Association of triglyceride–glucose index and its 6-year change with risk of hypertension: A prospective cohort study

Background and aimWe aimed to investigate the association of triglyceride–glucose (TyG) index and its dynamic change with risk of hypertension in rural Chinese and, further, to explore whether the TyG index mediates the obesity-related hypertension.Methods and resultsA prospective cohort study, including 10,309 subjects without hypertension at baseline, was conducted in 2007–2008 and followed up in 2013–2014. TyG index was calculated as Ln[fasting triglycerides (mg/dL) × fasting glucose (mg/dL)/2]. Logistic regression model was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs). Mediation analysis was performed to examine the contribution of the TyG index to the association of obesity-hypertension incidence. During a median follow-up of 6 years, 2073 subjects developed hypertension. In multivariate logistic model adjusted for age, sex, alcohol drinking, smoking, physical activity and education, monthly income, family history of hypertension, TC, and HDL-C, the risk of hypertension was 1.14 (1.07–1.22) for per-SD increase in TyG. After additional controlling for obesity, this association was nonsignificant (1.06, 0.99–1.13) and (1.05, 0.99–1.13) for BMI and WC, respectively. Increasing trends were found for hypertension incidence as the TyG change increased, with or without adjustment for obesity (all P_trend < 0.05). With per-SD increment in TyG change, the risks of hypertension incidence were 1.14 (1.07–1.22) for absolute TyG change, and 1.15 (1.08–1.22) for relative TyG change in multivariate logistic model; the results were significant after further adjustment for BMI or WC, respectively. The TyG index partially mediated the obesity-incident hypertension association: 6.84% for BMI and 6.68% for WC, respectively.ConclusionsElevated TyG index and its dynamic change were positively associated with risk of incident hypertension in rural Chinese population, and the TyG index may play a partially mediating role in obesity-related incident hypertension.     

Trends and complications associated with acute new-onset heart failure: a National Readmissions Database–based cohort study

Heart Failure Reviews - Literature regarding recent trends and outcomes of acute new-onset heart failure (AHF) with preserved ejection fraction (AHFpEF) and reduced ejection fraction (AHFrEF) is...     

Association between the triglyceride–glucose index and diabetic nephropathy in patients with type 2 diabetes: A cross-sectional study

Aims/IntroductionThe triglyceride–glucose (TyG) index has been proposed as a reliable and simple marker of insulin resistance. We investigated the association between TyG index and diabetic nephropathy (DN) in patients with type 2 diabetes.Materials and MethodsA consecutive case series of 682 adult patients with type 2 diabetes hospitalized in the Department of Endocrinology at the Tongji Hospital (Wuhan, Hubei, China) from January 2007 to December 2009 was included in this cross‐sectional analysis. Receiver operating characteristics curve analysis, correlation analysis and multiple logistic regression analysis were carried out.ResultsA total of 232 (34.0%) participants were identified with DN. Compared with the non‐DN group, the DN group had longer disease duration, and higher bodyweight, systolic blood pressure, diastolic blood pressure, glycated hemoglobin, triglycerides, total cholesterol, serum uric acid, 24 h‐urinary albumin, TyG index and homeostasis model assessment 2 estimates for insulin resistance (HOMA2‐IR; P < 0.05 for each). The TyG index with an optimal cut‐off point >9.66 showed a higher area under the receiver operating characteristic curve of 0.67 (P = 0.002) than HOMA2‐IR (area under the curve 0.61, P = 0.029) on receiver operating characteristic curve analysis for DN identification. Additionally, the TyG index positively correlated with the levels of metabolic indicators (bodyweight, glycated hemoglobin, triglycerides, total cholesterol, serum uric acid, fasting glucose and HOMA2‐IR) and natural logarithmic 24 h‐urinary albumin (P < 0.05 for each), but not natural logarithm of estimated glomerular filtration rate. On multiple regression analysis, an increased TyG index was shown to be an independent risk factor (odds ratio 1.91, P = 0.001) for DN.ConclusionsThe TyG index was independently associated with DN in patients with type 2 diabetes, and was a better marker than HOMA2‐IR for identification of DN in type 2 diabetes patients.     

Association of renin–angiotensin–aldosterone system gene polymorphisms with left ventricular hypertrophy in patients with heart failure with preserved ejection fraction: A case–control study

Background: Heart failure with preserved ejection fraction (HFpEF) has close ties with hypertension, though risk factors to the development of HFpEF in hypertensive patients are not fully understood. Left ventricular hypertrophy (LVH) signifies the susceptibility toward diastolic heart dysfunction, and genetic determinants of LVH as a result may serve as risk predictors for HFpEF in hypertension. We investigated the role of three renin–angiotensin–aldosterone system (RAAS) gene polymorphisms in the development of LVH in hypertensive patients with a diagnosis of HFpEF. Methods: A total of 176 hypertensive patients with a diagnosis of HFpEF were divided to cases with LVH and controls without. rs4343 and rs4291 of angiotensin-converting enzyme (ACE) and rs5186 of angiotensin receptor type 1 were genotyped using PCR-RFLP method. Results: Genotypes and allele frequencies were significantly different between the case and control groups for rs4343 and rs4291, whereas no difference was observed for rs5186.Conclusion: Increased ACE activity explains the significant association of rs4343 and rs4291 polymorphisms with LVH in the carriers. Furthermore, findings support the pathophysiologic links between RAAS and increased LV mass in hypertension and suggest a genetic susceptibility to HFpEF. Such polymorphisms may serve as risk predictors of HFpEF in hypertensive patients.     

Liver transplantation in patients with post-hepatectomy liver failure – A Northern European multicenter cohort study

BackgroundLiver transplantation (LTX) has been described as a rescue treatment option in severe, intractable post-hepatectomy liver failure (PHLF), but is not considered to be indicated for this condition by many hepatobiliary and transplant surgeons. In this article we describe the clinical experience of five northern European tertiary centers in using LTX to treat selected patients with severe PHLF.MethodsAll patients subjected to LTX due to PHLF at the participating centers were identified from prospective clinical databases. Preoperative variables, surgical outcome (both resection surgery and LTX) and follow-up data were assessed.ResultsA total of 10 patients treated with LTX due to severe PHLF from September 2008 to May 2020 were identified and included in the study. All patients but one were male and the median age was 70 years (range 49–72). In all patients the indication for liver resection was suspected malignancy, but in six patients post-resection pathology revealed benign or pre-malignant disease. There was no 90-day mortality after LTX. Patients were followed for a median of 49 months (13–153) and eight patients were alive without recurrence at last follow-up.DiscussionIn selected patients with PHLF LTX can be a life-saving procedure with low short-term risk.     

Health service use by community-dwelling patients with heart failure in northwest London, 2015–18: a retrospective cohort analysis

BackgroundHeart failure management is complex and requires multidimensional care. Clinical guidelines advocate for the use of integrated care, but few studies have described overall health service use by patients with heart failure. We describe overall care usage by community-dwelling patients with heart failure in northwest London using a dataset linked across multiple health-care settings.MethodsIn this retrospective cohort analysis, we used Whole Systems Integrated Care (WSIC) data, a dataset of individual clinical events from primary care, secondary care, and other (defined as community, mental health, and social care) services in northwest London to analyse a retrospective cohort of patients with heart failure. Patients who remain in the WSIC dataset, were aged at least 18 years on Jan 1, 2015, with known age and gender, and whose diagnosis was not made after their date of death. The primary outcome was health-care usage of each of the three service categories overall as well as individual components of secondary care (eg, outpatient appointments) and other services (eg, nursing contacts). Usage patterns were identified using k-means cluster analysis using all distinct contacts for the whole study period and visualised by a heatmap. Nine health-care use variables were used to identify clusters, and differences between clusters in both clustering and non-clustering variables were analysed using Kruskal-Wallis and Pearson χ² tests. This study was approved by the Discover Research Advisory Group.FindingsData from 39 301 patients with heart failure across 359 general practices between Jan 1, 2015, and Dec 31, 2018, were analysed. Almost all patients had some health service contact during the study period (21 226 [89·1%] of 23 828 in 2015; 24 876 [90·6%] of 27 443 in 2016; 28 663 [90·8%] of 31 554 in 2017; and 31 584 [91·1%] of 34 651 in 2018). Most commonly used services in 2018 were outpatient appointments (24 283 [70·1%] of 34 651 patients), general practitioner (GP) consultations (20 741 [59·9%] patients), unplanned accident and emergency visits (14 145 [40·8%] patients) and community services (13 762 [39·7%] patients), often for nursing. Use of cardiology-specific services ranged from 1005 (2·9%) patients for community visits to 8231 (23·8%) for outpatient visits. Five clusters of patients were identified, each with significantly different care usage patterns and distinct patient characteristics. Patterns included underuse of GP consultations, relative to the average use by the whole cohort, in patients living in more deprived areas; and increased use of other services in patients older than 75 years and those with three or more comorbidities.InterpretationHealth and social care service use was widespread but varied. Patterns of care usage suggest differences across patient groups. This might be due to variation in patients’ access to care and insufficiently integrated care at earlier stages of heart failure. The limitations of our study are that electronic health records like WSIC are not coded for research and subject to some biases; k-means testing is sensitive to the input variables and selection of k; and our findings require further validation and might not be generalisable to regions beyond the northwest London area. Further research is needed to characterise the patterns we have identified.FundingDr Foster (a Telstra Health company), the National Institute for Health Research (NIHR) Health Services Research, and the Imperial NIHR Biomedical Research Centre and the NIHR Collaboration for Leadership in Applied Health Research and Care for northwest London. The views expressed are those of the authors and not those of the NIHR.     

Sodium–glucose cotransporter-2 inhibitors in heart failure: Potential decongestive mechanisms and current clinical studies

Congestion is a key pathophysiological feature of heart failure (HF) syndrome that drives most of the clinical manifestations of acute HF and is related with poor quality of life and outcomes. Therefore, safe and effective decongestion is an important therapeutic target in the management of acute HF and despite the use of guideline-recommended loop diuretics, adequate decongestion is not always achieved in patients with acute HF. Recently, sodium–glucose cotransporter-2 (SGLT-2) inhibitors have been shown to provide clinical benefits across a broad spectrum of patients with HF, including consistent reduction in the risk of acute HF episodes. While the exact mechanisms underlying these benefits remain a matter of debate, a growing body of evidence suggests that effective decongestion may be partly responsible, especially in the setting of acute HF. In this review, we discuss the potential decongestive mechanisms of SGLT-2 inhibitors, such as osmotic diuresis, natriuresis, preservation of glomerular filtration and facilitation of interstitial drainage, which can collectively translate into effective and safe decongestion. Furthermore, we provide a comprehensive review of up-to-date clinical data of SGLT-2 inhibitor use in the acute HF population.     

A heart failure specialist’s perspective on cardiac surgery for heart failure

Aside from cardiac transplantation, ventricular assist devices, and the total artificial heart, cardiac surgery now also plays a major role in the overall management of the heart failure patient. For patients with heart failure, cardiac surgery has steadily moved from being a predominant rescue procedure (eg, aneursymectomy, rupture repair, transplantation) to surgical interventions that can prevent or delay the progression of cardiac dysfunction and failure; these operations now include coronary artery bypass surgery, ventricular restoration, and valvular repair/replacement. This article discusses the role and impact of these specific surgical interventions in the setting of ventricular dysfunction and heart failure.     

Bladder cancer with pioglitazone: A case–control study

BackgroundVaried reports suggest a contentious relationship of bladder malignancy with pioglitazone in patients with type 2 diabetes.AimTo study an association (prevalence and predictors) of bladder malignancy with pioglitazone therapy in Asian-Indian type 2 diabetes patients.MethodIn this observational multicenter study, type 2 diabetic patients attending out-patient diabetes-clinic were evaluated. A detailed history of anti-diabetic medication, dose, duration, pioglitazone usage, time since initiation of pioglitazone, physical examination, biochemical tests and details pertaining to prevalent neuropathy, retinopathy and nephropathy were recorded. Details of bladder cancer or any malignancy (if present), time since diagnosis, risk factors for bladder cancer and histopathology records were noted. The study cohort was divided into two groups-pioglitazone ever users (Group A) and never users (Group B).ResultsA total of 8000 patients were screened out of which 1560 were excluded. Among 6440 included patients, 1056 (16.3%) patients were in group A and 5384 (83.6%) group B. Patients on pioglitazone were older (59.1 vs 57.7 years, p < 0.001), had longer duration of diabetes (12.7 vs 10.6 years, p < 0.001) with poor glycemic control (HbA1c 8.5 vs 8.3%, p < 0.01). A total of 74 patients had prevalent bladder cancer [16 (1.5%) in Group A and 58 in Group B (1.0%)]. Prevalent bladder cancer was not significantly greater in ever-users (odds ratio OR = 1.29, 95% confidence interval CI, 0.83–2.00) compared to never-users (odds ratio OR = 0.94, 95% confidence interval CI, 0.834–1.061) of pioglitazone (p = 0.207). However, history of hematuria in pioglitazone-users; while older age (>58 year), history of smoking and hematuria in the whole cohort were significant associated with bladder cancer. In the entire study cohort, 254 patients; 3.5% of males (128 out of 3575) and 4.6% of females (126 out of 2713) developed any malignancy. Age was significantly associated with prevalent malignancy in people with diabetes (odds ratio OR 1.036, 95% confidence interval CI: 1.022–1.051, p = 0.00) on multivariate forward regression.ConclusionPioglitazone use in Asian-Indians is not associated with an increased bladder cancer risk. However, pioglitazone should be restricted in individuals with history of hematuria. Age more than 58 years is a significant risk factor for development of any malignancy, particularly bladder cancer.     

A statin in the treatment of heart failure? Controlled rosuvastatin multinational study in heart failure (CORONA): Study design and baseline characteristics

BACKGROUND: Previous prospective outcome studies of statins have not provided any guidance on benefit-risk in patients with heart failure. AIM: The primary objective is to determine whether rosuvastatin (10 mg) reduces the combined endpoint of cardiovascular mortality, non-fatal myocardial infarction or non-fatal stroke (time to first event). The first secondary endpoint is all-cause mortality. METHODS: CORONA is a randomized, double-blind, placebo-controlled trial. Briefly, men and women, aged > or =60 years with chronic symptomatic systolic heart failure of ischemic aetiology and ejection fraction < or =0.40 (NYHA class III and IV) or < or =0.35 (NYHA class II) were eligible if they were not using or in need of cholesterol lowering drugs. RESULTS: Mean age was 73 years (n=5016; 24% women), with 37% in NYHA II and 62% in NYHA III, ejection fraction 0.31, total cholesterol 5.2 mmol/L. Sixty percent have a history of myocardial infarction, 63% hypertension, and 30% diabetes. Patients are well treated for heart failure with 90% on loop or thiazide diuretics, 42% aldosterone antagonists, 91% ACE inhibitor or AT-I blocker, 75% beta-blockers, and 32% digitalis. CONCLUSION: CORONA is important for three main reasons: (1) A positive result is very important because of the high risk of the population studied, the increasing prevalence of elderly patients with chronic symptomatic systolic heart failure in our society, and the health economic issues involved. (2) If negative, new mechanistic questions about heart failure have to be raised. (3) If neutral we can avoid unnecessary polypharmacy.