2nd Annual Heart iN Diabetes Medical Conference:

Diabetes and Heart Failure: Converging Conditions Require Greater Attention

With Mikhail N. Kosiborod, MD, and Mark Kearney, MD 

EndocrineWeb sat down with Mikhail N. Kosiborod, MD, a cardiologist and professor of medicine at Saint Luke’s Mid America Heart Institute and the University of Missouri-Kansas City, a co-chair of the 2nd Annual Heart in Diabetes medical conference in Philadelphia, Pennsylvania to discuss the urgency behind a medical conference focused on two common, comorbid medical conditions—diabetes and cardiovascular disease.

The program addresses the intersection of diabetes and heart disease, which is presenting in a growing number of patients, said Dr. Kosiborod. At least 68% of  people diagnosed with diabetes who reach age 65 years will die due to cardiovascular disease.1

“Our approach to clinical management of patients with type 2 diabetes must factor in quality of life and data outcomes sooner, to consider the desirability of weight loss, and above all co-manage diabetes beyond hemoglobin A1c,” Dr. Kosiborod told EndocrineWeb.

Given that both diabetes and cardiovascular disease (CVD) raise the risk of heart failure (HF), and with half of all patients with HF dying within five years of the initial diagnosis,heart failure demands greater attention of endocrinologists and primary care physicians.2

Presentations on the intersection of HF and diabetes are highlighted given the demonstrated need to prompt earlier and more aggressive management of heart failure in patients with type 2 diabetes.2,3

Comorbid Diabetes and CVD Elevate Heart Failure Mortality

“We focused on the topic of heart failure in patients with diabetes because the occurrence of these two diseases concomitantly in the same patient is very common, and is on the rise. In fact, the number of patients with T2D is growing, the number of individuals with HF is growing, and the number of patients who have both conditions is increasing, as well,” said Dr. Kosiborod.

In addition, “we have contemporary data showing that only about a quarter of patients with heart failure have normal glucose tolerance, with the vast majority having either diabetes or prediabetes,” he said. “As important, evidence from both clinical trials and real-world studies indicate that heart failure has now become the most common CV event in patients with T2D.”2

“Above all, heart failure that develops in patients with type 2 diabetes is also associated with an ominous prognosis.”

“Treatment is complex since heart failure is not a homogenous condition, rather there is HF with reduced ejection fraction (HFrRF), meaning a decreased systolic performance of the left ventricle; and HF with preserved ejection fraction (HFpEF). Although the prognosis is poor in both, the pathophysiology and treatment of these two types of heart failure are quite different”.

It is encouraging that “there are promising developments and a great deal of clinical research ongoing in this area—so hopefully, this will produce effective new treatment interventions for patients with diabetes at risk of heart failure.

For now, the most important message for clinicians taking care of patients with T2D is that heart failure is common, frequently under-recognized and under-treated,” he said, “and, it’s really important to diagnose and appropriately treat HF in patients with diabetes. In addition, heart failure prevention is a critically important objective in this patient population because of the impact HF has on a patient’s prognosis”

Evolving Therapeutic Triage for HF and T2D 

In presenting a brief overview of the impact that the medications commonly prescribed for type 2 diabetes management within the context of chronic heart failure,2 Dr. Kosiborod offered the following:

  • While efficacious for glycemic control and atherosclerotic disease events, thiazolidinediones (TZDs, ie, pioglitazone) also promote weight gain and increase the risk of hospitalizations for HF.4
  • Based on data from the SAVOR-TIMI 53 trial,5 there is an increased risk of hospitalization for patients taking some DPP4i, such as saxagliptin – although the mechanism is unclear, and other compounds in the class have not been demonstrated to have a similar risk.
  • For GLP-1s, given the available data, this drug class appears neutral except in T2D patients with HFrEF for which there is an upward trend in composite CV events based on findings from the FIGHT trial.6
  • With regard to the SGLT2s, EMPA-Reg introduced the promise of a beneficial signal but the ongoing DECLARE trial, which is looking at CHF as an endpoint, which will confirm the efficacy of this drug class for heart failure prevention.7,8

“It’s time to reconsider the strategy of throwing more treatments at a patient with T2D in an attempt to improve glycemic control when none offer a reduction in heart failure risk,” he said, “for example, there are no randomized, clinical trials or real-world data on metformin, just observational findings, so at best there is no harm and the slight possibility of benefit.”

10/10:D Rule Assures Optimal Management of T2D and CHF

“It is a well-established fact that if you are over 40 years of age in the Western world, you have a least a 1 in 5 chance of developing heart failure,”1 said Mark Kearney, MD, the British Heart Foundation Professor of Cardiovascular and Diabetes Research and Institute Director, at the University of Leeds/UK, in speaking with EndocrineWeb following his presentation at the HiD conference.

 

“Heart failure manifests as fatigue, shortness of breath, and ultimately premature death,” making it a very important syndrome for endocrinologists to address when managing patients at risk for diabetes or with established T2D.3

Fortunately, there are well-established treatments for heart failure with reduced ejection fraction, particularly for patients with advanced (ischemic) heart failure that addresses 70% of these patients,” said Dr. Kearney. “The treatments include  ACE inhibitors and beta blockers, both of which are very effective.”9,10

“In one of our studies, we’ve shown that when a patient has both heart failure and T2D, patients with or without diabetes who were treated with the ACE inhibitor, ramipril, achieved a mortality risk reduction of 3%," he said, "but even more striking—patients with HFrEF benefited significantly more from treatment with the beta blocker, bisoprolol, such that patients with diabetes experienced a 9% reduction in risk of death for every 1 mg of the bisoprolol as compared to a 3% reduction for those without diabetes.”  These findings were attained irrespective of the level of diabetes control or treatment regime used.11

Thus, we’ve developed the 10:10:D rule.3 The recommended therapy for patients with T2D and ischemic CHF is 10 mg bisoprolol; 10 mg ramipril, and defibrillation.

Consider CHF in Patients with Diabetes to Treat Early

“It’s time to reconsider the strategy of throwing more antidiabetes treatments at a patient with type 2 diabetes in an attempt to improve glycemic control when none offer a reduction in heart failure risk,” Dr. Kosiborod said.

“For example, there are no randomized, clinical trials or real-world data on metformin, just observational findings, so at best there is no harm and the slight possibility of benefit.”

“In effect, there are some very promising developments and a great deal of in clinical research going on in this area but the most important message for now for any clinician taking care of patients with T2D is to know that heart failure is common, frequently under-recognized and under-treated,” he said,

“And, it’s really important to pay attention to both because of the prevalence and the impact that CHF has on a patient’s prognosis,” said Dr. Kosiborod.

Next Summary:
Hypertension in Diabetes: How Low to Go in Patients with Diabetes?
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