Katie Robinson

Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) was associated with reduced uninsured rates in the diabetes belt compared with non-belt counties, say researchers writing in 

The diabetes belt, a region across 15 southern and eastern states in which residents have high rates of diabetes, is an important region for public health interventions to reduce health disparities. This area is populated by more non-Hispanic African Americans than the rest of the country, and its population has a higher prevalence of obesity and sedentary lifestyle. Access to care and lack of health insurance coverage have been identified as the main reasons for health disparities in the region. While data has shown that insurance coverage increased  with the Medicaid expansion, under the ACA, in people aged 65 years or younger with diabetes, there are still no data on how the expansion has affected insurance coverage for low income adults in the same age group who live in the diabetes belt.

In this study, researchers examined trends in uninsured rates between 2012 and 2016 among low-income adults aged 65 years or younger to determine whether the ACA’s expansion of Medicaid impacted insurance coverage in the diabetes belt. Data for 3,129 counties were used to analyze trends in uninsured rates among populations with a household income at least 138 percent below the federal poverty level.

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In 2012, 39 percent of the population in the diabetes belt and 34 percent in non-Belt counties were uninsured (P < 0.001). In 2016 in states where Medicaid was expanded, uninsured rates fell to 13 percent and 15 percent, respectively. Adjusting for county demographic and economic factors, Medicaid expansion helped reduce uninsured rates by 12.3 percent in diabetes belt counties and by 4.9 percent in non-belt counties. Meanwhile, in 2016, uninsured rates were 15 percent higher for both diabetes belt and non-belt counties in the non-expansion states than in the expansion states.

“Initial disparities in uninsured rates between diabetes belt and non-belt counties have not existed since 2014 among expansion states,” wrote the authors, led by Min-Woong Sohn, Ph.D., of the University of Virginia in Charlottesville.

“Previous studies have shown that increased access to healthcare is generally associated with improved diagnosis and treatment of diabetes, greater adherence to medication regimens, fewer emergency room visits, and more outpatient visits,” the authors wrote. “Greater access to care also seems to improve medication use for diabetes, hypertension, and hyperlipidemia and leads to improved laboratory test results and blood pressure readings.”


	However, the authors recommended that further research is needed to examine whether and how Medicaid expansion may have contributed to an increase in the use of health services in order to prevent and treat diabetes in the diabetes belt.

Jennifer M. Lobo, Soyoun Kim, Hyojung Kang, et al.

 “Trends in Uninsured Rates Before and After Medicaid Expansion in Counties Within and Outside of the Diabetes Belt.”

. January 27, 2020. DOI https://doi.org/10.2337/dc19-0874 

Articles

Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) was associated with reduced uninsured rates in the diabetes belt compared with non-belt counties, say researchers writing in Diabetes Care.

Uninsured Rates Dip in the Diabetes Belt Where Medicaid Expanded

In post-myocardial infarction patients, chronically impaired renal failure and diabetes are both associated with an increased mortality risk, say researchers recently writing in

Diabetes is associated with both an increased risk of all-cause death, mainly driven by cardiovascular mortality, and poorer outcomes after acute myocardial infarction (AMI). While impaired glomerular filtration rate (GFR) is also associated with an increased risk of cardiovascular mortality, whether diabetes still confers a higher mortality risk in patients with impaired GFR remains unknown.

“The aim of this study was to assess the long-term prognostic significance of both diabetes and renal impairment in two prospective nationwide cohorts of AMI patients: FAST-MI 2005 and FAST-MI 2010,” wrote the authors, led by Louis Potier, M.D., of UniversitÃ© de Paris in France.

Both registries consecutively included AMI patients admitted to cardiac intensive care units within 48 hours of symptom onset during a specified one-month period. The analysis included 7,839 participants (mean age 66 years, 29 percent female, 27 percent with diabetes), of which 7,656 patients had creatinine values assessed before percutaneous coronary intervention. Researchers assessed all-cause mortality at five years according to estimated GFR (eGFR) and diabetes status at inclusion.

Five-year mortality was 38 percent in patients with diabetes versus 19 percent in patients without diabetes (adjusted hazard ratio [HR] 1.47, 95% CI 1.33–1.62, P < 0.001). According to eGFR, among all participants, five-year mortality rates were 8.1 percent for eGFR >90 mL/min, 17.7 percent for 60– 90 mL/min, 36.4 percent for 45–60 mL/ min, 57.6 percent for 30–45 mL/min, and 70.6 percent for <30 mL/min.

Further analysis suggested a gradual increase in mortality with decreasing renal function: adjusted HR versus eGFR >90 mL/min as reference 0.91 (95% CI 0.75– 1.11, P = 0.36) for eGFR 60–90 mL/min; 1.19 (0.96–1.46, P = 0.11) for 45–60 mL/ min; 1.48 (1.19–1.85, P = 0.001) for 30– 45mL/min, and 1.86 (1.48–2.35, P < 0.001) for <30 mL/min.

Moreover, increasing renal impairment was associated with an increased risk of death for participants with diabetes under a threshold of 60 mL/min but only below a threshold of 45 mL/min for participants without diabetes.

Compared with no diabetes, diabetes was associated with an increased risk of five-year death throughout eGFR categories, except for eGFR <30 mL/min: HR 1.45 (95% CI 1.01–2.09) for eGFR >90 mL/min, HR 1.54 (1.28–1.84, P < 0.001) for eGFR 60–90 mL/min, HR 1.64 (1.33–2.02, P < 0.001) for eGFR 45–60 mL/min, HR 1.28 (1.04–1.59, P = 0.02) for eGFR 30–45 mL/min.

“These results suggest that in post-myocardial infarction patients, 1) chronically impaired renal failure and diabetes are both associated with an increased risk of mortality, 2) renal function requires specific attention in patients with diabetes as soon as it is mildly impaired (45–60 mL/min), and 3) tight glycemic control, which is controversial in post-myocardial infarction patients (4), may not be essential in patients with diabetes with eGFR <30 mL/min,” the authors wrote.

The authors noted that the study was observational, with some missing data such as proteinuria in all patients and HbA1c in some patients, and that since 2010 newer glucose-lowering medications have documented an impact on cardiovascular and renal outcomes.

Louis Potier, Ronan Roussel, Marianne Zeller, et al. 

“Chronic Kidney Disease, Diabetes, and Risk of Mortality After Acute Myocardial Infarction: Insight From the FAST-MI Program.”

 January 23, 2020. doi: 10.2337/dc19-2209

In post-myocardial infarction patients, chronically impaired renal failure and diabetes are both associated with an increased mortality risk, say researchers recently writing in Diabetes Care.

Renal Failure, Diabetes Linked to Increased Mortality in Post-Myocardial Infarction

In post-myocardial infarction patients, chronically impaired renal failure and diabetes are both associated with an increased mortality risk, say researchers recently writing in 

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Louis Potier, Ronan Roussel, Marianne Zeller, et al.

 “Chronic Kidney Disease, Diabetes, and Risk of Mortality After Acute Myocardial Infarction: Insight From the FAST-MI Program.”

. January 23, 2020. doi: 10.2337/dc19-2209

Screening, testing and counseling for marijuana use is needed, especially in young patients presenting with cardiovascular disease, according to a review recently published in the 

Journal of the American College of Cardiology.

As more states are legalizing cannabis for both medicinal and recreational purposes, marijuana use is increasing, and is more prevalent in younger adults. The U.S. Food and Drug Administration has approved three cannabinoids for medical use: cannabidiol, an oral solution for the treatment of seizures in rare forms of epilepsy;  dronabinol (synthetic delta-9-tetrahydrocannabinol [THC]) to treat refractory chemotherapy-associated nausea/ vomiting and HIV-related anorexia/weight loss; and nabilone (synthetic chemical structure similar to THC) for refractory chemotherapy-associated nausea/vomiting.

Data from the National Health and Nutrition Examination Survey estimate that more than two million people with cardiovascular diseases currently use or have used marijuana in its variety of forms, including inhalation and vaping. Smoking marijuana carries many of the same cardiovascular health hazards as smoking tobacco. Observational studies have suggested an association between THC and a range of cardiovascular risks, but few randomized trials have been conducted to assess the effects of marijuana on cardiovascular risk. Recommendations are lacking to guide the cardiovascular community.

“This review summarizes cardiovascular considerations related to marijuana use, pharmacological interactions, and future steps to provide clearer guidance regarding its cardiovascular safety,” wrote the authors, led by Muthiah Vaduganathan, M.D., M.P.H., of Harvard Medical School in Boston.

Marijuana use may pose potential cardiovascular risk in patients with atherosclerotic cardiovascular disease, especially early after acute coronary syndromes. Smoking cannabis can lead to increases in heart rate and blood pressure, secondary to sympathetic nervous system activation, augmenting myocardial oxygen demands. While long-term use promotes tolerance and may be associated with less pronounced physiological effects, epidemiological studies have found a potential temporal link between marijuana use and myocardial infarction.

Meanwhile, a broad range of cardiac electrical effects, including atrial fibrillation and ventricular tachycardia, have been described with marijuana use, which may be explained by the increased catecholamines and b-adrenergic stimulation with THC that could raise arrhythmogenicity. Cerebrovascular events have also been reported in association with marijuana use, due to the direct vasculotoxic effects, alterations in hemodynamics, or incident atrial fibrillation/flutter.

Further, thrombosis and ischemia have been reported in the peripheral arteries with marijuana use, and delta-8 and delta-9-tetrahydrocannabinols have been shown to stimulate peripheral vasoconstriction. Cannabis use has also been associated with myocardial dysfunction, independent of coronary artery disease. Case reports have suggested associations of cannabis with stress cardiomyopathy and myocarditis/ myopericarditis, an entity ref

http://www.onlinejacc.org/content/75/3/320

erred to as toxic myocarditis. Additionally, heart transplant candidacy may be affected by marijuana use. Potential concerns include medication adherence due to the psychotropic effects of THC, infectious complications in the setting of immunosuppression, and interactions with tacrolimus.

In regard to pharmacological interactions, cannabinoids affect key classes of cardiovascular medications including antiarrhythmics, calcium-channel blockers, statins, beta-blockers, and warfarin, by inhibiting the cytochrome P (CYP) 450 family. However, limited clinical data are available to guide dose or therapeutic changes.

“In light of accumulating data suggesting prevalent use of marijuana, including among patients with established cardiovascular disease, it is important to integrate screening, counseling, and testing when appropriate into clinical care,” the authors wrote.

Questions to patients should include frequency, quantity, and methods of administration, and patients should be made aware potential cardiovascular hazards of marijuana use, especially when used via smoking/inhalation routes. Since marijuana is also being delivered in vaporized forms, especially among young adults, clinicians should counsel patients about the variable concentrations of psychoactive THC delivered via different methods of use, as vaporized cannabis may yield high concentrations with greater pharmacodynamic effects than smoked cannabis.

Additionally, it may be reasonable to perform urine toxicology in the setting of myocardial infarction and new-onset heart failure. Marijuana testing is also required before an evaluation for heart transplantation. Patients should be screened for and counseled regarding the hazards of concurrent use of other illicit drugs, especially those with known adverse cardiovascular effects, such as cocaine and methamphetamines. Meanwhile, multidisciplinary assessment with a pharmacist will help determine whether dose changes are required for therapies with known interactions.

“Shared decision making is encouraged if marijuana is used for symptom management or palliative purposes, incorporating estimates of life expectancy and cardiovascular risks,” the authors wrote.

“Cardiovascular specialists should be aware of local regulations and state-specific legalization status of marijuana products,” the authors wrote.

Ersilia M. DeFilippis, Navkaranbir S. Bajaj, Amitoj Singh, et al. 

“Marijuana Use in Patients With Cardiovascular Disease.”

. January 3, 2020. DOI: 10.1016/j.jacc.2019.11.025

Screening, testing and counseling for marijuana use is needed, especially in young patients presenting with cardiovascular disease, according to a review recently published in the Journal of the American College of Cardiology.