Novel diabetes drugs and the cardiovascular specialist

Recently, treatment with 2 newer classes of type 2 diabetes drugs were found to reduce events in patients with diabetes and cardiovascular (CV) disease, a group common in cardiology clinics. The sodium-glucose cotransporter 2 inhibitor, empagliflozin, markedly and rapidly reduced CV death and heart failure hospitalization, likely with hemodynamic/metabolic-driven mechanisms of action. More recently, the glucagon-like peptide–1 receptor agonists liraglutide and semaglutide also reduced CV death and/or major adverse CV events, but did so more slowly and did not influence heart failure risks, suggesting alternative mechanisms of benefit. We will discuss drug therapy for diabetes relative to CV risk, briefly summarize key findings of CV benefit from recent trials, discuss potential mechanisms for benefits of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide–1 agonists, and suggest how such drugs might be embraced by CV specialists to reduce CV events and mortality in their patients

The role of natriuretic peptide testing in guiding chronic heart failure management: Review of available data and recommendations for use

SummaryThe care of patients with heart failure can be challenging, with few objective tools available to assist in therapy decision-making. Natriuretic peptides are powerfully prognostic biomarkers in patients with heart failure and may represent an objective target for therapy. Accordingly, the use of biomarker-guided care with either B-type natriuretic peptide (BNP) or amino-terminal pro-B-type natriuretic peptide (NT-proBNP) has been recently explored. Over the past few years, a number of studies with heterogeneous inclusion criteria, methods and results have been performed. We have reviewed the available literature, summarizing the results of biomarker-guided heart failure trials and deriving recommendations for optimal application of biomarker-guided heart failure care based on the experience gained. In general, positive studies had low BNP or NT-proBNP target concentrations (∼100pg/mL and ∼1000pg/mL, respectively) and achieved lower natriuretic peptide concentrations compared with standard care. Patients in the biomarker-guided arms of the studies typically received more aggressive heart failure care and had no excess adverse outcomes. In the recent ProBNP Outpatient Tailored Chronic Heart Failure Therapy (PROTECT) study, patients treated with biomarker-guided care also had improved quality of life and significantly better reverse remodeling on echocardiography compared with patients who received standard care. In conclusion, heart failure therapy guided by a goal to reduce natriuretic peptide concentrations below prognostically-meaningful levels results in more aggressive heart failure care, is well tolerated and is associated with superior outcomes

Effects of canagliflozin on cardiovascular biomarkers in older adults with type 2 diabetes

Background: Sodium glucose co-transporter 2 (SGLT2) inhibitors may reduce cardiovascular and heart failure risk in patients with type 2 diabetes mellitus (T2DM). Objectives: To examine the effects of canagliflozin on cardiovascular biomarkers in older patients with T2DM. Methods: In 666 T2DM patients randomized to receive canagliflozin 100 or 300 mg or placebo, we assessed median percent change in serum N-terminal pro-B type natriuretic peptide (NT-proBNP), high-sensitivity troponin I (hsTnI) , soluble (s)ST2, and galectin-3 from baseline to 26, 52, and 104 weeks. Results: Both serum NT-proBNP and serum hsTnI levels increased in placebo recipients but remained largely unchanged in those randomized to canagliflozin. Hodges-Lehmann estimates of the difference in median percent change between pooled canagliflozin and placebo were –15.0%, –16.1%, and –26.8% for NT-proBNP, and –8.3%, –11.9%, and –10.0% for hsTnI at weeks 26, 52, and 104, respectively (all P <0.05). Serum sST2 was unchanged with canagliflozin and placebo over 104 weeks. Serum galectin-3 modestly increased from baseline with canagliflozin versus placebo, with significant differences observed at 26 and 52 weeks but not at 104 weeks. These results remained unchanged when only patients with complete samples were assessed. Conclusions: Compared to placebo, treatment with canagliflozin delayed rise in serum NT-proBNP and hsTnI over 2 years in older T2DM patients. These cardiac biomarker data provide support for beneficial cardiovascular effect of SGLT2 inhibitors in T2DM

Opacity in hedge funds:Does it create value for investors and managers?

This paper investigates if opacity (as measured by derivatives usage) creates value for investors and the managers of hedge funds that charge performance fees. Since we do not identify a positive relation between opacity and managers’ revenue, it is not possible to state that opacity is a source of manager’s value creation for hedge fund investors and managers. However, considering that opacity is positively associated with risk-taking and negatively related with investors’ adjusted returns, we suggest policies aiming at protecting investors, especially those less qualified. We examine a unique and comprehensive database related to the positions in derivatives taken by managers, which was enabled due to specific disclosure regulatory demands of the Brazilian Securities Exchange Commission, where detailed information on hedge funds’ portfolio allocation should be provided on a monthly basis.Este artigo investiga se a opacidade (mensurada pela utilização de derivativos) cria valor tanto para os investidores quanto para os gestores de fundos de hedge (que cobram taxas de performance). Como não foi verificada uma relação positiva entre opacidade e a receita do gestor, não é possível afirmar que ela crie valor para esses agentes ou mesmo para os investidores. Embora tenha sido constatado que a opacidade esteve positivamente associada à tomada de risco e negativamente relacionada com o retorno ajustado do fundo, foram sugeridas medidas de proteção para os investidores, especialmente os menos qualificados. Foi empregada uma base de dados única e abrangente relacionada a posições em derivativos em fundos. Isso foi possível devido àsnormas de divulgação da Comissão de Valores Mobiliários brasileira, que obrigam os gestores a publicar ao final de cada mês as informações detalhadas da alocação da carteira de cada fundo

Optimization of in vitro organogenesis in passion fruit (Passiflora edulis f. flavicarpa)

A organogênese in vitro de maracujá foi estudada pela indução de gemas adventícias em discos de folha cultivados em meio de cultura suplementado com benziladenina (BAP) ou thidiazuron (TDZ). Nitrato de prata (AgNO3) foi adicionado ao meio de cultura de indução de gemas adventícias para minimizar o efeito do acúmulo de etileno no desenvolvimento dos brotos. Tanto BAP (0; 2,2; 4,4; 6,6 µmol L-1) como TDZ (0; 1,1; 2,2; 3,4 µmol L-1) foram eficientes em promover o desenvolvimento de brotos. Embora diferenças significativas no uso de AgNO3 (23,5 µmol L-1) não tenham sido detectadas, gemas adventícias desenvolvidas em meio de cultura suplementado com AgNO3 eram mais vigorosas. O número de explantes com gemas obtidos no meio de cultura suplementado com TDZ e AgNO3 (5,6) foi maior do que aquele obtido com BAP e AgNO3 (3,0). Os meios de cultura MSM + ácido giberélico (GA3), MSM + água de coco ou ½ MSM foram utilizados para o alongamento dos brotos, os quais foram incubados em frascos com tampas ventiladas ou tampas normais. Os melhores resultados foram obtidos cultivando-se as gemas adventícias no meio de cultura MSM + água de coco em frascos com tampas ventiladas. As plântulas transferidas para meio de cultura MSM + ácido indol butírico enraizaram num período de 30 dias. A organogênese in vitro de maracujazeiro foi otimizada utilizando-se TDZ + AgNO3 para a indução de gemas adventícias. A transferência das gemas para meio de cultura MSM + água de coco e a incubação em frascos com tampas ventiladas favoreceu o alongamento e o desenvolvimento de plântulas.In vitro organogenesis of passion fruit was studied by the induction of adventitious buds from leaf discs in culture media supplemented with benzyladenine (BAP) or thidiazuron (TDZ). To minimize adverse effects of ethylene accumulation on shoot development, silver nitrate (AgNO3) was added to the induction media. Both BAP (0; 2.2; 4.4; 6.6 µmol L-1) and TDZ (0; 1.1; 2.2; 3.4 µmol L-1) were effective in promoting shoot development. Although no significant differences were detected using AgNO3 (23.5 µmol L-1), buds grown in AgNO3-supplemented media were more vigorous. The number of explants with buds obtained using TDZ and AgNO3-supplemented media (5.6) were higher than those obtained using BAP and AgNO3 (3.0). MSM + giberrellic acid (GA3), MSM + coconut water, and ½ MSM culture media were tested for shoot bud elongation, incubated in flasks covered with either non-vented or vented lids. Best results were obtained by culturing buds in MSM + coconut water media in flasks covered with vented lids. Plantlets transferred to MSM + indol butyric acid (IBA) media rooted in a 30-day period. Passion fruit organogenesis was enhanced by using TDZ and AgNO3 for bud induction. Transferring the buds to MSM + coconut water media and incubating in flasks with vented lids favored shoot elongation and plantlet development

Natriuretic Peptide Testing in Primary Care

The incidence, as well as the morbidity and mortality associated with heart failure (HF) continue to rise despite advances in diagnostics and therapeutics. A recent advance in the diagnostic and therapeutic approach to HF is the use of natriuretic peptide (NP) testing, including both B-type natriuretic peptide (BNP) and its amino terminal cleavage equivalent (NT-proBNP). NPs may be elevated at an early stage among those with symptoms as well among those without. The optimal approach for applying NP testing in general populations is to select the target population and optimal cut off values carefully. Superior diagnostic performance is observed among those with higher baseline risk (such as hypertensives or diabetics). As well, unlike for acute HF, the cut off value for outpatient testing for BNP is 20-40 pg/mL and for NTproBNP it is 100-150 ng/L. In symptomatic primary care patients, both BNP and NT-proBNP serve as excellent tools for excluding HF based on their excellent negative predictive values and their use may be cost effective. Among those with established HF, it is logical to assume that titration of treatment to achieve lower NPs levels may be advantageous. There are several ongoing trials looking at that prospect