Обзор американских кардиологических журналов за неделю (ссылки)

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Glucose Control No Guarantee Against HF

By Michael Smith, North American Correspondent,
November 22, 2011

Action Points
Explain that a meta-analysis of eight randomized trials found that tight glycemic control did not decrease the risk of heart failure in patients with type 2 diabetes.


Note that for the subgroup treated with thiazolidinediones, the risk of heart failure was actually increased.
Review

For patients with type 2 diabetes, tight glycemic control does not reduce the risk of heart failure, according to a large meta-analysis.

Indeed, one class of drugs used to control glucose – the thiazolidinediones – may actually increase the risk, according to John McMurray, MD, of the University of Glasgow in Glasgow, Scotland, and colleagues.

The findings appear to contradict epidemiological evidence that has suggested a link between blood glucose, as measured by glycated hemoglobin (HbA1c) levels, and heart failure, McMurray and colleagues reported in the November issue of the American Heart Journal.

The reason for the apparent contradiction is "uncertain," but the researchers argued there are several possible explanations, including insufficient duration of treatment or follow-up, treatment too late in the disease course, and off-target toxicity of some treatments.

As well, they noted, it may be that hyperglycemia does not directly cause heart failure in diabetic patients, but instead is a marker of some other factor.

The findings come from a meta-analysis of eight randomized controlled trials that compared standard treatment with more aggressive glycemic control.

All told, the studies included 37,229 patients, although the study size varied sharply, from 153 to 11,140. Follow-up averaged from 2.3 to 10.1 years.

The researchers found:
Overall, participants given more intensive glucose-lowering regimens, had a weighted mean HbA1c concentration that was 0.9% lower than those offered conventional treatment.
There were 1,469 episodes of heart failure, including 107 deaths.
The overall event rate did not differ between groups -- 8.0 per 1,000 person-years of follow-up – although event rates varied markedly among the trials.
With meta-analytic pooling, intensive glucose control did not significantly increase the overall occurrence of heart failure. The odds ratio was 1.20, with a 95% confidence interval from 0.96 to 1.48.


However, in a prespecified analysis, the researchers broke out the four trials in which a large proportion of patients were treated with thiazolidinediones (also known as glitazones) and found an increased risk of heart failure associated with intensive glycemic control.

The odds ratio for heart failure, given intensive control, was 1.33, with a 95% confidence interval from 1.02 to 1.72, they reported.

Conversely, in the subgroup of trials that mainly used other anti-diabetic drugs -- sulfonylureas, metformin, or insulin – intensive treatment had little effect. The odds ratio for heart failure was 0.96, with a 95% confidence interval from 0.81 to 1.13.

McMurray and colleagues cautioned that the eight studies were conducted over a 13-year period during which diabetes management "has changed significantly."

They added that they did not have patient-level data and can't say anything about the relative benefits or harms of specific treatment regimens.

As well, potential modifiers of the effect – such things as age and duration of disease – could not be measured because of the small number of trials in the meta-analysis, the researchers noted.

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World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease
Los Angeles • November 3 - 5, 2011

Clinicians Greet Early Results for Type 2 Biologic
LOS ANGELES -- In this exclusive video, Yehuda Handelsman, MD, president and organizer of the World Congress on Insulin Resistance, Diabetes, and Cardiovascular Disease, talks about early results for a new monoclonal antibody for diabetes and other highlights of this year’s meeting.
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Overworked Kidneys May Be Tied to Stroke Risk
LOS ANGELES -- Renal hyperfiltration may be associated with a greater risk of stroke, especially in patients with the metabolic syndrome or diabetes, researchers found.
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One in Four May Have Hidden Prediabetes, Diabetes
LOS ANGELES -- Free screening by trained volunteers can pick up cases of dysglycemia and other diabetic conditions in the general population, researchers found.
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Selective Antibody Ups Insulin Sensitivity in Mouse Model
LOS ANGELES -- A monoclonal antibody selectively stimulated insulin signaling in vitro and improved fasting blood sugar in an animal study, but its effects on humans remain to be seen, researchers reported here.
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Pounds May Creep Back with Low-fat, Low-Carb Diets
LOS ANGELES -- Diets that cut out fats or carbohydrates may not lead to sustained weight reduction, according to a meta-analysis.
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Weight Loss Enriches Diabetics’ Quality of Life
LOS ANGELES -- Shedding excess pounds offers physical and mental health benefits for patients with type 2 diabetes, researchers found.
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Sleep Apnea Complicates Things in Diabetes
LOS ANGELES -- Diabetes patients with obstructive sleep apnea may have more autonomic dysfunction and also may be at greater risk of hypoglycemia, researchers said here.
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ISAR-REACT 4: Abciximab-heparin combo, bivalirudin similarly reduced risk for death
By

AHA Scientific Sessions 2011

ORLANDO, Fla. — Two commonly used anti-clotting regimens, abciximab plus heparin and bivalirudin, were similarly effective in preventing death, subsequent MI or need for further revascularization in patients with non-ST-segment elevation MI undergoing percutaneous coronary intervention.

Among patients assigned to abciximab (ReoPro, Centocor and Eli Lilly) plus unfractionated heparin (n=861), 10.9% experienced the primary composite endpoint of death, large recurrent MI, urgent target vessel revascularization or major bleeding in 30 days vs. 11% of patients assigned to bivalirudin (n=860; RR=0.99; 95% CI, 0.74-1.32). The secondary endpoint of efficacy in death, any recurrent MI or urgent TVR was also similar with dual therapy (12.8%) compared with bivalirudin (13.4%; RR=0.96; 95% CI, 0.74-1.25).

Furthermore, patients taking the abciximab-heparin combination were more likely to experience major bleeding than those taking bivalirudin (4.6% vs. 2.6%; RR=1.84; 95% CI, 1.1-3.07).”.

“These findings … show that bivalirudin might be the preferred drug in patients undergoing PCI for an acute MI, with or without ST-segment elevation,” Adnan Kastrati, MD, professor of interventional cardiology at Technische Universitat, Munich, Germany, said at a press conference.

The double blind ISAR-REACT 4 study included 1,721 patients with acute non-ST-segment elevation MI.

“Understanding which treatment works better is important because non-ST-segment elevation MI patients are in danger of further cardiovascular problems,” Kastrati said in a press release. “The results of PCI in these patients are strongly dependent on the efficacy and safety of the anti-clotting drugs used during the procedure.” – by Casey Murphy

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EXCELLENT: Everolimus-eluting stent noninferior to sirolimus-eluting stent in inhibition of late loss

Park KW. J Am Coll Cardiol. 2011;58:1844-1854.
By

The efficacy of everolimus-eluting stents in the inhibition of neointimal growth was noninferior to that of siroliumus-eluting stents, researchers found in an analysis of the EXCELLENT trial.

The prospective, randomized, open-label, multicenter trial was designed to compare angiographic outcomes of everolimus-eluting stents vs. sirolimus-eluting stents head-to-head. Researchers studied more 1,443 patients with 1,927 lesions who underwent percutaneous coronary intervention with random assignment to an everolimus-eluting stent (n=1,079) or sirolimus-eluting stent (n=364) from June 2008 to July 2009. Routine angiography was recommended at 9 months. The primary endpoint was in-segment late loss at 9 months; major secondary outcomes included in-stent late loss at 9 months, target lesion failure, cardiac death, nonfatal MI, target lesion revascularization and stent thrombosis at 12 months.

According to results, angiographic follow-up data at 9 months were available for 924 patients (1,215 lesions) and clinical follow-up was available for 1,428 patients. Mean in-segment late loss was 0.11 ± 0.38 mm in the everolimus-eluting stent group and 0.06 ± 0.36 mm in the sirolimus-eluting stent group (P for noninferiority=.0382). In-stent late loss was also noninferior in the everolimus-eluting stent group (0.19 ± 0.35 mm) compared with the sirolimus-eluting stent group (0.15 ± 0.34 mm in the sirolimus-eluting stent group (P for noninferiority=.0121).


Additional data showed no significant between-group differences in clinical endpoints. Incidence of target lesion failure was 3.75% in the everolimus-eluting stent group vs. 3.05% in the sirolimus-eluting stent group (P=.53). Definite and definite/probable stent thrombosis rates were 0.37% in the everolimus-eluting stent group vs. 0.83% in the siroliumus-eluting stent group (P=.38).
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SWEETHEART: Number of new diabetes cases higher in women
By

AHA Scientific Sessions 2011

ORLANDO, Fla. — Women with STEMI and non-STEMI had higher rates of newly diagnosed diabetes compared with men, according to data from the SWEETHEART registry.

“The objective of the study was to determine the prevalence of abnormal glucose metabolism in MI patients in clinical practice, to see if this does have an impact on hospital long-term outcomes after MI and, of course, to evaluate the adherence to guidelines for management of different subgroups of patients with abnormal glucose metabolism,” Anselm K. Gitt, MD, of Institut für Herzinfarktforschung at the Universität Heidelberg, Germany, said during a presentation of the registry’s results.


To identify abnormal glucose metabolism and document acute treatment and outcome, Gitt and colleagues enrolled 2,767 patients with STEMI or non-STEMI into the registry. An oral glucose tolerance test was performed 4 days after acute MI in patients with previously unknown diabetes. The researchers also examined the effect of newly diagnosed diabetes on 3-year mortality of MI and differences between men and women in the prevalence of abnormal glucose metabolism.

“If you look at patient characteristics, you can see what you typically see in registries in acute coronary syndrome or MI: that females are older,” Gitt said, noting that there was about an 8-year difference between men and women in the registry. “You can also see that there are differences in concomitant diseases, and you can see that already 30% of females had known diabetes, as compared with 23% of the male population.”

Because women were older and had a higher prevalence of known diabetes, the researchers were interested in how many more patients would receive a new diagnosis of diabetes, Gitt said.

Overall, at the time of MI, women had a higher rate and longer duration of diabetes (10 years vs. 7 years). They also had a higher prevalence of newly diagnosed impaired glucose metabolism when compared with men. Using an oral glucose tolerance test, the researchers identified another 19.8% of women with manifest diabetes vs. 15.3% of men. However, an additional 18.1% of women vs. 23.3% of men had impaired glucose tolerance or impaired fasting glucose. Nevertheless, at 68%, women had a higher prevalence of combined already known and newly diagnosed pathologic glucose metabolism than men (60.5%).

Researchers found that 3-year mortality rates for women with newly diagnosed diabetes (30.5%) were similar to women with previously identified diabetes (30%). In addition, women experienced prior MI and percutaneous coronary intervention less frequently than men.

For more information:
Gitt AK. Abstract #15682. Presented at: American Heart Association Scientific Sessions 2011; Nov. 12-16; Orlando, Fla.