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Provided by ASHP Sponsored by AstraZeneca Pharmaceuticals
Cardio-Renal Complications of Type 2 Diabetes Mellitus: Focus on Heart Failure
Proceedings from a Live Webinar Wednesday, February 26, 2020 1:00 p.m. – 2:00 p.m. ET
On-demand Activity Release Date: March 2, 2020 Expiration Date: August 26, 2020 This webinar is not accredited for continuing education.
FACULTY Ralph J. Riello, III, Pharm.D., BCPS Cardiovascular Critical Care Pharmacist Coronary Intensive Care Unit (CICU) Yale New Haven Hospital Department of Pharmacy Services Heart and Vascular Center New Haven, Connecticut View faculty bio at http://www.ashpadvantage.com/t2dheartfailure
ASHP Financial Relationship Disclosure Statement Planners, presenters, reviewers, ASHP staff, and others with an opportunity to control CE content are required to disclose relevant financial relationships with ACCME-defined commercial interests. All actual conflicts of interest have been resolved prior to the continuing education activity taking place. ASHP will disclose financial relationship information prior to the beginning of the activity. A relevant financial relationship is a defined as a financial relationship between an individual (or spouse/partner) in control of content and a commercial interest, in any amount, in the past 12 months, and products and/or services of the commercial interest (with which they have the financial relationship) are related to the continuing education activity. An ACCME-defined commercial interest is any entity producing, marketing re-selling, or distributing healthcare goods or services consumed by, or used on, patients. The ACCME does not consider providers of clinical serve directly to patients to be commercial interests—unless the provider of clinical service is owned, or controlled by, an ACCME-defined commercial interest.
© 2020 American Society of Health-System Pharmacists, Inc. All rights reserved. 2
Cardio‐Renal Complications of Type 2 Diabetes Mellitus: Focus on Heart Failure
Ralph J. Riello III, Pharm.D., BCPS
Clinical Pharmacy Specialist, Cardiovascular Critical Care
Yale New Haven Hospital
New Haven, Connecticut
Provided by ASHP Sponsored by AstraZeneca Pharmaceuticals
• Ralph J. Riello III
– Janssen, Johnson & Johnson, Portola, and
AstraZeneca: consultant
All other planners, presenters, reviewers, ASHP staff, and
others with an opportunity to control content report no
financial relationships relevant to this activity.
Disclosures
© 2020 American Society of Health-System Pharmacists, Inc. All rights reserved. 3
Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
Learning Objectives
• Recognize the causative role of type 2 diabetes mellitus (TD2M) in the development of cardiovascular and renal disease
• Define the prevalence, pathophysiology, and healthcare burden of heart failure (HF) in the United States
• Discuss the risk of HF as an underappreciated complication of T2DM
• Describe the progression of chronic kidney disease (CKD) as a common comorbidity of T2DM
T2DM: Cardio‐Renal Complications
© 2020 American Society of Health-System Pharmacists, Inc. All rights reserved. 4
Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
T2DM Epidemiology
Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Accessed February 1, 2020.
Burrows NR, et al. Morbid Mortal Weekly Rep. 2017;66:1165‐70. American Diabetes Association. Diabetes Care. 2019;42(Suppl 1);S103‐S123.
30.3 millionHad BP ≥140/90 mmHg or on antihypertensive medications75%
Die from cardiovascular (CV) disease50%
Of CKD is attributable to diabetes25%
At risk of developing HF50%
T2DM Pathophysiology
Inzucchi SE, Sherwin RS. Cecil Medicine. 2011;267.
++
‐‐
‐‐
hepatic glucose production
pancreatic insulinsecretion
pancreatic glucagonsecretion
gutcarbohydratedelivery &absorption
incretineffect
peripheralglucose uptake
TZDsMetformin
DPP‐4 inhibitors
GLP‐1Ragonists
SUs
Insulin
renal glucose excretion
SGLT‐2 inhibitors
HYPERGLYCEMIAHYPERGLYCEMIA
© 2020 American Society of Health-System Pharmacists, Inc. All rights reserved. 5
Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
T2DM and CVD Pathophysiology
Kasznicki J et al. Arch Med Sci. 2014;10:546‐56.
Diabetes mellitus
Metabolic Disturbances(Hyperglycemia, Hyperinsulinemia, Insulin Resistance, Dyslipidemia, Obesity)
Oxidative stress, Glycation
Autonomic neuropathy
Inflammation
Cardiac fibrosisCardiac dysfunction
Endothelial dysfunctionAtherosclerotic CVD (ASCVD)
Heart Failure
Activation of Reticular Activating
System (RAS)
Coronary Artery Disease (CAD)
T2DM and HF Pathophysiology
Marwick, TH et al. J Am Coll Cardiol. 2018;71:339‐51.
Perfusion
CAD
Hypertrophy Apoptosis
Δ Glucose UtilizationΔ Fatty Acid UtilizationΔ EC CouplingMitochondrial FunctionDiastolic Dysfunction
Systolic Dysfunction
Diabetic HF
Impaired glucosehandling insulin
resistance
Oxidative Stress
Inflammation Hypertension
Atherosclerosis
Cardiomyocytes
Compliance
AutonomicDysfunction
SystemicMyocardium
Fibrosis
Diabetes
© 2020 American Society of Health-System Pharmacists, Inc. All rights reserved. 6
Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
Cardiorenal T2DM Complications
Verma S et al. Lancet. 2018;393:3‐5.
Diabetes affects the
FILTER
Diabetes affects the
PUMP
Diabetes affects the
PLUMBING ASCVD
HEART FAILURE
RENAL DISEASE
HF as a T2DM Complication
Ofstad AP et al. Heart Fail Rev. 2018;23:303‐23.Low Wang C et al. Circulation. 2016;133:2459‐502.Seferović PM et al. Eur Heart J. 2015;36:1718‐27.
Jia G et al. Diabetologia. 2018;61:21‐8.
HEART FAILURE
T2DM causes ischemic HF by increasing CAD and
hypertension risk
T2DM directly induces myocardial structural and
functional changes
© 2020 American Society of Health-System Pharmacists, Inc. All rights reserved. 7
Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
HF is more likely than myocardial infarction or stroke to be the first cardiovascular complication of type 2 diabetes?
a. True
b. False
Heart Failure
© 2020 American Society of Health-System Pharmacists, Inc. All rights reserved. 8
Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
Epidemiology
Benjamin E et al. Circulation. 2018;137:e67‐e492.
• 6.5 million adults with HF– Increase 46% by 2030
• 960,000 new cases diagnosed annually• 46% five‐year survival rate after diagnosis
– 1 in 9 deaths attributed to HF
• $30.7 billion in healthcare costs per year• #1 hospitalization cause among age >65 y/o
– 25% readmitted within 30 days
• Heart is unable to pump blood at a rate commensurate with tissue demand or only can with high filling pressures
McMurray JJ et al. Eur Heart J. 2012;33:1787‐847. Aziz F et al. J Clin Med Res. 2013;5:327‐34.
Yancy CW et al. Circulation. 2013;62:1495‐539.
Pathophysiology
Impaired left ventricular (LV) filling• During diastole, LV fills with blood• Improper relaxation reduces stroke volume
Impaired blood ejection• During systole, LV ejects blood• Improper ejection reduces cardiac output
© 2020 American Society of Health-System Pharmacists, Inc. All rights reserved. 9
Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
• LV ejection fraction (EF) is key HF measurement
Yancy CW et al. Circulation. 2013;62:1495‐539. Bloom MW et al. Nat Rev Dis Primers. 2017;3:1‐19.
Classification
• Portion of blood pumped from heart with each beat– ≥50% is normal
• HF with reduced EF (HFrEF)– ≤40% or systolic HF
• HF with preserved EF (HFpEF) – ≥50% or diastolic HF
• Gold standard assessment of cardiac function
Yancy CW et al. J Am Coll Cardiol. 2013;62:e147‐239.Flores AS et al. J Thorac Dis. 2015;7:2139‐50.
Echocardiography
• Diagnostic ultrasound measurement of LVEF, cardiac volume, mass
• Characterizes structural, flow abnormalities
• Reveals subclinical HF– Predict future CV risk
© 2020 American Society of Health-System Pharmacists, Inc. All rights reserved. 10
Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
Biomarker
Nakagawa Y et al. Peptides. 2019; 111:18‐25.Huelsmann M et al. Eur Heart J. 2008;29:2259‐64.Yancy CW et al. Circulation. 2013;128:e240‐e327.
• Counterregulatory, vasoactive hormone– Myocytes release during ventricular wall stress
– Elevated levels indicate HF, rise with severity
• Assay identifies T2DM patients at risk for HF
Kaplan‐Meier Analysis of 631 T2DM Patients Using NT‐proBNP at Cutoff of 125 pg/mL2
1.00
0.95
0.90
0.20
0.15
0.10
0.05
0
0 2 4 6 8 10 12
Months
Death or Unplanned
CV Hospitalization
NT‐proBNP >125 pg/mL (n=358)NT‐proBNP <125 pg/mL (n=273)
P<0.0001
• N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP)
Redfield MM et al. N Engl J Med. 2016;375:1868.Seferović PM et al. Eur Heart J. 2015;36:1718‐27.
Borlaug B. Nat Rev Cardiol. 2014;11:507‐15.Yancy C et al. J Am Coll Cardiol. 2013;62:e147‐e149.
Classification
• Systolic LV dysfunction • Diastolic LV dysfunction
• LV dilation • No LV dilation
• Eccentric LV remodeling • Concentric LV remodeling
• Due to loss of systolic function, typically afteran acute cardiac event
• Due to pro‐inflammatoryCV and non‐CV co‐existing conditions
• Associated with coronary artery disease risk factors (eg, hypertension, diabetes, advanced age, smoking, dyslipidemia)
• Associated with hypertension, obesity, diabetes, metabolic syndrome, lung disease, smoking, and iron deficiency
• Accounts for nearly 50% of all HF cases • Accounts for >50% of all HF cases
HFrEF (Systolic HF) HFpEF (Diastolic HF)
© 2020 American Society of Health-System Pharmacists, Inc. All rights reserved. 11
Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
Yancy CW et al. Circulation. 2013;128:e240‐e327. Yancy CW et al. J Am Coll Cardiol. 2017;70:776‐803.
StagingACCF/AHA Stages of HF NYHA Functional Classification
AAt high risk for HF but without structural heart disease or symptoms of HF
None
BStructural heart disease but without signs or symptoms of HF
INo limitation of physical activity. Ordinary physical activity does not cause symptoms* of HF.
CStructural heart disease with prior or current symptoms of HF
INo limitation of physical activity. Ordinary physical activity does not cause symptoms of HF.
IISlight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF.
IIIMarked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF.
IVUnable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest.
DRefractory HF requiring specialized interventions
IVUnable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest.
Existing HF
HF Risk
The ACCF/AHA stages progressively worsen such that patients cannot revert to an earlier stage. NYHA functional classes can progress in either direction.
Platz E et al. Eur J Heart Fail. 2015;17:906‐16.Mayo Clinic Cardiology. 2012:858‐63.
Presentation
Trouble SleepingDifficulty breathing at night when recumbent
Swelling in Feet and Ankles
Pulmonary EdemaPleural Effusion
Ascites
+Edema and Fluid Retention Sudden weight gain 2‐3 lbs in 24 hours
Dyspnea
Fatigue and Exercise Intolerance
Dry Cough
Loss of Appetite
© 2020 American Society of Health-System Pharmacists, Inc. All rights reserved. 12
Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
Disease Progression
Gheorghiade M et al. Am J Cardiol. 2005;96:11G‐17G.Jencks SF et al. N Engl J Med. 2009;360:1418‐28.De Couto G et al. Nat Rev Cardiol. 2010;7:334‐44.
• Cardiac function progressively declines after acute HF hospitalization
• Exacerbations more frequent after HF diagnosis– >60% readmission rate within 1 year
Acute Event
Myo
cardial Function
Time
Adapted from Gheorghiade M, et al. Am J Cardiol. 2005
Mortality After Acute HF
Loehr L et al. Am J Cardiol. 2008;101:1016‐1022.Chen J et al. JAMA. 2011;306:1669‐1678.
10%
22%
42%
0
20
40
60
Day 30 Year 1 Year 5
Deaths (%
of Patients)
Time after Hospitalization
31% 31% 30%28%
30%
0
10
20
30
40
2000 2002 2004 2006 2008
Risk‐Adjusted 1‐year
Mortality (%
)
Year
Atherosclerosis Risk in Communities (ARIC) Study
US Acute Care Study
© 2020 American Society of Health-System Pharmacists, Inc. All rights reserved. 13
Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
HF Hospitalization Rates by EF
Steinberg BA et al. Circulation. 2012;126:65‐75.Andersson C Vasan RS. Heart Fail Clin. 2014;10:377–88.
52% 51% 50% 51% 49% 47%
15% 14% 14% 14% 13% 14%
33% 35% 36% 35% 38% 39%
2005 2006 2007 2008 2009 2010
HFpEF
HFrEF
40‐50%
HF Rehospitalization Risk by Time
Caughey M et al. Am J Cardiol. 2018;122:108‐14.
30 Days
HFpEF
Incidence Rate per 100
Person‐Yea
rs
90 Days 6 Months 1 Year
HFrEF0
40
80
120
160
HFpEFHFrEF HFpEFHFrEF HFpEFHFrEF
© 2020 American Society of Health-System Pharmacists, Inc. All rights reserved. 14
Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
Which of the following patient characteristics is associated with an increased risk of heart failure hospitalization?
a. No prior hospitalization for acute decompensated heartfailure
b. Reduced N‐terminal pro‐B‐type natriuretic peptide level
c. Presence of comorbid type 2 diabetes mellitus
d. Absence of comorbid chronic kidney disease
HF as a Complication of T2DM
© 2020 American Society of Health-System Pharmacists, Inc. All rights reserved. 15
Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
T2DM and HF Risk
Nichols GA et al. Diabetes Care. 2004;27:1879‐84.Cavender MA et al. Circulation. 2015;132:923‐31.
Zhou L et al. Current Diabetes Reviews. 2009;5:171‐84.Vijaykumar S et al. Exp Rev Cardiovasc Ther. 2018;16:123‐31.
Patients with T2D are
2.5x more likely to develop HF than people
without diabetes
Risk of hospitalization
from heart failure was
33% higherin patients with diabetes
Even with optimal glycemic management, patients with T2D
and HF have a high risk of
morbidity and mortality
The prevalence of HF in US
patients with T2DM is
as high as 22%
HF Risk by T2DM Control
Iribarren C et al. Circulation. 2001;103:2668‐73.
4.5
5.86.3
8.3
9.2
0
1
2
3
4
5
6
7
8
9
10
<7 7 to <8 8 to <9 9 to <10 10
Rates of HF Hospitalization or
Death per 1000 Person‐Years
Hemoglobin A1C (%)
≥
© 2020 American Society of Health-System Pharmacists, Inc. All rights reserved. 16
Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
HF Risk by T2DM Control
Matsushita K et al. Diabetes. 2010;59:2020–6.Hemoglobin A1c (%)
Adjusted in
cidence rate of HF
(per 1000 patient years) P
roportio
n of P
opulatio
n (%
)
HF risk increases linearly above an A1c 5.0%
HF Risk by T2DM and Age
Nichols GA et al. Diabetes Care. 2001;24:1614–9.
Prevalence of HF by AgeIncidence of HF by Age
Age at baselinePrevalence rate per 1000 People
400
300
200
100
0<45 45–54 55–64 65–74 75–84 85–94 95+
Diabetes patients
Control patients
80
60
40
20
0<45 45–54 55–64 65–74 75–84 85–94 95+
Age at baseline
Incidence rate per 1000 People
Diabetes patients
Control patients
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Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
HF and T2DM Share Risk Factors
Thomas MC. Curr Cardiol Rev. 2016;12:249‐55.
Hypertension
Advanced AgeDyslipidemia
Chronic Kidney Disease
CoronaryHeart Disease
Obesity
RISKFACTORSFOR HF
ALL are associated with diabetes
Risk of T2DM Complications
Bergenstal RM et al. Am J Med. 2010;123:374.e9‐374.e18.Foley RN et al. J Am Soc Nephrol. 2005;16:489‐95.Haffner SM et al. N Engl J Med. 1998;339:229‐34.
Noel RA et al. Diabetes Care. 2009;32:834‐8.Trautner C et al. Diabetes Care. 1997;20:1147‐53.
Events per 1000 Patient‐years0 20 40 60 80 100
CHF
MI (prior MI)
PVD
Stroke (prior MI)
MI (no prior MI)
Death
Stroke (no prior MI)
Pancreatitis
End Stage Renal Disease
Blindness
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Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
Risk of T2DM Complications
Shah AD et al. Lancet Diabetes Endocrinol. 2015;3:105‐13.
16%
14%
12%10%
4%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
PAD Heart Failure Nonfatal MI Stroke CV death
Initial C
V event presentations (of
6,137 events in
T2DM cohort,%
)
16%
27%
25%
32%
Diastolic LVDn=61
LV Dysfunction Precedes HF in T2DM
Shah AD et al. Lancet Diabetes Endocrinol. 2015;3:105‐13.
Systolic LVDn=106
Normal LVFunctionn=124
Systolic andDiastolic LVD
n=95
● 68% of T2DM patients had LV dysfunction (LVD) 5 years after diagnosis
● LVD was without evidence of inducible ischemia by stress testing at baseline
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Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
Undiagnosed HF is Common in T2DM
Boonman‐de Winter LJ et al. Diabetologia. 2012;55:2154–62.
●High risk subsets−BMI ≥30 kg/m2
−Hypertension−Age >65 y/o−Female−Fatigue−Dyspnea
No HF72%
HFrEF5%
HFpEF23%
T2DM Patients Previously Undiagnosed with HF (n=581)
T2DM Worsens HF Hospitalization Risk
Cavender MA et al. Circulation. 2015;132:923‐31.
5.9%
9.4%
0%
2%
4%
6%
8%
10%
Incidence of HF
Hospitalization (%)
DiabetesNo Diabetes
Risk of HF hospitalization was 33% higher in T2DM patients
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Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
Comorbid T2DM and HF Worsens Survival
Bertoni AG et al. Diabetes Care. 2004;27:699‐03.
0
0.25
0.50
0.75
1.00
Years
Proportion Surviving
0 1 2 43 5
Diabetes with incident HF(n=46,720)
Diabetes without HF(n=69,083)
P<0.001
HF significantly decreased survival in T2DM patients
T2DM Worsens Overall CV Risk
MacDonald MR et al. Eur Heart J. 2008;29:1377‐85.
CV Death or Hospitalization Due to HF60
40
20
0
Follow‐Up (Years)0 0.5 1.0 1.5 2.0 2.5 3.0 3.5
Diabetes (HFrEF)
No Diabetes (HFrEF)Diabetes (HFpEF)
No Diabetes (HFpEF)
Cumulative In
cidence, % T2DM increased CV morbidity
and mortality, irrespective of EF
© 2020 American Society of Health-System Pharmacists, Inc. All rights reserved. 21
Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
Relative to patients without type 2 diabetes mellitus, which complication occurs most commonly?
a. End stage renal disease
b. Myocardial infarction
c. Heart failure
d. Stroke
CKD as a Complication of T2DM
© 2020 American Society of Health-System Pharmacists, Inc. All rights reserved. 22
Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
CKD is a Common T2DM Complication
Afkarian M et al JAMA. 2016;316:602‐10.
●~26% of T2DM patients have diabetic nephropathy −Persistent albuminuria, reduced glomerular filtration rate (GFR), or both
High CKD Prevalence Among T2DM
Murphy D et al. Ann Intern Med. 2016;165:473‐81.
4.15.3
14.3
19.1
0
5
10
15
20
25
1988‐1994 2011‐2012
Prevalence of CKD (%)
Without DiabetesDiabetes
Prevalence of CKD is 3 times higher in T2DM
© 2020 American Society of Health-System Pharmacists, Inc. All rights reserved. 23
Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
CKD Progression in T2DM
Williams ME. Med Clin North Am. 2013;97:75‐89.
Preclinical Incipient diabeticnephropathy
Overt diabeticnephropathy
End‐stagerenal disease
Proteinuria
Mesangial nodules (Kimmelsteil‐Wilson lesions)Tubulointerstitial fibrosis
Mesangial expansion,glomerular basementmembrane thickening,arteriolar hyalinosis
Microalbuminuria,hypertension
Proteinuria, nephrotic syndrome, GFRGFR
Renalhypertrophy
GFR
Functional
Structural
Years0
50
100
150
GFR
(mL/min/1.73 m
2)
Urin
ary protein excre
tion
(mg/24 hours)
5000
1000
200
20
5 10 15 20 25
Cardio‐Renal T2DM Connection
Connelly K et al. Cell Metab. 2018;28:813‐15.
Diabetes
Na+ RetentionHypervolemiaRAAS activationNeurohumoral
ActivationInflammationIschemia
Altered Energetics
Consider cardio‐renal systems together
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Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
CKD Increases HF Risk
Nayor M et al. Eur J Heart Fail. 2017;19:615‐23.
Cumulative in
cidence of HF CKD HFrEF
CKD HFpEFNo CKD HFrEFNo CKD HFpEF
0 2 4 6 8 10 12
8%
6%
4%
2%
0%
Years7281764479948318859688458983
No. at Risk
511596648711783854906CKDNo CKD
Higher incidence rates of HF among CKD patients
CKD Progression Worsens CV Risk
Go AS et al. N Engl J Med. 2004;351:1296‐305.
Reduced GFR increases risk of major adverse CV events
2.113.65
11.29
21.8
36.6
0
5
10
15
20
25
30
35
40
≥60 45‐59 30‐44 15‐29 <15
Estimated GFR (ml/min/1.73m2)
Age‐Standardized Rate of CV Events
(per 100 person/yr)
© 2020 American Society of Health-System Pharmacists, Inc. All rights reserved. 25
Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
Which of following statements describing diabetic nephropathy is true?
a. Prevalence of CKD is equivalent with and without diabetes
b. Risk of HF decreases with progressive renal dysfunction
c. Proteinuria and GFR increase with the progression to ESRD
d. Decreased GFR correlates with risk for adverse CV events
Summary
© 2020 American Society of Health-System Pharmacists, Inc. All rights reserved. 26
Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
Summary
• T2DM is associated with multiple cardio‐renal comorbidities, worse outcomes, and increased healthcare costs
• Both HF and T2DM prevalence are increasing• Diabetes increases risk for HF, CVD, and CKD• Earlier identification and management of T2DM patients at risk for HF is critical
Potential Action Items
• Evaluate type 2 diabetes mellitus (T2DM) patients for risk of cardiovascular and renal complications
• Collaborate with a multidisciplinary team of endocrinology, cardiology, and nephrology specialists early in the diabetes care continuum
• Help develop a T2DM management algorithm prioritizing antihyperglycemic agents with demonstrated cardiorenal benefits
• Optimize individual T2DM treatment plans to reduce heart failure hospitalization rates among at risk patients
• Champion discussion of diabetes as a risk equivalent for heart failure among pharmacy, nursing, and medical colleagues
© 2020 American Society of Health-System Pharmacists, Inc. All rights reserved. 27
Cardio‐Renal Complication of Type 2 Diabetes Mellitus: Focus on Heart Failure
Selected Resources
• Dunlay SM, Givertz MM, Aguilar D et al. Type 2 diabetes mellitus and heart failure: a scientific statement from the American Heart Association and the Heart Failure Society of America: this statement does not represent an update of 2017 ACC/AHA/HFSA heart failure guideline update. Circulation. 2019; 140:e294‐e324.
• Cherney DZI, Repetto E, Wheeler DC et al. Impact of cardio‐renal‐metabolic comorbidities on cardiovascular outcomes and mortality in type 2 diabetes mellitus. Am J Nephrol. 2020;51(1):74‐82.
• Kenny HC, Abel ED. Heart failure in type 2 diabetes mellitus: impact of glucose‐lowering agents, heart failure therapies, and novel therapeutic strategies. Circulation Research. 2019;124:121‐41.
Thank you for joining us
• On‐demand activity coming March 2020
• Related topics in this series coming soon www.ashpadvantage.com/t2dheartfailure/
www.ashpadvantage.com/t2dheartfailure
This activity is not eligible for CE Credit
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