With emerging data suggesting that therapies for type 2 diabetes mellitus (T2DM) can impact outcomes among patients with heart failure (HF), and vice versa, but no single document that comprehensively addresses both conditions, the American Heart Association and Heart Failure Society of America joined forces to develop a scientific statement to fill this gap, explains Shannon M. Dunlay, MD, MS, FAHA, lead author of the statement published in Circulation.
The purpose of the statement, write Dr. Dunlay and colleagues, is “to summarize current understanding of the epidemiology, pathophysiology, and outcomes of patients with type 2 DM and HF. In addition, it provides a review of contemporary data on the efficacy and safety of pharmacological and lifestyle management options in patients with DM at risk for HF and those with established disease.” Dr. Dunlay summarizes the most important points made in the paper as follows:
- “DM can contribute to the development of HF through multiple mechanisms. First, it increases the risk of developing coronary artery disease which can lead to ischemia and heart failure. Second, hyperglycemia in patients with DM can cause changes in the metabolism of the heart muscle which can lead to fibrosis and apoptosis.
- “Patients with HF and DM have worse clinical outcomes than patients with HF without DM. They have higher risk of death and hospitalization and, on average, worse quality of life.
- “Glycemic goals in patients with DM and HF should be individualized to reflect the patient’s severity of HF, other medical conditions, and overall prognosis (Figure). In most patients with diabetes and symptomatic heart failure, a goal A1C of 7%-8% is appropriate. More stringent goals may be appropriate in patients who have no other serious comorbidities and a long life expectancy. As patients develop advanced heart failure or other end-stage medical conditions, less stringent goals may be appropriate.
- “Some medications to lower blood sugar in diabetes can impact the risk of developing cardiovascular disease, including HF, and can impact outcomes in those who already have HF.
- “Metformin is reasonable to use in patients with DM at risk of or with established HF but should be held in patients presenting with acute conditions that cause lactic acidosis, such as cardiogenic shock.
- “SGLT2-inhibitors are the only class of glucose-lowering agents that have been shown to reduce the risk of HF hospitalization in patients with DM. They are a good choice for most patients with DM and heart failure or those at high risk for heart failure.
- “GLP-1 receptor agonists may reduce the overall risk of cardiovascular events in patients with DM but have not been shown to prevent HF.
- “Insulin is sometimes required to achieve adequate glycemic control in individuals with DM and HF; it should be used with caution and close monitoring.
- “There is no evidence that DPP-4 inhibitors provide cardiovascular benefit, and some may increase the risk of hospitalization for HF. There are better choices for patients with, or at high risk for, HF.
- “Thiazolidinediones should not be used in patients with HF and may increase the risk of HF in those without the condition.
- “Overall, ACE inhibitors, ARBs, and angiotensin receptor neprilysin inhibitors improve glycemic control in patients with heart failure and reduced ejection fraction. Spironolactone may modestly worsen glycemic control. Of the three HF beta blockers (carvedilol, bisoprolol, metoprolol succinate), carvedilol may have the most favorable effects on glycemic control.
- “/Patients with DM and HF often have complex medical regimens and can have to see multiple clinicians to effectively manage both. It is important to develop an individualized plan of care for each patient and to ensure effective communication and coordination of care across all members of the healthcare team. Lifestyle management is of utmost importance. Exercise is safe and beneficial.”
Dr. Dunlay concludes that “this is an exciting time in the management of patients with DM and HF; there are many clinical trials currently underway that will help to better define the optimal management of patients with both conditions.”
Type 2 Diabetes Mellitus and Heart Failure: A Scientific Statement From the American Heart Association and the Heart Failure Society of America: This statement does not represent an update of the 2017 ACC/AHA/HFSA heart failure guideline update.