Heart Failure in the Diabetic Patient

Maria Rosa Costanzo, M.D., F.A.C.C., F.A.H.A.Medical Director, Midwest Heart Specialists-Advocate Medical Group Heart Failure and Pulmonary Arterial Hypertension Programs

Medical Director, Edward Hospital Center for Advanced Heart FailureNaperville, Illinois, U.S.A.

“We demonstrate that young subjects with uncomplicated type 1 diabetes mellitus have impaired myocardial energetics irrespective of the duration of diabetes and that the impaired cardiac energetics status is independent of coronary microvascular function. We postulate that impairment of cardiac

energetics in these subjects primarily resultsfrom metabolic dysfunction rather than

microvascular impairment.”

Prevalence of DM in General Population with and without HF

Study/Date

No. of Subjects

Mean Age (yrs)

HF Prevalenc

e

Prevalence of DM with HF

Prevalence of DM without

HF

Rotterdam/01

5255 69 3.4% 17.5% 10.3%

Italy/97 1339 74 9.5% 29.6% 13.2%

Rekjavik/05

19381 - 3.8% 11.6% 3.4%

Olmstead /06

655 77 All with HF

13%-25% -

Prevalence of DM in Populations with and without LVSDStudy/Date

No. of Pts

Mean Age (yrs)

Definition of LVSD by EF

LVSD Pr1evalenc

e

Prevalence of

symptomatic LVSD

LVSD + DM

No LVSD, DM

ECHOES/01 3960 61 < 40 % 1.8% 1% 30% 3.8%

Copenhagen/03 764 66 ≤ 40% 4.7 67% 7.2% 5.9%

Poole/99 817 76 Visual Ass.

7.5% 21% 10% 6%

Glasgow/’97 1640 50 ≤ 35% 7.7% 23% 12.4% 2.5%

Vasteras/01 401 75 LWMI < 1.7%

6.8% 54% 22% 7%

Olmsted/03 1888 63 ≤ 50% 6.5% - 17% 6.8%

Copenhagen/05 188 69 < 45% 100% 100% 25.5% -

Prevalence of DM in Patients with HF in Clinical Trials

Clinical Trial Prevalence %

SOLVD 25.8MERIT-HF 24.5ELITE II 24.0Val-HeFT 25.4COPERNICUS 25.7OPTIME (hospitalized) 44.2VMAC (hospitalized) 47.0

DM and Mortality in HF: Clinical Trials Populations

Trial Treatment NO. of Pts. Mortality Risk of DM (HR)

SOLVD/91 Enalapril 6797 Overall 1.29HF due to CAD 1.37HF, no CAD 0.98

BEST/01 Bucindolol 2708 HF due to CAD 1.333HF, no CAD 0.98

DIG/97 Digoxin 6422 HF due to CAD 1.43HF, no CAD, not stated

DIAMOND-HF

Dofetilide 5491 Women 1.7Men 1.4

CHARM/03 Candesartan

7599 Insulin 1.80No Insulin 1.50

DM and Mortality in HF: Non Clinical Trials Populations

Location/Date No. of Patients Mortality Risk of DM (HR)

Rotterdam/01 5540 3.19

Framingham/93 9405 Women 1.70Men 0.99

Scotland/00 66547 Women 1.5Men 1.55

USA/99 170,239 Black 1.11White 1.22

USA/05 495 1.71

USA/05 554 No insulin 0.95Insulin 4.30

France/04 1246 HF due to CAD 1.54HF, no CAD 0.65

Olmstead/06 665 Overall 1.48HF due to CAD 1.11HF, no CAD 1.79

Italy/03 2843 1.44

Risk Factors For Congestive Heart Failure

Wilson PW. Am J Cardiol 1997;80:3-8

0 2 4 6 8 10

Hypertension

MyocardialInfarction

Angina Pectoris

Diabetes Mellitus

Left VentricularHypertrophy

Valvular Heart Disease

Relative Risk of CHF

WomenMen

Prediction of Heart Failure in Women with CAD

(Bibbins-Domingo K, et al. Circulation 2004;1424-1430)

Diabetes 3.1

Atrial Fib 2.9

CrCL 40-60 1.2

<40 2.3

SBP 120-139 1.6

140-159 2.1

<159 2.1

Smoking Past 1.2

Current 1.9

BMI 25-36 1.2

>36 1.9

LBBB 1.6

LVH 1.5

CABG 1.3

Adjusted HR for HF

02468

1012

HF

Hos

p. an

d/or

D

eath

< 7 7-<8 8-<9 9-<10 >10

Hemoglobin A1c %

Glycemic Control and HF Among Adult Pts. with Diabetes

allmenwomen

Iribarren C et al. Circulation 2001; 103: 2668

All: p = 0.0001Men: p = 0.0001Women: p = 0.009

Association between Elevated Blood Glucose and Outcome in Acute HF

in a Multinational Cohort of 6,212 Subjects

30-Day Mortality Rates According to Admission Blood Glucose

Risk of Death Associated with Elevated BG as a Function of the Presence or

Absence of DM on Admisssion

Mebaaza A et al. JACC 2013; 61:820-9

Association of HgbA1c with Risk of HF in 10 Studies with Maximally

adjusted Covariates

Association of HgbA1c with Risk of HF in Patients Subgroups

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

0.64

1.06

0.82

0.89

0.79

0.44

0.97

0.75

0.84

1.01

0.85

0.73

0.85 0.84

0

0.2

0.4

0.6

0.8

1

1.2

Log

Mor

talit

y R

elat

ive

Ris

k

CONSENSUS SAVE SMILE SOLVD-P SOLVD-T TRACE PooledEstimate

Effect of ACEI on Mortality from HF in Diabetic and Non-Diabetic patients

Non-Diabetic

Series2

Shekelle PG et al. JACC 2003; 41:1529-38

0.66

0.81

0.67 0.68

0.62

0.81

0.65

0.77

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

Log

Mor

taki

ty R

elat

ive

Ris

k

CIBIS-II COPERNICUS MERIT-HF Pooled Estimate

Effects of Beta-Blockers on Mortality from HF in Diabetic and Non-Diabetic Patients

Nnon-Diabetic

Diabetic

Shekelle PG et al. JACC 2003; 41:1529-38

ConclusionsHF and DM commonly coexistEach condition increases the likelihood of

developing the otherWhen HF and DM coexist in the same patient the

risk of morbidity and mortality increases markedlyScreening strategies are needed to identify DM

patients at high risk of HD and those with asymptomatic LVSD

A strong effort must be made to place patients with coexisting HF and DM on optimal HF therapy

Strategies for managing DM in patients with HF must be tested in prospective controlled clinical trials

Patients with both DM and HF require the care of a multidisciplinary team aware of the unique issues characterizing the two conditions.