diabetes and heart failure: truth and · pdf file 2020-02-28 · diabetes and heart...

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

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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

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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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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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Diabetes and Heart Failure: Truth and Consequences

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Exercise Capacity is diminished in patients with HFpEF and T2DM

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