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Heart failure and diabetes mellitus


Overview

Heart failure: A major cardiovascular complication of diabetes mellitus

This review discusses the epidemiology, pathogenesis and clinical course of heart failure in patients with diabetes and describes therapeutic strategies for the treatment of heart failure in this population.

Summary points
  • Epidemiological studies indicate that a close association exists between diabetes and heart failure.
  • Heart failure with reduced ejection fraction and heart failure with preserved ejection fraction have distinctly different pathogeneses.
  • Many patients with diabetes have undiagnosed heart failure. The prognosis for patients with both diabetes and heart failure is poor and outcomes are worse than in those who only have one of the conditions. Higher levels of plasma glucose are associated with worse outcomes.
  • The treatment of heart failure in patients with diabetes is similar to that in the absence of diabetes. In addition, the impact of glycemic control and anti-hyperglycemic agents on cardiovascular outcomes must be considered.
  • In patients with diabetes and heart failure with reduced ejection fraction, the main goal of therapy is the reversal of the maladaptive effects of pathological activation of the sympathetic nervous system and the renin-angiotensin-aldosterone system.
  • The results of several clinical studies suggest that angiotensin receptor blockade may improve outcomes in patients with diabetes and heart failure with preserved ejection fraction.
  • Although some studies have shown that stricter glycemic control is associated with decreased risk of heart failure in patients with diabetes, others found no correlation.

Bahtiyar G, Gutterman D, Lebovitz H. Curr Diab Rep 2016; 16: 116. doi: 10.1007/s11892-016-0809-4

Clinical update: Cardiovascular disease in diabetes mellitus

This review summarizes the mechanisms of atherosclerotic cardiovascular disease (ACSVD) and heart failure in diabetes mellitus, strategies for management of these conditions in diabetes and special considerations for treatment of diabetes in patients with ASCVD or heart failure.

Summary points
  • Atherosclerotic cardiovascular disease (ACSVD) is the main cause of disability and mortality in patients with diabetes.
  • Multiple pathophysiologic factors contribute to the development of ACSVD in patients with diabetes, including hyperglycemia, insulin resistance and hyperinsulinemia, dyslipidemia, inflammation, oxidative stress, endothelial dysfunction, hypercoagulability and vascular calcification.
  • A complex risk-reduction program simultaneously addressing multiple factors has a greater chance of reducing the risk of ACSVD. Appropriate interventions may include lipid-lowering therapy, blood pressure control and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy, antithrombotic medications, lifestyle modifications, glycemic control and bariatric surgery, or some combination thereof.
  • Of the currently available glucose-lowering therapies, metformin and sodium-glucose cotransporter-2 inhibitors have been shown to improve some cardiovascular outcomes, while glucagon-like peptide 1 receptor agonists were generally neutral and dipeptidyl peptidase 4 inhibitors could increase the risk of heart failure.
  • Because most patients with diabetes are at some risk of developing ASCVD, lifestyle modifications are warranted. In patients with known ASCVD, treatment should be primarily focused on reducing cardiovascular risk.
  • Diabetic cardiomyopathy commonly presents as heart failure with preserved ejection fraction and, less frequently, reduced ejection fraction.
  • Pathophysiological mechanisms underlying the development of heart failure in patients with diabetes are complex and may include metabolic abnormalities, functional alterations, structural changes in the myocardium and autonomic neuropathy.
  • In the management of patients with concurrent diabetes and heart failure, the effects of glucose-lowering therapies on cardiovascular outcomes should be taken into consideration.

Low Wang CC et al. Circulation. 2016; 133:2459-502. DOI:10.1161/CIRCULATIONAHA.116.022194

Contents

Back to collection

  1. Overview
  2. Epidemiology
  3. Pathophysiological mechanisms of heart failure in diabetes
  4. Assessment and screening
  5. Glycemic management and heart failure outcomes