HF carries highest risks of death, greatest decreases in lifespan in these patients

Type 2 diabetes and heart failure can be a deadly combination, especially when it occurs in those newly diagnosed with diabetes. Originally published June 29, this report from researchers in Denmark details the full scope of cardiovascular risks observed in patients with type 2 diabetes.

In patients with newly diagnosed type 2 diabetes (T2D), heart failure (HF) carries the highest absolute and relative risks of death and greatest decrease in lifespan within 5 years compared with other cardiovascular or renal diseases, according to new research published in Circulation: Cardiovascular Quality and Outcomes.

“Our objective was to estimate, at every year since T2D diagnosis, the absolute risk of death, the risk ratio (RR) of death, and the decrease in lifespan within 5 years following the development of HF, ischemic heart disease (IHD), stroke, CKD [chronic kidney disease], and peripheral artery disease (PAD),” wrote Bochra Zareini, MD, of the Herlev and Gentofte University Hospital, Hellerup, Denmark, and colleagues.

To do so, they used nationwide registries from Denmark to identify 153,403 patients with newly diagnosed T2D, whom they followed for a median of 9.7 years. Patients were free of other prior cardiovascular and renal diseases.

Zareini et al. estimated 5-year risk of death, risk ratios, and decreases in lifespan associated with HF, IHD, stroke, PAD, and CKD. They found the highest 5-year risk of death in patients who had developed HF (47.6%; 95% CI: 44.8-50.3), compared with patients who developed IHD (21%; 95% CI: 20-22), stroke (34.5%; 95% CI: 32.6-36.4), CKD (27.7%; 95% CI: 25.5-30.0), and PAD (37.1%; 95% CI: 34.6-39.5).

In addition, the 5-year relative risk (RR) of death in patients who developed HF within 5 years of a diagnosis of T2D was three times greater (RR: 3.0; 95% CI: 2.9-3.1) than that of those without cardiovascular and renal disease. These 5-year ratios were lower in those with IHD (RR: 1.3; 95% CI: 1.3-1.4), stroke (RR: 2.2; 95% CI: 2.1-2.2), chronic kidney disease (RR: 1.7; 95% CI: 1.7-1.8), and peripheral artery disease (RR: 2.3; 95% CI: 2.3-2.4).

Patients who developed HF also had lowered life expectancy compared with those without cardiovascular or renal disease and lived an average of 11.7 months less (95% CI: 11.6-11.8). Those with conditions other than HF demonstrated smaller decreases in lifespan as follows:

  • Ischemic heart disease: 1.6 months less (95% CI: 1.5-1.7).
  • Stroke: 6.4 months less (95% CI: (6.3-6.5).
  • Chronic kidney disease: 4.4 months less (95% CI: 4.3-4.6).
  • Peripheral artery disease: 6.9 months less (95% CI: 6.8-7.0).

Compared with other comorbid conditions, the presence of HF combined with any other diagnosis carried the greatest mortality risk and the greatest decrease in lifespan. Patients with a combination of HF and CKD (63.7%; 95% CI: 53.7-73.7) carried highest risk of death 5 years after T2D diagnosis, followed by HF and stroke (54.1%; 95% CI: 44.7-63.5), while patients with HF combined with PAD and IHD had lower risks (48.5%; 95% DI: 36.4-60.5; and 45.5%; 95% CI: 42.3-48.7, respectively).

The number of months of life lost over 5 years was greatest in those with a combination of HF and CKD (18.2 months less; 95% CI: 18.1-18.3), followed by HF plus stroke (16.2 months less; 95% CI: 16.1-16.4), HF and PAD (14.3 months less; 95% CI: 14.2-14.4), and HF and IHD (11 months less; 95% CI: 10.9-11.2).

Study limitations included the absence of several clinical factors affecting severity of HF and T2D, including functional class, smoking status, and vital measurements including heart rate, blood pressure, biochemical parameters such as N-terminal pro-b-type natriuretic peptide, glucose levels, and hemoglobin A1c. In addition, researchers did not include data on microvascular complications.

“In a nationwide real-life cohort of >150 000 patients with newly diagnosed T2D, we found that HF development alone or in combination with stroke, CKD, or PAD conferred the highest 5-year risk of death. This translated into an average reduction of 12 to 25 months lived within the next 5 years and a 3- to 5-fold increased 5-year risk of death compared with patients with T2D free of cardiovascular disease,” wrote Zareini and fellow researchers.

“Although not the most frequent complication, HF was clearly associated with the most unfavorable prognosis in patients with T2D. When providing care for patients with T2D, we hope that our findings contribute to assessing risk profiles and prognosis, especially concerning the importance of evaluating patients with T2D regularly for HF,” they concluded.

BreakingMED spoke with Robert H. Eckel, MD, American Diabetes Association President of Medicine and Science, about this study. He noted that this was a “solid study, with good data,” but added that the results were not surprising.

Nevertheless, Eckel said: “The strength of this study is that we have new-onset patients who were followed for a wide variety of cardiovascular disease outcomes. And HF trumped everything else.”

He also noted a few limitations of the study, including the lack of biochemical or biomarker data for HF or any other complication, and the inclusion of primarily white, Scandinavian participants.

“We know that Black people have much more hypertension, and Latinos have probably more alterations and other risk factors for cardiovascular disease,” Eckel explained.

How can these results inform clinicians caring for their patients with newly diagnosed T2D?

“The recognition of HF needs to be made more convincingly and earlier. There’s really not a standard approach to this other than what is currently recommended—people who may have any kinds of symptoms of HF (edema, shortness of breath) should get a brain natriuretic peptide (BNP) test. If that level is normal, probably no additional pursuit of it is needed. If it’s elevated, an echocardiogram should be obtained, and then decisions made about therapy,” Eckel concluded.

E.C. Meszaros, Contributing Writer, BreakingMED™

Zareini reported no disclosures.

This study was supported by the Danish Heart Association and Boehringer Ingelheim.

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Topic ID: 76,13,730,3,13,190,192