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  • Diabetes and Heart Failure: Truth and Consequences

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    Paul P. Doghramji, MD, FAAFP

    Family Practice Physician

    Collegeville Family Practice & Pottstown Medical Specialists, Inc.

    Medical Director of Health Services, Ursinus College – Collegeville, PA

    Attending Family Practice Physician, Pottstown Memorial Medical Center – Pottstown, PA

    Diabetes and Heart Failure: Truth and Consequences

    Learning Objectives

    ▪ Assess patients with type 2 diabetes mellitus for cardiovascular

    (CV) risk, including heart failure

    ▪ Describe the results of cardiovascular outcomes trials of

    glucose-lowering medications for type 2 diabetes mellitus,

    focusing on heart failure

    ▪ Select glucose-lowering medication shown to be beneficial in

    patients with type 2 diabetes mellitus at risk of heart failure

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  • Diabetes and Heart Failure: Truth and Consequences

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    Coronary Heart Disease

    Atherothrombotic Brain Infarction

    Intermittent Claudication

    Congestive Heart Failure

    Cardiovascular Death

    Cardiovascular Disease

    A n

    n u

    a l

    a g

    e -a

    d ju

    s te

    d e

    v e

    n t

    ra te

    p e

    r 1

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    Framingham Heart Study

    Women without Diabetes Women with Diabetes

    Men without Diabetes Men with Diabetes

    Kannel WB, McGee DL. JAMA. 1979;241:2035-2038.

    Diabetes Mellitus as a Cardiovascular Risk Factor

    Linear Relationship Between Glycemic Control and HF

    RR = relative risk

    For every

    1% increase

    in A1c

    15% increase in RR of

    HF

    Erqou S, et al. Eur J Heart Fail. 2013;15:185-193.

    10 studies involving 178,929 patients with diabetes and 14,176 incident cases of HF

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  • Diabetes and Heart Failure: Truth and Consequences

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    Patients with T2DM are

    2.5x more likely to develop HF than people without T2DM1,2

    Risk of hospitalization from HF is

    33% higher in patients with T2DM3

    Even with optimal glycemic management,

    patients with T2DM have a high risk of

    morbidity and mortality4

    1. Nichols GA, et al. Diabetes Care. 2004;27(8):1879-1884.

    2. Komanduri S, et al. J Community Hosp Intern Med Perspect. 2017;7(1):15-20.

    3. Cavender MA, et al. Circulation. 2015;132:923-931.

    4. Vijaykumar S, et al. Exp Rev Cardiovasc Ther. 2018;16(2):123-131.

    Patients with T2DM are at greater risk of developing HF and being hospitalized due to HF

    UKPDS = United Kingdom Prospective Diabetes StudyStratton IM, et al. BMJ. 2000;321:405-412.

    43% 37% 19% 16% 14% 12%

    Lower-extremity

    amputation or fatal

    peripheral vascular

    disease (P

  • Diabetes and Heart Failure: Truth and Consequences

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    Initial Presentation of Cardiovascular Disease in T2DM

    2.98

    1.72

    1.64

    1.62

    1.58

    1.56

    1.54

    1.53

    1.45

    1.43

    0 0.5 1 1.5 2 2.5 3 3.5

    Peripheral Arterial Disease

    Ischemic Stroke

    Stroke Not Further Specified

    Stable Angina

    Coronary Disease Not Further Specified

    Heart Failure

    Non-fatal Myocardial Infarction

    Unstable Angina

    Transient Ischemic Attack

    Unheralded Coronary Death

    Adjusted Hazard Ratio*

    Shah AD, et al. Lancet Diabetes Endocrinol. 2015;3;105-113. *Adjusted for age, sex, body mass index, deprivation, HDL cholesterol, total cholesterol,

    systolic blood pressure, smoking status, and statin and antihypertensive medications

    *Excluding patients admitted for acute HF caused by acute coronary syndrome without evidence of systolic or diastolic dysfunction

    van den Berge JC, et al. Diabetes Care. 2018;41(1):143-149.

    American Diabetes Association. Short and long-term prognosis of patients with acute heart failure with and without diabetes: Changes over the last three

    decades, American Diabetes Association, 2018. Copyright and all rights reserved. Material from this publication has been used with the permission of American

    Diabetes Association.

    Total Population 30-Day Event-Free Survivors

    Worse Prognosis in Patients with HF and T2DM*

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  • Diabetes and Heart Failure: Truth and Consequences

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    Heart Failure with Preserved Ejection Fraction (HFpEF)

    ▪ Also referred to as “diastolic heart failure”

    ▪ Characterized by signs and symptoms of heart failure

    and LVEF > 50%

    ▪ Heart failure associated with intermediate reductions

    in LVEF (40% to 49%) is also commonly grouped into

    this category

    Pathophysiology of HFpEF

    ▪ Abnormalities of active ventricular relaxation and passive

    ventricular compliance, resulting in ventricular stiffness and

    higher diastolic pressures

    ▪ These pressures are transmitted through atrial and pulmonary

    venous systems, reducing lung compliance

    ▪ A combination of decreased lung compliance and cardiac

    output leads to symptoms

    ▪ Physiologic stressors, such as a hypertensive crisis, can

    overcome compensatory mechanisms and result in

    pulmonary edema Borlaug BA, Paulus WJ. Heart failure with preserved ejection fraction: pathophysiology, diagnosis, and treatment. Eur Heart J. 2011;32(6):670–679.

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  • Diabetes and Heart Failure: Truth and Consequences

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    Epidemiology

    ▪ ~5 million persons in the United States have been diagnosed

    with heart failure, with an incidence of more than 650,000 new

    diagnoses per year

    ▪ Almost one-half of patients with heart failure have preserved

    ejection fraction

    ▪ Risk factors: older age, female sex, obesity, hypertension,

    tobacco use, diabetes mellitus, coronary artery disease (CAD),

    valvular heart disease, and atrial fibrillation

    Lee DS, Gona P, Vasan RS, et al. Relation of disease pathogenesis and risk factors to heart failure with preserved or reduced ejection fraction: insights from the

    Framingham Heart Study of the National Heart, Lung, and Blood Institute. Circulation. 2009;119(24):3070–3077.

    Chronic Kidney

    Disease

    Coronary Heart

    Disease

    AnemiaDyslipidemia

    Advanced

    Age

    Sleep ApneaHypertension

    Obesity

    Thomas MC. Curr Cardiol Rev. 2016;12:249-255.

    Heart Failure Diabetes Mellitus

    All of the Major Risk Factors for HF are Associated with Diabetes

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  • Diabetes and Heart Failure: Truth and Consequences

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    How Heart Failure Is Diagnosed

    ▪ History & Physical examination

    ▪ Risk scoring - Seattle Heart Failure Model, ADHERE

    Clinical Evaluation

    ▪ CBC, lytes, urinalysis, BUN, SCr, glucose, fasting lipids, LFTs, TSH

    ▪ Biomarkers - BNP, NT-proBNP

    ▪ Chest X-ray

    ▪ 12-lead ECG

    ▪ 2-dimensional echocardiogram with Doppler

    ▪ Angiogram

    Testing

    Yancy CW, et al. J Am Coll Cardiol. 2013;62(16):e147-e239.

    Signs and Symptoms of HFpEF

    ▪ Fatigue

    ▪ Weakness

    ▪ Dyspnea

    ▪ Orthopnea

    ▪ Paroxysmal nocturnal dyspnea

    ▪ Jugular venous distention on exam

    ▪ S3 heart sound

    ▪ Displaced apical impulse

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  • Diabetes and Heart Failure: Truth and Consequences

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    Framingham Criteria for Diagnosis of Heart Failure

    Major criteria

    ▪ Acute pulmonary edema

    ▪ Cardiomegaly

    ▪ Hepatojugular reflux

    ▪ Neck vein distention

    ▪ Paroxysmal nocturnal

    dyspnea/orthopnea

    NOTE: Heart failure is present in patients with at least two major criteria or one major and two minor criteria (positive

    likelihood ratio = 10; negative likelihood ratio = 0.4)

    Minor criteria ▪ Ankle edema

    ▪ Dyspnea on exertion

    ▪ Hepatomegaly

    ▪ Nocturnal cough

    ▪ Pleural effusion

    ▪ Tachycardia (pulse > 120)

    McKee PA, Castelli WP, McNamara PM, Kannel WB. The natural history of congestive heart failure: the Framingham study. N Engl J Med. 1971;285(26):1441–1446.

    Diagnostic Tests

    ▪ Brain natriuretic peptide (BNP)

    ▪ IN ER:

  • Diabetes and Heart Failure: Truth and Consequences

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    Diagnostic Tests (cont’d)

    ▪ Trans-thoracic echocardiogram (TTE)

    ▪ Preferred test to confirm HFpEF

    ▪ The combined finding of normal left ventricular systolic

    function and diastolic dysfunction confirms HFpEF

    ▪ Transesophageal echocardiography is not recommended

    for routine evaluation of HFpEF

    Chinnaiyan KM, Alexander D, Maddens M, McCullough PA. Curriculum in cardiology: integrated diagnosis and management of diastolic heart failure. Am Heart J.

    2007;153(2):189–200.

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    Exercise Capacity is diminished in patients with HFpEF and T2DM

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