Monday, May 29, 2023
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Health Sciences Clinical Professor of Family Medicine
University of California, Irvine School of Medicine
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This activity is intended for primary care physicians, endocrinologists, cardiologists, nurses, physician assistants, pharmacists, and other members of the healthcare team who treat and manage adults with diabetes mellitus.
The goal of this activity is for learners to be better able to diagnose and manage heart failure among patients with diabetes mellitus.
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Health Sciences Clinical Professor of Family Medicine
University of California, Irvine School of Medicine
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Heart failure may not be the first cardiovascular complication of diabetes to come to mind, but the authors of the current consensus statement note that it is the most common initial presentation of cardiovascular disease in modern studies. Diabetes is associated with 2- to 4-fold increase in the risk for heart failure, and the prevalence of heart failure in diabetes is currently 22% and is rising. This is an even bigger public health problem considering that the global prevalence of diabetes has risen approximately 30% in the past decade.
The relationship between heart failure and diabetes is bidirectional. About 60% of patients with heart failure have evidence of insulin resistance. The risk for heart failure in diabetes appears particularly high for Black, Hispanic, and Native American adults. The current consensus guideline provides recommendations regarding the diagnosis and treatment of heart failure in the setting of diabetes.
All US patients with diabetes should undergo annual biomarker testing to allow for early diagnosis of progressive but presymptomatic heart failure, and treatment with an agent from the sodium-glucose cotransporter 2 (SGLT2) inhibitor class should expand among such patients to include everyone with stage B heart failure ("pre-heart failure") or more advanced stages, according to a recommendation from an American Diabetes Association consensus report published June 1 in Diabetes Care.
The report notes that until now, "implementation of available strategies to detect asymptomatic [heart failure in patients with diabetes] has been suboptimal." The remedy for this is that, "among individuals with diabetes, measurement of a natriuretic peptide or high-sensitivity cardiac troponin is recommended on at least a yearly basis to identify the earliest [heart failure] stages and implement strategies to prevent transition to symptomatic [heart failure]."
Written by a 10-member panel chaired by Rodica Pop-Busui, MD, PhD, and endorsed by the American College of Cardiology, the document also set thresholds for levels of these biomarkers that are diagnostic for a more advanced stage (stage B) of heart failure in patients with diabetes but without heart failure symptoms:
'Inexpensive' Biomarker Testing
"Addition of relatively inexpensive biomarker testing as part of the standard of care may help to refine [heart failure] risk prediction in individuals with diabetes," the report says.
"Substantial data [indicate] the ability of these biomarkers to identify those in stage A or B [heart failure] at highest risk of progressing to symptomatic [heart failure] or death," which is useful because "the risk in such individuals may be lowered through targeted intervention or multidisciplinary care."
It is "impossible to understate the importance of early recognition of" heart failure, the authors declare. However, the report also cautions that, "using biomarkers to identify and in turn reduce risk for [heart failure] should always be done within the context of a thoughtful clinical evaluation, supported by all information available."
The report, written during March 2021 to March 2022, cites the high prevalence and increasing incidence of heart failure in patients with diabetes as the rationale for the new recommendations.
For a person with diabetes who receives a heart failure diagnosis, the report details several management steps, starting with an evaluation for obstructive coronary artery disease, given the strong link between diabetes and atherosclerotic cardiovascular disease.
It highlights the importance of interventions that involve nutrition, smoking avoidance, minimized alcohol intake, exercise, weight loss, and relevant social determinants of health, but focuses in greater detail on a range of pharmacologic interventions. These include treatment of hypertension for people with early-stage heart failure with an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker, a thiazide-type diuretic, and a mineralocorticoid receptor antagonist, such as spironolactone or the newer, nonsteroidal agent finerenone for patients with diabetic kidney disease.
Dr Busui, from the Division of Metabolism, Endocrinology, and Diabetes at the University of Michigan, Ann Arbor, and colleagues cite recent recommendations for using guidelines-directed medical therapy to treat patients with more advanced, symptomatic stages of heart failure, including heart failure with reduced or with preserved ejection fraction.
'Prioritize' the SGLT2-Inhibitor Class
The consensus report also summarizes the roles for agents in the various classes of antidiabetes drugs now available, with particular emphasis on the role for the sodium-glucose cotransporter 2 (SGLT2)-inhibitor class.
SGLT2 inhibitors "are recommended for all individuals" with diabetes and heart failure, it says. "This consensus recommends prioritizing the use of [SGLT2 inhibitors] in individuals with stage B [heart failure] and that [SGLT2 inhibitors are] an expected element of care in all individuals with diabetes and symptomatic" heart failure.
Other agents for glycemic control that receive endorsement from the report are those in the glucagonlike peptide 1 receptor agonist class. "Despite the lack of conclusive evidence of direct [heart failure] risk reduction" with this class, it gets a "should be considered" designation, based on its positive effects on weight loss, blood pressure, and atherothrombotic disease.
Similar acknowledgment of potential benefit in a "should be considered" role goes to metformin. However, the report turned a thumb down for both the class of dipeptidyl peptidase 4 inhibitors and the thiazolidinedione class and said that agents from the insulin and sulfonylurea classes should be used "judiciously."
The report did not identify any commercial funding. Several of the writing committee members listed personal commercial disclosures.
Diabetes Care. Published online June 1, 2022.[1]
