthcare implications of CVD in person with diabetes. The ideal drugs to improve outcomes in T2DM are those having antiglycemic efficacy in addition to cardiovascular (CV) safety, which has to be determined in appropriately designed CV outcome trials as mandated by regulatory agencies. Available evidence is largely supportive of metformin's CV safety and potential CVD risk reduction effects, whereas sulfonylureas are either CV risk neutral or are associated with variable CVD risk. Pioglitazone was also associated with improved CVD risk in patients with diabetes. The more recent antihyperglycemic medications have shown promise with regards to CVD risk reduction in T2DM patients at a high CV risk. Glucagon-like peptide-1 receptor agonists, a type of incretin-based therapy, were associated with better CV outcomes and mortality in T2DM patients, leading to the Food and Drug Administration approval of liraglutide to reduce CVD risk in high-risk T2DM patients. Ongoing and planned randomized controlled trials of the newer drugs should clarify the possibility of class effects, and of CVD risk reduction benefits in low-moderate CV risk patients. While metformin remains the first-line antiglycemic therapy in T2DM, glucagon-like peptide-1 receptor agonists should be appropriately prescribed in T2DM patients with baseline CVD or in those at a high CVD risk to improve CV outcomes. Dipeptidyl peptidase-4 inhibitors and sodium-glucose cotransporter-2 inhibitors are discussed in the second part of this review.

Cardiogenic shock during heart failure hospitalizations: Age-, sex-, and race-stratified trends in incidence and outcomes.

The objectives were to study the overall and age-, sex-, and race-stratified incidence of cardiogenic shock (CS) during heart failure hospitalizations (HFHs) not complicated by acute coronary syndromes (ACS), utilization of short-term mechanical circulatory support (MCS) and in-hospital mortality with non-ACS-related CS, and respective temporal trends. Data are lacking regarding the epidemiology of non-ACS-related CS during HFHs. METHODS: Retrospective observational analysis of the National Inpatient Sample 2005-2014 to identify all HFHs in adult patients without concomitant ACS. RESULTS: Of 8,333,752 HFHs, incidence rate of non-ACS-related CS was 8.7 per thousand HFHs (N = 72,668), a 4-fold increase from 4.1 to 15.6 per thousand HFHs between 2005 and 2014 (Ptrend < .001). Among those with non-ACS-related CS, utilization rates of intra-aortic balloon pump, extracorporeal membrane oxygenation, and temporary ventricular assist devices were 12.8%, 1.4%, and 2.5%, respectively. Respective 2005 to 2014 trends were 14.2% to 10.7%, 0.6% to 1.8%, and 0.8% to 2.7% (Ptrend for all, <.001). In-hospital mortality rate was 27.1%, with a substantial decrease from 42.4% in 2005 to 23.3% in 2014 (Ptrend < .001). These temporal trends were largely consistent across age, sex, and race subgroups. CONCLUSION: During HFHs in the United States, non-ACS-related CS occurred infrequently but was associated with substantial mortality. Non-ACS-related CS incidence and certain MCS utilization rates increased, and in-hospital mortality rate decreased between 2005 and 2014. These trends were generally homogenous across the age, sex, and race groups. The observed trends in incidence and mortality may be a reflection of increased identification of CS during HFHs, although further study is needed to assess whether temporal changes in care may have influenced outcomes.

Cardiac Magnetic Resonance for Diagnosis and Risk Stratification.

Cardiac MRI (CMR) is an essential tool for the evaluation of the patient with hypertrophic cardiomyopathy (HCM). First, the accurate morphologic imaging and measures that are possible with CMR help to ascertain the diagnosis. Second, the tissue characterization that can be done with MRI helps to define the abnormalities in the myocardium and to identify areas of fibrosis that have been linked to increase risk of sudden cardiac death and heart failure. In addition, CMR can help distinguish HCM from similar disease processes.

Antithrombotic Management of Patients With Prosthetic Heart Valves.

Valvular heart disease is a major public health issue. The prevalence of valvular heart disease is expected to increase due to an aging population. Valve dysfunction manifests as valve stenosis, regurgitation, or both due to various etiologies. Valve repair and replacement are the main treatment options for severe valve dysfunction. Valve replacement is achieved by using either a mechanical or a bioprosthetic valve. Mechanical valves are more durable but require lifelong anticoagulation with associated complications. Bioprosthetic valves usually require anticoagulation only transiently after implantation but are less durable and degenerate more rapidly. In this article, we discuss antithrombotic regimens in persons after valve operations. We discuss general issues and antithrombotic recommendations for patients undergoing surgical bioprosthetic valve replacement, mechanical valve replacement (including different regimens for different positions and types of mechanical valves), mitral valve repair, and transcatheter aortic valve replacement. In addition, we discuss the antithrombotic management of patients in special circumstances, including patients with mechanical valves who have recurrent bleeding or thrombotic events, patients with mechanical valves undergoing surgery, and pregnant women with mechanical valves.

Correlation between electrocardiographic changes and coronary findings in patients with acute myocardial infarction and single-vessel disease.

BACKGROUND: Correlation of ST-segment elevation on the 12-lead electrocardiogram (ECG) with the expected affected coronary territory is established in patients with ST-elevation myocardial infarction (STEMI). In patients with non-ST-elevation myocardial infarction (NSTEMI), correlation of ischemic ECG abnormalities with the affected coronary territory has not been well-established. We sought to investigate the correlation of electrocardiographic abnormalities with the location of 1-vessel obstructive coronary artery disease (CAD) in patients with both STEMI and NSTEMI. METHODS: In this retrospective study, the charts of all patients referred for coronary angiography in 2012 were reviewed. Patients with a single obstructive coronary artery plus angina-equivalent symptoms and an elevated cardiac troponin I was included. Available ECGs were interpreted by an experienced cardiologist (WSA) blinded to the result of angiography. Patients with complete bundle branch block or ventricular pacing were excluded. Ischemic ECG changes were correlated to a coronary territory based on predefined criteria. RESULTS: Of 131 included patients (mean age 64±13 years; 74% male), 29 had STEMI and 102 had NSTEMI. Eleven of 11 patients (100%) with anterior STEMI had left anterior descending artery (LAD) obstructive CAD. Of 18 patients with inferior STEMI, 14 (78%) had right coronary artery (RCA) obstructive CAD, 3 (17%) had left circumflex artery (LCX) artery obstructive CAD, and 1 (5%) had LAD obstructive CAD. Of 102 NSTEMI patients, 53 (52%) had definite ECG ischemic abnormalities. Of 31 patients with anterior definite ECG ischemic abnormalities, 30 (97%) had LAD obstructive CAD, and 1 (3%) had RCA obstructive CAD. Of 22 patients with inferior definite ECG ischemic abnormalities, 14 (64%) had RCA obstructive CAD, 5 (23%) had LCX obstructive CAD, and 3 (14%) had LAD obstructive CAD. CONCLUSIONS: Patients with anterior STEMI had LAD obstructive CAD. Patients with inferior STEMI were highly likely to have RCA or LCX obstructive CAD. Only half of NSTEMI patients had definite ischemic ECG abnormalities. When present, anterior ischemic ECG changes in patients with single vessel CAD with NSTEMI were predictive of LAD obstructive CAD.

Cardiovascular benefits and safety of non-insulin medications used in the treatment of type 2 diabetes mellitus.

Diabetes mellitus is a growing in exponential proportions. If the current growth trend continues, it may result in every third adult in the United States having diabetes mellitus by 2050, and every 10th adult worldwide. Type 2 diabetes mellitus (T2DM) confers a 2- to 3-fold increased risk of cardiovascular (CV) events compared with non-diabetic patients, and CV mortality is responsible for around 80% mortality in this population. Patients with T2DM can have other features of insulin resistance-metabolic syndrome like hypertension, lipid abnormalities, and obesity which are all associated with increased CV disease and stroke risk even in the absence of T2DM. The management of a T2DM calls for employing a holistic risk factor control approach. Metformin is the first line therapy for T2DM and has been shown to have cardiovascular beneficial effects. Intense debate regarding the risk of myocardial infarction with rosiglitazone led to regulatory agencies necessitating cardiovascular outcome trials with upcoming anti-diabetic medications. Glucagon like peptide-1 agonists and sodium glucose co-transporter-2 inhibitors have shown promising CV safety and additional CV benefit in recent clinical trials. These drugs have favorable effects on traditional CV risk factors. The findings from these studies further support that fact that CV risk factor control plays an important role in reducing morbidity and mortality in T2DM patients. This review article will discuss briefly the cardiovascular safety and benefits of the oral medications which are currently being used for T2DM and will then discuss in detail about the newer medications being investigated for the treatment of T2DM.

Association of chest pain versus dyspnea as presenting symptom for coronary angiography with demographics, coronary anatomy, and 2-year mortality.

INTRODUCTION: The association of chest pain versus dyspnea with demographics, coronary angiographic findings, and outcomes of patients undergoing coronary angiography is unknown. MATERIAL AND METHODS: We studied 1,053 patients who had coronary angiography to investigate the association of chest pain versus dyspnea with demographics, coronary angiographic findings, and outcomes. RESULTS: Of 1,053 patients, 654 (62%) had chest pain, 229 (22%) had dyspnea, and 117 (11%) had chest pain and dyspnea. Patients with dyspnea were older (p < 0.0001) and had higher serum creatinine (p = 0.0011), lower left ventricular ejection fraction (LVEF) (p < 0.0001), more cardiogenic shock (p = 0.0004), less obstructive coronary artery disease (CAD) (p < 0.0001), less percutaneous coronary intervention (p < 0.0001), and similar 2-year mortality. Stepwise Cox regression analysis showed no significant difference in mortality between chest pain and dyspnea. Significant risk factors for time to death were age (hazard ratio (HR) = 1.07, p < 0.0001), serum creatinine (HR = 1.5, p < 0.0001), body mass index (HR = 0.93, p = 0.005), and obstructive CAD graft (HR = 3.2, p = 0.011). CONCLUSIONS: Patients undergoing coronary angiography presenting with dyspnea were older and had higher serum creatinine, lower LVEF, more frequent cardiogenic shock, less obstructive CAD, and less percutaneous coronary intervention compared to patients presenting with chest pain but similar 2-year mortality.