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CME / ABIM MOC / CE

Is Diabetes Duration Linked to Heart Failure?

  • Authors: News Author: Mitchel L. Zoler, PhD; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 3/17/2023
  • Valid for credit through: 3/17/2024, 11:59 PM EST
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  • Credits Available

    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

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

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.

Upon completion of this activity, participants will:

  • Describe the association of diabetes duration and glycemic control with HF risk, according to an analysis of data from UK Biobank
  • Identify clinical implications of the association of diabetes duration and glycemic control with HF risk, according to an analysis of data from UK Biobank
  • Outline implications for the healthcare team


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All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.


News Author

  • Mitchel L. Zoler, PhD

    Freelance writer, Medscape

    Disclosures

    Mitchel L. Zoler, PhD, has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has no relevant financial relationships.

Editor/Nurse Planner

  • Leigh Schmidt, MSN, RN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Leigh Schmidt, MSN, RN, CNE, CHCP, has no relevant financial relationships.

Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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In support of improving patient care, Medscape, LLC is jointly accredited with commendation by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

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This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

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    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

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    Medscape, LLC has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 0.25 AAPA Category 1 CME credits. Approval is valid until 3/17/2024. PAs should only claim credit commensurate with the extent of their participation.

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CME / ABIM MOC / CE

Is Diabetes Duration Linked to Heart Failure?

Authors: News Author: Mitchel L. Zoler, PhD; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 3/17/2023

Valid for credit through: 3/17/2024, 11:59 PM EST

processing....

Clinical Context

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.

Study Synopsis and Perspective

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.

Study Highlights

  • The study sample comprised 23,754 individuals with diabetes but without HF during baseline recruitment of UK Biobank.
  • Researchers examined associations of self-reported diabetes duration and HbA1c as markers of glycemic control with incident HF with multivariate Cox models adjusting for traditional risk factors, including age, sex, and race.
  • During follow-up (median, 11.7 years), investigators identified 2081 incident HF cases.
  • Diabetes duration and HbA1c levels both were positively associated with HF risk in a dose-response manner (P trend <. 001 for each), after multivariable adjustment.
  • Hazard ratios for diabetes durations of 5 to < 10, 10 to < 15, and ≥ 15 years were 1.09 (95% CI: 0.97, 1.23), 1.13 (95% CI: 0.97, 1.3), and 1.32 (95% CI: 1.15, 1.53), respectively (vs < 5 years).
  • Hazard ratios for HbA1c 7% to < 7.5%, 7.5% to < 8%, and ≥ 8% were 1.15 (95% CI: 1.02, 1.31), 1.07 (95% CI: 0.91, 1.26), and 1.46 (95% CI: 1.3, 1.65), respectively (vs < 7%).
  • Risk for HF was particularly high in persons with longest diabetes duration (≥ 15 years) and poorer glycemic control (HbA1c ≥ 8.%; P interaction = .026), with 98% increased HF incidence vs persons with diabetes duration < 5 years and baseline HbA1c < 7%, after adjustment.
  • The statistically multiplicative joint association between diabetes duration and glycemic control on HF risk occurred regardless of age, sex, or race and persisted after excluding participants with undiagnosed diabetes, type 1 diabetes, or persons with non-HF deaths during follow-up.
  • Diabetes duration and HbA1c levels significantly, but modestly, improved the prediction of long-term HF risk beyond traditional HF risk factors.
  • The investigators concluded that HF risk among individuals with diabetes increases with longer diabetes duration and increasing HbA1c levels, which may cause myocardial structural and functional changes likely to underlie the pathogenesis of HF among people with diabetes.
  • If considered in clinical practices and policy making, the findings may help inform individualized HF prevention in patients with diabetes.
  • Compared with the traditional prediction model among individuals with diabetes, diabetes duration and HbA1c levels may also improve prediction accuracy for HF.
  • An accompanying editorial noted that diabetes duration may reflect cumulative effects of various adverse diabetes-related processes causing myocardial damage.
  • Such processes may include hyperglycemia, glucotoxicity, lipotoxicity, hyperinsulinemia, advanced glycosylation end products, oxidative stress, mitochondrial dysfunction, cardiac autonomic neuropathy, and coronary microvascular dysfunction.
  • Longer duration diabetes may also worsen declining kidney function, in turn, increasing HF risk.
  • When evaluating HF risk, clinicians may need to consider diabetes duration more systematically, as most current HF risk-assessment tools do not include it, and they should be aware of particularly increased HF risk in patients with both poor glycemic control and long-standing diabetes.
  • Such patients may particularly benefit from more intensive treatments to prevent adverse outcomes including HF.
  • A 2022 ADA consensus report recommended clinicians measure natriuretic peptide or high-sensitivity cardiac troponin at least annually in all people with diabetes to identify HF at the earliest stages and begin interventions to prevent transition to symptomatic HF.
  • Study limitations include likely underestimation of diabetes duration because of sole reliance on HbA1c to identify diabetes; possible lack of generalizability to races other than European White; combining type 1 and type 2 diabetes; and lack of analysis subdividing incident HF cases into persons with preserved vs reduced left ventricular ejection fractions.
  • Further studies are needed in more diverse groups.

Clinical Implications

  • Risk for HF among individuals with diabetes increases with longer diabetes duration and increasing HbA1c levels.
  • The findings may help inform individualized HF prevention in patients with diabetes.
  • Implications for the Healthcare Team: When evaluating HF risk, clinicians may need to consider diabetes duration more systematically, as most current HF risk-assessment tools do not include it.

 

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