Diabetes undertreated among patients with HF and reduced ejection fraction
medwireNews: Diabetes is common among patients who have heart failure with reduced ejection fraction (HFrEF) and both conditions together are undertreated despite being associated with a particularly high risk for hospitalization and death, US research suggests.
Findings from 4970 patients with chronic HF and a left ventricular ejection fraction of 40% or less who were enrolled in the Change the Management of Patients With HF (CHAMP-HF) registry between December 2015 and October 2017 revealed that 42% also had diabetes.
Those with both HF and diabetes were significantly more likely to die or experience HF hospitalization than those with HF alone during a median follow-up of 15 months, at a corresponding 30% versus 23%, independently of 11 pre-specified covariates (adjusted hazard ratio=1.35).
Yet this contemporary, real-world outpatient registry with participants from 152 US sites revealed that few of the patients were treated with appropriate target doses of guideline-directed HF therapies regardless of whether or not they had diabetes, with this true for a maximum of 27% of patients across all HF drug classes.
In addition, the use of antihyperglycemic therapies known to improve cardiovascular outcomes – including sodium-glucose cotransporter (SGLT)2 inhibitors – was less than 5%, even among the highest-risk patients with established atherosclerotic cardiovascular disease or chronic kidney disease.
“Unfortunately, rates of use of HF and [diabetes] therapies remained relatively stagnant over time with few substantive therapeutic changes made in current practice,” the researchers note in the Journal of the American College of Cardiology: Heart Failure.
“Taken together, comorbid [diabetes] identifies a distinct high-risk subset of patients with chronic HFrEF and represents a key target population for optimization of existing antihyperglycemic and guideline-directed HF therapies.”
The participants had a median age of 68 years and 29% were women. Overall, 73.5% were White and 64% had coronary artery disease. The median glycated hemoglobin level was 7.2% (55 mmol/mol) among the 724 of 2085 patients with comorbid diabetes for whom data were available.
Patients with diabetes were on average significantly older, non-White, and had higher rates of established atherosclerotic cardiovascular disease and cardiovascular comorbid conditions than those without diabetes.
Most individuals with diabetes were taking one (46%) or two (23%) antihyperglycemic therapies, although a quarter (24%) were untreated with this type of medication.
Antiglycemic therapies among those being treated included: metformin (40%); insulin (33%); sulfonylureas (24%); dipeptidyl peptidase-4 inhibitors (10%); glucagon-like peptide-1 receptor agonists (4%); SGLT2 inhibitors (2%); and thiazolidinediones (2%).
At baseline, among patients with diabetes, HF drugs consisting of ACE inhibitor/angiotensin receptor blockers (ARBs), angiotensin receptor-neprilysin inhibitors (ARNIs), beta blockers, and mineralocorticoid receptor antagonists (MRAs) were taken at any dose by a corresponding 62%, 16%, 80%, and 33.5%, but target doses were only taken by a respective 12%, 1%, 23%, and 26%.
For patients without diabetes, the corresponding baseline use of any dose was 65%, 15%, 80%, and 37%, while target doses were only taken by 10%, 0.5%, 17.5%, and 27%, respectively.
Diabetes was associated with a greater use of ARNIs at baseline (adjusted odds ratio=1.22) but not other HF drug classes, after adjusting for key covariates.
After 1 year of observation, HF drug use among patients with diabetes fell for ACE inhibitors and ARBs from 62% to 58%, whereas that of ARNIs rose slightly from 16% to 23%, beta blockers from 80% to 83%, and MRAs from 33.5% to 37%.
Similarly limited changes in the use of these HF drugs were seen among patients without diabetes.
“Patients with HFrEF and [diabetes] face higher risk-adjusted HF hospitalization and mortality rates,” conclude Javed Butler (University of Mississippi Medical Center, Jackson) and colleagues.
“Despite this excess risk, these contemporary data describe major gaps in the use and target dose achievement of HF therapies and antihyperglycemic therapies.
“Incomplete guideline-directed medical therapy in this high-risk population represents an important target for quality improvement via multi-disciplinary care pathways.”
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