heart failure in the diabetic patient
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Heart Failure in the Diabetic Patient. Maria Rosa Costanzo, M.D., F.A.C.C., F.A.H.A. Medical Director, Midwest Heart Specialists-Advocate Medical Group Heart Failure and Pulmonary Arterial Hypertension Programs Medical Director, Edward Hospital Center for Advanced Heart Failure - PowerPoint PPT PresentationTRANSCRIPT
Heart Failure in the Diabetic Patient
Maria Rosa Costanzo, M.D., F.A.C.C., F.A.H.A.Medical Director, Midwest Heart Specialists-Advocate Medical Group Heart Failure and Pulmonary Arterial Hypertension Programs
Medical Director, Edward Hospital Center for Advanced Heart FailureNaperville, Illinois, U.S.A.
“We demonstrate that young subjects with uncomplicated type 1 diabetes mellitus have impaired myocardial energetics irrespective of the duration of diabetes and that the impaired cardiac energetics status is independent of coronary microvascular function. We postulate that impairment of cardiac
energetics in these subjects primarily resultsfrom metabolic dysfunction rather than
microvascular impairment.”
Prevalence of DM in General Population with and without HF
Study/Date
No. of Subjects
Mean Age (yrs)
HF Prevalenc
e
Prevalence of DM with HF
Prevalence of DM without
HF
Rotterdam/01
5255 69 3.4% 17.5% 10.3%
Italy/97 1339 74 9.5% 29.6% 13.2%
Rekjavik/05
19381 - 3.8% 11.6% 3.4%
Olmstead /06
655 77 All with HF
13%-25% -
Prevalence of DM in Populations with and without LVSDStudy/Date
No. of Pts
Mean Age (yrs)
Definition of LVSD by EF
LVSD Pr1evalenc
e
Prevalence of
symptomatic LVSD
LVSD + DM
No LVSD, DM
ECHOES/01 3960 61 < 40 % 1.8% 1% 30% 3.8%
Copenhagen/03 764 66 ≤ 40% 4.7 67% 7.2% 5.9%
Poole/99 817 76 Visual Ass.
7.5% 21% 10% 6%
Glasgow/’97 1640 50 ≤ 35% 7.7% 23% 12.4% 2.5%
Vasteras/01 401 75 LWMI < 1.7%
6.8% 54% 22% 7%
Olmsted/03 1888 63 ≤ 50% 6.5% - 17% 6.8%
Copenhagen/05 188 69 < 45% 100% 100% 25.5% -
Prevalence of DM in Patients with HF in Clinical Trials
Clinical Trial Prevalence %
SOLVD 25.8MERIT-HF 24.5ELITE II 24.0Val-HeFT 25.4COPERNICUS 25.7OPTIME (hospitalized) 44.2VMAC (hospitalized) 47.0
DM and Mortality in HF: Clinical Trials Populations
Trial Treatment NO. of Pts. Mortality Risk of DM (HR)
SOLVD/91 Enalapril 6797 Overall 1.29HF due to CAD 1.37HF, no CAD 0.98
BEST/01 Bucindolol 2708 HF due to CAD 1.333HF, no CAD 0.98
DIG/97 Digoxin 6422 HF due to CAD 1.43HF, no CAD, not stated
DIAMOND-HF
Dofetilide 5491 Women 1.7Men 1.4
CHARM/03 Candesartan
7599 Insulin 1.80No Insulin 1.50
DM and Mortality in HF: Non Clinical Trials Populations
Location/Date No. of Patients Mortality Risk of DM (HR)
Rotterdam/01 5540 3.19
Framingham/93 9405 Women 1.70Men 0.99
Scotland/00 66547 Women 1.5Men 1.55
USA/99 170,239 Black 1.11White 1.22
USA/05 495 1.71
USA/05 554 No insulin 0.95Insulin 4.30
France/04 1246 HF due to CAD 1.54HF, no CAD 0.65
Olmstead/06 665 Overall 1.48HF due to CAD 1.11HF, no CAD 1.79
Italy/03 2843 1.44
Risk Factors For Congestive Heart Failure
Wilson PW. Am J Cardiol 1997;80:3-8
0 2 4 6 8 10
Hypertension
MyocardialInfarction
Angina Pectoris
Diabetes Mellitus
Left VentricularHypertrophy
Valvular Heart Disease
Relative Risk of CHF
WomenMen
Prediction of Heart Failure in Women with CAD
(Bibbins-Domingo K, et al. Circulation 2004;1424-1430)
Diabetes 3.1
Atrial Fib 2.9
CrCL 40-60 1.2
<40 2.3
SBP 120-139 1.6
140-159 2.1
<159 2.1
Smoking Past 1.2
Current 1.9
BMI 25-36 1.2
>36 1.9
LBBB 1.6
LVH 1.5
CABG 1.3
Adjusted HR for HF
02468
1012
HF
Hos
p. an
d/or
D
eath
< 7 7-<8 8-<9 9-<10 >10
Hemoglobin A1c %
Glycemic Control and HF Among Adult Pts. with Diabetes
allmenwomen
Iribarren C et al. Circulation 2001; 103: 2668
All: p = 0.0001Men: p = 0.0001Women: p = 0.009
Association between Elevated Blood Glucose and Outcome in Acute HF
in a Multinational Cohort of 6,212 Subjects
30-Day Mortality Rates According to Admission Blood Glucose
Risk of Death Associated with Elevated BG as a Function of the Presence or
Absence of DM on Admisssion
Mebaaza A et al. JACC 2013; 61:820-9
Association of HgbA1c with Risk of HF in 10 Studies with Maximally
adjusted Covariates
Association of HgbA1c with Risk of HF in Patients Subgroups
Erqou S. et al. Eur J Heart Fail 2013; 15: 185-193
0.64
1.06
0.82
0.89
0.79
0.44
0.97
0.75
0.84
1.01
0.85
0.73
0.85 0.84
0
0.2
0.4
0.6
0.8
1
1.2
Log
Mor
talit
y R
elat
ive
Ris
k
CONSENSUS SAVE SMILE SOLVD-P SOLVD-T TRACE PooledEstimate
Effect of ACEI on Mortality from HF in Diabetic and Non-Diabetic patients
Non-Diabetic
Series2
Shekelle PG et al. JACC 2003; 41:1529-38
0.66
0.81
0.67 0.68
0.62
0.81
0.65
0.77
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
Log
Mor
taki
ty R
elat
ive
Ris
k
CIBIS-II COPERNICUS MERIT-HF Pooled Estimate
Effects of Beta-Blockers on Mortality from HF in Diabetic and Non-Diabetic Patients
Nnon-Diabetic
Diabetic
Shekelle PG et al. JACC 2003; 41:1529-38
ConclusionsHF and DM commonly coexistEach condition increases the likelihood of
developing the otherWhen HF and DM coexist in the same patient the
risk of morbidity and mortality increases markedlyScreening strategies are needed to identify DM
patients at high risk of HD and those with asymptomatic LVSD
A strong effort must be made to place patients with coexisting HF and DM on optimal HF therapy
Strategies for managing DM in patients with HF must be tested in prospective controlled clinical trials
Patients with both DM and HF require the care of a multidisciplinary team aware of the unique issues characterizing the two conditions.