chapter 28 jonathan g. howlett , john c. macfadyen
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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
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