Canadian Diabetes Association Clinical Practice Guidelines

Treatment of Diabetes in People with Heart Failure

Chapter 28

Jonathan G. Howlett, John C. MacFadyen

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association

Treat heart failure in patients with diabetes the SAME

as you would a patient without diabetes

METFORMIN recommended if eGFR >30 mL/min

If eGFR <60 mL/min, use RAAS blockade carefully

Do NOT use thiazolidinediones

2013Diabetes in Heart Failure Checklist

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association

• Diabetic cardiomyopathy

• 2 to 4-fold increase incidence of heart failure in DM

• Asymptomatic abnormalities of ventricular systolic

and diastolic function, independent of ischemic

heart disease or systemic hypertension

• Independent risk factors for CHF– Elevated A1C

– Microalbuminuria

Diabetes → Increased Risk of Heart Failure Independent of Ischemia

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association

Use the same heart failure therapies in diabetes as you would

in non-diabetes based on the Canadian Cardiovascular Society

(CCS) Recommendations (www.ccsguidelineprograms.ca)

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association

• Beta-blocker for systolic heart failure if indicated

• Same target drug dose as indicated by CCS

• If eGFR <60 mL/min– Starting dose of ACEi/ARB should be halved with gradual

up-titration– Monitor electrolytes, creatinine, blood pressure, weight

within 7-10 days of starting

Use Same Treatments as in Non-diabetes …

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association

ACEi = Angiotensin-Converting Enzyme inhibitor; CHF = Chronic Heart Failure; MI = Myocardial Infarction; SU = Sulfonylurea

Tayside, Scotland (population 400,000)

n=422 with CHF and diabetes

Antihyperglycemic therapy:– Metformin alone n=68– SU alone n=217– Combination n=137

Cum

ulat

ive

mor

talit

y

1.0

0.8

0.6

0

0.4

0.2

Time (days)

0 1000 2000 3000 4000 5000

Sulfonylurea monotherapy

Metformin monotherapy + combination

Evans JM, et al. Am J Cardiol 2010;106:1006-10.

Metformin Use in Heart Failure Patients

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association

Veterans Affairs• 6,185 with CHF & DM• Oral antihyperglycemic:

- With metformin (n=1,561)

- Without metformin

• Statistically adjusted for co-variables

Death: 0.76 (0.63-0.92) p < 0.01CHF hospitalization: 0.93 (0.74-1.18) p = 0.56Total hospitalization: 0.94 (0.83-1.07) p = 0.35

Sur

viva

l est

imat

es

1.00

0.95

0.90

0.75

0.85

0.80

Time (days)

0 700100 200 300 600400 500

Metformin

No metformin

p = 0.01

Aguilar D, et al. Circ Heart Fail 2011;4:53-8.

Metformin Use in Heart Failure Patients

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association

Use metformin in heart failure patients when eGFR >30 mL/min

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association

1. Individuals with diabetes and heart failure should

receive the same heart failure therapies as those

identified in the evidence- based Canadian

Cardiovascular Society heart failure recommendations

(http://www.ccsguidelineprograms.ca) [Grade D, Consensus]

Recommendation 1

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association

2. In people with diabetes and heart failure and an

eGFR <60 mL/min, or if combined RAAS blockade

is employed:

– Starting doses of ACE inhibitors or angiotensin

receptor II antagonists (ARBs) should be halved [Grade D, Consensus].

– Serum electrolytes and creatinine, blood pressure

and body weight, as well as heart failure

symptoms and signs, should be monitored within

7-10 days of any initiation or titration of therapy [Grade D, Consensus]

Recommendation 2

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association

– Dose-up titration should be more gradual (with monitoring of blood pressure, serum potassium and creatinine) [Grade D, Consensus].

– The target drug doses should be the same as those identified in the evidence-based Canadian Cardiovascular Society recommendations on heart failure (http://www.ccsguidelineprograms.ca), if well tolerated [Grade D, Consensus]

Recommendation 2 (continued)

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association

3. Beta blockers should be prescribed when indicated for systolic heart failure, as they provide similar benefits in people with diabetes compared with people without diabetes [Grade B, Level 2]

Recommendation 3

CDA Clinical Practice Guidelines

www.guidelines.diabetes.ca – for professionals

1-800-BANTING (226-8464)

www.diabetes.ca – for patients