MD Conference Express AHA 2013 - (Page 38)
SELECTED UPDATES ON HEART FAILURE AND DIABETES
Managing Patients With Heart Failure
and Diabetes
Written by Maria Vinall
It is currently estimated that 5.1 million adults in the United States have heart failure (HF). By
the year 2030, this number is expected to increase by 25%. Over the last several decades, there
has also been a marked increase in the prevalence of diabetes [Centers for Disease Control and
Prevention. Available at http://www.cdc.gov/diabetes/statistics]. David Aguilar, MD, Baylor
College of Medicine, Houston, Texas, USA, discussed the relationship between and coexistence
of these two diseases.
Diabetes has long been known to amplify the risk for all forms of cardiovascular disease (CVD)
and when it develops in patients with HF, it is associated with increased mortality (Table 1) [Cubbon
RM et al. Diab Vasc Dis Res 2013; Martinez-Selles M et al. Eur J Heart Fail 2012; MacDonald MR et al.
Eur Heart J 2008; From AM et al. Am J Med 2006].
Table 1. Increased Mortality in Patients With HF and Diabetes Mellitus
Study
Adjusted Risk (95% CI)
Population-Based Studies
Olmstead County
RR, 1.33 (1.07-1.66)
United Kingdom
HR, 1.72 (1.29-2.28)
Clinical trials
MAGIC meta-analysis
HR, 1.41 (1.35-1.47)
CHARM
HFrEF
HR, 1.55 (1.38-1.74)
HFpEF
HR, 1.84 (1.51-2.26)
HFpEF=heart failure with preserved ejection fraction; HFrEF=heart failure with reduced ejection fraction.
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The increased mortality is even more striking among older individuals (aged ≥65 years) with
diabetes who go on to develop HF, with such patients having a mortality rate of 32.7/100 personyears compared with similarly aged diabetes patients without HF who have a mortality rate of
3.7/100 person-years (HR, 10.6; 95% CI, 10.4 to 10.9) [Bertoni AG et al. Diabetes Care 2004]. The
coexistence of diabetes and HF is also associated with an increased the rate of HF hospitalizations
[Shah AM et al. Eur J Heart Fail 2010; MacDonald MR et al. Eur Heart J 2008; Murcia AM et al. Arch
Intern Med 2004]. Future studies are needed to better understand the complex interaction of these
2 diseases and to develop treatment strategies to lower the health burden of HF and diabetes, noted
Dr. Aguilar.
Mary N. Walsh, MD, St. Vincent Heart Center, Indianapolis, Indiana, USA, discussed whether
the presence of diabetes should influence the management of patients with HF. Dr. Walsh
reinforced diabetes as a driver of HF adding that this is particularly true for women [Levy D et
al. JAMA 1996], even among those with no other risk factors and especially when the diabetes is
uncontrolled [Bibbins-Domingo K et al. Circulation 2004]. She then asked "Are diabetic patients HF
patients?" The answer is "Yes" according to the 2001 American College of Cardiology Foundation
(ACCF)/American Heart Association (AHA) guidelines for the evaluation and management of
chronic HF in adults [Hunt SA et al. J Am Coll Cardiol 2001] in which Stage A HF includes patients
with diabetes.
Whether and how diabetes influences short- and long-term outcomes among patients with
HF appears to be related to multiple factors including time, age, and sex. In one study of >116,000
patients (13% with diabetes), diabetes was a significant independent predictor of mortality at 1
year. The longer term risk was greatest in younger patients, particularly women. Diabetes was also a
significant independent predictor of readmission for HF, and again, the risk was greatest in younger
women [MacDonald M et al. Circ Heart Fail 2008].
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