CARDIOVASCULAR OUTCOME IN TYPE 2 DIABETES AND ATRIAL FIBRILLATION- How to modify the increased cardiovascular risk?
Main Article Content
Abstract
The increased cardiovascular risk in patients with type 2 diabetes mellitus (DM) is further augmented by the presence of atrial fibrillation (AF). Therefore, the treatment strategy should be directed at improving the metabolic situation – e.g. avoiding marked fluctuations of blood glucose levels – and eliminating AF. Some of the life-style modifications recommended for patients with type 2 DM – such as weight reduction, engagement in regular physical activity, and cessation of tobacco use – can decrease the susceptibility to AF. The first-line pharmacological therapy of type 2 DM is metformin which also decreases the susceptibility to AF by improving insulin sensitivity. The most effective add-on therapy, especially in diabetes with atrial fibrillation, are sodium-glucose cotransporter 2 (SGLT2) inhibitors, dapagliflozin and empagliflozin. These drugs have been shown to reduce hospitalization for heart failure, cardiovascular mortality and the risk of incident atrial fibrillation. A promising new agent is the non-steroidal mineralocorticoid receptor antagonist finerenone. It reduced cardiovascular death, and the risks of hospitalization and new-onset AF. Since the risk of stroke and thromboembolism is especially high in DM with AF, nearly all affected patients need anticoagulation. Direct oral anticoagulants are more effective and safer than vitamin K antagonists. Atrial fibrillation occurs in type 2 DM despite optimal treatment of metabolic and clinical risk factors. In the past, antiarrhythmic drug treatment was used with limited success. In contrast to antiarrhythmic drug therapy, catheter ablation is an effective and safe treatment modality for the restoration of sinus rhythm. Since the long-term arrhythmia-free survival after catheter ablation is lower among patients with type 2 DM, individual ablation strategies are required in some of these patients. In summary, DM patients with AF require optimal treatment of metabolic risk factors, concomitant diseases, and specific strategies to prevent AF.
Keywords:
Type 2 Diabetes, Atrial Fibrillation, Antidiabetic Medication, Catheter Ablation
Article Details
How to Cite
MEINERTZ, Thomas; COSTARD-JÄCKLE, Angelika; KUCK, Karl-Heinz.
CARDIOVASCULAR OUTCOME IN TYPE 2 DIABETES AND ATRIAL FIBRILLATION- How to modify the increased cardiovascular risk?.
Medical Research Archives, [S.l.], v. 12, n. 12, dec. 2024.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/6025>. Date accessed: 06 jan. 2025.
doi: https://doi.org/10.18103/mra.v12i12.6025.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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2 Huxley RR, Filion KB, Konety S, Alonso A. Meta-analysis of cohort and case-control studies of type 2 diabetes mellitus and risk of atrial fibrillation. AmJ Cardiol. 2011;108:56-62. Doi:10.1016/j.amjcard.2011.03.004.
3 Xiang H, Xue Y, Chen Z, Yu Y, Peng Y, Wang J, et al. The Association Between Left Ventricular Hypertrophy and the Occurrence and Prognosis of Atrial Fibrillation: A Meta-Analysis. Front Cardiovasc Med. 2021;8:639993. Doi: 10.3389/fcvm.2021.639993.
4 Bohne LJ, Johnson D, Rose RA, Wilton SB, Gillis AM. The Association Between Diabetes Mellitus and Atrial Fibrillation: Clinical and Mechanistic Insights. Front Physiol. 2019;10:135. Doi:10.3389/fphys.2019.00135.
5 Costard-Jäckle A, Tschöpe D, Meinertz T. Cardiovascular outcome in type 2 diabetes and atrial fibrillation. Herz 2019;44:522–525. Doi: 10.1007/s00059-018-4704-4.
6 Lorenzo-Almorós A, Casado Cerrada J, Álvarez-Sala Walther LA, Méndez Bailón M, Lorenzo González Ó. Atrial Fibrillation and Diabetes Mellitus: Dangerous Liaisons or Innocent Bystanders? J Clin Med. 2023;12(8):2868. Doi: 10.3390/jcm12082868.
7 Du X, Ninomiya T, de Galan B, Abadir E, Chalmers J, Pillai A, et al.; ADVANCE Collaborative Group. Risks of cardiovascular events and effects of routine blood pressure lowering among patients with type 2 diabetes and atrial fibrillation: results of the ADVANCE study. Eur Heart J. 2009;30:1128-1135. Doi: 10.1093/eurheartj/ehp055.
8 Echouffo-Tcheugui JB, Shrader P, Thomas L, Gersh BJ, Kowey PR, Mahaffey KW, et al. Care Patterns and Outcomes in Atrial Fibrillation Patients With and Without Diabetes: ORBIT-AF Registry. J Am Coll Cardiol. 2017;70):1325-1335. Doi: 10.1016/j.jacc.2017.07.755.
9 Kwon S, Lee SR, Choi EK, Ahn HJ, Lee SW, Jung JH et al. Association Between Atrial Fibrillation and Diabetes-Related Complications: A Nationwide Cohort Study. Diabetes Care. 2023;46:2240-2248. Doi: 10.2337/dc23-0931.
10 Wang A, Green JB, Halperin JL, Piccini JP Sr. Atrial Fibrillation and Diabetes Mellitus: JACC Review Topic of the Week. J Am Coll Cardiol. 2019;74:1107-1115. Doi: 10.1016/j.jacc.2019.07.020.
11 Pathak RK, Middeldorp ME, Meredith M, Mehta AB, Mahajan R, Wong CX, et al. Long-Term Effect of Goal-Directed Weight Management in an Atrial Fibrillation Cohort: A Long-Term Follow-Up Study (LEGACY). J Am Coll Cardiol. 2015;65:2159-2169. Doi: 10.1016/j.jacc.2015.03.002.
12 Chung MK, Eckhardt LL, Chen LY, Ahmed HM, Gopinathannair R, Joglar JA, et al.; American Heart Association Electrocardiography and Arrhythmias Committee and Exercise, Cardiac Rehabilitation, and Secondary Prevention Committee of the Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; and Council on Lifestyle and Cardiometabolic Health. Lifestyle and Risk Factor Modification for Reduction of Atrial Fibrillation: A Scientific Statement from the American Heart Association. Circulation. 2020;141:e750-e772. Doi: 10.1161/CIR.0000000000000748.
13 Chang SH, Wu LS, Chiou MJ, Liu JR, Yu KH, Kuo CF, et al. Association of metformin with lower atrial fibrillation risk among patients with type 2 diabetes mellitus: a population-based dynamic cohort and in vitro studies. Cardiovasc Diabetol. 2014;13:123. Doi: 10.1186/s12933-014-0123-x.
14 Zheng RJ, Wang Y, Tang JN, Duan JY, Yuan MY, Zhang JY. Association of SGLT2 Inhibitors With Risk of Atrial Fibrillation and Stroke in Patients With and Without Type 2 Diabetes: A Systemic Review and Meta-Analysis of Randomized Controlled Trials. J Cardiovasc Pharmacol. 2022;79:e145-e152. Doi: 10.1097/FJC.0000000000001183.
15 Zelniker TA, Bonaca MP, Furtado RHM, Mosenzon O, Kuder JF, Murphy SA, et al. Effect of Dapagliflozin on Atrial Fibrillation in Patients With Type 2 Diabetes Mellitus: Insights From the DECLARE-TIMI 58 Trial. Circulation. 2020;141:1227-1234. Doi:10.1161/CIRCULATIONAHA.119.044183.
16 Böhm M, Slawik J, Brueckmann M, Mattheus M, George JT, Ofstad AP, et al. Efficacy of empagliflozin on heart failure and renal outcomes in patients with atrial fibrillation: data from the EMPA-REG OUTCOME trial. Eur J Heart Fail. 2020;22:126-135. Doi: 10.1002/ejhf.1663. .
17 Bonnesen K, Heide-Jørgensen U, Christensen DH, Lash TL, Hennessy S, Matthews A, et al. Comparative Cardiovascular Effectiveness of Empagliflozin Versus Dapagliflozin in Adults with Treated Type 2 Diabetes: A Target Trial Emulation. Circulation. 2024 Aug 29. Doi:10.1161/circulationaha.124.068613. .
18 Lim J, Kwak S, Choi YJ, Rhee TM, Park CS, Kim B, et al. Differing Efficacy of Dapagliflozin Versus Empagliflozin on the Risk of Incident Atrial Fibrillation in Patients With Type 2 Diabetes: A Real-World Observation Using a Nationwide, Population-Based Cohort. J Am Heart Assoc. 2024;13:e030552. Doi: 10.1161/JAHA.123.030552.
19 Bohne LJ, Jansen HJ, Dorey TW, Daniel IM, Jamieson KL, Belke DD, et al. Glucagon-Like Peptide-1 Protects Against Atrial Fibrillation and Atrial Remodeling in Type 2 Diabetic Mice. JACC Basic Transl Sci. 2023;8:922-936. Doi:10.1016/j.jacbts.2023.01.005.
20 Wei J, Wang R, Ye H, Wang Y, Wang L, Zhang X. Effects of GLP-1 receptor agonists on arrhythmias and its subtypes in patients with type 2 diabetes: A systematic review and meta-analysis. Front Endocrinol (Lausanne). 2022;13:910256. Doi:10.3389/fendo.2022.910256.
21 Stoll L, Lo JC. GLP-1 Receptor Agonists, the Holy Grail Preventing Atrial Fibrillation in Patients With T2D? JACC Basic Transl Sci. 2023;8:937-938. Doi: 10.1016/j.jacbts.2023.03.022.
22 Nreu B, Dicembrini I, Tinti F, Sesti G, Mannucci E, Monami M. Major cardiovascular events, heart failure, and atrial fibrillation in patients treated with glucagon-like peptide-1 receptor agonists: An updated meta-analysis of randomized controlled trials. Nutr Metab Cardiovasc Dis. 2020;30:1106-1114. Doi: 10.1016/j.numecd.2020.03.013.
23 Kume O, Takahashi N, Wakisaka O, Nagano-Torigoe Y, Teshima Y, Nakagawa M, et al. Pioglitazone attenuates inflammatory atrial fibrosis and vulnerability to atrial fibrillation induced by pressure overload in rats. Heart Rhythm. 2011;8:278-285. Doi: 10.1016/j.hrthm.2010.10.029.
24 Zhang Z, Zhang X, Korantzopoulos P, Letsas KP, Tse G, Gong M, et al. Thiazolidinedione use and atrial fibrillation in diabetic patients: a meta-analysis. BMC Cardiovasc Disord. 2017;17:96. Doi:10.1186/s12872-017-0531-4.
25 Filippatos G, Bakris GL, Pitt B, Agarwal R, Rossing P, Ruilope LM, et al.; FIDELIO-DKD Investigators. Finerenone Reduces New-Onset Atrial Fibrillation in Patients With Chronic Kidney Disease and Type 2 Diabetes. J Am Coll Cardiol. 2021;78:142-152. Doi: 10.1016/j.jacc.2021.04.079.
26 Ashburner JM, Go AS, Chang Y, Fang MC, Fredman L, Applebaum KM, et al. Effect of Diabetes and Glycemic Control on Ischemic Stroke Risk in AF Patients: ATRIA Study. J Am Coll Cardiol. 2016;67(3):239-47. Doi:10.1016/j.jacc.2015.10.080.
27 Patti G, Lucerna M, Cavallari I, Ricottini E, Renda G, Pecen L, et al. Insulin-Requiring Versus Noninsulin-Requiring Diabetes and Thromboembolic Risk in Patients with Atrial Fibrillation: PREFER in AF. J Am Coll Cardiol. 2017;69:409-419. Doi:10.1016/j.jacc.2016.10.069.
28 Saliba W, Barnett-Griness O, Elias M, Rennert G. Glycated hemoglobin and risk of first episode stroke in diabetic patients with atrial fibrillation: A cohort study. Heart Rhythm. 2015;12:886-92. Doi: 10.1016/j.hrthm.2015.01.025.
29 Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, et al.; ESC Scientific Document Group. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021;42:373-498. Doi:10.1093/eurheartj/ehaa612.
30 Itzhaki Ben Zadok O, Eisen A. Use of non-vitamin K oral anticoagulants in people with atrial fibrillation and diabetes mellitus. Diabet Med. 2018;35:548-556. Doi: 10.1111/dme.13600.
31 Ruff CT, Giugliano RP, Braunwald E, Hoffman EB, Deenadayalu N, Ezekowitz MD, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383:955-962. Doi: 10.1016/S0140-6736(13)62343-0 .
32 Veglio M, Bruno G, Borra M, Macchia G, Bargero G, D’Errico N, et al. Prevalence of increased QT interval duration and dispersion in type 2 diabetic patients and its relationship with coronary heart disease: a population-based cohort. J Intern Med. 2002;251:317-524. Doi:10.1046/j.1365-2796.2002.00955.x.
33 Blomström-Lundqvist C, Gizurarson S, Schwieler J, Jensen SM, Bergfeldt L, Kennebäck G, et al. Effect of Catheter Ablation vs Antiarrhythmic Medication on Quality of Life in Patients With Atrial Fibrillation: The CAPTAF Randomized Clinical Trial. JAMA. 2019;321:1059-1068. Doi:10.1001/jama.2019.0335.
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