Tuesday, March 28, 2023
Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™
ABIM Diplomates - maximum of 0.25 ABIM MOC points
Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)
Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)
Physician Assistant - 0.25 AAPA hour(s) of Category I credit
IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit
This activity is intended for diabetologists/endocrinologists, cardiologists, family medicine/primary care clinicians, internists, nurses, pharmacists, physician assistants, and other members of the health care team for patients with diabetes who may be at risk for heart failure (HF).
The goal of this activity is for learners to be better able to describe the association of diabetes duration and glycemic control with HF risk, according to an analysis of data from UK Biobank, a large-scale, population-based prospective cohort study including detailed information on diabetes-related factors.
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CME / ABIM MOC / CE Released: 3/17/2023
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Worldwide prevalence of heart failure (HF), the end-stage clinical manifestation of heart disease, is ≥ 26 million. One-year mortality after HF diagnosis approaches 30%.
“Diabetic cardiomyopathy” refers to myocardial dysfunction present with diabetes, independent of coronary artery, hypertrophy, and valvular heart disease. Emerging evidence suggests diabetes as a risk factor for HF, with diabetes duration and glycemic control both affecting myocardial structure and function.
The longer people had diabetes, the greater their rate of incident HF, suggests a recently published review[1] of prospectively collected observational data from nearly 24,000 people with diabetes in the UK Biobank.[2]
The findings "add to the growing body of evidence suggesting that duration of diabetes is an important and independent determinant of heart failure among patients with diabetes," commented Justin B. Echouffo-Tcheugui, MD, PhD, in an accompanying editorial.[3]
Collectively, the new UK Biobank results and prior findings, "provide additional persuasive evidence that the link between duration of diabetes and [HF] is real," although the physiological mechanisms behind the relationship remain incompletely understood, wrote Echouffo-Tcheugui, an endocrinologist at Johns Hopkins Medicine in Baltimore, Maryland.
"The duration of diabetes may reflect cumulative effects of various adverse processes in the setting of diabetes" that result in "intrinsic myocardial lesions," he suggested.
These adverse processes might include hyperglycemia and also glucotoxicity, lipotoxicity, hyperinsulinemia, advanced glycosylation end products, oxidative stress, mitochondrial dysfunction, cardiac autonomic neuropathy, and coronary microvascular dysfunction. Long-duration diabetes may also contribute to declining kidney function, which can further worsen HF risk.
The upshot is that clinicians may need to consider more systematically the duration of diabetes when assessing people with diabetes for HF.
Existing risk-assessment tools for predicting HF in people with diabetes "have not always accounted for diabetes duration," Echouffo-Tcheugui noted.
Intensify Heart Failure Detection With Longer Diabetes Duration"Active [HF] detection should perhaps be intensified with increased diabetes duration," Echouffo-Tcheugui suggested in his editorial.
He noted that a 2022 consensus report by the American Diabetes Association[4] recommends clinicians measure natriuretic peptide or high-sensitivity cardiac troponin in all persons with diabetes "on at least a yearly basis to identify the earliest [HF] stages and implement strategies to prevent transition to symptomatic [HF]."
The UK Biobank study[1] was run by investigators primarily based in China and included data from 23,754 people with type 1 or type 2 diabetes and no HF at baseline. The prospectively collected data allowed for a median follow-up of 11.7 years, during which time 2081 people developed incident HF.
In an analysis that divided participants into 4 categories of diabetes duration (< 5, 5-9, 10-14, and ≥ 15 years) and adjusted for potential confounders, HF incidence showed a significant 32% increased incidence among persons with diabetes for ≥ 15 years compared with persons with diabetes for < 5 years. Persons with a diabetes duration of 5 to 14 years showed a trend toward having more incident HF compared with persons with diabetes for < 5 years, but the difference was not significant.
An adjusted analysis also showed poor glycemic control at baseline (glycated hemoglobin [HbA1c] ≥ 8%) significantly linked with a 46% increased incidence of HF compared with persons with baseline A1c < 7%.
Additive Effect?When the authors analyzed the effect of both these variables, they saw a roughly additive effect.
Patients with diabetes for at least 15 years and a baseline HbA1c ≤ 8% had a 98% increased incidence of HF compared with persons who had diabetes for fewer than 5 years and a baseline HbA1c < 7%, after adjustment. This association was independent of age, sex, and race.
These findings "highlight the paramount role of the duration of diabetes and its interaction with glycemic control in the development of [HF]," the authors concluded.
"Long duration of diabetes and poor glycemic control may result in structural and functional changes in the myocardium, which is likely to underlie the pathogenesis of [HF] among individuals with diabetes," they added.
In his editorial,[3] Echouffo-Tcheugui lauded the report for its "robust" analyses that included a large sample and accounted for key confounders, such as glycemic control; however, he also cited 8 "shortcomings" of the study, including its sole reliance on HbA1c levels to identify diabetes, a likely underestimation of diabetes duration, the lumping together of people with type 1 and type 2 diabetes, and lack of a subanalysis of incident HF in persons with preserved or reduced left ventricular ejection fraction.
Among prior reports of evidence also suggesting an effect of diabetes duration on incident HF, Echouffo-Tcheugui cited a study he led, published in 2021,[5] that analyzed prospective, longitudinal, observational data from 9734 adults enrolled in the Atherosclerosis Risk in Communities study.[6] The results showed that, compared with persons without diabetes, the incidence of HF rose with longer diabetes duration, with the highest risk among persons with diabetes for at least 15 years, who had a 2.8-fold increase in HF vs the reference group. Each 5-year increase in diabetes duration was associated with a significant 17% relative increase in HF incidence.
The study received no commercial funding. The authors and editorialist have reported no relevant financial relationships.
