Archive for the ‘Diabetes and Heart’ Category

This is not a breaking news story. It’s the same old secret that was exposed in JUPITER  trial with Rosuvostatin 14 years ago. Yes, I am talking about the relationship between the usage of statin and the occurrence of diabetes. Now, we have this huge study on possible diabetes progression with statins. It’s not from a small journal to ignore. 

83 thousand patients data, the world’s largest series on link between statin therapy and diabetes.


This study has this to conclude

Diabetogenic statins

Something* happens as the statins antagonize the HMG COA  enzyme that resides within the delicate membranes of the endoplasmic reticulum inside the most specialized cells in our human body, called hepatocytes.

*What is that something?

Image source Umme Aiman et al Journal of Pharmacology and Pharmacotherapeutics 5(3):181-5DOI: 10.4103/0976-500X.136097

How to go about this issue?

With-holding statin in as many as possible is the best thing for such diabetic  (non-diabetic?) patients. But, the more pragmatic option is to ignore these negative studies, and instead intensify diabetes management if it worsens. After all, we can’t afford to lose the prodigious evidence-based cardio-vascular protective effects of statins and earn the wrath of our patients and peers you know!

Further Interest

1.Mansi IA, Chansard M, Lingvay I, Zhang S, Halm EA, Alvarez CA. Association of Statin Therapy Initiation With Diabetes ProgressionA Retrospective Matched-Cohort StudyJAMA Intern Med. Published online October 04, 2021. doi:10.1001/jamainternmed.2021.5714

2.Aiman U, Najmi A, Khan RA. Statin induced diabetes and its clinical implications. J Pharmacol Pharmacother. 2014 Jul;5(3):181-5. doi: 10.4103/0976-500X.136097. PMID: 25210397; PMCID: PMC4156828.


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No one would have Imagined a generally Innocuous entity called Diabetes will emerge into a  “single disease sub-speciality” in medicine”. Thanks to the global authorities  & pharma Industry for making this speciality a formidable one. The link between diabetes and cardiology is so strong, now with pharmacological strategies looking for overlapping Indications.


Let me share a presentation in one of the cardiology meet in 2017 at Thiruvananthpuram.TAN CSI meet , India.


Click here for a  PDF version 

The days are gone when anti-diabetic drugs were alleged to increase CVD mortality. New generation anti-diabetic drugs (SGLT-2 Inhibitors) are coming up that actively dictate and demand us to use it for reducing CVD risk.

(Am I crazy, to look ahead for stand-alone Indication for SGLT Inhibitors for cardiac failure in non-diabetic as well, as a powerful osmotic diuretic !)

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  • Diabetes mellitus is a pro-coagulant state,especially so in severe uncontrolled states.(1)
  • This is mediated by increased  levels of   plasminogen  activator Inhibitor.(PAI 1 and 2
  • This tilts  anti-fibrinolytic  forces towards thrombosis.
  • High PAI-1 is an Independent risk factor for MI in young individuals (3)
  • During STEMI the success rate of  fibrinolysis is significantly lower in diabetic population because high levels of PAI 1 .
  • The triad of DM,Obesity, Insulin resistance is a powerful predictor of  poor  response to thrombolysis.


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In the  2013 American diabetic association(ADA)  annual meet  a paper was presented   which raised  many eye brows ! . The  results were flashed across mainstream media. Published in New England journal of medicine online.

Look Ahead ADA lifes style  NEJM

It may be a  well conducted  trial  but  poorly interpreted  one . It reports one of  the dubious   observations  as a major conclusion  and  confuse the public.

Life style modification is the key to prevent  major diabetic  and cardiac events  . This is well  proved beyond doubt.

Epidemiological evidence  from various  global health  statistics  accumulated over a century will vouch for primary prevention of  diabetic and cardio vascular disease .

Link to Editorial on Look Ahead  : http://www.nejm.org

Why this study wants to make  a mockery of this fact ?  .Fortunately the accompanying  editorial  has  realistically  reported the implications of this study.

Final message

I argue the medical fraternity and patients to ignore this  study . It can be convincingly concluded something is seriously wrong with the outcome analysis  ,  however  modern may be the statistics. Some  groups are obviously worried about the natural and effective control of diabetic by good life style alone . It is a clear case of confusing the public .

There is huge collective evidence  and  common sense  for the  increased physical activity to reduce  cardio vascular risk  (INTERHEART)

Final Message

If life style modification is not going to help  . . . what is the alternative  to our patients ?

Drugs . . . yes  . . . one has to depend on it   . . . this study  seems to suggest .

To me, this is  a dangerous study   . It  plays a spoil sport on a great fact and  belief . This paper  should never have been published in a journal  like  NEJM . Atleast the conclusion  should  have  been re-written !

I guess this study would  promote the  Homo-sapiens  to  be inactive  and  make them diabetic and  consume drugs  perennially !



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Those who answered  “Yes” ,  can leave this article . Those who answered  “No” read further .

* Logic would tell us myocardial revascularisation should correct  stress induced ischemia and it  should disappear promptly  . This does not happen in all cases  real world  ! That is  why medicine is  different  from mathematical science .

Some of the  reasons for  persistence of stress positivity even after an apparently successful PCI are  . . .

  1. Incomplete  correction of ischemia. (Ideally  to be referred as failed PCI )
  2. Error in Identifying culprit 9Angina related artery ) .Common feature of poorly worked up  multivessel CAD.
  3. Re-stenosis /Re-occlusion
  4. Doing very early stress test without giving time for revascularisation to work *
  5. Rapid progression of non culprit lesions .(Sub -optimal medical management )
  6. Chronic N0-Reflow phenomenon  surrounding  area of infarct .(Especially in  PCI of CTOs)
  7. Dyskinetic  or grossly remodeled ventricular segments  can result in non ischemic positive EST response (ST drag **)
  8. Associated systemic conditions especially  Anemia/ SHT & LVH -(False positive )
  9. Many diabetic patients may  continue to show stress ischemia due to  small vessel disease.
  10. A  patient with  syndrome X  characters  can have incidental  epicardial lesion as well . In such a patient EST will always be positive .

* Optimal time to do  EST  for assessing the  efficacy of  PCI/CABG is not established .Six months may be the reasonable point .If done within 2- 3 months it may  end  up  in embarrassment for the Interventionist . (So only it is kept at 6 months , this also help us  greatly  as  we can always blame it on poor life style control and progression of  the disease !)

** No reference  for this  , a  personal observation .We know  Q leads following MI ,  will show ST elevation during stress test especially if the segments are dyskinetic  . In leads diagonally opposite to q leads ,  ST depression is observed . This may not be  a evidence for true  ischemia . It probably represents   ST drag due to mechanical stretch .

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