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Diabetes and heart failure: liaisons dangereuses

ESC Congress Report

Heart failure is a common complication in patients with diabetes mellitus, and patients with failing hearts have an increased risk of developing diabetes. Whatever the underlying original condition, the combination is associated with a very serious prognosis. Thus, a session on this topic is important and timely.
Some key take home messages from the session:

  • The combination of diabetes and heart failure is common and carries a very unfavourable prognosis.
  • Some glucose lowering drugs may be deleterious for patients with heart disease.
  • Metformin not as risky as typically assumed.
  • Treatment of heart failure is essentially the same whether the patient has diabetes or not.

View the Slides from this session in ESC Congress 365

Read the ESC Practice Guidelines on Diabetes, Pre-Diabetes and Cardiovascular Diseases

Hector Ventura
(New Orleans, US) gave an overview of the epidemiology and mentioned several epidemiological studies, among them a 30-year follow-up of Framingham and UKPDS data. He said that a 1% increase of HbA1c increases the likelihood of developing heart failure by 15% in patients with type 2 diabetes. Additionally, there is an almost linear relation between the prevalence of heart failure with increasing HbA1c. Patients with heart failure have a high hospitalisation rate, an example from a US data base indicated at least 3% annually.

Rudolf De Boer (Groningen, NL) discussed the pathophysiology of the association between diabetes and heart failure. That the latter disease promotes diabetes may be explained by a combination of increased insulin resistance, fatigue with reduced physical activity and a reduced skeletal muscle mass decreasing the uptake of glucose. Moreover, there is an increased release of various cytokines influencing organs of importance for glucose handling, among them pancreas, the liver and kidneys. Finally, drugs used in heart failure treatment may provoke diabetes among them beta-blockers.
That diabetes promotes heart failure is related to co-morbidities; among them accelerated atherosclerosis and hypertension. A compromised renal function is also important and estimation of the glomerular filtration (GFR) may indeed provide more accurate prognostic information than the left ventricular ejection fraction in patients with diabetes and heart failure.
De Boer reminded us that one should always look for infections, especially in the urinary and respiratory tracts if the health of patients with diabetes and heart failure deteriorate. They are prone to infections and inflammatory activation is mutually cumbersome for the diabetes and the heart failure situations. Hyperglycemia drives infections and inflammation which is a burden for the failing heart.
The issue of a specific cardiomyopathy was briefly touched upon. It relates to deficiencies in the Ca2+ transportation in the myocardium, which impacts contractile function as well as relaxation. In animal diabetes models fibrosis accumulates and certain glucose- lowering drugs may counteract this process, among them metformin and DPP4 inhibitors. Accumulation of free fatty acids is another concern, since it causes an energetic imbalance. Glucose is more efficient as fuel in the failing heart and lack of possibility to utilise glucose may therefore by a burden, a problem that increases if the diabetes is less well controlled.

Michel Komajda (Paris, FR) addressed the question of whether heart failure patients with diabetes should be treated differently with regard to glucose lowering drugs (GLD), than those free from heart failure. He believes that glucose control is important but the impact of GLD may differ considerably and some of these drugs may indeed be disadvantageous.
Metformin is considered contraindicated in acute heart failure due to a certain risk for lactic acidosis. This risk is probably over exaggerated, and if kidney function is fairly well preserved, patients may continue this drug. Meta analysis favours the use of Metformin in heart failure patients, and there are claims that it decreases hospitalisations, although no formal trials have been conducted.
Sulfonylureas increases the risk for heart failure by 30-50% compared to Metformin in large registry based studies from among other areas the UK.
Insulin may also be a problem, although the recent ORIGIN trial did not give any indications that insulin provoked heart failure in people at high cardiovascular risk and diabetes. This may depend on the fact that the patients were treated to near normoglycaemia and insulin used without a reasonable glycaemic control may act differently and be disadvantageous.
TZDs cause water and sodium retention and are contraindicated in patients with overt or impending heart failure.
DPP4 inhibitors are under debate with regard to safety in patients with heart failure due to the unexpected finding that there were more patients with heart failure among those treated with such drugs in the SAVOR and EXAMINE trials. While no conclusions can be drawn yet, the drugs cannot be considered contraindicated, but use should be performed with caution.
In animal experiments GLP-1 agonists have been found cardioprotective.

Heart failure treatment in diabetes was the last issue addressed and Krishna Prasad (London, GB) summarised that currently there are no indications that drugs and other measures used in heart failure patients without diabetes is less (or more) efficient in those with diabetes. Since patients with diabetes are at a much higher risk, the therapeutic yield calculated is larger among such patients. It was underlined that for patients in sinus rhythm with increased heart rate, common in patients with diabetes, ivabradine has been shown of clear benefit.

In summary, this session contained a useful summary for the practising physician on how to manage heart failure in people with diabetes and vice versa.




Diabetes and heart failure: liaisons dangereuses

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.