Hemogram parameters such as mean platelet volume (MPV), neutrophil/lymphocyte ratio (NLr), red cell distribution width and platelet distribution width are widely used inflammatory indicators to assess prognosis in various cardiovascular diseases. In this study, we aimed to investigate the role of hemogram parameters to predict the development of contrast-induced nephropathy (CIN) in patients presenting with non-ST segment elevation myocardial infarction (non-STEMI) and treated with percutaneous coronary intervention (PCI).All pateints who underwent PCI with a diagnosis of non-STEMI between 2017 and 2020 in our center were included retrospectively in this study.A total of 387 patients were included in this retrospective study. Advanced age , diabetes mellitus , congestive heart failure , volume of contrast medium , MPV  and NLr  were found as independent risk factors associated with CIN development according to multivariate logistic regression analysis. A cut off value of 5.5 for NLr was associated with 79.6 % sensitivity and 79.5 % specificity and 9.05 for MPV was associated with 64.1 % sensitivity and 58.7 % specificity in prediction of CIN development.Hematological parameters, assessed by routine blood count analysis may serve as a promising and useful marker for CIN especially when used in combination with traditional risk factors. MPV and NLr were demonstrated as predictors of CIN development in non-STEMI patients who were treated with PCI in our study. Contrast-induced nephropathy (CIN) is a kind of acute kidney injury associated with intravascular contrast media (CM) use and one of the well-known complications of cardiac catheterization procedures. CIN is defined as the increase in serum creatinine (Cr) level at least 0.5 mg/dL or 25 % than baseline serum Cr within 48–72 h after contrast medium exposure . Its incVasoconstriction, direct cellular toxicity and inflammation are risk factors for CIN development , 6], , , 9], , , 11]. S. S11]. SAll patients who underwent PCI with a diagnosis of non-STEMI between 2017 and 2020 in our center were included retrospectively in this study. Local hospital electronic database and patients’ files were screened to obtain demographic, clinical and laboratory parameters. Medical treatments which were either applied in hospital or have been previously in use by the patients were also recorded. Non-ST elevation myocardial infarction was diagnosed according to recent guidelines . Presenc1c value>6.5 % or use of antidiabetic medicine was indicative of diabetes mellitus (DM) [Congestive heart failure diagnosis was based on a previous history of heart failure, or objective evidence of reduced left ventricular ejection fraction (LVEF) ≤40 % assessed by echocardiography on admission . Transthtus (DM) . CoronarHemogram parameters  which were obtained at first admission recorded . Baseline serum Cr level obtained from first admission biochemical analysis was accepted as ‘baseline Cr’ and the maximum serum Cr level which was obtained at least 48 h after contrast administration was accepted as ‘maximal Cr’ value. Two groups generated according to CIN development; CIN developed as CIN (+) and CIN non-developed as CIN (−). The primary endpoint of this study was the occurrence of CIN. Human Studies and Research Committee of our institution approved the study and patient consent was waived accordingly.All statistical tests were conducted using the Statistical Package for the Social Sciences 22.0 . Continuous variables are expressed as mean ± SD, and categorical data are expressed as number (n) and percentages (%). Chi-square test was used to assess differences in categorical variables between groups. Student’s t-test or Mann Whitney U test was used to compare unpaired samples as needed. Variables having linear correlation were evaluated by using Pearson’s correlation test and nonlinear variables were evaluated by using Spearman’s correlation test. The correlation of hemogram parameters with CIN development was investigated. Logistic regression analysis was used to identify independent variables of CIN in the study population. Area under the receiver operating curve (ROC) was calculated to assess the ability of hemogram parameters to estimate outcomes. Significance was assumed at a 2-sided p<0.05.Five hundred and twenty-nine patients were evaluated, after exclusion of patients as defined in methodology and those with lack of data, finally a total of 387 patients were included in this retrospective study. The mean age was 65.9 ± 10.9 and 60.5 % were male. Baseline Cr level was 1.05 ± 0.28. When patients were grouped according to CIN development as CIN (+) and CIN (−); 74 (19.1 %) patients formed the CIN (+) and 313 (80.9 %) patients formed CIN (−) group. Both groups were similar in terms of gender, body mass index, smoking status, hyperlipidemia, HT, history of stroke and received medical treatment. However, advanced age , DM , patients with a history of CAD , CHF  and volume of CM used  were significantly higher in CIN (+) group. In terms of laboratory markers; maximal urea , maximal Cr , uric acid , troponin , fasting blood glucose  were significantly higher and albumin  level was significantly lower in CIN (+) group. Furthermore, PDW , MPV  and NLr  were significantly higher in CIN (+) group. All demographical, clinical and laboratory characteristics of the two groups are presented in detail in To further evaluate individual risk factors for CIN development, univariate logistic regression analysis was performed for age, DM, history of CAD and CHF, volume of CM, albumin, uric acid, troponin, fasting glucose, PDW, MPV levels and NLr, respectively. By univariate logistic regression analysis, advanced age, volume of CM used, history of DM, CHF, albumin, PDW, MPV levels and NLr were found to be correlated with CIN development. These variables were assessed in the multivariate logistic regression model. Advanced age , history of DM , history of CHF , volume of CM , MPV  and NLr  were found as independent risk factors associated with CIN development by multivariate logistic regression analysis . ROC anaThe prevalence of CIN development was found 19.1 % and hematological parameters were found to be useful for predicting CIN development in our study. Preprocedural assessment of the hematological parameters may raise suspicion to foresee the incidence of CIN in patients with non-STEMI. The independent predictors of CIN development were advanced age, history of DM, CHF, volume of CM, MPV and NLr. Close follow-up of patients with MPV>9.05 and NLr>5.5 on admission as an additional clue to other risk factors may help to define patients under risk of CIN development.Contrast medium is a part of diagnostic and therapeutic approaches especially in cardiology era and CM use raised due to developments in interventional cardiology. CIN is one of the vital complications that can occur due to CM exposure. In addition to relation between CIN and increased morbidity/mortality, the prolonged hospital and intensive care unit stays and increased need for hemodialysis, CIN development may cause raised cost on health care system . InflammHigh RDW is a finding of impaired erythropoiesis and indicates raised oxidative stress and chronic inflammation. The prognostic role of high RDW in various cardiac circumstances such as CAD, acute coronary syndrome, CHF and paroxysmal atrial fibrillation was shown , 22. TheOur study was conducted in a single center and designed retrospectively. Evaluating additional inflammation markers such as high-sensitive C-reactive protein might give further information about the inflammatory status and opportunity to correlate with hematological parameters. Post-procedural creatinine level was obtained at least 48 h after contrast exposure; therefore, some patients who had a later increase in serum Cr levels after discharge may have been missed.Contrast medium use is increasing due to developments in diagnostic and therapeutic approaches in interventional cardiology. Contrast-induced renal injury leads to increased morbidity, mortality, health care costs and prolonged hospital stays. Iatrogenic and predictable nature of CIN marks it as a cornerstone for ongoing cardiovascular and nephrology research, with a focus on risk factors and preventative, diagnostic and therapeutic measures. A chronic inflammatory response may play a role in the pathogenesis of CIN, and hematological parameters, assessed by routine blood count analysis may serve as a promising and useful marker for CIN development especially when used in combination with traditional risk factors. Mean platelet volume and NLr were demonstrated as predictors of CIN development in non-STEMI patients who were treated with PCI in our study. Larger and prospective studies are needed to evaluate the relationship between hematological parameters and prevalence of CIN.


To identify primary factors contributing to hemodialysis-related headache (HRH) in maintenance hemodialysis (MHD) patients.Adult outpatients receiving MHD were prospectively enrolled from a hemodialysis (HD) center of a tertiary hospital in China. Twelve dialysis sessions were successively monitored for each patient. HRH is defined as having at least three headache episodes that begin during HD and resolve within 72 h of HD session completion. Blood gas analysis during headache episodes and body composition analysis after dialysis were conducted. Hour-to-hour vital sign variability during dialysis was assessed using the metric of average real variability (ARV). Multivariable logistic regression analysis was conducted to explore the factors triggering HRH.p = 0.039), decreased blood sodium level , increased ARV of intradialysis systolic blood pressure  and ratio of overhydration to dry weight  were found to be independent risk factors for HRH.A total of 95 Chinese MHD patients were enrolled, with 92 patients  included in the final analysis. The mean age of the 92 patients was 59.3 ± 17.5 years, and the median dialysis vintage was 27.1 (12–46.2) months. Among them, 12 patients (13%) complained of 42 headache attacks, and eight (8.7%) were diagnosed with HRH. For eight patients with HRH, headache occurred 100.3 ± 69.5 min after the start of dialysis, with a mean VAS score of 4.3 ± 1 points. The quality of headaches was dull (six patients), pulsating (one patient), or stabbing pain (one patient); all the headaches were bilateral, with one having concomitant vomiting. The intradialysis headache duration and the whole headache duration were 98.8 ± 68.1 and 120 (65–217.5) minutes, respectively. Younger age (OR = 0.844, 95% CI 0.719–0.991, This study suggested a significant attribution of blood sodium, hydration status and blood pressure variability to HRH.The online version contains supplementary material available at 10.1186/s10194-023-01701-2. Headache is a commonly reported neurological symptom in patients undergoing maintenance hemodialysis (MHD) –7. AccorThe pathophysiology of HRH remains multifactorial and controversial. Past studies identified possible contributors, such as differences in blood urea, arterial hypertension and hypotension, sodium washout, an elevated predialysis sodium level, or a decreased magnesium level –6. HowevThe aim of the present study was to determine the dominant factors for HRH in MHD patients with blood biochemistry measurements during headache episodes, assessments of intradialysis vital sign variability, and volume assessment based on body composition analysis., or consciousness disorder preventing cooperation with investigators; (4) active severe infection, e.g., intracranial infection, severe pneumonia; (5) admission to hospital for any reason; (6) having schedules of kidney transplant operations or transferring dialysis center within 2 months after the enrollment day such that the study had to be suspended; and (7) refusal to consent to the study.The single-center prospective cohort study was conducted at the Hemodialysis Center of the West China Fourth Hospital of Sichuan University, a public tertiary hospital affiliated with Sichuan University in China. Study participants were recruited between October 17, 2022 and February 24, 2023. The inclusion criteria were (1) outpatients aged 18 years or older and (2) received regular hemodialysis (HD) for at least 3 months. The exclusion criteria were as follows: (1) peritoneal dialysis; (2) a previous history of primary or secondary headaches  with attacks occurring more than 50% of the time between HD sessions, which was assessed through clinical interview and electronic medical records; (3) dementia, cognitive impairmentClinical information was gathered through electronic medical records, including demographic details, etiologies of end-stage renal disease, coexisting diseases, dialysis vintage and HD prescription. Serum biochemical indexes were obtained based on the blood samples measured in a central laboratory from a routine clinical examination in the HD center, which was gathered within three months, close to the enrollment day. The urea reduction ratio (URR) was defined as the percentage drop in blood urea nitrogen levels from before to after a dialysis session, which was calculated using the simple formulation 1-(post-urea nitrogen/pre-urea nitrogen) × 100 (%) .Patients in this study underwent 2–3 acetate HD treatments per week. Two different types of anticoagulation, including low molecular weight heparin anticoagulation and citrate anticoagulation, were employed for a 4-h HD treatment according to the patient’s clinical condition. Blood flow was 200‐350 mL/min, and dialysate flow was 500‐700 mL/min . The ultrafiltration volume was determined by interdialysis weight gain.2) of non-fistula limbs throughout the dialysis session . There were no interventions by the investigators.HD treatments (12 sessions per patient) over a period of 4–6 weeks were consistently recorded, including data on ultrafiltration volume, dialysate flow, blood flow, and vital signs such as pulse, BP, and blood oxygen saturation  were collected at the time of the headache attack and then subjected to blood gas analysis (BGA) using the same handheld blood gas analyser . Body composition analysis (BCA) using the same body composition monitor , following the machine manual , was perFor patients without HRH, BGA and BCA were performed during and after a routine HD treatment, respectively. The measuring time of BGA in the control group was consistent with the most common onset time of headaches in the HRH group.Variability assessment of hourly vital signs during HD treatment employed the average real variability (ARV) metric, representing the mean of the absolute differences between successive measurements. ARV offers a notable advantage, as it considers not only the amplitude of fluctuations in the study target but also the time sequence of these fluctuations , 13. Formentclasspt{minimat test or Wilcoxon rank sum test was used to compare continuous variables between the HRH and non-HRH groups, and the chi-square test was applied to compare proportions. Univariable and multivariable logistic regression analyses were conducted with the dependent variable defined as a patient having HRH. Variables at P < 0.05 in the univariate analysis and those considered clinically relevant to HRH based on prior studies   or a > 0.05)  in patieBP fluctuations over time are denoted as BP variability (BPV). MHD patients often experience increased BPV during HD due to the rapid removal of metabolic substances, vasoactive mediators, and body fluids, leading to dramatic alterations in hemodynamics and the internal environment , 13, 15.The present study has some limitations. First, the sample size was small, and the relatively low incidence of HRH resulted in an uneven sample size between the HRH and non-HRH groups, which inevitably weakened the reliability of the differences between the two groups. Second, although pre-filtration BGA was well-accepted by patients due to advantages such as being free of venipuncture, requiring a small specimen, and providing rapid feedback of results, it did not measure blood magnesium, which is closely correlated with HRH . Third, The prospective cohort study revealed an 8.7% incidence of HRH in MHD patients over a 12-HD session observational period based on the latest ICHD III criteria. Factors associated with an increased risk of HRH include younger age, a relatively low blood sodium level, heightened variability of intradialysis SBP, and imbalanced hydration. Further large-scale, high-quality studies are necessary to comprehensively understand the contributing factors and develop effective treatment strategies for HRH.Additional file 1.


Atrial fibrillation (AF) is a very common arrhythmia with significant incidence rate and mortality. Several studies have shown a notable correlation between non-alcoholic fatty liver disease (NAFLD) and AF. It has been observed that serum cholinesterase (SChE) levels are elevated in individuals with fatty liver. However, the relationship between the SChE index and AF is still unclear. Therefore, the purpose of this study is to explore the association between the SChE index and the prevalence of AF in patients with hypertension.We collected cross-sectional data from January 2018 to April 2021 based on a retrospective study of cardiovascular disease. A total of 748 patients with hypertension were included, of whom 165 had AF. We used logistic regression models to test the relationship between SChE and the prevalence of AF in hypertensive patients.P < 0.001). After adjusting for potential confounding factors, this correlation was still significant . The stability of the model was verified by adjusting the variable type of SChE. The data were further stratified according to whether the patient had fatty liver. In the stratified data, the correlation between SChE and atrial fibrillation was still significant (P < 0.05).In hypertensive patients, the SChE index was significantly associated with AF (OR = 0.723, Our study showed that SChE was significantly negatively correlated with the occurrence of AF in patients with hypertension. And this correlation was not affected by whether the patient had fatty liver. Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia, affecting approximately 300–1000 million individuals worldwide . EpidemiThe pathophysiological mechanisms of AF primarily involve electrical remodeling and structural remodeling . Its occThe research center and population for this cross-sectional analysis are part of a retrospective study of cardiovascular diseases conducted from September 2021 to April 2022 in the cardiovascular ward of Guang 'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China. This study involved the extraction of de-identified electronic medical records of inpatients from the cardiovascular department, covering the period from 2010 to 2022. By conducting clustering analysis on the clinical information, we were able to identify and summarize the characteristic syndromes of patients diagnosed with AF. Guang’anmen Hospital granted ethical approval for this experiment, which strictly complied with the Declaration of Helsinki (2021). We used cross-sectional data collected in the database for the period January 2018 to April 2021, including 748 patients with hypertension, 165 of whom had AF. Inclusion criteria included: (1) HT patients; (2) participants over the age of 18. Exclusion criteria included: (1) participants with acute coronary syndrome, hypertensive crisis, or other diseases that cause significant hemodynamic abnormalities; (2) participants with NYHA cardiac function rating of 3 or above; (3) participants with malignant tumors, infections or hematological diseases; and (4) participants with missing SChE data.We collected four parts of data. 1. Demographic data: including age, sex, nationality, height, weight, smoking and drinking; 2. Diagnostic information on basic diseases such as hypertension, coronary heart disease (CHD), arrhythmia, diabetes and hyperlipidemia; 3. Cardiac ultrasound data, including Left atrial diameter (LAD), Left ventricular end-diastolic diameter (LVDD), Ejection fraction (EF), Aortic regurgitation (AR), Mitral valve regurgitation (MR), Tricuspid Regurgitation (TR), Left ventricular systolic dysfunction (LVSD), Regional wall motion abnormality (RWMA)0.4. Laboratory test data, including platelet (PLT), Lymphocyte count (LYMPH), Neutrophil count (NEUT), Fasting Blood Glucose (FBG), Uric acid (UA), Triglyceride (TG), High-density lipoprotein cholesterol (HDL-C), Low-density lipoprotein cholesterol (LDL-C), Serum creatinine (Scr), High sensitivity C-reactive protein (hs-CRP), Thyroid stimulating hormone (TSH), serum cholinesterase (SChE).Hypertension is defined as previously having a HT history or being diagnosed based on office blood pressure (BP), which includes systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg, or both .Coronary heart disease is defined as previously having a CHD history or confirmed by the International Cardiology guidelines, which includes typical clinical angina manifestations, electrocardiographic changes, and coronary angiography .Arrhythmia is defined as abnormal frequency and/or rhythm of heart beats, including ventricular and supraventricular arrhythmias .Diabetes is defined as previously having a diabetes history or being diagnosed based on blood glucose  .Hyperlipidemia, including high total cholesterol (TC), high total triglyceride (TG), mixed high TC and high TG, high low-density lipoprotein cholesterol (LDL-C), and lowered high-density lipoprotein cholesterol (HDL-C) .χ2 test, and descriptive parameters were shown as mean (SD) for continuous variables and proportions for categorical variables. Initially, we explored the relationship between SChE levels and AF prevalence through a logistic regression model. Then, we verified the stability of the model by adjusting the SChE variable type.This study included the clinical data of 784 patients with hypertension in the original database and interpolated the missing data. Among them, height and weight were interpolated according to the mean, and the remaining missing data were filled by multiple interpolation method of the mice function. We stratified participants into two groups based on whether they had atrial fibrillation. And tested the differences between two populations by P-value < 0.05 was considered statistically significant. All statistical analyses were performed using R4.2.2.In addition, we studied the combined effect of fatty liver and SChE on the prevalence of atrial fibrillation. The sample data were divided into two groups according to whether fatty liver was combined. In the stratified data, the correlation between SChE and the prevalence of AF was further explored. In multivariable models, we adjusted for variables indicated as potential confounders: Age, Sex, Nationality, NLR, HCRP, LDL-C, TG, TC, Scr, UA, LYMPH, Pah, RWMA, LVSD, TR, MR, AR, Left ventricular diastolic dysfunction, EF, LVDD, LAD, β-blocker use, Hyperhomocysteinemia, Hyperlipidemia, CHD and Course of HT. A two-sided A total of 784 subjects were included in the analysis. The characteristics of subjects are shown in Table P < 0.001). In the minimally adjusted model , the result did not have obvious changes . We also detected the same connection in the fully adjusted model . For sensitivity analysis, we handled SChE as a categorical variable (Quartile), and found the same trend as well.We used univariate logistic regression analysis to evaluate the association between SChE and the prevalence of AF. Meanwhile, we also showed the non-adjusted and adjusted models in Fig. A similar result was observed in the hierarchical analysis, shown in Fig. Hypertension is widely recognized as the predominant risk factor for AF. Studies have demonstrated that individuals with hypertension are 1.7 times more likely to develop AF compared to those with normal blood pressure , 11. MorSerum cholinesterase, also known as pseudo- or butyryl-cholinesterase (BChE), is synthesized by hepatocytes, and its half-life in serum is 11 days . The conFor individuals diagnosed with hypertension, it is crucial to promptly identify high-risk patients who may develop atrial fibrillation. This early identification enables early screening, diagnosis, and intervention. Timely and accurate diagnosis of AF can effectively prevent complications, reduce hospitalization related to AF, and lower the mortality rate associated with AF. Although many studies have confirmed that serum biomarkers, echocardiographic markers and specific patterns on brain imaging can predict AF –54. HoweOur study has some limitations. First, this was a cross-sectional study and no statements about causality are made. Second, our study had small samples and was single center, which may cause bias. Although we adjusted for confounders in the multivariate analysis, the potential confounders were not completely eliminated. Third, hospitalized patients were typically older and had more underlying diseases. Last, diagnosis of NAFLD was made by ultrasonography rather than liver biopsy, the gold standard technique for detecting fatty liver. And the subjects' drinking history also lacked detailed records, so it was still unclear whether fatty liver was caused by alcohol. In addition, we only included HT patients in this study. Therefore, the suitable population of our findings is limited. Moreover, studies of a large and diverse population should be conducted to further verify. To our knowledge, this is the first study to investigate the association between the SChE index and AF patients with HT.In conclusion, our study showed that SChE was significantly negatively correlated with the prevalence of AF in patients with hypertension. And this correlation was not affected by whether patients with fatty liver.


P > .05). In comparison to the control group, the experimental group demonstrated healthier behavior. Blood pressure and weight control during pregnancy were better than control group. The frequency of adverse pregnancy was inferior to control group. The number of adverse neonatal conditions was inferior to control group. The postpartum quality of life score was higher in the experimental group compared to the control group. The combination of IKAP health education and cluster based care has a better effect on blood pressure control compared to the sole use of cluster based care. This approach can reduce the likelihood of experiencing adverse pregnancy outcomes and help improve the quality of life for patients after delivery.To analyze the impact of information-knowledge-attitude-practice (IKAP) health education incorporated with cluster-based care on blood pressure control, pregnancy outcome and life quality in those who have gestational hypertension, and to provide methodological backing for the care of patients. A total of 80 patients with pregnancy-induced hypertension were selected as the research objects and randomly divided into control and experimental groups, with 40 cases in each group. The control group received routine cluster care, which included providing individual and group health information through the distribution of health education manuals to hypertensive patients during pregnancy and their families. The experimental group received additional IKAP health education, including data collection, health knowledge imparted, concept change and behavior generation process. Blood pressure control status was measured and recorded. Adverse pregnancy outcomes include placenta previa, cesarean section, hyperamniotic fluid, fetal distress, and postpartum hemorrhage. Postpartum quality of life conditions, including physical activity, emotional awareness, physical discomfort, mental health, sleep quality, postpartum anxiety or depression, and general health were evaluated. Age, prepregnancy BMI, and educational level did not significantly vary between the 2 groups( The exact pathogenesis of hypertensive diseases in pregnancy is still not fully understood. The pathogenic causes and mechanisms of preeclampsia are very complex and are considered to be a disease with multiple factors, mechanisms and pathways. It has been theorized that when the infiltration ability of extravillus trophoblast cells is impaired, the recast ability of uterine spiral arteriole is inhibited, and placental implantation contribute to the occurrence of diseases.In China, there has been a trend of women delaying their childbearing age, resulting in an increasing proportion of elderly pregnant women and greater attention on hypertensive diseases during pregnancy. Related animal experiments have revealed that the newborns with fetal growth restriction exhibit decreased diaphragmatic contraction capacity, which leads to impaired respiratory function. In severe cases, it may affect the development of the nervous system, resulting in cerebral palsy, slow intellectual development and decreased control. The increased risk of metabolic diseases such as obesity and diabetes in childhood and adulthood also increases the financial and mental burden on their families.Hypertensive diseases during pregnancy can lead to detrimental effects on vital organs such as the cardiovascular, liver, kidney and brain organs. Related studies have demonstrated that placental function is inhibited due to insufficient placental injection in hypertensive patients during pregnancy. Fetal growth is limited, increases the likelihood of premature birth and low birth weight, and results in abnormal expression of substances like endothelin in umbilical cord blood.; Furthermore, these conditions affect the coagulation and fibrinolytic system, which limits the growth and development of the fetus, further increases the probability of neonatal death, and significantly deteriorates both adults and children’s physical and mental health. With the improvement in living standards and advancements in medical and health technology, anxiety and depression during pregnancy have attracted the attention of scholars and experts. Studies have shown that prolonged anxiety during pregnancy can lead to small gestational age; The proportion of low fetal weight caused by negative emotions during pregnancy increased by at least 25% compared with normal pregnant women; In severe cases, it can also raise the probability of preterm birth and other adverse pregnancy outcomes. This highlights the importance of prenatal and postnatal care for hypertension during pregnancy. A separate study revealed that during the latter stages of pregnancy, there exists an inverse relationship between the severity of depression and the duration of walking as a physical activity. Additionally, walking was found to have a positive correlation with anxiety levels. Exercise holds promise as a potentially efficacious approach for addressing certain manifestations of depression. Engaging in appropriate physical activity during pregnancy not only yields psychological benefits for expectant mothers and enhances mood, but also exerts a positive impact on the regulation of fasting and postprandial blood sugar levels, as well as HbAc1, in pregnant women diagnosed with gestational diabetes. There exists a favorable correlation between the performance of physical activity and the management of gestational diabetes mellitus. Considering these factors, the study proposed an analysis of the impact of information-knowledge-attitude-practice (IKAP) health education combined with cluster based care on blood pressure control, pregnancy outcome and quality of life of pregnant patients with high blood pressure, hoping to improve suffers disease control and pregnancy outcome, as well as improve their postpartum quality of life.Studies have also shown a higher incidence of anxiety and depression in hypertensive patients during pregnancy compared to ordinary pregnant women; Poor mental state will affect the health of both mother and child, and postpartum anxiety and depression will affect their postpartum quality of life. The following were the inclusion requirements: Patients were older than 18 years and younger than 35 years; Suffering from pregnancy-induced hypertension; The pelvic assessment is normal, the fetus is healthy and weighs more than 4 kg; Clear mental awareness, able to communicate and communicate normally; Single pregnancy; No bad habits such as smoking and drinking; Accept the experiment’s risks and complete the informed consent form. The following are the exclusion requirements: Hypertensive disease before pregnancy; Twin pregnancy or cannot be delivered vaginally; Have other medical and surgical complications or mental illness; Patients with a family history of hypertensive diseases during pregnancy; Gestational age >42 weeks; Can not visit at any time, cannot determine the specific person. The 80 participants who satisfied the requirements were split into 2 groups at random, with 40 patients in each of the control and experimental groups.The study used convenience sampling method to select 80 patients with pregnancy-induced hypertension who were hospitalized in West China Second Hospital of Sichuan University from April 2022 to April 2023. Patient examination indicators and data information are complete and reliable, and ethical standards should be strictly complied with in the selection process. The study was approved by the Ethics Committee of the Second Affiliated Hospital of Sichuan University . 40 patients in the experimental group were combined with IKAP health education on the basis of the control group. The specific measures were as follows; Data collection: Collect all kinds of information at admission, such as age, education level, living habits, eating habits and occupation; The researchers also gained a comprehensive understanding of the participants family situations and mental health status. Focus on the understanding of nutrition and hypertensive diseases during pregnancy; The demand of health education during pregnancy was analyzed and the corresponding education plan was made; Health knowledge teaching: Health education for hypertensive patients in pregnancy was conducted through effective communication skills; The language of the nursing staff responsible for health education should be easy to understand and speak at a moderate speed to avoid the boredom of patients; At the same time, it is necessary to observe the reaction of patients and their families to ensure that they fully understand the content of health education. The specific teaching contents include rationalizing diet, making a corresponding diet plan according to the patient’s gestational age and blood pressure control, and teaching the patient to flexibly adjust the diet plan using the food exchange method; Actively communicate with patients, provide them with psychological counseling, improve treatment confidence; The patient’s blood pressure self-test, as far as possible to ensure that the blood pressure is within a reasonable and controllable range; Patients need to carry out reasonable health exercise during pregnancy, aerobic exercise under the guidance of medical staff, and run for about half an hour after meals; Change of concept: change the health knowledge and cognition of patients and their families, understand the impact of bad habits on health, and ensure that they maintain good living habits; Behavior generation: After receiving health knowledge education and guidance, patients self-concept changed, leading them to consciously implement healthy behavior activities, and ensure the health of mothers and infants in accordance with health education plans.In this study, 80 participants were divided into 2 groups, 40 of which were control group (CG), and routine cluster-based care was implemented. That is, individual and collective health promotion is carried out through the distribution of health education manuals to hypertensive patients during pregnancy and their families.The general information of the 2 groups included age, prepregnancy BMI, and education level. Healthy behaviors mainly include diet control, proper exercise and regular blood pressure measurement; Pregnancy indicators include amniotic fluid index, BMI, pregnancy weight gain, and blood pressure measurements. Pregnancy outcomes included placenta previa, cesarean section, hyperamniotic fluid, fetal distress, and postpartum hemorrhage. Neonatal conditions were divided into neonatal asphyxia, neonatal pneumonia, neonatal hypoxia, neonatal growth retardation and hyperbilirubinemia. The labor pain of the 2 groups was compared by digital pain scoring method. The anxiety degree of patients was quantified by referring to the clinical anxiety score scale. Nursing satisfaction includes 3 kinds: very satisfied, satisfied and dissatisfied, and very satisfied and satisfied are total nursing satisfaction. Postpartum quality of life conditions include physical activity, emotional awareness, physical discomfort, mental health, sleep quality, postpartum anxiety or depression, and general health.t test, variance test and rank test were used for comparison between groups.The research data were analyzed by SPSS 25.0 software. Counting data were tested by chi-square distribution. The measurement data adopts the standard of mean plus minus. In this study, 80 participants who met the requirements were allocated into 2 groups at random, 40 patients in each CG and For example, General information, including age, prepregnancy BIM and education level, was provided for both groups. Table 2 and 22.62 ± 2.82 kg/m2, respectively. In the CG, the proportion of patients with high school education or below was 18.4%; The proportion of patients with college education or above was 81.4%; In the CG, the proportion of patients with high school education or below was 15.3%; The proportion of patients with college education or above was 84.7%. Age, prepregnancy BMI, and educational attainment were significantly different between the 2 groups.In Table The health behaviors of the patients in the study mainly included diet control, appropriate exercise and regular blood pressure measurement. The comparison of the health behaviors of the 2 groups of patients is shown in Figure In Figure Pregnancy indicators included amniotic fluid index, BMI, weight gain during pregnancy, and blood pressure measurements. Table 2, 17.81 ± 2.54 kg and 135.12 ± 6.25 mm Hg, respectively. The measurements of amniotic fluid index, BMI, pregnancy weight gain, and blood pressure were 109.83 ± 28.72 mm, 20.51 ± 1.62 kg/m2, 16.59 ± 2.84 kg and 130.34 ± 5.32 mm Hg, respectively. The mean measurements of amniotic fluid index, BMI, pregnancy weight gain, and hypertension and high blood pressure were reduced by 15.98 mm Hg, 1.13 kg/m2, 1.22 kg/m2, and 4.78 mm Hg, respectively. Amniotic fluid index, BMI, weight gain during pregnancy, blood pressure and hypertension between the 2 groups varied significantly across pregnancies (P < .05).In Table Pregnancy outcomes included placenta previa, cesarean section, hyperamniotic fluid, fetal distress, and postpartum hemorrhage. Table In Table Neonatal conditions were divided into neonatal asphyxia, neonatal pneumonia, neonatal hypoxia, neonatal growth retardation and hyperbilirubinemia. Table P < .05).In Table The study used digital pain scoring method to compare the delivery pain of the 2 groups of patients, and Figure P > .05), there was a difference (P < .05) at subsequent points in time.In Figure The degree of anxiety in the study was quantitatively estimated by referring to the clinical anxiety score scale. The comparison of prenatal anxiety between the 2 groups was shown in Figure P < .05).In Figure Calculations were made to determine the diastolic blood pressure and systolic blood pressure. Table P > .05). Both blood pressures were found to be different following breastfeeding (P < .05).In Table A questionnaire was applied to quantitatively compare the nursing satisfaction of patients. Nursing satisfaction includes 3 types: very satisfied, satisfied and dissatisfied. The total of very satisfied and satisfied is nursing satisfaction. Figure P < .05).In Table Quality of life conditions include 7 aspects: physical activity, emotional awareness, physical discomfort, mental health, sleep quality, postpartum anxiety or depression, and general health. In this study, the quality-of-life score scale was applied to quantitatively compare the postpartum life quality. The quality of life after giving birth gets better as the number goes up. Table P < .05).In Table ,17 Pregnant women with pregnancy-induced hypertension may experience edema and proteinuria after 20 weeks of pregnancy. Mild symptoms include no symptoms or mild dizziness, and severe symptoms include headache or vomiting.,19 Relevant studies have shown that maternal tension and anxiety during pregnancy and postpartum will have a great negative impact on it. Especially the prognosis and postpartum life quality, happy and relaxed mood will ensure the basic stability of blood pressure and contribute to the prevention and rehabilitation of pregnant women with hypertension during pregnancy, so health education and nursing are particularly important.,21 By changing the nursing process of patients, cluster based care ensures the continuity of patients and supports comprehensive nursing through practice.,23 Nursing measures, the strength of opinion evidence and implementation determine the practical effect of cluster based care. Its characteristics are systematic and comprehensive, and it is widely used in clinical nursing of diseases.,25 Related studies have demonstrated that cluster care can improve maternal labor pain and postpartum conditions. The IKAP health education theory integrates information, knowledge, belief and behavior organically, based on knowledge, belief, and behavior theory. The process of knowledge acquisition, belief establishment and continuous change of behavior is the step of behavior change. Guided by the principles of patient-centered mental and physical healthcare, IKAP health education constantly promotes health knowledge to patients and their families according to their condition and psychological changes, strengthens their disease cognition and participation in diagnosis and treatment, and positively changes their concepts and living habits. Studies have shown that IKAP health education model can improve patients’ pregnancy outcomes and newborn health conditions.Hypertensive disease during pregnancy is a complication unique to pregnant women. The incidence of hypertensive disease during pregnancy has been increasing due to the rising life pressure faced by women, which can have severe consequences for both mothers and newborns, including maternal and fetal death.P > .05). The diet control ratio of For example, and CG was 97.5% and 70%, respectively. The proportion of appropriate exercise was 97.5% and 67.5% respectively. The proportion of regular blood pressure measurement was 95% and 50% respectively (P < .05), indicating that IKAP health education combined with diet control, appropriate exercise and regular blood pressure measurement of cluster care had a more significant effect than that of cluster care alone. In the CG, the measurements of amniotic fluid index, BMI, pregnancy weight gain, and blood pressure were 125.81 ± 30.21 mm, 21.64 ± 1.82 kg/m2, 17.81 ± 2.54 kg and 135.12 ± 6.25 mm Hg, respectively. The measurements of amniotic fluid index, BMI, pregnancy weight gain, and blood pressure were 109.83 ± 28.72 mm, 20.51 ± 1.62 kg/m2, 16.59 ± 2.84 kg, and 130.34 ± 5.32 mm Hg, respectively. There were statistically significant variations in pregnancy markers, including amniotic fluid index, BMI, weight gain during pregnancy, and blood pressure and hypertension (P < 0.05). The For example, pregnancy index greatly outperformed the CG’s, indicating that IKAP health education combined with cluster-based care had more obvious control effect. Prenatal anxiety levels showed statistically significant variations (P < 0.05). The anxiety degree of the For example, was reduced more than the CG, indicating that the effect of IKAP health education combined with cluster care on the anxiety relief of patients was better than that of cluster care alone. In contrast to the For example, the incidence of unfavorable pregnancy outcomes was considerably greater in the CG. The results of the pregnancies differed statistically significantly (P < .05), indicating that IKAP health education combined with cluster-based care can help reduce the probability of adverse pregnancy. Compared with the CG, neonatal asphyxia, neonatal pneumonia, neonatal hypoxia, neonatal growth retardation, neonatal hyperbilirubinemia, and total number in the For example, were reduced by 7, 3, 2, 4, 5, and 21, respectively, indicating that IKAP health education combined with cluster care can reduce the frequency of neonatal adverse conditions. The systolic blood pressure of the CG before and after nursing was 169.12 ± 15.32 mm Hg and 135.12 ± 6.25 mm Hg, respectively. The diastolic blood pressure before and after treatment was 103.63 ± 10.56 mm Hg and 90.45 ± 8.67 mm Hg, respectively. The systolic blood pressure before and after the treatment group was 168.93 ± 15.15 mm Hg and 130.93 ± 5.32 mm Hg, respectively. The diastolic blood pressure before and after treatment was 103.25 ± 10.27 mm Hg and 81.05 ± 7.25 mm Hg, respectively. Both systolic and diastolic blood pressure were considerably lower in the For example, after breastfeeding compared to the CG (P > 0.05). The difference of systolic and diastolic blood pressure after nursing was statistically significant (P < .05), indicating that IKAP health education combined with cluster-based care had more effective blood pressure management. The scores of physical activity, emotional awareness, physical discomfort, mental health, sleep quality, postpartum anxiety or depression, and overall health of the EGs were 78.8 ± 5.4, 86.9 ± 4.9, 87.1 ± 6.9, 77.9 ± 5.6, 80.1 ± 3.5, 81.2 ± 6.4, and 84.6 ± 6.2, respectively. Compared to the CG, the For example, had considerably better postpartum quality of life ratings. Significant variations in the postpartum quality of life  or depression, and overall health scores between the 2 groups were found statistically (P < 0.05).In this study, patients with pregnancy-induced hypertension were chosen as the study objects to analyze the application effect of IKAP health education combined with cluster-based care. There were no notable variations in age, prepregnancy BIM and education level (In summary, IKAP health education combined with cluster care can further improve postpartum patients physiological and psychological states. However, there are still areas for improvement in the research. Further improvements can be made by increasing the sample size to enhance the scientific validity and accuracy of the study findings.Data curation: Jiao Wen.Formal analysis: Jiao Wen.Investigation: Xiuping Liu.Methodology: Jiao Wen.Supervision: Xiuping Liu.Writing – original draft: Jiao Wen.Writing – review & editing: Jiao Wen, Xiuping Liu.


Routine blood pressure measurement is important for the early detection of various diseases. Recently, cuffless blood pressure estimation methods that do not require cuff pressurization have attracted attention. In this study, we investigated the effect of the light source wavelength on the accuracy of blood pressure estimation using only two physiological indices that can be calculated with photoplethysmography alone, namely, heart rate and modified normalized pulse volume. Using a newly developed photoplethysmography sensor that can simultaneously measure photoplethysmograms at four wavelengths, we evaluated its estimation accuracy for systolic blood pressure, diastolic blood pressure, and mean arterial pressure against a standard cuff sphygmomanometer. Mental stress tasks were used to alter the blood pressure of 14 participants, and multiple linear regression analysis showed the best light sources to be near-infrared for systolic blood pressure and blue for both diastolic blood pressure and mean arterial pressure. The importance of the light source wavelength for the photoplethysmogram in cuffless blood pressure estimation was clarified. High arterial blood pressure (BP) is known worldwide as a risk factor for various diseases, including cardiovascular disease ,2,3. BecTo address this problem, “cuffless BP”—a method of BP estimation that does not require cuff pressurization—has been explored ,23,24,25Instead, we have studied a method for estimating BP from a single PPG based on findings from circulation physiology and psychophysiology ,25. ThisThe proposed method performs BP estimation using a single PPG, but in previous studies, the light source used for PPGs has generally been restricted to near-infrared (NIR) light . NIR andPhotoplethysmography involves obtaining waveforms of changes in the volume of blood vessels by using the optical absorption characteristics of blood ,37. It iIn this study, we constructed a multiwavelength PPG sensor, as shown in The PPGs were obtained by sampling at a frequency of 60 Hz, performing analog-to-digital conversion using a microcontroller , and then importing the data into a computer. The PPG waveforms were processed as shown in BP is calculated using CO and TPR as BP = CO × TPR . Taking surement . The samIn this study, we investigated how the wavelength of the light source affects the proposed method by measuring BP simultaneously with both a cuff sphygmomanometer and the 4-wavelength PPGs obtained using the multiwavelength PPG sensor shown in The experiment was conducted in a conference room where the temperature was kept at 20–24 °C. Each participant sat at rest in a chair with both hands on a desk in front of them. A PPG sensor was attached to the index finger of each participant’s left hand, and a cuff sphygmomanometer  was attached to their upper right arm. The PPG sensor was attached to the tip of the participant’s index finger using tape to ensure that all 4 LEDs and the PD were in contact with the finger without loosening and that the participant did not feel pressure. The finger with the PPG sensor and the upper arm with the cuff were supported at heart level. The participant was instructed to remain as still as possible during the measurement to reduce the effects of motion artifacts.As shown in In total, 14 volunteers ) were recruited from within Ishikawa College and participated in this study. To do so, volunteers had to be at least 18 years old and free of cardiovascular disease at the time of the experiment. The BPs of the participants measured with a cuff sphygmomanometer are summarized in N = 14) because previous studies on BP estimation based on pulse wave velocity and PPGs have shown that a small number of participants is acceptable unless there is a specific reason indicating otherwise, such as the use of machine learning. For example, Payne et al. [N = 12, Patzak et al. [N = 12, and the previous study on the proposed method used N = 13 [The sample size of this study was relatively small , mNPV , SBP , DBP , and MAP  for each period were calculated to normalize the distribution.MA1 = ln SBPMA1 − ln SBPBL1 = ln (SBPMA1/SBPBL1)). Based on Equation (1), Δln SBP, Δln DBP, and Δln MAP are expressed as follows [Furthermore, to suppress individual differences, the difference values  for each value of BL2, MA1, and MA2 based on the value of BL1 were calculated, respectively, and used in the data analysis Estima, b, and c in Equations (2)–(4) were obtained using multiple linear regression analysis with Δln SBP, Δln DBP, and Δln MAP as the objective variables and Δln HR and Δln mNPV as the explanatory variables. Via the natural exponential transformation (exp) of Equations (2)–(4), the ratio of BP to the reference value BL1 was calculated  = SBPMA1/SBPBL1). With this method, if the cuff sphygmomanometer value at BL1 is known, then the estimated BP for BL2, MA1, and MA2 can be obtained as the difference from the BP values obtained using Equations (2)–(4).The values of the coefficients BL1, DBPBL1, and MAPBL1 by the exponentially transformed estimated Δln SBP, Δln DBP, and Δln MAP, as in Equations (5)–(7), we obtain the estimated SBP, DBP, and MAP [Therefore, by multiplying the known SBP and MAP :(5)EstimThe estimation accuracy was evaluated by comparing the estimated values of SBP, DBP, and MAP with those measured with a cuff sphygmomanometer.The results of the multiple linear regression analysis using the Δln MAP, Δln SBP, and Δln DBP measured with a cuff sphygmomanometer as the objective variables and the Δln HR and Δln mNPV calculated from the PPG at each wavelength as the explanatory variables are given in R2), NIR shows the highest accuracy for Δln SBP, while blue shows the highest accuracy for both Δln DBP and Δln MAP. For Δln SBP, although NIR has the best accuracy, blue also has a high accuracy of R2 = 0.612. In addition, for Δln SBP and Δln MAP, the accuracy of R2 > 0.5 is excellent. Comparing each BP shows a trend of joint best accuracy for Δln SBP and Δln MAP, followed by Δln DBP. Shapiro–Wilk tests did not detect a strong violation of the normality of the distribution in the residuals .As shown in Scatter plots of the measured Δln SBP, measured Δln DBP, and measured Δln MAP obtained using the cuff sphygmomanometer and the estimated Δln SBP, estimated Δln DBP, and estimated Δln MAP at each wavelength are shown in R2 values for the three types of BP  and compared them using a one-way repeated measures analysis of variance (ANOVA). For post hoc comparison, we used Tukey’s honestly significant difference (HSD) test for multiple comparisons. The one-way repeated measures ANOVA revealed the main effect of type, F = 18.74, p = 0.002. The subsequent post hoc Tukey’s HSD test for multiple comparisons revealed that the mean R2 of green was less than that of blue, red, and NIR. This result indicates that wavelengths other than green should be used as the light source with this method. The inferiority of green LEDs is due to the low R2 of DBP, which is clearly dependent on the TPR [In  the TPR . TherefoR2 values in R2 (=0.634) in the order of NIR > blue > red > green. Similarly, for DBP and MAP, the order is blue > NIR > red > green, so blue is the optimal wavelength (R2 = 0.497 for DBP and R2 = 0.630 for MAP). However, these differences were not statistically significant. Furthermore, we focus on the values of the standard partial regression coefficient (std. β) of the β coefficients for HR (a) and mNPV (b) at the optimal wavelengths  in a was larger than b for std. β. For DBP, b was larger than a. For MAP, a and b were about the same. Previous studies have shown that HR depends on CO in SBP [β, whereby the a of HR is dominant in SBP and the b of mNPV is dominant in DBP, agrees well with physiological trends.Focusing on the O in SBP ,41, TPR O in SBP . BecauseO in SBP ,30,31,32In this study, the optimal wavelengths for SBP, DBP, and MAP were different, which is likely because of the differences in the optical properties of biological tissues. The depth to which light penetrates biological tissue differs depending on wavelength, with longer-wavelength light penetrating deeper. Regarding the wavelengths used in this study, blue, green, red, and NIR reach deeper in that order, such that NIR can reach deep blood vessels, whereas blue can only reach peripheral ones in the epidermis. Therefore, using NIR gives information about relatively large blood vessels in deep areas, which have large changes in blood vessel volume, and the HR can be obtained with high accuracy; however, the information about peripheral blood vessels in the epidermis is lost among that about deep vessels. On the other hand, because blue reaches only the epidermis, it is thought that using it produces PPGs that reflect well the information about peripheral vessels. Therefore, we reason that NIR, which is better at measuring HR, and blue, which is better at measuring mNPV, can estimate SBP and DBP more accurately, respectively. For MAP, both blue and NIR are highly accurate, but in this study, at least among the participants before the experiment, the intensity of light emitted from the body was set to be constant at each wavelength, so the difference in the accuracy of the HR obtained from the PPG at each wavelength was lower while that of the blue estimation was higher. In other words, if a light source is available that can emit sufficiently strong light, then blue is the optimal wavelength for this method. Based on the above results, although no statistically significant difference was found for the trend of the present results, we believe that the results have a certain significance when physiological and optical characteristics are considered.This study has several limitations. First, the participants were relatively few in number and included only healthy Japanese men and women of approximately the same age; therefore, the effects of the age, skin color, and health status of the participants require further investigation. Regarding the small number of data, we note that this study is at the stage of basic investigation and not at the stage of attempting practical application. Second, the participants were measured only while physically still, but it is known that PPGs are strongly affected by motion artifacts and that the effect varies depending on the wavelength of the light source ; therefoDespite the above limitations, we have proposed a BP estimation method that requires only a simple PPG sensor, unlike a cuff sphygmomanometer or methods that require PPGs and ECGs. Furthermore, we have clarified the differences in the measurement accuracy due to the differences in light source wavelengths, which have not been considered to date.In this study, we investigated the optimal light source wavelength for cuffless BP estimation using only the HR and mNPV obtained from PPGs. Using a PPG sensor capable of measuring PPGs simultaneously at four different wavelengths, we evaluated the accuracy of the estimation by performing multiple regression analysis on the HR and mNPV at each wavelength obtained for the SBP, DBP, and MAP measured both from the PPGs and using a cuff sphygmomanometer. From the results, although not significant, NIR was found to be the most accurate wavelength for SBP, and blue was found to be that for DBP and MAP. These results are consistent with physiological findings and indicate that the light source wavelength will become an important factor in cuffless BP estimation using PPGs in the future and that the accuracy of BP estimation can be improved by selecting the optimal wavelength according to the type of blood pressure.


Cardiovascular disease is the leading cause of morbidity and mortality globally. Echocardiography is a commonly used method for assessing the condition of patients with cardiovascular disease. However, little is known about the population characteristics of patients who are recommended for echocardiographic examinations.The National Ambulatory Medical Care Survey was a cross-sectional survey previously undertaken in the USA. In this study, publicly accessible data from the National Ambulatory Medical Care Survey database  were utilized to create a nomogram based on significant risk predictors. The study was performed in accordance with the relevant guidelines and regulations stipulated in the National Ambulatory Medical Care Survey database. Patients were randomly assigned to one of two groups: training cohort or validation cohort. The latter was used to assess the reliability of the prediction nomogram. Decision curve analysis was performed to evaluate the net benefit. Propensity score matching analysis was used to evaluate the relevance of echocardiography to clinical decision-making.P < 0.01).A total of 217,178 outpatients were enrolled. Multivariable logistic regression analysis demonstrated that hypertension, hyperlipidemia, coronary artery disease/ischemic heart disease/history of myocardial infarction, congestive heart failure, major reason for visit, metropolitan statistical area, cerebrovascular disease/history of stroke or transient ischemic attack, previously assessed, insurance, referred, diagnosis, and reason for visit were all predictors of echocardiogram prescription in outpatients. The reliability of the predictive nomogram was confirmed in the validation cohort. After propensity score matching, there was a significant difference in new cardiovascular agent prescriptions between the echocardiogram and no echocardiogram groups (In this cohort study, a nomogram based on the characteristics of outpatients was developed to predict the possibility of prescribing echocardiography. The echocardiogram group was more likely to be prescribed new cardiovascular agents. These findings may contribute to providing information about the gap between actual utilizations and guidelines and the actual outpatient practice, as well as meeting the needs of outpatients. The groEchocardiography is the primary imaging modality to diagnose cardiac conditions . ImagingHowever, little is known about the demographics of patients who are recommended for echocardiographic examinations. In this study, using publicly available data from the National Ambulatory Medical Care Survey (NAMCS), we sought to describe the characteristics of this population, establish a nomogram for predicting echocardiogram prescription, and describe the relationship between echocardiogram prescription and the use of new cardiovascular agents.2.2.1.https://www.cdc.gov/nchs/ahcd/index.htm. Accessed November 29, 2022).The NAMCS was a cross-sectional, two-stage sample survey conducted in the USA by the National Center for Health Statistics, a Centers for Disease Control and Prevention unit. The NAMCS database comprises responses of non-federally employed ambulatory physicians to a standardized survey instrument. The survey protocol was approved by the Research Ethics Review Board of the National Center for Health Statistics and written informed consent was obtained from all the participants. The form includes fields for demographic data, diagnoses, and medications. The keying and coding of survey data are performed by trained hospital staff, are subject to internal quality control procedures, and have an error rate of 0%–1%  to generate reliable national estimates of patients prescribed an echocardiogram. The exclusion criteria were as follows: patients under the age of 18 years ; patients whose codes for reason for a visit were treatment module, injury, adverse effect module, test results module, administrative module, entries that were not codable, and blank entries ; patients involved in pregnancy and pregnancy-related events ; and patients whose records were incomplete . Eventually, a total of 217,178 patients were enrolled, and were randomly assigned to a training cohort  and a validation cohort   . As preg 86,871) . Given t2.2.The variables included age, sex, race, insurance means/expected sources of payment for the visit (self-pay was designated as “no insurance” and the other sources were designated as “yes”), tobacco use, reasons for visit , major reason for visit , whetherpatient was referred for this visit (designated as “referred”), whether the patient attended the practice before (designated as “previously assessed”), diagnosis (whether the first three diagnoses were cardiac disease), cerebrovascular disease/history of stroke or transient ischemic attack (designated as CEBVD), congestive heart failure (CHF), coronary artery disease/ischemic heart disease/history of myocardial infarction (designated as “CAD”), diabetes, hyperlipidemia, hypertension, obesity, chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), end-stage renal disease (ESRD), metropolitan statistical area (MSA), and new cardiovascular agents prescribed (designated as “NCAP”) (from RX1 to RX8). The cardiovascular medication codes were 040–056, 081–083, 154–158, 173, 174, 211, 212, 241, 252, 261, 262, 283, 285, 316, 317, 274, 275, 303, 319, 325, 340, 342, 396, 430, and 433 . The car2.3.t-test was used to compare differences between two groups . For variables with <30% missing values , missing data were filled in using multiple imputation. Patient characteristics were presented as mean ± SD or frequency and percentage, as appropriate. Potential candidate variables were screened using least absolute shrinkage and selection operator (LASSO) regression with 10-fold cross-validation followed by a multivariable logistic regression analysis of the variables derived from LASSO regression. Variables with a P-value < 0.05 were included in the nomogram model. A nomogram for predicting the probability of prescribing an echocardiogram was subsequently constructed based on the results from the final regression analysis. A visual calibration curve comparing the apparent probability, bias-corrected probability, and ideal probability curves was generated to show the calibration of the prediction model. Decision curve analysis (DCA) was undertaken to assess the clinical usefulness of the prediction model. Propensity score matching (PSM) was used to limit possible selection deviation between the two groups and was carried out as a 1:3 ratio nearest neighbor matching. The following variables were included: age, sex, race, insurance, reason for visit, major reason for visit, referred, tobacco use, previously assessed, diagnosis, CEBVD, CHF, CAD, diabetes, hyperlipidemia, hypertension, obesity, COPD, and MSA. P-values < 0.05 were considered significant. All statistical analyses were performed using R software (version 4.1.2) with the dplyr, pROC, glmnet, mice, caret, rms, rmda, ResourceSelection, ggplot2, forestplot, and MatchIt packages.Pearson’s chi-squared test or the 3.3.1.n = 2,973) and a no-echocardiogram group . Significant differences in age, sex, race, tobacco use, insurance, reason for visit, referred, previously assessed, diagnosis, CEBVD, CHF, CAD, diabetes, hyperlipidemia, hypertension, obesity, and MSA were detected between the two groups  were included. Patients were divided into an echocardiogram group  (P = 0.228). For each patient, higher total points indicated a higher probability of being prescribed an echocardiogram.In the training cohort, LASSO regression was conducted for each candidate. The results of the univariate logistic regression analysis for all the candidates are shown in = 0.892) . The Hos3.3.In the training cohort, the area under the curve (AUC) was 0.885 , and theA total of 86,871 patients were used for the internal validation of the nomogram. The AUC was 0.893 , indicat3.4.P < 0.01) (The conditions of the two groups of patients (echocardiogram/no-echocardiogram) were significantly different . After P < 0.01) . The abo4.Our study is the first to develop a model for predicting echocardiography prescriptions based on outpatient variables. Hypertension, CHF, CEBVD, hyperlipidemia, CAD, major reason for visit, MSA, previously assessed, insurance, referred, diagnosis of cardiac disease, and reason for the visit were found to be predictors for the prescription of echocardiography. Echocardiography is an important test to assess heart structure and function. Based on our findings, echocardiography prescription was associated with the use of cardiovascular agents. Echocardiography imaging of cardiac structure and function can help guide patient management.To reduce healthcare costs for outpatients with hypertension, especially the newly diagnosed, key aspects of the visit include determining the status of blood pressure control, medication use, and screening for complications when needed . To our Early referral among outpatients, especially when the cause for the visit is a new concern, is associated with better outcomes, fewer patient disputes, and reduced medical costs –25. It iWe discovered that geographic and economic disparities exist in the use of echocardiography. Different living spaces correspond to distinct lifestyles and medical behaviors. In our study, patients from MSAs, with adding points in the nomogram model, were more likely to be prescribed an echocardiography. Other studies have shown geographic disparities in medication use or quality of care among patients , 27. NumWhen integrated with clinical and ECG findings in an outpatient setting, echocardiography could be useful for the identification of ischemic cardiomyopathy when the reason for the visit was related to heart disease, or when cardiac disease was considered the initial diagnosis. Echocardiography, in conjunction with coronary angiography or computed tomographic coronary angiography, aids in the accurate detection of coronary heart disease. In the Appropriate Use Criteria for echocardiography guidelines, echocardiography is appropriate for the initial evaluation of patients with myocardial ischemia/infarction, valve disease, heart failure, cardiomyopathy, structure, and function, or for re-evaluation of these patients with a change in clinical status. The assessment of inferior vena cava size and collapsibility using echocardiography should allow for the prediction of readmission risk in patients with heart failure, as inadequate assessment of volume status leading to persistent congestion is an important contributing factor to rehospitalization –9, 33. HThe benefit of echocardiography over other imaging modalities is that it is widely available, inexpensive, and a bedside procedure. Echocardiography is usually the preferred method for the assessment of the size, segmental wall motion, and function of the left ventricle, the hemodynamics of the valve, and pulmonary pressure. Besides, it is also a useful tool in the diagnosis of myocardial infarction, heart failure, and congenital heart disease –9, 40. AOur study aims at providing clinical practice data on echocardiography in a real-world setting. We could provide information about the disparity between actual utilizations and guidelines and actual outpatient practice. Currently, echocardiogram prescription, according to the guidelines –46, shouOur study had several limitations. First, a degree of internal bias was inevitable given the retrospective nature of the study. Due to the lack of follow-up data, we did not know whether the therapeutic changes following echocardiography had an impact on prognosis. Second, some potentially meaningful predictors, such as body mass index, were not assessed due to a lack of data (>30% missing). Third, we employed internal validation rather than external correction, thus the samples in this database can only be deemed representative of the population. Accordingly, we endeavor to undertake an external validation assessment using a different database in the future.In conclusion, in this study, we demonstrated that hypertension, CHF, referred, CEBVD, hyperlipidemia, CAD, major reason for visit, previously assessed, MSA, insurance, diagnosis, and reason for the visit were predictors of prescribing echocardiography in outpatients, and built a characteristic nomogram to provide physicians with an intuitive tool for practical prediction. Our internal validation confirmed the good accuracy and conformity of the model, along with its net benefit. For each outpatient, a higher total score reflected a greater possibility of being prescribed an echocardiogram. The echocardiogram group was more likely to be prescribed new cardiovascular agents. These findings may contribute to providing information about the gap between actual utilizations and guidelines and the actual outpatient practice, as well as meeting the needs of outpatients.


Diabetic kidney disease (DKD) causes a progressive decline in renal function, leading to end-stage kidney disease (ESKD), and increases the likelihood of cardiovascular events and mortality. The recent introduction of the sodium-glucose co-transporter 2 (SGLT-2) inhibitor has been a game changer in managing chronic kidney disease (CKD) and congestive heart failure (CHF). These agents not only slow down the progression of kidney disease but also have cardioprotective benefits, including for patients with congestive heart failure and atherosclerotic cardiovascular disease. Some evidence suggests that they can decrease the risk of stroke as well. This review aims to provide a comprehensive overview of the role of SGLT-2 inhibitors in CKD and CHF and their efficacy in stroke prevention. This review includes a comparison with glucagon-like peptide-1 (GLP-1) agonist and finerenone; focuses on safety data, the potential benefits beyond glycemic control, and a review of significant trials; and provides guidance in clinical practice. Diabetic kidney disease is the most common type of chronic kidney disease (CKD) and end-stage kidney disease (ESKD), with substantial morbidity and mortality worldwide ,2. ChronTraditional medical management for CKD and CHF includes blood pressure control, tight glycemic management, and renin–angiotensin–aldosterone system (RAAS) blockade. In practice, angiotensin-converting enzyme inhibitors (ACE inhibitors) or angiotensin receptor blockers (ARBs) are the first line of agents in patients with hypertension and DKD, even in the absence of proteinuria. ACE inhibitors/ARBs have been shown to decrease the risk of progression of CKD in patients with proteinuria, although these agents have not been shown to reduce the progression to ESKD in nonproteinuric patients ,5,6.The introduction of SGLT-2 inhibitors has radically changed the therapeutic landscape for CKD and CHF patients. This has added new opportunities for improving outcomes in these patients. SGLT-2 inhibitors were initially developed as glucose-lowering medication. Still, during the earlier cardiovascular outcome trials (CVOTs), it became clear that there is a significant advantage for kidney protection and cardioprotection.Currently, four SGLT-2i agents are available in North America: canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin, whereas the fifth agent, sotagliflozin, is a combined SGLT-1 and SGLT-2 inhibitor that the FDA recently approved in May 2023 for use in the USA.2. This effect is almost nonexistent with an eGFR below 30 mL/min per 1.73 m2 [SGLT-2 inhibitors work by inhibiting the SGLT-2 channel found in the proximal convoluted tubules. This channel is primarily responsible for absorbing most of the filtered glucose, which is >90%. This leads to glucosuria, which is more pronounced in individuals with diabetes than in non-diabetic individuals. The extent of glucose reduction is influenced by kidney function, and it declines when the eGFR falls below 60 mL/min per 1.73 mThe renoprotective benefits of SGLT-2 inhibitors are independent of the glycosuria effect. It is proposed that SGLT-2 inhibitors reduce sodium reabsorption, leading to increased sodium delivery to the macula densa, which causes negative feedback through the tubuloglomerular feedback mechanism. This results in decreased intraglomerular pressure, causing lowered glomerular hyperfiltration . Refer tIt has also been proposed that SGLT-2 inhibitors exert renal protection by improving tubular hypoxia by blocking proximal tubular reabsorption of glucose, reducing the workload of the proximal tubules . ChronicBeyond glucosuria, they also contribute to modest bp control, kaliuresis, and reduction in oxidative stress, as well as reducing markers of inflammation and fibrosis such as interleukin-6, monocyte chemoattractant protein 1 (MCP-1), nuclear factor-kB, urinary IL-6 as well as serum tumor necrosis factor receptor 1 (TNFR1) ,12.These kidney protective benefits lead directly to an improved metabolic profile and indirectly to beneficial effects on cardiovascular disease. Cardioprotective benefits include a decline in arterial stiffness and improvement in endothelial function. SGLT-2 inhibitors also cause diuresis and natriuresis, which may cause a reduction in preload ,14.Initial cardiovascular outcome trials (CVOTs), including EMPA-REG OUTCOME and CANVAS, were the first to demonstrate the kidney benefit as a secondary outcome. Subsequently, CREDENCE, DAPA-CKD, and EMPA-KIDNEY are the major randomized clinical trials that have solidified prior findings that SGLT-2 inhibitors are effective in slowing the progression to ESKD, reducing albuminuria, and preventing adverse outcomes, including the need for dialysis and cardiovascular mortality. All three trials were terminated early due to strong evidence of efficacy.2 and albuminuria  of 300–5000 mg/g) and 3.9% of patients had an eGFR less than 30 mL/min per 1.73 m2. It showed that canagliflozin at a dose of 100 mg once daily was effective in reducing the incidence of ESKD, heart failure hospitalization, all-cause mortality, and cardiovascular mortality, as well as doubling serum creatinine by approximately 30–35% [2, it was found that it was equally effective in slowing down the progression of kidney disease as compared to patients with an eGFR greater than 30 mL/min/1.73 m2 [The CREDENCE trial included patients with an eGFR 30–90 mL/min/1.73 my 30–35% . In a se/1.73 m2 .2, proteinuria of 200 to 5000 mg/g, and one-third of the participants in this study had nondiabetic CKD. This trial showed that dapagliflozin 10 mg once daily was able to reduce the incidence of ESKD, all-cause mortality, and cardiac mortality by approximately 35–45%, doubling serum creatinine. The DAPA-CKD trial demonstrated that the protective benefit increases with an increasing hemoglobin A1c level as well as with increased proteinuria and decreased eGFR [DAPA-CKD included patients with an eGFR of 25 to 75 mL/min per 1.73 msed eGFR ,18.2  or an eGFR of 45 to 89 mL/min/1.73 m2 . This was the first trial that included patients with no albuminuria; most patients in this trial (54%) had known chronic diabetic kidney disease. It demonstrated that empagliflozin 10 mg daily reduces the incidence of ESKD, cardiovascular mortality, and all-cause mortality by 25–30%, doubling serum creatinine. The most significant benefit was seen in patients with albuminuria ≥ 300 mg/g and less effect in patients with lower levels of proteinuria [The EMPA-KIDNEY trial is the most recent, published in November 2022, which included patients with an eGFR of 20 to 44 mL/min/1.73 mteinuria . In thisThe DAPA-HF, EMPEROR-Reduced, and EMPEROR-Preserved trials showed improvement in cardiovascular outcomes and a reduction in death and heart failure hospitalizations ,21,22.The DAPA-HF and EMPEROR-Reduced trials focused on patients with congestive heart failure with reduced left ventricular ejection fraction, which was at or below 40%. On the other hand, the EMPEROR-Preserved trial involved patients with a left ventricular ejection fraction greater than 40% ,21,22.2, and it showed significant improvements in composite primary outcomes, including reducing cardiovascular death and heart failure hospitalization by 24% [The DAPA-HF trial included patients with chronic heart failure with LVEF < 40% and an eGFR ≥ 30 mL/min per 1.73 mn by 24% . The DAPn by 24% .The EMPEROR-Reduced trial enrolled patients with an eGFR >20 mL/min per 1.73 m and lower mean LVEF of up to 27% compared to up to 31% in the DAPA-HF trial. Empagliflozin reduced the combined risk of primary outcomes, including cardiovascular death or heart failure hospitalization, in patients with or without diabetes by 22% [The EMPEROR-Preserved clinical trial was groundbreaking as it included patients with heart failure, regardless of whether they had mildly reduced ejection fraction or preserved ejection fraction or whether they had diabetes or not. Empagliflozin decreased the incidence of heart failure hospitalization and cardiovascular death by approximately 20%. Although, in this study, 23% of patients discontinued treatment, which was on the higher side, this outcome was similar in other treatment groups as well [Similarly, the DELIVER trial was published in September 2022 and included patients with LVEF >40% with medical therapy. In this study, dapagliflozin showed a reduction in the primary composite endpoint by 18% .SGLT-2 inhibitors have been very successful in improving outcomes in chronic kidney disease and cardiovascular disease. However, when it comes to preventing strokes, the available data are not yet as compelling.Chronic kidney disease frequently coexists with other complex medical problems, including cardiovascular disease and stroke. Many experts believe that chronic kidney disease is an independent risk factor for stroke, and chronic kidney disease is present in over 40% of patients with stroke Stroke and chronic kidney disease have many risk factors in common, such as hypertension, diabetes mellitus, and atrial fibrillation. In the DECLARE-TIMI 58 trial, dapagliflozin was shown to decrease the incidence of atrial fibrillation .In theory, one would believe that as SGLT-2 inhibitors improved outcomes in diabetes, kidney disease, and cardiovascular disease, they would also reduce the risk of stroke, but that has not been the case so far.Multiple meta-analysis trials from recent cardiovascular outcome trials (CVOTs) showed no effect of SGLT-2 inhibitors in preventing strokes . A meta-Journal of the American Heart Association suggested that an SGLT-2 inhibitor can decrease the incidence of new stroke by 20% in patients with atrial fibrillation [However, most recently, in May 2023, an observational study from Taiwan published in the illation . This waDiabetic Ketoacidosis (DKA): DKA is a serious, life-threatening complication in patients with DM. SGLT-2 inhibitors can cause euglycemic diabetic ketoacidosis in patients with type 1 diabetes, but it is less common in Type-2 DM . A recenIn clinical practice, it is essential to identify patients with high risk for DKA, which includes recent surgery, starvation, acute illness, alcohol abuse, and those on high doses of insulin. Patients should be educated about the “sick day” plan to reduce the risk of DKA. This includes holding off on the SGLT-2 inhibitor for 2–3 days before surgery and temporary discontinuation during episodes of sickness or poor oral intake.It has been postulated that SGLT-2 inhibitors can increase the risk of urogenital infections due to glucosuria. SGLT-2 inhibitors can increase the risk of urogenital infection, such as vulvovaginal candidiasis, by 2–4 times, especially in female patients. In rare cases, SGLT-2 inhibitors are also associated with Fournier’s gangrene .Patients must be educated and counseled on maintaining daily hygiene and monitoring for signs of early infection. Consider topical or oral antifungal therapy rather than discontinuation of the SGLT-2 inhibitor.A recent meta-analysis found that there is no increased incidence of urinary tract infections (UTIs) with SGLT-2 inhibitors as compared to other agents ,33.Expert consensuses suggest continuing SGLT-2 inhibitors in patients with recurrent urinary tract infections if there is an indication and exercising caution in those with a history of complicated recurrent urinary tract infections as well as chronic indwelling Foley catheters, but this is not an absolute contraindication.The CANVAS trial indicated that there was a doubling of the risk of lower-limb amputation in the canagliflozin groups, and this mainly involved toe or metatarsal amputation and fractures .However, subsequent major clinical trials, including CREDENCE, reported no difference in the risk of amputation between SGLT-2 inhibitors and amputation or fracture. As a result, in 2020, the FDA removed its black box warning for canagliflozin and amputation risk .In practice, clinicians are advised to educate patients to perform frequent foot examinations, timely intervention, and referral to evaluate for peripheral vascular disease.Due to their natriuretic effects, SGLT-2 inhibitors can increase the risk of volume depletion, especially if combined with diuretics. The DAPA-HF trial reported an increased incidence of volume depletion, especially in patients who were taking furosemide or its equivalent dose ≥ 40 mg daily. In this trial, the placebo group had a 6.8% incidence of volume depletion, whereas it was 9.0% in the dapagliflozin group. Although they have a synergistic natriuretic effect along with loop diuretics, this effect seems weaker compared to a combination of loop diuretics and metolazone .In conclusion, the risk of volume depletion should be considered in patients who are already on diuretics therapy, especially the elderly, and those at risk of hypovolemia such as hypotension, fasting, acute sickness, or syncope. It is recommended to assess volume status before initiation of an SGLT-2 inhibitor. Refer to the Mineralocorticoid Receptor Antagonists (MRAs) : MineralA new nonsteroidal MRA, finerenone, has been shown to improve proteinuria and blood pressure control in these patients. The FIDELIO-DKD trial included patients with type 2 diabetes mellitus with albuminuria and chronic kidney disease, and these patients were on an ACE inhibitor/ARB at baseline. It found that finerenone decreased the incidence of the primary outcome in terms of the decline of the eGFR by 40% or more by 27%. No significant impact on all-cause mortality or progression into ESKD was noted. It has also been associated with an increased risk of hyperkalemia  Tab.In these trials, most patients were not on a combination of SGLT-2 inhibitor and finerenone, so further data are needed to see if this combination provides any additional benefit .However, in the DAPA-CKD trial, it was reported that 229 out of 4304 patients were receiving MRAs, and this number was too small to determine any significant benefit from this combination. Nonetheless, finerenone is a great addition to the list of medications available for the management of diabetic kidney disease to improve outcomes.The Kidney Disease Improving Global Outcomes (KDIGO) 2022 guideline as well as the American Diabetes Association 2022 guideline advise using ≥30 mg/day finerenone in patients with albuminuria despite being on a combination of ACE inhibitor and SGLT-2 inhibitor .In multiple trials, GLP-1 agonists have proven their efficacy in cardiovascular and kidney protective benefits . The AWAIn clinical practice, if the desired glycemic control is not achieved despite being on first-line glucose-lowering therapy and SGLT-2 inhibitor, we recommend adding the GLP-1 agonist due to its cardio- and reno-protective benefit.Avoid combining GLP-1 agonist with dipeptidyl peptidase 4 (DPP-4) inhibitors as there are no clear-cut data yet available that DPP inhibitors improve outcomes in cardiovascular disease or chronic kidney disease.2 [SGLT-2 inhibitors have caused a paradigm shift in the management of diabetic kidney disease. The most recent EMPA-KIDNEY trial has confirmed that these agents are not only beneficial in slowing down the progression of underlying kidney disease, including non-diabetes chronic kidney disease, but also benefit patients with low levels of albuminuria and those with an eGFR as low as 20 mL/min/1.73 m2 .DAPA-CKD has shown that dapagliflozin can slow down the progression of CKD, regardless of the etiology of CKD, whether it is diabetic kidney disease, hypertensive kidney disease, or glomerulonephritis. It also showed that the protective benefit increases with increased albuminuria and increased hemoglobin A1c, and its effects were also consistent over the spectrum of various eGFR values. SGLT-2 inhibitors provided more absolute benefit in terms of protection for patients who are at the highest absolute risk, including those patients with a low eGFR, high proteinuria, and elevated HbA1c ,18.Even regarding heart health, patients at the highest risk of cardiovascular events derive the maximum benefit from these medications. In trials focusing on heart failure and cardiac outcomes, SGLT-2 inhibitors were shown to be beneficial for secondary cardiac prevention. However, recent trials with chronic kidney disease patients indicated that they are also efficacious for the primary prevention of cardiovascular disease. This again confirms that chronic kidney disease should be considered a cardiac risk equivalent .Based on this information, current clinical indications for SGLT-2 inhibitor therapy have been expanded to include patients with or without diabetes mellitus and chronic kidney disease, chronic kidney disease with or without albuminuria, congestive heart failure regardless of diabetes, and diabetes mellitus and congestive heart failure with preserved or low ejection fraction ,43.These agents also have a favorable safety profile and should be strongly considered for their protective benefits in patients with chronic kidney disease, atherosclerotic cardiac disease, and heart failure. There is overwhelming evidence showing the effectiveness of these agents in cardiac and kidney protection, and it may not be ethically feasible to carry out additional randomized controlled trials on patients in these groups using SGLT-2 inhibitors.These data have been incorporated into the guidelines of major medical societies, replacing metformin as the first line of treatment for patients with DM. The American Diabetes Association recommended SGLT-2 inhibitors for organ protection in patients with diabetes mellitus type 2 irrespective of their hemoglobin A1c . The KDIIn clinical practice, we should anticipate around a 20–30% drop in the eGFR after starting an SGLT-2 inhibitor, which does not represent an acute kidney injury . ActuallThis transient decrease in the eGFR has been attributed to an improvement in intraglomerular hypertension, which in turn leads to reno-protection. This is a reversible decrease in the eGFR and should not prompt clinicians to discontinue therapy until the drop in the eGFR is greater than 30%2 [2 [2 [The DAPA-CKD trial showed that dapagliflozin can be started with an eGFR as low as 25 mL/min/1.73 m2 ,18. Subs2 [2 . Recent 2 [2 [2 . Upon inAn attempt should be made to maximize ACE inhibitor/ARB therapy, but this should not delay the introduction of SGLT-2 inhibitors.Finally, the “Sick day” plan should be discussed with patients clearly, and they should be counseled to withhold SGLT-2 inhibitors if fasting, acutely sick, hypovolemic, or hypotensive. Refer to SGLT-2 inhibitors have come a long way from glucose-lowering medication to first-line therapy for cardiac and renal protection in CKD and CHF patients. They have assumed a central role in DKD and cardiovascular management, and their efficacy is beyond doubt. Therefore, clinicians should consider including SGLT-2 inhibitors in their treatment plans for patients with CKD and CHF regardless of diabetes status to ensure optimal outcomes.Their indications are expanding, and more research is needed to evaluate their efficacy in patients with CKD due to ADPKD, tubulointerstitial nephritis, and those on dialysis/transplant and immunosuppression therapy for stroke prevention.The following is a list of a few ongoing trials: the RENAL LIFECYCLES, to study the effects of dapagliflozin on dialysis or transplant patients; the PRESERVE trial, to study the effect of dapagliflozin on peritoneal glucose uptake and ultrafiltration in PD patients; and the CONFIDENCE trial, to study the combination of finerenone and empagliflozin.SGLT-2 inhibitors have filled a large void in the management of DKD. Nonetheless, there is still room for further improvement. New agents such as finerenone, selective endothelin A receptor antagonists, and GLP-1 agonists have been added to the treatment arsenal and should be considered as additional options. However, further studies are required to evaluate the efficacy of these agents in non-diabetic individuals as well as any additional benefit noted in combination with SGLT-2 inhibitors.