scholarly journals Novel multidisciplinary cardiometabolic clinic in a UK tertiary cardiology centre: early activity, interventions and potential for cardiovascular risk optimisation

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
R Narain ◽  
L Bijman ◽  
H Joshi ◽  
M Chen
Keyword(s):  
Beta Blockers ◽  
Lipid Lowering ◽  
Current Evidence ◽  
Pharmacological Management ◽  
Funding Sources ◽  
Increased Risk ◽  
Related Hospitalisation ◽  
Cardiac Centre ◽  
Risk Patients ◽  
Glucagon Like Peptide 1

Abstract Introduction Diabetes mellitus (DM) is associated with increased risk of adverse cardiovascular (CV) outcomes and a 2.5x risk of heart failure (HF). The potential to improve clinical outcomes in patients with DM and cardiovascular diseases (CVD) have been augmented by evidence from CV outcome trials of sodium-glucose co-transporter 2 inhibitors (SGLT2) and glucagon-like peptide 1 receptor agonists (GLP-1) demonstrating significant reduction in major adverse CV events (MACE) and reduction in HF-related hospitalisation. Purpose To review the initial activity and clinical interventions resulting from an innovative cardiometabolic clinic (CMC) service within an NHS tertiary cardiac centre, incorporating a consultant diabetologist and cardiologist, in which high risk patients' are addressed simultaneously. Methods Patient data (biochemistry, radiology results and observations including weight, symptoms, blood pressure, blood glucose) and clinic activity (consultation notes and GP correspondence) were reviewed retrospectively over a 6 month period from 29/09/2020 to 29/03/2021. Results A total of 144 patients were referred to CMC, of which 64 were seen during the study period, 6 did not attend, and 74 await an appointment. Of the 64 seen, 13 were discharged back to the referrer and/or to a more appropriate clinician. Referrals to other specialists have been made for 26 patients to augment their care. Initiation of SGLT2 and GLP-1 was recommended for 31 and 9 patients, respectively. Up-titrationof existing SGLT2i and GLP-1 was carried out for two patients already on each of these agents. Additionally, 28 other medications were initiated or optimised (5 diuretics, 3 antihypertensives, 3 lipid-lowering therapies, 2 beta blockers, 1 angiotensin-receptor blocker, 1 anticoagulant, 2 orlistat, 8 metformin and 3 other anti-diabetic). Medications for 12 patients were stopped due to intolerance. Each consultation included lifestyle interventions as per latest ESC guidelines. Among the 32 patients in whom antidiabetic drugs (including SGLT2, GLP-1) have been initiated or titrated, reduction in HbA1c has been observed in 11 patients (mean reduction 17.7 mmol/mol), while 3 have noted an increase (mean 4.7 mmol/mol) and results are pending for 18 patients. Collection of outcomes including hospitalisations for HF, CV events, ejection fraction, and is ongoing. The above has been achieved despite limitations imposed by the remote nature of the clinic due to the COVID-19 pandemic, which limits blood tests, echocardiograms and observations. This limitation is expected to be ameliorated by conducting in-person clinics in future. Conclusions Running of CMC in a MDT setting facilitates optimisation of the pharmacological management of risk factors in patients with cardiac and metabolic disease, particularly incorporation of current evidence-based therapies. Emerging outcomes indicate the potential impact of this service on patients' long term CV outcomes. FUNDunding Acknowledgement Type of funding sources: None.

Double Diabetes: A Growing Problem Requiring Solutions

2021 ◽  
Author(s):  
Djordje S. Popovic ◽  
Nikolaos Papanas
Keyword(s):  
Diabetes Mellitus ◽  
Therapeutic Interventions ◽  
Metabolic Phenotype ◽  
Lipid Lowering ◽  
Glucose Disposal ◽  
Increased Risk ◽  
Glucagon Like Peptide 1 ◽  
Reliable Marker ◽  
Estimated Glucose Disposal Rate ◽  
Double Diabetes

AbstractThe growing proportion of type 1 diabetes mellitus (T1DM) patients with clinical features of insulin resistance (IR) has led to the description of a distinctive T1DM subgroup, still unrecognised by current guidelines, called double diabetes, assumingly associated with poorer metabolic phenotype and increased risk of micro- and macrovascular complications. The main goal of identifying double diabetes, estimated to be present in up to half of T1DM patients, is timely implementation of appropriate therapeutic interventions to reduce the increased risk of chronic complications and other adverse metabolic traits associated with this condition. Proposed diagnostic criteria are largely divided into three different groups: family history of type 2 diabetes mellitus (T2DM), obesity/metabolic syndrome, and IR. Estimated glucose disposal rate may prove the most reliable marker of double diabetes. In addition to general measures (diet, physical activity, antihypertensive, and lipid-lowering medications, etc.) and development of new insulin preparations with more hepatic action, double diabetes patients may derive more benefit from agents developed for T2DM. Indeed, such potentially promising agents include glucagon-like peptide-1 receptor agonists, sodium-glucose contrasporter-2 inhibitors, and their combination. We are now awaiting long-term trials assessing metabolic and vascular benefits of these medications in double diabetes.

Pharmacological Management of Diabetic Nephropathy

2020 ◽  
Vol 18 (2) ◽  
pp. 139-147 ◽  
Author(s):  
Vasilios Papademetriou ◽  
Sofia Alataki ◽  
Konstantinos Stavropoulos ◽  
Christodoulos Papadopoulos ◽  
Kostas Bakogiannis ◽  
...  
Keyword(s):  
Diabetic Nephropathy ◽  
Renin Angiotensin System ◽  
Lipid Lowering ◽  
Pharmacological Management ◽  
Drug Classes ◽  
Sodium Glucose Cotransporter ◽  
Glucagon Like Peptide 1 ◽  
Lipid Lowering Agents ◽  
The Impact ◽  
Ras Inhibitors

Introduction:Diabetes mellitus (DM) is one of the most common diseases worldwide. Its adverse effects on several body organs, have made treatment of DM a priority. One of the most serious complications of DM is diabetic nephropathy (DN).Objective:The aim of this review is to critically discuss available data on the pharmacological management of DN.Objective:A comprehensive review of the literature was performed to identify studies assessing the impact of several drug classes on DN.Results:Several studies have been conducted in order to find a novel and effective treatment of DN. So far, the cornerstone therapy of DN consists of renin-angiotensin system (RAS) inhibitors, agents that decrease the synthesis of intrarenal angiotensin II or block its receptors. Their antiproteinuric and antihypertensive effects can not only decelerate the progress of DN but prevent its onset as well. Novel antidiabetic drugs, such as sodium-glucose cotransporter 2 inhibitors (SGLT-2i) and glucagon-like peptide- 1 receptor agonists (GLP-1 RA), are promising agents in the therapy of DN, due to their positive effect on renal and cardiovascular adverse events. From lipid-lowering agents, atorvastatin improves DN up to stage 3 and substantially reduces CVD.Conclusion:RAS inhibitors, SGLT-2i and GLP-1 agonists were found to be beneficial for the treatment of DN. Larger renal trials are needed in order to incorporate these drugs into the first line treatment of DN.

Umbrella Review on Non-Statin Lipid-Lowering Therapy

2021 ◽  
pp. 107424842110029
Author(s):  
Semira Abdi Beshir ◽  
Nadia Hussain ◽  
Asim Ahmed Elnor ◽  
Amira S. A. Said
Keyword(s):  
Unmet Need ◽  
Lipid Lowering ◽  
Current Evidence ◽  
Atherosclerotic Cardiovascular Disease ◽  
Lipid Lowering Therapy ◽  
Pcsk9 Inhibitors ◽  
Icosapent Ethyl ◽  
Lipid Lowering Drug ◽  
Increased Risk ◽  
Lowering Drug

Dyslipidemia, particularly increased low-density lipoprotein cholesterol (LDL-C) levels, are associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD) events. There is an unmet need for ASCVD risk reduction even with the optimal use of statin therapy, which has led to an ongoing search for novel targets for cholesterol reduction to decrease ASCVD events. Objectives: The main aim of this review was to summarize current evidence on approved and emerging non-statin lipid-lowering therapies. Methods and Materials: Recent literature on U.S. FDA approved non-statin lipid-lowering therapies and evolving lipid-lowering drugs currently under development was reviewed. Results and Discussion: In the past 20 years, the emergence of non-statin cholesterol-lowering drugs has changed the landscape of dyslipidemia management. Food and Drug Administration approval of non-statin lipid-lowering therapies such as ezetimibe, proprotein convertase subtilisin/Kexin type 9 (PCSK9) inhibitors (evolocumab, alirocumab), bempedoic acid and combination of bempedoic acid and ezetimibe, evinacumab and other triglyceride-lowering agents (eg, icosapent ethyl) has emerged. The European Commission has also recently approved inclisiran for treatment of hypercholesterolemia and mixed hypercholesterolemia even though FDA has put the approval of this drug on hold. Recent guidelines have incorporated PCSK9 inhibitors to treat patients with primary hyperlipidemia and patients with very high-risk ASCVD, who could not achieve adequate lipid-lowering with combination therapy of maximally tolerated statin and ezetimibe. Icosapent ethyl use as an adjunct therapy to statins is also recommended to reduce the risk of ASCVD in patients with hypertriglyceridemia. Conclusion: Despite cost limitations, the uptake of PCSK9 inhibitors is increasing. Approval of bempedoic acid alone or in combination with ezetimibe has provided additional oral lipid-lowering drug alternatives to ezetimibe. Various lipid-lowering drug targets are under investigation.

Statins in Stroke

2019 ◽  
Vol 26 (33) ◽  
pp. 6174-6185 ◽  
Author(s):  
Konstantinos Aznaouridis ◽  
Constantina Masoura ◽  
Charalambos Vlachopoulos ◽  
Dimitris Tousoulis
Keyword(s):  
Ischemic Stroke ◽  
Primary Prevention ◽  
Recurrent Events ◽  
Pleiotropic Effects ◽  
Lipid Lowering ◽  
Current Evidence ◽  
High Dose ◽  
Cerebrovascular Event ◽  
Increased Risk ◽  
Prevention Studies

Background: Stroke is a major cause of mortality and disability in modern societies. Statins are effective medications in decreasing cardiovascular events through lipid lowering and pleiotropic effects. Objective: To summarize current evidence regarding the role of statins in the prevention and management of stroke. Methods: A narrative review of current evidence regarding the effect of statins in stroke management. Electronic searches of MEDLINE, EMBASE and Cochrane Databases were performed. Results: In primary prevention of stroke in patients with risk factors but no established cardiovascular disease, potent statins such as atorvastatin and rosuvastatin have shown some benefits, but the clinical relevance of this effect is questionable. In populations at higher risk of stroke, such as patients with established coronary heart disease, the majority of relevant studies have shown a beneficial effect of statins in preventing stroke. Similarly, in patients with a previous cerebrovascular event, there is a clear benefit of statins for the prevention of recurrent events. The use of statins is not associated with an increased risk of intracranial bleeding in primary prevention studies. There may be an increased incidence of non-fatal hemorrhagic stroke with high dose statins in patients with a previous cerebrovascular event. Patients who experience a stroke while on statins should not discontinue statins. In addition, statins are associated with better survival and improved functional outcome when administered during the acute phase of stroke in statin-naive patients. In contrast, statins do not confer any benefit in patients with acute ischemic stroke who receive thrombolysis. Conclusion: Treatment with statins prevents ischemic stroke, especially in patients with high cardiovascular risk and established atherosclerotic disease. It seems that both lipid lowering and pleiotropic effects contribute to these effects.

A cluster-controlled clinical trial of two prophylactic silicone sacral dressings to prevent sacral pressure injuries in critically ill patients

2019 ◽  
pp. 21-26 ◽  
Author(s):  
Monica Stankiewicz ◽  
Jodie Gordon ◽  
Joel Dulhunty ◽  
Wendy Brown ◽  
Hamish Pollock ◽  
...  
Keyword(s):  
Clinical Trial ◽  
Intensive Care ◽  
Similar Efficacy ◽  
Care Patient ◽  
Controlled Clinical Trial ◽  
Cost Difference ◽  
Increased Risk ◽  
Pressure Injury ◽  
Risk Patients ◽  
The Mean

Objective Patients in the intensive care unit (ICU) have increased risk of pressure injury (PI) development due to critical illness. This study compared two silicone dressings used in the Australian ICU setting for sacral PI prevention. Design A cluster-controlled clinical trial of two sacral dressings with four alternating periods of three months' duration. Setting A 10-bed general adult ICU in outer-metropolitan Brisbane, Queensland, Australia. Participants Adult participants who did not have a sacral PI present on ICU admission and were able to have a dressing applied for more than 24 hours without repeated dislodgement or soiling in a 24-hour period (>3 times). Interventions Dressing 1 (Allevyn Gentle Border Sacrum™, Smith & Nephew) and Dressing 2 (Mepilex Border Sacrum™, Mölnlycke). Main outcomes measures The primary outcome was the incidence of a new sacral PI (stage 1 or greater) per 100 dressing days in the ICU. Secondary outcomes were the mean number of dressings per patient, the cost difference of dressings to prevent a sacral PI and product integrity. Results There was no difference in the incidence of a new sacral PI (0.44 per 100 dressing days for both products, p = 1.00), the mean number of dressings per patient per day (0.50 for both products, p = 0.51) and product integrity (85% for Dressing 1 and 84% for Dressing 2, p = 0.69). There was a dressing cost difference per patient (A$10.29 for Dressing 1 and A$28.84 for Dressing 2, p < 0.001). Conclusions Similar efficacy, product use and product integrity, but differential cost, were observed for two prophylactic silicone dressings in the prevention of PIs in the intensive care patient. We recommend the use of sacral prophylactic dressings for at-risk patients, with the choice of product based on ease of application, clinician preference and overall cost-effectiveness of the dressing.

Stroke in chronic renal failure

2008 ◽  
Vol 149 (15) ◽  
pp. 691-696
Author(s):  
Dániel Bereczki
Keyword(s):  
Risk Factors ◽  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Renal Disease ◽  
Chronic Renal Disease ◽  
Kidney Diseases ◽  
Cerebrovascular Diseases ◽  
Lipid Lowering ◽  
Increased Risk ◽  
Intracerebral Hemorrhages

Chronic kidney diseases and cardiovascular diseases have several common risk factors like hypertension and diabetes. In chronic renal disease stroke risk is several times higher than in the average population. The combination of classical risk factors and those characteristic of chronic kidney disease might explain this increased risk. Among acute cerebrovascular diseases intracerebral hemorrhages are more frequent than in those with normal kidney function. The outcome of stroke is worse in chronic kidney disease. The treatment of stroke (thrombolysis, antiplatelet and anticoagulant treatment, statins, etc.) is an area of clinical research in this patient group. There are no reliable data on the application of thrombolysis in acute stroke in patients with chronic renal disease. Aspirin might be administered. Carefulness, individual considerations and lower doses might be appropriate when using other treatments. The condition of the kidney as well as other associated diseases should be considered during administration of antihypertensive and lipid lowering medications.

Biochemical Markers in Patients with Readmission for Congestive Heart Failure

2018 ◽  
Vol 69 (7) ◽  
pp. 1687-1691
Author(s):  
Razan Al Namat ◽  
Mihai Constantin ◽  
Ionela Larisa Miftode ◽  
Andrei Manta ◽  
Antoniu Petris ◽  
...  
Keyword(s):  
Heart Failure ◽  
Congestive Heart Failure ◽  
Rural Areas ◽  
Discharge Planning ◽  
Difficult Problem ◽  
Uncontrolled Hypertension ◽  
Medical Attention ◽  
Family Doctors ◽  
Increased Risk ◽  
Risk Patients

Repetitive or recurrent hospitalizations are a general major health issue in patients with chronic disease. Congestive heart failure, is associated with a high incidence and presence of early rehospitalization, but variables in order to identify patients at increased risk and also an analysis of potentially remediable factors contributing to readmission have not been previously reported and it remains still a difficult problem. We retrospectively assessed 100 patients aged between 48-85 years old, of which 75% were men, who had been hospitalized with documentation of congestive heart failure in St. Spiridon County Emergency Hospital. They were hospitalized between 2010-2017. Even if recurrent heart failure was the most common cause for readmission or rehospitalization, other cardiac disorders and noncardiac illnesses were also accounted for readmission. Predictive factors of an increased probability of readmission included prior patient�s medical heart failure history, heart failure decompensation precipitated or accelerated by an ischaemic episode, atrial fibrillation or uncontrolled hypertension. Factors contributing to preventable readmissions included noncompliance with medications or diet, inadequate discharge planning or follow-up, failure of both social support system and the seek of a promp medical attention when symptoms reappeared. We also identified an inappropriate colaboration with family doctors especially for the patients from rural areas. Patients were more likely to cite side effects of prescribed medications rather than nonadherence as a precipitating factor for readmission. Thus, we can appreciate that early rehospitalization in patients with congestive heart failure may be avoidable in up to 50% of cases. Identification of high risk patients is possible and also necessary shortly after admission in order to identify nonpharmacological interventions designed to decrease readmission frequency.

Antidiabetics: Structural Diversity of Molecules with a Common Aim

2018 ◽  
Vol 25 (18) ◽  
pp. 2140-2165 ◽  
Author(s):  
Jelena B. Popovic-Djordjevic ◽  
Ivana I. Jevtic ◽  
Tatjana P. Stanojkovic
Keyword(s):  
Structural Diversity ◽  
World Health ◽  
Common Disease ◽  
Peroxisome Proliferator ◽  
Epidemic Disease ◽  
Peroxisome Proliferator Activated Receptor ◽  
Increased Risk ◽  
Dipeptidyl Peptidase Iv Inhibitors ◽  
Glucagon Like Peptide 1 ◽  
Health Organization

Background: Diabetes mellitus type 2 (DMT2) is an endocrine disease of global proportions which is currently affecting 1 in 12 adults in the world, with still increasing prevalence. World Health Organization (WHO) declared this worldwide health problem, as an epidemic disease, to be the only non-infectious disease with such categorization. People with DMT2 are at increased risk of various complications and have shorter life expectancy. The main classes of oral antidiabetic drugs accessible today for DMT2 vary in their chemical composition, modes of action, safety profiles and tolerability. Methods: A systematic search of peer-reviewed scientific literature and public databases has been conducted. We included the most recent relevant research papers and data in respect to the focus of the present review. The quality of retrieved papers was assessed using standard tools. Results: The review highlights the chemical structural diversity of the molecules that have the common target-DMT2. So-called traditional antidiabetics as well as the newest and the least explored drugs include polypeptides and amino acid derivatives (insulin, glucagon-like peptide 1, dipeptidyl peptidase-IV inhibitors, amylin), sulfonylurea derivatives, benzylthiazolidine- 2,4-diones (peroxisome proliferator activated receptor-γ agonists/glitazones), condensed guanido core (metformin) and sugar-like molecules (α-glucosidase and sodium/ glucose co-transporter 2 inhibitors). Conclusion: As diabetes becomes a more common disease, interest in new pharmacological targets is on the rise.

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