Chronic Disease Management in

Heart Failure and Diabetes

Dr Vivek BaligaConsultant Internal Medicine

Baliga Diagnostics Pvt Ltd

Introduction• Heart failure and diabetes are closely inter-related conditions

• Diabetes increased the risk of heart failure by 6 - 8 fold

• Recent ATLAS trial found that the proportion of patients with diabetes who develop HF is around 20%

• Can be 2 separate entities that are closely inter-related

Heart Failure

What is Heart Failure?• Inability of the heart to work as an efficient

pump• Systolic heart failure - Poor contraction• Diastolic heart failure - Poor relaxation

• Can be due to a number of causes• Coronary artery disease• Viral infections• Pregnancy• Hypertension• Diabetes• Congenital heart disease• Drugs - alcohol, cocaine• Idiopathic - No cause identified

How Common Is It?• A 2013 update from the American Heart Association (AHA)

estimated that there were 5.1 million people with HF in the United States in 2006.

• Heart failure costs the nation an estimated $30.7 billion each year in USA

• There are an estimated 23 million people with HF worldwide

• Reliable estimates of heart failure are lacking in India because of the absence of a surveillance programme to track incidence, prevalence, outcomes and key causes of heart failure.

How Common Is It?• The annual incidence of HF for patients with CHD ranges from 0.4%

to 2.3% per year

• This suggests that 1.2 – 6.9 lakh Indians could develop symptomatic HF due to CHD every year

Definition Of Heart Failure

Classification of Heart Failure

Symptoms

Management - Investigations

Management - Investigations

Management - Investigations

Investigations - Summary

Investigations - Summary

Treatment - Stage A

Treatment - Stage B

Treatment - Stage B

Treatment - Stage B

Treatment - Stage C

Treatment - Stage C

Treatment - Stage C HFrEF

Treatment - Stage C HFrEF

Treatment - Stage C HFrEF

Treatment - Stage C HFrEF• Digoxin may be used - Can reduce hospitalisation

• Nutritional supplements are not recommended

• Hormonal therapies other than to correct any deficiencies are not recommended

• Avoid drugs such as certain painkillers, TZDs (glitazones) and certain antiarrhythmics

• Omega 3 PUFA supplements may be of some benefit

Lifestyle• Not much advice can be given that will alter long term prognosis.• Patient understanding of the condition is essential

• Give advice on drugs prescribed - benefits and side effects• Advice on device management - when to notify their doctor

• Avoid excessive fluid intake, follow advice of the doctor regarding this during summer or during illness.

• Stop smoking• Low salt diet• Maintain a healthy body weight• Avoid alcohol completely if possible• Exercise to a point where it becomes only mildly difficult to breathe

Lifestyle• Get a good night’s rest - sleep at 45 degrees

• Sexual activity is OK, provided there are no undue symptoms• Medication for erectile dysfunction may be needed.

Information websiteshttp://www.heartfailurematters.org

http://www.heartsense.in

Device Therapy - ICD

Device Therapy - CRT

End of Life Care

End of Life Care

Challenges• Challenges lie at the root causes of heart failure

• Regulations to limit the salt content of foods have a great potential to reduce the burden of hypertension, CHD and subsequent incidence of HF across a wide spectrum of the population

• Tobacco taxation that includes beedis and smokeless tobacco provides the most powerful tool to immediately reduce consumption of tobacco and helps decrease the overall CVD burden, including HF.

Challenges• Strict lifestyle measures need to be adopted – Patient

compliance is a problem• Delayed presentation many times – higher mortality• Better survival with earlier treatment means increased

rehospitalisation rate – nearly 6 fold increase compared to those who are not hospitalised.

• Changing profile of patients – higher number of co-morbid factors

• Poor follow up care – lack of a structured community heart failure rehab program

Solution?• Better patient education – We seem to really lacking with respect to

this.

• Using serial biomarkers – May not be very practical for cost reasons though studies have shown reduced rehospitalisation rates as treatment can be started early

• Telemedicine – Regularly call the patient, text messaging, apps etc.

• But who will follow up??

Diabetes Mellitus

What Is Diabetes?‘High blood sugar’

Absent insulin secretion - Type I diabetes

Reduced insulin secretion

Reduced sensitivity of cells to insulinType II diabetes

DEFINITIONFasting > 126 mg/dL

PPBG > 200 mg/dL

HbA1c > 6.5%

In patients with symptoms of high

blood sugar, a random > 200 mg/dL

Scope of the Problem• The prevalence of diabetes increased tenfold, from 1.2% to 12.1%,

between 1971 and 2000.

• It is estimated that 61.3 million people aged 20-79 years live with diabetes in India (2011 estimates). This number is expected to increase to 101.2 million by 2030.

• 77.2 million people in India are said to have pre-diabetes.

• Indians get diabetes on average 10 years earlier than their Western counterparts.

Scope of the Problem• Lifestyle changes have lead to decreased physical activity,

increased consumption of fat, sugar and calories, and higher stress levels, affecting insulin sensitivity and obesity.

• The annual cost for India due to diabetes was about $38 billion in 2011.

• According to the WHO, if one adult in a low-income family has diabetes, “as much as 25% of family income may be devoted to diabetes care.”

• According to the World Economic Forum, cardiovascular disease, cancer, chronic respiratory disease, diabetes and mental health conditions will cost India 126 trillion rupees between 2012 and 2030.

Symptoms

Testing - Who To Test?• Test all adults who are overweight (BMI ≥ 25) and have additional

risk factors• Physical inactivity• First degree relatives with diabetes• Women with history of gestational diabetes• Those with hypertension and high cholesterol• Polycystic ovarian syndrome• Previous A1c testing ≥ 5.7%

• Begin testing after age 45 years• If normal, then repeat every 3 years at least (or more frequently)

Testing - What To Test?• Fasting blood glucose - Checked after a minimum of 8 hours

fasting• Postprandial blood glucose - Checked 2 hours after a meal or

after a 75 gm glucose load• Hemoglobin A1c - Checked at any time• Check kidney function including ultrasound abdomen• Eye Check Up• Nerve conduction studies• Cardiovascular examination and testing if needed

Treatment• Start with lifestyle changes - 150 min exercise/wk, weight loss of >

5%• Different classes of drugs with different effects on blood glucose• Stepwise approach is followed• When choosing glucose-lowering medications for overweight or

obese patients with type 2 diabetes, consider their effect on weight.• Metformin, if not contraindicated and if tolerated, is the preferred

initial pharmacological agent for type 2 diabetes.• Consider initiating insulin therapy (with or without additional

agents) in patients with newly diagnosed type 2 diabetes and markedly symptomatic and/or elevated blood glucose levels or A1C.

Treatment

Treatment

Prevention• Patients with prediabetes should be referred to an intensive diet and

physical activity behavioural counselling program • Targeting a loss of 7% of body weight and should increase their

moderate-intensity physical activity (such as brisk walking) to at least 150 min/week.

• Follow-up counselling and maintenance programs should be offered for long term success in preventing diabetes.

• Metformin therapy for prevention of type 2 diabetes should be considered in those with prediabetes, especially in those with BMI ≥ 35 kg/m2, those aged ≥ 60 years, and women with prior gestational diabetes mellitus.

Prevention• Screening for and treatment of modifiable risk factors for

cardiovascular disease is suggested.

• Diabetes self-management education and support programs are appropriate venues for people with prediabetes to receive education and support to develop and maintain behaviours that can prevent or delay the onset of diabetes.

• Technology-assisted tools including Internet-based social networks, distance learning, DVD-based content, and mobile applications can be useful elements of effective lifestyle modification to prevent diabetes.

Diet• Low fat intake - The quality of

fat consumed is more important than the quantity (e.g.: Mediterranean diets).

• Eat complex carbohydrates - Whole grain

• Nuts and berries are great!• Dairy products and red meat to

a minimum

Exercise• Moderate exercise, such as brisk walking or other

activities of equivalent intensity, has been also observed to improve insulin sensitivity and reduce abdominal fat content in children and young adults

• 150 min/week of moderate-intensity exercise and showed beneficial effect on glycaemia in those with prediabetes

• Both resistance training and endurance exercise appear to have beneficial effects on waist circumference, insulin sensitivity, and thus diabetes risk

Yoga• Regular practice of yoga can help

reduce levels of stress, enhance mobility, lower blood pressure and improve overall wellbeing

• Reduces weight• Long-term/more intensive yoga practice could have beneficial health

consequences by altering leptin and adiponectin• Yoga offers a promising lifestyle intervention for decreasing weight-

related type 2 diabetes risk factors and potentially increasing psychological well-being

Eyes, Feet and Nerves• Optimizing glycemic control, blood pressure, and serum lipid control

is key to reducing the risk for and slowing the progression of diabetic retinopathy

• Achieving glycemic control can effectively prevent or delay diabetic peripheral neuropathy and may slow their progression in T2DM

• All patients with T2DM should have a foot examination annually using 10-g monofilament testing plus pinprick sensation, vibration perception, or ankle reflexes

Technology Assistance• Mobile applications for weight loss and diabetes prevention have

been validated for their ability to reduce A1C in the setting of prediabetes

• The CDC’s Diabetes Prevention Recognition Program (DPRP) http://www.cdc.gov/diabetesprevention/recognition/index.htm) has begun to certify electronic and mobile health-based modalities as effective vehicles

Apps

Calorie Counter

Pro

BG Monitor

Diabetes

Diabetes In

Check

Diabetes Connect

Glooko

mySugr Diabetes Logbook

Self Monitoring

Diabetes and Heart Failure• Diabetic Cardiomyopathy• Every 1% increase in HbA1c leads to an 8% increase in HF• Requires the absence of CAD and the presence of LVH, fibrosis and

decreased compliance • Cause is likely multi-factorial but clearly related to hyperglycaemia,

hyperinsulinemia, enhance FFA utilization, and oxidative stress• Treatment involves strict sugar control with usual heart failure

treatment strategies• High mortality - 50% die within 5 years

Conclusion• Heart failure and diabetes are inter-related conditions that carry

significant morbidity and mortality together.

• Simple lifestyle measures can help prevent both conditions and reduce risk significantly

• Challenges remain in patient compliance and the following of medical advice.

• Rehabilitation and advisory programs could potentially reduce disease burden and improve outcomes.

THANK YOU!!!