Current Cardiology Reviews

It is well established that diabetes mellitus is actually a multisystem disease responsible for a great burden of morbidity and mortality globally since it causes several cardiovascular complications; macro as well as micro-vascular [1]. This attitude is mainly attributed to the fact that these patients show a high risk for the development of atherosclerotic lesions for various causes such as hyperglycaemia, dyslipidemia and insulin resistance, resulting in impaired platelet function, endothelial, vascular smooth muscle cell dysfunction and abnormal coagulation [2]. Therefore it is easily assumed that individualized treatment strategy is needed and for that cause stratification of cardiovascular risk among these patients has become a necessity. As a result, several models have been developed over the last decades which highlighted specific risk factors for developing cardiovascular disease including age more than 40 years, male gender, history of relative suffering from premature CHD, blood pressure and high LDL levels, presence of microalbuminuria or obstructive sleep apnea [3].

Taking all the above mentioned into account, researchers concluded that efficient management of cardiovascular risk is in fact a critical component of diabetes care. Kyriakos et al. reviewed clinical trials and concluded that this medication is showed to be effective in lowering the risk of cardiovascular disease without burden the renal function [4]. In addition, a new group of hypoglycemic drugs has been used to treat diabetes type 2.; the active sodium glucose co-transporter (SGLT2) or SGLT2 inhibitors. It has been shown that besides the treatment of diabetes, this drug class is responsible for the mildness of the cardiovascular events shown in patients with diabetes type 2 [5]. However, there are controversial data regarding the existence of a class effect [6].

Many scientific committees strongly recommend the incretin-based therapies, dipeptidyl peptidase 4 (DPP-4) inhibitors and glucagon- like peptide 1 (GLP-1) receptor agonists, as an option for add-on therapy to first-line therapy with metformin or other antidiabetic medications [7, 8].

Finally, we should not forget to mention a new pivotal intervention in the effective management of diabetes mellitus and its severe complications. Bariatric surgery including procedures like Roux-en-Y Gastric Bypass, Sleeve Gastrectomy, Laparoscopic Adjustable Gastric Banding as it is summarized by Damaskos et al. [9,10]. This approach improves clinically appropriate endpoints that include the remission of various comorbidities and the lowering of cardiovascular risks together with serious cardiovascular events but the emphasis should be given on appropriate patient selection with a long-term period of follow-up [11].

In conclusion, diabetes mellitus is undoubtedly a complex disease. The purpose of this thematic issue is to highlight the new therapeutic approaches like incretin-based therapies, the SGLT2 inhibitors and the bariatric procedures.

Aging is a growing medical concern. Despite more people living longer, the economical impact is likely to be severe, and pressures on healthcare providers are constantly growing to treat aging-related conditions and disorders. It is estimated, that in the US, life expectancy will go from ~76 years of age in 2010 to 80 years in 2030 [1], a pattern that is similar to a host of industrialised countries. Indeed, in the United Kingdom, recent analysis has shown that male life expectancy has increased from 69 years in 1970 to 78 years in 2010, and female life expectancy from 75 years to 82 years in the same time period [2]. As a result, incidence of aging-related diseases such as Cardiovascular Disease (CVD), dementia, and cancer is likely to increase substantially [3]. It is no surprise, therefore, that research into medical advancements and lifestyle behaviours and the impact of these on aging populations has gathered a lot of interest in the academic community, as seen by the Physiological Society announcing a year of ‘Understanding Ageing’ in 2015. This has led to the growth of research in aging, and also specifically cardiovascular aging. Lifestyle choices can have significant influence on how our cardiovascular system ages. We see individuals who are fitter and regularly exercise, live longer than unfit/sedentary individuals [4, 5], which could be due to changes in our cardiovascular system. Such favourable changes in our cardiovascular system with simple modifications in our lifestyle thus offers a significant promise in helping to counteract the impact of aging on our bodies. This small collection of reviews, encompasses the effects of diet, exercise and physical activity on the ‘aging cardiovascular system’, and provides some novel insights into the mechanisms by which these affect our vascular and cardiac tissues. The first review [6] puts forward the argument that resistance exercise could affect vascular aging via modulation of arterial stiffness and Matrix Metalloproteinases (MMP). Older individuals display elevated levels of arterial stiffness (as measured by pulse wave technology) compared to younger individuals [7], with recent evidence supporting the view that exercise can reduce arterial stiffness in humans [8]. Dr. Knox demonstrates some data to suggest that arterial remodelling with exercise may be a result of altered MMP regulation, but more work is needed to observe this link in humans. The second review [9] discusses the role of aging on the body’s endogenous endothelial repair capacity, via the reduction and dysfunction of endothelial progenitor cells, and how exercise and dietary behaviour modulate both the number and function of these cells. The effects vary from improving bone marrow niche environment and pro-apoptotic stimuli to promoting our own stem/progenitor cell repair mechanisms on our ageing vasculature. The subsequent review by Beaumont et al. [10] uses masters athlete’s as a model of lifelong exercisers, and the differences in cardiac structure and function between master’s athlete’s and inactive older people. We observe that masters athletes display better diastolic function than sedentary age-matched controls, which appears to be maintained into the 8th decade of life. Interestingly, the review does not demonstrate much evidence on differences in systolic function, and a much debated measure of systolic function, ejection fraction, does not appear to be different between sedentary controls and masters athletes, being suggestive that lifelong exercise does not improve cardiac health via modulations in ejection fraction. The final review in our collection, by Peace et al. [11], provides an insight into carotid and coronary arterial function, with subsequent focus on the role of advancing age on both, and the potential for exercise to act as a countermeasure for the agingassociated deleterious effects. They also purport that, since coronary artery function is difficult and incredibly invasive to measure and quantify, that we can use carotid artery function as a surrogate, as it appears to show similar structural and functional changes with disease conditions, offering clinicians and researchers a non-invasive global measure of arterial function that could be used to determine risk of myocardial infarction, stroke, and other atherosclerotic-mediated events. Together, these reviews provide evidence for the importance of lifestyle modifications and behaviour change to treat ageassociated cardiovascular problems, which could subsequently have significant effects on healthcare burden and quality of life of patients. However, translation of such work into practice is often poor at best, and thus strategies must be put into place by governing bodies, healthcare providers, and clinicians to encompass such lifestyle strategies to treat disease.

In this issue of Current Cardiology Reviews, a mini-thematic review of the important role of Interventional Cardiology and the cardiac cath lab in the management of cardiac arrest has been presented. Cardiac arrest is becoming an ever important topic for multiple reasons. Science is expanding regarding cardiac arrest, which includes the understanding of the processes involved, the appropriate use of new techniques and innovative devices in the management of these patients. The role of Interventional Cardiologists in the management of these patients is also expanding. Thus this mini-thematic review summarizes how Interventional Cardiologists and the Catheterization laboratory can have a major impact in improving the care of these patients, ultimately increasing the survival of those suffering cardiac arrest. In this review, Rao P and Kern KB have outlined ways in which communities can improve their local outcomes from out of hospital cardiac arrest [1]. Articles by Reddy S, Lee K, Kumar K and Lotun K have outlined the management of cardiac arrest patients with both ST elevation and Non ST elevation myocardial infarction [2, 3]. No review on cardiac arrest patients is complete without addressing post resuscitation care with targeted temperature control and addressing arrhythmias. Taimoor H and Shetty R have reviewed the current guidelines of targeted temperature management [4]. Prakash G and Hutchinson M have addressed the management of arrhythmias and defibrillator implantation in the survivors of cardiac arrest [5]. There is ample positive data regarding immediate cardiac catheterization of cardiac arrest patients with ST Elevation myocardial infarction. The Pearl Trial is underway to define the optimal management of cardiac arrest patients with non ST elevation myocardial. Yadav K and Truong T have reviewed the important considerations for patients who have cardiac arrest while undergoing cardiac procedures in the catheterization laboratory. Sundaram and Lotun have addressed the issue of refractory out of hospital cardiac arrest especially the use of mechanical CPR devices and Extracorporeal Cardiopulmonary Resuscitation (ECPR) [6]. They have summarized a potential new approach for these patients, by mechanical support and performing coronary intervention [7]. This mini-thematic review provides a comprehensive overview of the perspective of Interventional Cardiologists in the management of cardiac arrest patient’s along with the post resuscitation management.