Heart failure: an underappreciated complication of diabetes

Recently, the American Diabetes Association (ADA) released a report entitled Heart Failure: An Underappreciated Complication of Diabetes ” expert consensus report, put forward clinical management recommendations on the management of heart failure (HF) in diabetic patients, and “two charts and one table” grasp the core content.

epidemic status — Serious complications of diabetes that have not received enough attention

Consensus states that HF ​​has been recognized as a common complication of diabetes , the prevalence of HF in diabetic patients is as high as 22% and the incidence is still rising. HF is a major cardiovascular complication in diabetic patients and may also be the first manifestation of cardiovascular disease, and can occur in diabetic patients even in the absence of hypertension, coronary heart disease, or valvular heart disease.

Heart Failure Prevention: Focus on ‘Modifiable Risk Factors’

Risk factors for HF in diabetic patients include duration of diabetes, poor glycemic control, uncontrolled hypertension, hyperlipidemia, higher BMI, microalbuminuria, renal function Insufficiency, ischemic heart disease and peripheral arterial disease. The consensus pointed out that although most of them are “modifiable risk factors”, the overall control rate is still poor, emphasizing the importance of careful evaluation and intervention of each risk factor in clinical practice.

Clinical diagnosis: 4 stages of heart failure

The consensus pointed out that clinicians should obtain the comprehensive medical history of patients as much as possible, and carefully screen the symptoms and signs of HF. These are the keys to early detection and clinical diagnosis of HF. Physical examination, laboratory evaluation and imaging, biomarker testing, non-invasive cardiac imaging findings to make judgments. 1. What are the possible symptoms of heart failure? Usually, common symptoms of HF include exertional dyspnea, fatigue and edema. The symptoms of HFpEF patients are similar to those of HFrEF patients. CXR, chest x-ray; HFpEF, heart failure with preserved ejection fraction; hs-TNcEF, heart failure with reduced ejection fraction Troponin; JVD, jugular vein dilation; LV, left ventricle. Figure 1 Screening and diagnostic methods for different HF stages2. Heart failure is divided into 4 stages

Heart failure stage A: with risk factors for HF

Defined as those with risk factors for HF but People with no obvious symptoms. Anyone diagnosed with diabetes who has the risk factors shown in Figure 1 falls into stage A HF.

Heart failure stage B: abnormal test results

Many people with diabetes are in this stage , early diagnosis of HF means that treatment can be given as early as possible to prevent adverse outcomes. Stage B is defined as asymptomatic but with at least one of the following features: 1) evidence of structural heart disease; 2) abnormal cardiac function; or3) Elevated levels of natriuretic peptide or cardiac troponin. It is recommended to measure natriuretic peptide or high-sensitivity cardiac troponin at least annually to determine the presence of stage B HF. BNP (50 pg/mL), NT-proBNP (125 pg/mL), or high-sensitivity cardiac troponin (>99% upper reference limit) can be used as diagnostic cutoffs. The identification of abnormal markers of natriuretic peptides or high-sensitivity cardiac troponin should be part of an individualized management decision plan.

Heart failure stage C/D: the onset of significant clinical symptoms

defined as a previous Patients with past or current HF symptoms. In conclusion, regarding the diagnosis and staging of HF:

➤ Clinicians should grasp the possible clinical symptoms, signs and physical examination results of patients with HF;

➤ Recommended laboratory evaluations in patients with HF include natriuretic peptides, complete blood count, urinalysis, serum electrolytes, blood urea nitrogen, serum creatinine, glucose, fasting lipids, liver function, and TSH . In addition, chest X-ray and 12-lead ECG are recommended;

➤ Imaging evaluation, such as transthoracic echocardiography, may provide additional information for patients with suspected or confirmed HF

➤ When HF is diagnosed in diabetic patients, clinicians should assess the possibility of obstructive CAD.

Treatment strategy: different stages, each with its own emphasis

3width /img>Figure 2 Multidisciplinary individualized diagnosis and treatment strategies for diabetes with different HF stages1. Lifestyle and nutrition therapy span>Consensus points out that lifestyle and nutritional therapy are important components of HF management, and recommends:

➤Minimize alcohol intake as much as possible, avoid smoking, and monitor serum potassium regularly;< /span>

➤ Regular exercise, exercise mode should be individualized;

➤ Weight loss is recommended, which can improve cardiometabolic risk factors. and may reduce the risk of HF;

➤Nutrition therapy strategies should be individualized based on caloric needs, food preferences in individual and cultural contexts, the presence or absence of overweight or obesity, and comorbidities. The intake of saturated fat should be reduced, the intake of trans fat should be avoided, and the intake of high-energy-density foods (<125 kcal/100g) should be reduced; it is recommended to appropriately increase vegetables, fruits and whole grains, poultry, fish, and low-fat dairy products. Intake of products, legumes, non-tropical vegetable oils and nuts, a DASH or Mediterranean diet is recommended. 2. Drug therapy

for patients with heart failure stage A and B

The treatment principle is “improving risk factors and stabilizing structural heart disease”. Effective management of known risk factors, including hypertension, diabetes, obesity, dyslipidemia, and atherosclerotic disease, reduces the risk of progression to overt HF. With effective treatment, stage B HF can be stable for many years. Management points:

➤ACEI and ARB are the drugs of choice for the treatment of hypertension in patients with stage A and B T1DM or T2DM, especially in the presence of proteinuria and/or CAD;

➤Studies show that thiazide diuretics or ACEIs are more effective than calcium channel blockers in preventing symptomatic HF, and they are recommended for diabetic patients with hypertension;

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➤In asymptomatic HF patients with diabetes and DKD, the use of nonsteroidal MRA feneridone reduces DKD progression and reduces the risk of HF events;< /p>➤ Careful monitoring of serum potassium levels is required when using MRA and other RAAS blockers.

Treatment points for HFrEF patients with stage C and D heart failure


➤ Drug recommendations in patients with diabetes and HFrEF are similar to those in non-diabetic patients, including ARNI, ACEI or ARB, evidence-based beta-blockers, MRA and SGLT2 inhibitor;

➤Sacubitril/valsartan is the first-line treatment drug for diabetic patients with HFrEF, which is superior to ACEI or ARB. Treatment points for HFpEF:

➤ In patients with HFpEF, consider spironolactone or sacubitril/ Valsartan therapy;

➤In patients with HFpEF, SGLT-2 inhibitor therapy has been shown to reduce the risk of hospitalization for HF.

Hyperlipidemia Management

For High Risk/Confirmed HF Diabetic patients:

➤It is recommended to choose statin therapy according to the patient’s age and accompanying risk factors;

➤ Statins are recommended for all patients with diabetes over the age of 40;

➤ For younger populations (20-39 years), if there is other risk of ASCVD in addition to diabetes Statins are recommended;

➤The benefit of statins in elderly diabetic (>75 years old) patients is still unclear, but presumed to be beneficial.

Hyperglycemic Management

For Diabetes at High Risk for HF/Confirmed HF Patients:

➤Drug-lowering drugs have different effects on the risk of HF, and individualized cardiovascular risk factors should be carefully evaluated before selection;

< p>➤ SGLT2 inhibitors are recommended as a priority for patients with stage B HF, and SGLT2 inhibitors are the intended treatment for all diabetic patients with symptomatic HF (stages C and D, including patients with HFpEF); p>

➤If T2D patients at high risk of HF/diagnosed HF need additional glycemic control, GLP-1RA, metformin, or a combination of both, non-sulfonylureas should be preferred;

➤DPP-4 inhibitors or TZDs are not recommended for diabetic patients with stage B, C, and D HF;

➤if additional glycemic control can be increased with insulin therapy. Table 1 Drug therapy for hyperglycemia in patients with diabetes and heart failure

Yimaitong compiled by: Rodica Pop-Busui, James L. Januzzi, B. Dennis Green, Butalia, Bruemmer William B. Horton, Colette Knight, Moshe Levi, Neda Rasouli, Caroline R. Richardson; Heart Failure: An Underappreciated Complication of Diabetes. A Consensus Report of the American Diabetes Association. Diabetes Care 7 July 2022;45(7):1670– 1690. https://doi.org/10.2337/dci22-0014