Co-morbidities in AHF : Diabetes

DIABETES AS SIGNIFICANT DIABETES AS SIGNIFICANT COMORBIDITY IN ACUTE HEART COMORBIDITY IN ACUTE HEART

FAILURE FAILURE

Chair of Internal medicine, Belgrade University School of MedicineBoard member, Heart Failure Association of the ESCBoard member, Heart Failure Association of the ESC

Prof. Petar M. Seferović, MD, PhD, FESC, FESCCorresponding member of Serbian Academy of Sciences and Arts

President, Heart Failure Society of Serbia

Acute heart failureAcute heart failure and diabetes and diabetesClinical considerationsClinical considerations

Survival for combined outcome (HF death or hospitalization) by diabetic status

Aguilar et al. Am J Cardiol 2010;105:373–377

Clinical characteristics in AHF patients in different registries

Farmakis D, et al. Rev Esp Cardiol. 2015;68(3):245-8.

Seferovic et al. Clin Chem Lab Med 2014; 52(10): 1437–1446

AHF in diabetics vs non-diabetics: Clinical features and profiles

Comorbidities in acute heart Comorbidities in acute heart failure (failure (diabeticdiabetics vss vs non-diabetic non-diabetics)s)

CV comorbiditiesCV comorbidities in in diabetesdiabetesnn Chronic HFChronic HF (p (p<0.0001<0.0001))nn CADCAD (p (p<0.0001<0.0001))nn CardiomyopathyCardiomyopathy (p (p<0.0001<0.0001))nn Periferal vascular diseasePeriferal vascular disease (p (p<0.0001<0.0001))nn Obesity, dyslipidemiaObesity, dyslipidemia (p (p<0.0001<0.0001))nn Arterial hypertensionArterial hypertension (p (p<0.0001<0.0001))

NNon-CV comorbidities in on-CV comorbidities in diabetesdiabetesnn Chronic renal diseaseChronic renal disease (p (p<0.0001<0.0001))nn AnemiaAnemia (p (p<0.0001<0.0001))nn COPDCOPD (p (p<0.0001<0.0001))

Parissis JT, et al. Int J Cardiol. 2012;157(1):108-13.

Registry of the management of patients treated for acutely decompensated heart failure in >200 US hospitals

§ Multicenter § Observational § Open label§ Electronic web-based§ >150,000 pts

•Average age: 72.5 years•Women: 52%•Ischemic etiology (CAD): 60%•Renal insufficiency: 30%•Diabetes: 44%•Preserved LV systolic function: ~50%•Atrial fibrillation: 31%

The ADHERE Registry(Acute Decompensated Heart Failure National Registry)

• Acute Heart Failure Global Survey of Standard Treatment (ALARM-HF) – in-hospital observational survey

• 4593 patients hospitalized for AHF, 45% diabetics• Europe, Mexico, Australia• DM compared to non-DM patients: clinical phenotype treatment regimes in-hospital outcome


Age and functional status in Age and functional status in patients with AHF (patients with AHF (diabeticdiabeticss vs.vs.

non-diabeticnon-diabetics)s)Clinical Clinical characteristicscharacteristics

Diabetics Diabetics (N=2229, (N=2229, 45%45%))

Non diabetics Non diabetics (N=2724, 55%)(N=2724, 55%)

pp

Age (y)Age (y) <0.0001<0.0001

<55<5556-8056-80>80>80

10.2%10.2%76.8%76.8%12.7%12.7%

20.3%20.3%62.7%62.7%16.8%16.8%

Functional status before admission 0.0330.033NYHA I-IINYHA I-IINYHA III-IVNYHA III-IV

9.1%9.1%71.8%71.8%

12.0%12.0%69.9%69.9%


Clinical presentations and Clinical presentations and precipitating factors in patients with precipitating factors in patients with AHF (AHF (diabeticdiabeticss vs.vs. non-diabetic non-diabetics)s)

Clinical characteristicsClinical characteristics DiabeticsDiabetics Non diabeticsNon diabetics pp

Clinical Clinical presentationpresentation<0.0001<0.0001

<0.0001<0.0001<0.0001<0.0001

Acutely Acutely decompensated decompensated CHFCHFAcute de novo HFAcute de novo HFPulmonary edemaPulmonary edema

69.1%69.1%

30.9%30.9%39.3%39.3%

59.6%59.6%

40.4%40.4%34.7%34.7%

Precipitating factors<0.0001<0.0001<0.0001<0.0001

ACSACSValvular heart diseaseValvular heart disease

44.1%44.1%11.1%11.1%

30.9%30.9%15.3%15.3%


Cardiogenic shock develops more often Cardiogenic shock develops more often among diabetics with acute MIamong diabetics with acute MI

Lindholm MG, Eur J Heart Fail 2005

Prognostic impact of diabetes in Prognostic impact of diabetes in acute decompensated heart failureacute decompensated heart failure

Burger AJ, Am J Cardiol 2005

The Vasodilation in the Management of Acute Congestive HF (VMAC) trial

Strong predictors of survival in DM patientsStrong predictors of survival in DM patients

SBP SBP ≤≤100mmHg100mmHg – survival rate 74%, SBP 101-120mmHg – survival rate 92% – survival rate 74%, SBP 101-120mmHg – survival rate 92%SBP 121-159mmHg – survival rate 96%, SBP ≥160mmHg – survival rate 96%SBP 121-159mmHg – survival rate 96%, SBP ≥160mmHg – survival rate 96%

Log rank=213.7, p<0.001


Insulin-Dependent Diabetes Is AssociatedInsulin-Dependent Diabetes Is AssociatedWith Increased Mortality in Patients With Advanced With Increased Mortality in Patients With Advanced Heart FailureHeart Failure

624 patients with advanced HF and systolic dysfunction.Smooky and Fonarow, AHJ 2005.

P=0.0002

No DM

DM, no insulin

DM, insulin

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10 11 12Months

Surv

ival

(%)

0 1 2 3 4 5 6 7 8

20

40

60

80

100

Nondiabetic subjects without prior MIDiabetic subjects without prior MINondiabetic subjects with prior MIDiabetic subjects with prior MI

Years

Surv

ival (%

)

Diabetes and AHF Diabetes and AHF Etiology of HF vs. risk of death Etiology of HF vs. risk of death

Haffner SM et al. NEJM 1998;339:229–234

Patients with DM but no CHD experience a similar rate of death as patients without DM but with CHD

In-hospital outcome In-hospital outcome in acute heart in acute heart failure (failure (diabeticdiabetics vss vs non-diabetic non-diabetics)s)

OutcomeOutcome DiabeticsDiabetics Non diabeticsNon diabetics pp

DeathDeath 11.7%11.7% 9.8%9.8% 0.010.01

Functional status on dischargeFunctional status on discharge 0.0160.016

NYHA I-IINYHA I-II 64%64% 67%67%

NYHA III-IVNYHA III-IV 36%36% 33%33%


Positive predictorsn Beta/blockers * (p= 0.014)n ACEi/ARBs* (p <0.001)n PCI (p <0.001)

Negative predictorsn Age (p=0.032)n SBP<100mmHg (p<0.001)n Non compliance (p=0.005)n Arterial hypertension (p=0.022)n Cr >1.5mg/dl (p=0.029)n LVEF <50% (p <0001)n Lenth of stay in CCU (p= 0.021)

* Before admission

Predictors of in-hospital outcome Predictors of in-hospital outcome of patients with diabetes and of patients with diabetes and AHFAHF


nn Multinational cohortMultinational cohortnn 6,212 patients with AHF6,212 patients with AHFnn Europe, USA, Asia, AfricaEurope, USA, Asia, Africann EElevated blood glucose at admission levated blood glucose at admission to predict to predict all-cause mortality by 30 all-cause mortality by 30 daysdays

Mebazaa A, et al. J Am Coll Cardiol. 2013;61(8):820-9.

Hyperglycemia is a predictor of poor outcome in AHF

Arch Intern Med. 2009;169(5):438-446

In H

ospi

tal M

orta

lity

(%)

Average Post-admission Glucose

Multivariate analysis of factors associated Multivariate analysis of factors associated with 30-Day mortality in a fully adjusted with 30-Day mortality in a fully adjusted

modelmodel


30-Day Mortality rates according to the level of glucose

Cumulative hazard for death associated with hyperglicemia in AHF

Blood glucose concentration at admission – powerful predictor in AHF


Risk of death and elevated blood glucose level in presence/absence

of DM on admission


30-day mortality and hyperglycemia: 30-day mortality and hyperglycemia: Comparison among various continentsComparison among various continents

Umpierrez GE et al. J Clin Endocrinol Metab. 2002;87:978-982.

Hyperglycemia Is an independent marker of in-patient mortality in patients with undiagnosed

diabetes

In-hospital Mortality Rate

(%)

Newly Discovered

Hyperglycemia

Patients With History of Diabetes

Patients With

Normoglycemia

P < 0.01

P < 0.01

Hyperglicemia and AHF: Hyperglicemia and AHF: Treatment targetsTreatment targets

Myocardial remodelling in HFPEFImportance of comorbidities for systemic proinflammatory state

Paulus WJ, Tschöpe C. J Am Coll Cardiol 2013;62(4):263-71

Kidney function is a key factor in Kidney function is a key factor in AHF worsening in diabetes AHF worsening in diabetes

Differences in therapeutic modalities Differences in therapeutic modalities of AHF during hospitalizationof AHF during hospitalization

TherapyTherapy DMDM non-DMnon-DM ppBeta-blockersBeta-blockersDigoxinDigoxinOral/TTS nitratesOral/TTS nitratesCCBCCBAspirinAspirinClopidogrelClopidogrelNitrates i.v.Nitrates i.v.DopamineDopamineAdrenalineAdrenaline

49.7%49.7%32.0%32.0%31.0%31.0%0.9%0.9%61.7%61.7%21.4%21.4%48.6%48.6%14.6%14.6%2.6%2.6%

45.0%45.0%27.3%27.3%20.6%20.6%2.0%2.0%53.4%53.4%16.2%16.2%35.1%35.1%11.7%11.7%4.3%4.3%

0.0010.001<0.001<0.001<0.001<0.0010.0020.002

<0.001<0.001<0.001<0.001<0.001<0.0010.0030.0030.0020.002

InterventionalInterventionalCABGCABGPCIPCI

3.8%3.8%15.3%15.3%

2.2%2.2%10.8%10.8%

0.0010.001<0.001<0.001


Glucose control in AHF with T2D often Glucose control in AHF with T2D often unknown or untreated at dischargeunknown or untreated at discharge

tt Short acting insulinShort acting insulinttMMetformin and etformin and sulfonylureas (after sulfonylureas (after clinical stabilization, clinical stabilization, no severe renal no severe renal dysfunction)dysfunction)

ttAvoid glitazonesAvoid glitazonesttNew antiglycemic New antiglycemic drugs minor?drugs minor?

ttDiabetic Diabetic retinopathyretinopathy

Acute heart failure: Acute heart failure: Hyperglycemic control Hyperglycemic control strategystrategy

§ Diabetes is frequently associated with AHF

§ AHF and diabetes are frequently associated with CAD and several co-morbidities

§ Diabetics with AHF have higher in-hospital and long term mortality/morbidity

§ Age, low LVEF, renal function, low SBP, ACS and absence of life saving therapies were more frequent in high risk group

Acute heart failure and diabetes: frequently associated

Conclusions

From Cradle to Grave (Michael Johnson, 2007)CARDIODIABETIC CONTINUUM

Co-morbidities in AHF : Diabetes

Healthcare

Transcript of Co-morbidities in AHF : Diabetes