Glycemic Control in Diabetic Foot Ulcers: A Comparative Analysis of Wound and Wound-free Periods in Adult Patients with type 1 and type 2 diabetes mellitus.

AIM: To determine whether there are differences in glycemia during wound and wound-free states among individuals with diabetes at a Multidisciplinary Diabetic Foot and Wound Clinic from 2012-2019. METHODS: We conducted a retrospective analysis of prospectively collected data over 7.4 years from the Johns Hopkins Multidisciplinary Diabetic Foot and Wound Clinic. Participants with diabetic foot ulcers (DFUs) were observed during at least one wound period and one wound-free period and had at least one hemoglobin A1C (A1C) measurement in both a wound and wound-free period. The A1C measurements were aggregated and summarized across wound and wound-free periods, and compared using the Wilcoxon matched-pairs signed rank test. RESULTS: 206 eligible participants with a total of 623 wounds were included in this analysis. Participants were followed for a median period of 2.4 years (876 days). There were no significant differences in mean, minimum, and maximum A1C between the aggregate wound and wound-free period, with median (interquartile range [IQR]) values of 7.6% (6.6%, 9.1%) and 7.5% (6.6%, 9.1%) for mean A1C (p = 0.43), 6.9% (6.0%, 8.0%) and 6.8% (6.0%, 8.1%) for minimum A1C (p = 0.78), and 8.6% (7.1%, 10.9%) and 8.5% (7.0%, 10.7%) for maximum A1C (p = 0.06) in the wound and wound-free period respectively. CONCLUSIONS: This retrospective study showed similar levels of A1C during wound and wound-free periods, but given limitations of missing A1C and small sample size, further studies leveraging continuous glucose monitoring (CGM) data are needed to understand whether glycemia worsens in the setting of a DFU.

Racial Disparities in Access and Use of Diabetes Technology Among Adult Patients With Type 1 Diabetes in a U.S. Academic Medical Center.

OBJECTIVE: Recent studies highlight racial disparities in insulin pump (PUMP) and continuous glucose monitor (CGM) use in children and adolescents with type 1 diabetes (T1D). This study explored racial disparities in diabetes technology among adult patients with T1D. RESEARCH DESIGN AND METHODS: This was a retrospective clinic-based cohort study of adult patients with T1D seen consecutively from April 2013 to January 2020. Race was categorized into non-Black (reference group) and Black. The primary outcomes were baseline and prevalent technology use, rates of diabetes technology discussions (CGMdiscn, PUMPdiscn), and prescribing (CGMrx, PUMPrx). Multivariable logistic regression analysis evaluated the association of technology discussions and prescribing with race, adjusting for social determinants of health and diabetes outcomes. RESULTS: Among 1,258 adults with T1D, baseline technology use was significantly lower for Black compared with non-Black patients (7.9% vs. 30.3% for CGM; 18.7% vs. 49.6% for PUMP), as was prevalent use (43.6% vs. 72.1% for CGM; 30.7% vs. 64.2% for PUMP). Black patients had adjusted odds ratios (aORs) of 0.51 (95% CI 0.29, 0.90) for CGMdiscn and 0.61 (95% CI 0.41, 0.93) for CGMrx. Black patients had aORs of 0.74 (95% CI 0.44, 1.25) for PUMPdiscn and 0.40 (95% CI, 0.22, 0.70) for PUMPrx. Neighborhood context, insurance, marital and employment status, and number of clinic visits were also associated with the outcomes. CONCLUSIONS: Significant racial disparities were observed in discussions, prescribing, and use of diabetes technology. Further research is needed to identify the causes behind these disparities and develop and evaluate strategies to reduce them.

Cardiovascular Risk Heterogeneity in Adults with Diabetes: Selective Use of Coronary Artery Calcium in Statin Use Decision-making.

Current American College of Cardiology/American Heart Association and American Diabetes Association guidelines recommend statin therapy for all patients with diabetes between the ages of 40 and 75, including those without cardiovascular disease (CVD). While diabetes is a major CVD risk factor, not all patients with diabetes have an equal risk of CVD. Thus, a more risk-based approach warrants consideration when recommending statin therapy for the primary prevention of CVD. Coronary artery calcium (CAC) is a noninvasive imaging modality that can help risk stratify patients with diabetes for future CVD events. CAC has been extensively studied in large cohorts such as the Multi-Ethnic Study of Atherosclerosis and found to outperform other novel risk stratification tools including carotid intima-media thickness. Moreover, a CAC score of 0 has been shown to be useful in downgrading the estimated risk of a CVD event in patients with diabetes and an intermediate Pooled Cohort Equation score. As clinicians weigh the recommendation for a lifelong therapy and the problem of statin nonadherence and patients weigh concerns about adverse effects of statins, the decision to initiate statin therapy in patients with diabetes is ideally a shared one between patients and providers, and CAC could facilitate this discussion.

What Clinicians Need to Know About the Cardiovascular Effects of the Most Recent Classes of Drugs Used for Type 2 Diabetes.

The treatment of cardiovascular disease in patients with diabetes has seen a sea change in recent years with the development of novel antihyperglycemic agents. The impact of sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1 RAs), two medication classes introduced in the United States in the wake of increased scrutiny by the US Food and Drug Administration on cardiovascular disease and antihyperglycemic agents, highlight this progression. In recent trials, SGLT2 inhibitors have demonstrated significant reductions in admissions for heart failure in patients with established cardiovascular disease and those at risk of cardiovascular disease, as well as significant reductions in major adverse cardiovascular events for those with established cardiovascular disease. GLP-1 RAs have exhibited consistent reductions in major adverse cardiovascular events for patients with established cardiovascular disease. These developments have led the 2019 American Diabetes Association guidelines to recommend considering each patient's cardiovascular history when selecting antihyperglycemic agents. The goal of this article is to review recent updates and provide relevant strategies for providers on SGLT2 and GLP-1 RAs in treating cardiovascular disease in patients with diabetes.

N-terminal pro-B-type natriuretic peptide and B-type natriuretic peptide for identifying coronary artery disease and left ventricular hypertrophy in ambulatory chronic kidney disease patients.

Elevated natriuretic peptide levels are common in patients with chronic kidney disease (CKD), as is the presence of coronary artery disease (CAD) and left ventricular hypertrophy (LVH). It was hypothesized that N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) and B-type natriuretic peptide (BNP) levels could identify CAD and LVH in asymptomatic patients with CKD. Clinical, laboratory, and echocardiographic data were collected prospectively in 54 ambulatory patients with CKD not requiring dialysis. CAD was defined by previous myocardial infarction or coronary revascularization. The median age was 70 years (interquartile range [IQR] 57 to 76). Fourteen patients (26%) had CAD, and 30 (56%) had LVH. Median NT-pro-BNP was 724 pg/ml (IQR 168 to 2,950), median BNP was 137 pg/ml (IQR 31 to 391), and the median glomerular filtration rate (GFR) was 31 ml/min/1.73 m2 (IQR 21 to 42). A strong correlation was found between NT-pro-BNP and BNP levels (R = 0.74, p <0.0001), but only moderate correlations were found between NT-pro-BNP and GFR (R = -0.45, p = 0.0006) and between BNP and GFR (R = -0.38, p = 0.005). There was no trend of an increase in the prevalence of LVH or CAD with decreasing GFR. However, across progressive NT-pro-BNP and BNP quartiles, the prevalences of LVH and CAD increased significantly. Receiver-operating characteristic curves showed that these 2 markers are similar and significant predictors for indicating LVH (area under the curve [AUC] 0.72, p = 0.005 for NT-pro-BNP; AUC 0.72, p = 0.007 for BNP) and CAD (AUC 0.80, p = 0.001 for NT-pro-BNP; AUC 0.82, p = 0.0004 for BNP; p = 0.45 for NT-pro-BNP vs BNP). In conclusion, NT-pro-BNP and BNP levels are significant and equivalent indicators of CAD and LVH in asymptomatic patients with CKD.

Intermittent cardiac troponin-I screening is an effective means of surveillance for a perioperative myocardial infarction.

OBJECTIVE: Several studies suggest that cardiac troponin-I (cTn-I) is a more sensitive indicator of cardiac injury compared with other biochemical markers of injury, but the strategy with the highest diagnostic yield (true positive and true negative) for perioperative surveillance is unknown. The authors undertook a prospective evaluation of the perioperative incidence of myocardial infarction (MI) and evaluated surveillance strategies for the diagnosis of MI. DESIGN: Prospective, cohort study. SETTING: Two university hospitals. PARTICIPANTS: Four hundred sixty-seven high-risk patients requiring noncardiac surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The diagnosis of myocardial injury was determined by cardiac protein markers combined with either postoperative changes on 12-lead electrocardiography or 1 of 3 clinical symptoms consistent with MI (chest pain, dyspnea, requirement for hemodynamic support). A receiver operating characteristic curve evaluating troponin in the diagnosis of MI revealed a value of 2.6 ng/mL as having the highest sensitivity and specificity. The sensitivity and specificity of cTn-I value > or =2.6 ng/mL, troponin > or =1.5 ng/mL, total creatine kinase (CK) > or =170 IU/L with MB > or =5%, and CK-MB > or =8 ng/mL were compared. Surveillance strategies were determined on a subset of patients (n = 257). The incidence of MI was 9.0% by cTn-I > or =2.6 ng/mL criteria, 19% by cTn-I > or =1.5 ng/mL, 13% by CK-MB mass, and 2.8% by CK-MB%. The specificity of cTn-I > or =2.6 ng/mL as an indicator of MI was 98%, and its positive predictive value (PPV) was 85%. Cardiac troponin-I > or =2.6 ng/mL had equal specificity but greater PPV than the cTn-I > or =1.5 ng/mL (specificity 98% and PPV 79%). If surveillance of cTn-I > or =2.6 ng/mL was used to detect MI, then the strategy with the highest diagnostic yield was surveillance on postoperative days 1, 2, and 3. CONCLUSIONS: Perioperative cardiac injury continues to occur frequently after noncardiac surgery, as detected by cTn-I. Serial monitoring of cardiac troponin-I on postoperative days 1, 2, and 3 provides the strategy with the highest diagnostic yield for surveillance of MI.

N-terminal pro-B-type natriuretic peptide for predicting coronary disease and left ventricular hypertrophy in asymptomatic CKD not requiring dialysis.

BACKGROUND: N-Terminal pro-B-type natriuretic peptide (NT-proBNP) level predicts underlying heart disease in the general population. However, because NT-proBNP clearance may depend on renal function, the significance of an elevated level in patients with chronic kidney disease (CKD) without cardiac symptoms is uncertain. We sought to determine whether there is an association between NT-proBNP level and coronary artery disease (CAD) and left ventricular hypertrophy (LVH) in this population. METHODS: We enrolled 207 ambulatory patients with CKD not on dialysis therapy. Medical records were reviewed for cardiac history and risk factors. NT-proBNP and troponin T (cTnT) levels were measured. Echocardiograms were analyzed from 99 patients. RESULTS: NT-proBNP levels were elevated in 116 patients (56%), and 67 patients (33%) had experienced prior CAD events (myocardial infarction or revascularization). The prevalence of advanced age, diabetes, prior CAD events, myocardial injury (cTnT > 0.03 ng/mL [>0.03 microg/L]), and LVH increased, whereas glomerular filtration rate decreased, across quartiles of NT-proBNP levels. After adjustment for glomerular filtration rate, cTnT level, age, and diabetes, NT-proBNP remained an independent indicator of prior CAD events compared with quartile 1 (cTnT range, 4 to 116 pg/mL) for quartile 2 (range, 122 to 490 pg/mL): odds ratio, 1.6; 95% confidence interval, 0.5 to 5.0; for quartile 3 (range, 490 to 1,819 pg/mL): odds ratio, 5.3; 95% confidence interval, 1.7 to 16.2; and for quartile 4 (>1,975 pg/mL): odds ratio, 4.1; 95% confidence interval, 1.3 to 13.5. For patients with echocardiograms, NT-proBNP level predicted prior CAD events independent of LVH. CONCLUSION: NT-proBNP level elevation in asymptomatic patients with CKD reflects underlying ischemic heart disease and hypertrophy independent of renal function in a population with anticipated high cardiac morbidity.

The value of preoperative pharmacologic stress testing before vascular surgery using ACC/AHA guidelines: a prospective, randomized trial.

OBJECTIVE: To evaluate the validity of preoperative cardiac stress testing using clinical predictors from the American College of Cardiology/American Heart Association Guidelines on Perioperative Evaluation before Noncardiac Surgery in patients undergoing vascular surgery. DESIGN: Prospective, randomized pilot study. SETTING: Academic medical center. PARTICIPANTS: Patients undergoing elective abdominal aortic, infrainguinal, and carotid vascular surgery. INTERVENTIONS: After stratification by American College of Cardiology/American Heart Association (ACC/AHA) Guideline parameters, 99 patients were randomized to preoperative cardiac stress testing or to no stress testing and followed for up to 12 months postoperatively for adverse cardiac outcomes. MEASUREMENTS AND MAIN RESULTS: Before hospital discharge of 46 patients who underwent preoperative stress testing, 7 (15%) had inducible ischemia with no adverse postoperative cardiac outcomes, whereas only 1 (3%) of 39 patients (85%) with no ischemia had a nonfatal adverse cardiac outcome (p = not significant). Of 53 patients without preoperative stress testing, only 2 (4%) had a nonfatal adverse postoperative cardiac outcome. There were no cardiac deaths. At 12-month follow-up in 79 (80%) patients, there was 1 nonfatal adverse cardiac outcome (no stress test) and 1 cardiac death (abnormal stress test), reflecting a 1% 12-month cardiac morbidity and mortality. CONCLUSION: In this small prospective, randomized study evaluating the validity of preoperative cardiac stress testing using ACC/AHA Guidelines before major vascular surgery, preoperative cardiac stress testing offered no incremental value for determining postoperative adverse cardiac outcomes. Larger randomized clinical trials are needed to confirm these findings.

Anti-atherosclerotic effects of statins: lessons from prevention trials.

Statins are best-known for their lipid-lowering effects and have been shown to significantly impact the natural progression of coronary atherosclerosis. The mechanism through which they exert this effect is thought to be primarily due to their ability to reduce low-density lipoprotein cholesterol levels. However, there is increasing evidence that statins exert a myriad of other beneficial effects on the vascular wall, thus altering the course of atherosclerotic disease. This article will review the prevention trial literature as it pertains to the effects of statin therapy on atherosclerosis.

Percutaneous coronary intervention vs. medical therapy: what are the implications for women?

There have been eight major studies assessing percutaneous coronary intervention (PCI) vs. medical therapy in the past 10 years. Women were inadequately represented in many of these studies, but because of similar long-term survival curves in women and men, most of the PCI data can be applied to women until more trials are published. According to currently available data, PCI offers greater angina relief and improvement in exercise tolerance than medicine alone, but has a greater risk of procedure-related complications in women. As a result of the rapid advancement of cardiovascular therapy, many of these studies did not incorporate optimal medical therapy or current PCI therapies. It is likely that for most patients (including women) with moderate angina, the best management may be a combination of PCI, medical therapy, and lifestyle changes.

Reducing global risk for cardiovascular disease: using lifestyle changes and pharmacotherapy.

Cardiovascular disease (CVD) is the leading cause of death and disability in industrialized societies, due in large part to the lack of a comprehensive approach to control the risk factors for atherosclerosis. One strategy for reducing an individual's global CVD risk relies on a targeted approach that modifies each of the major independent risk factors prevalent in both symptomatic (secondary prevention) and asymptomatic (primary prevention) patients. These interventions include lipid lowering, smoking cessation, blood pressure control, glycemic control, regular exercise, and the use of various medications. This review offers an evidence-based strategy toward reducing an individual's global risk for CVD by addressing the modifiable, major independent risk factors.