co-morbidities in ahf : diabetes
TRANSCRIPT
DIABETES AS SIGNIFICANT DIABETES AS SIGNIFICANT COMORBIDITY IN ACUTE HEART COMORBIDITY IN ACUTE HEART
FAILURE FAILURE
Chair of Internal medicine, Belgrade University School of MedicineBoard member, Heart Failure Association of the ESCBoard member, Heart Failure Association of the ESC
Prof. Petar M. Seferović, MD, PhD, FESC, FESCCorresponding member of Serbian Academy of Sciences and Arts
President, Heart Failure Society of Serbia
Acute heart failureAcute heart failure and diabetes and diabetesClinical considerationsClinical considerations
Survival for combined outcome (HF death or hospitalization) by diabetic status
Aguilar et al. Am J Cardiol 2010;105:373–377
Clinical characteristics in AHF patients in different registries
Farmakis D, et al. Rev Esp Cardiol. 2015;68(3):245-8.
Seferovic et al. Clin Chem Lab Med 2014; 52(10): 1437–1446
AHF in diabetics vs non-diabetics: Clinical features and profiles
Comorbidities in acute heart Comorbidities in acute heart failure (failure (diabeticdiabetics vss vs non-diabetic non-diabetics)s)
CV comorbiditiesCV comorbidities in in diabetesdiabetesnn Chronic HFChronic HF (p (p<0.0001<0.0001))nn CADCAD (p (p<0.0001<0.0001))nn CardiomyopathyCardiomyopathy (p (p<0.0001<0.0001))nn Periferal vascular diseasePeriferal vascular disease (p (p<0.0001<0.0001))nn Obesity, dyslipidemiaObesity, dyslipidemia (p (p<0.0001<0.0001))nn Arterial hypertensionArterial hypertension (p (p<0.0001<0.0001))
NNon-CV comorbidities in on-CV comorbidities in diabetesdiabetesnn Chronic renal diseaseChronic renal disease (p (p<0.0001<0.0001))nn AnemiaAnemia (p (p<0.0001<0.0001))nn COPDCOPD (p (p<0.0001<0.0001))
Parissis JT, et al. Int J Cardiol. 2012;157(1):108-13.
Registry of the management of patients treated for acutely decompensated heart failure in >200 US hospitals
§ Multicenter § Observational § Open label§ Electronic web-based§ >150,000 pts
•Average age: 72.5 years•Women: 52%•Ischemic etiology (CAD): 60%•Renal insufficiency: 30%•Diabetes: 44%•Preserved LV systolic function: ~50%•Atrial fibrillation: 31%
The ADHERE Registry(Acute Decompensated Heart Failure National Registry)
• Acute Heart Failure Global Survey of Standard Treatment (ALARM-HF) – in-hospital observational survey
• 4593 patients hospitalized for AHF, 45% diabetics• Europe, Mexico, Australia• DM compared to non-DM patients: clinical phenotype treatment regimes in-hospital outcome
Parissis JT, et al. Int J Cardiol. 2012;157(1):108-13.
Age and functional status in Age and functional status in patients with AHF (patients with AHF (diabeticdiabeticss vs.vs.
non-diabeticnon-diabetics)s)Clinical Clinical characteristicscharacteristics
Diabetics Diabetics (N=2229, (N=2229, 45%45%))
Non diabetics Non diabetics (N=2724, 55%)(N=2724, 55%)
pp
Age (y)Age (y) <0.0001<0.0001
<55<5556-8056-80>80>80
10.2%10.2%76.8%76.8%12.7%12.7%
20.3%20.3%62.7%62.7%16.8%16.8%
Functional status before admission 0.0330.033NYHA I-IINYHA I-IINYHA III-IVNYHA III-IV
9.1%9.1%71.8%71.8%
12.0%12.0%69.9%69.9%
Parissis JT, et al. Int J Cardiol. 2012;157(1):108-13.
Clinical presentations and Clinical presentations and precipitating factors in patients with precipitating factors in patients with AHF (AHF (diabeticdiabeticss vs.vs. non-diabetic non-diabetics)s)
Clinical characteristicsClinical characteristics DiabeticsDiabetics Non diabeticsNon diabetics pp
Clinical Clinical presentationpresentation<0.0001<0.0001
<0.0001<0.0001<0.0001<0.0001
Acutely Acutely decompensated decompensated CHFCHFAcute de novo HFAcute de novo HFPulmonary edemaPulmonary edema
69.1%69.1%
30.9%30.9%39.3%39.3%
59.6%59.6%
40.4%40.4%34.7%34.7%
Precipitating factors<0.0001<0.0001<0.0001<0.0001
ACSACSValvular heart diseaseValvular heart disease
44.1%44.1%11.1%11.1%
30.9%30.9%15.3%15.3%
Parissis JT, et al. Int J Cardiol. 2012;157(1):108-13.
Cardiogenic shock develops more often Cardiogenic shock develops more often among diabetics with acute MIamong diabetics with acute MI
Lindholm MG, Eur J Heart Fail 2005
Prognostic impact of diabetes in Prognostic impact of diabetes in acute decompensated heart failureacute decompensated heart failure
Burger AJ, Am J Cardiol 2005
The Vasodilation in the Management of Acute Congestive HF (VMAC) trial
Strong predictors of survival in DM patientsStrong predictors of survival in DM patients
SBP SBP ≤≤100mmHg100mmHg – survival rate 74%, SBP 101-120mmHg – survival rate 92% – survival rate 74%, SBP 101-120mmHg – survival rate 92%SBP 121-159mmHg – survival rate 96%, SBP ≥160mmHg – survival rate 96%SBP 121-159mmHg – survival rate 96%, SBP ≥160mmHg – survival rate 96%
Log rank=213.7, p<0.001
Parissis JT, et al. Int J Cardiol. 2012;157(1):108-13.
Insulin-Dependent Diabetes Is AssociatedInsulin-Dependent Diabetes Is AssociatedWith Increased Mortality in Patients With Advanced With Increased Mortality in Patients With Advanced Heart FailureHeart Failure
624 patients with advanced HF and systolic dysfunction.Smooky and Fonarow, AHJ 2005.
P=0.0002
No DM
DM, no insulin
DM, insulin
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10 11 12Months
Surv
ival
(%)
0 1 2 3 4 5 6 7 8
20
40
60
80
100
Nondiabetic subjects without prior MIDiabetic subjects without prior MINondiabetic subjects with prior MIDiabetic subjects with prior MI
Years
Surv
ival (%
)
Diabetes and AHF Diabetes and AHF Etiology of HF vs. risk of death Etiology of HF vs. risk of death
Haffner SM et al. NEJM 1998;339:229–234
Patients with DM but no CHD experience a similar rate of death as patients without DM but with CHD
In-hospital outcome In-hospital outcome in acute heart in acute heart failure (failure (diabeticdiabetics vss vs non-diabetic non-diabetics)s)
OutcomeOutcome DiabeticsDiabetics Non diabeticsNon diabetics pp
DeathDeath 11.7%11.7% 9.8%9.8% 0.010.01
Functional status on dischargeFunctional status on discharge 0.0160.016
NYHA I-IINYHA I-II 64%64% 67%67%
NYHA III-IVNYHA III-IV 36%36% 33%33%
Parissis JT, et al. Int J Cardiol. 2012;157(1):108-13.
Positive predictorsn Beta/blockers * (p= 0.014)n ACEi/ARBs* (p <0.001)n PCI (p <0.001)
Negative predictorsn Age (p=0.032)n SBP<100mmHg (p<0.001)n Non compliance (p=0.005)n Arterial hypertension (p=0.022)n Cr >1.5mg/dl (p=0.029)n LVEF <50% (p <0001)n Lenth of stay in CCU (p= 0.021)
* Before admission
Predictors of in-hospital outcome Predictors of in-hospital outcome of patients with diabetes and of patients with diabetes and AHFAHF
Parissis JT, et al. Int J Cardiol. 2012;157(1):108-13.
nn Multinational cohortMultinational cohortnn 6,212 patients with AHF6,212 patients with AHFnn Europe, USA, Asia, AfricaEurope, USA, Asia, Africann EElevated blood glucose at admission levated blood glucose at admission to predict to predict all-cause mortality by 30 all-cause mortality by 30 daysdays
Mebazaa A, et al. J Am Coll Cardiol. 2013;61(8):820-9.
Hyperglycemia is a predictor of poor outcome in AHF
Arch Intern Med. 2009;169(5):438-446
In H
ospi
tal M
orta
lity
(%)
Average Post-admission Glucose
Multivariate analysis of factors associated Multivariate analysis of factors associated with 30-Day mortality in a fully adjusted with 30-Day mortality in a fully adjusted
modelmodel
Mebazaa A, et al. J Am Coll Cardiol. 2013;61(8):820-9.
30-Day Mortality rates according to the level of glucose
Cumulative hazard for death associated with hyperglicemia in AHF
Blood glucose concentration at admission – powerful predictor in AHF
Mebazaa A, et al. J Am Coll Cardiol. 2013;61(8):820-9.
Risk of death and elevated blood glucose level in presence/absence
of DM on admission
Mebazaa A, et al. J Am Coll Cardiol. 2013;61(8):820-9.
30-day mortality and hyperglycemia: 30-day mortality and hyperglycemia: Comparison among various continentsComparison among various continents
Umpierrez GE et al. J Clin Endocrinol Metab. 2002;87:978-982.
Hyperglycemia Is an independent marker of in-patient mortality in patients with undiagnosed
diabetes
In-hospital Mortality Rate
(%)
Newly Discovered
Hyperglycemia
Patients With History of Diabetes
Patients With
Normoglycemia
P < 0.01
P < 0.01
Myocardial remodelling in HFPEFImportance of comorbidities for systemic proinflammatory state
Paulus WJ, Tschöpe C. J Am Coll Cardiol 2013;62(4):263-71
Kidney function is a key factor in Kidney function is a key factor in AHF worsening in diabetes AHF worsening in diabetes
Differences in therapeutic modalities Differences in therapeutic modalities of AHF during hospitalizationof AHF during hospitalization
TherapyTherapy DMDM non-DMnon-DM ppBeta-blockersBeta-blockersDigoxinDigoxinOral/TTS nitratesOral/TTS nitratesCCBCCBAspirinAspirinClopidogrelClopidogrelNitrates i.v.Nitrates i.v.DopamineDopamineAdrenalineAdrenaline
49.7%49.7%32.0%32.0%31.0%31.0%0.9%0.9%61.7%61.7%21.4%21.4%48.6%48.6%14.6%14.6%2.6%2.6%
45.0%45.0%27.3%27.3%20.6%20.6%2.0%2.0%53.4%53.4%16.2%16.2%35.1%35.1%11.7%11.7%4.3%4.3%
0.0010.001<0.001<0.001<0.001<0.0010.0020.002
<0.001<0.001<0.001<0.001<0.001<0.0010.0030.0030.0020.002
InterventionalInterventionalCABGCABGPCIPCI
3.8%3.8%15.3%15.3%
2.2%2.2%10.8%10.8%
0.0010.001<0.001<0.001
Parissis JT, et al. Int J Cardiol. 2012;157(1):108-13.
Glucose control in AHF with T2D often Glucose control in AHF with T2D often unknown or untreated at dischargeunknown or untreated at discharge
tt Short acting insulinShort acting insulinttMMetformin and etformin and sulfonylureas (after sulfonylureas (after clinical stabilization, clinical stabilization, no severe renal no severe renal dysfunction)dysfunction)
ttAvoid glitazonesAvoid glitazonesttNew antiglycemic New antiglycemic drugs minor?drugs minor?
ttDiabetic Diabetic retinopathyretinopathy
Acute heart failure: Acute heart failure: Hyperglycemic control Hyperglycemic control strategystrategy
§ Diabetes is frequently associated with AHF
§ AHF and diabetes are frequently associated with CAD and several co-morbidities
§ Diabetics with AHF have higher in-hospital and long term mortality/morbidity
§ Age, low LVEF, renal function, low SBP, ACS and absence of life saving therapies were more frequent in high risk group
Acute heart failure and diabetes: frequently associated
Conclusions