Expert discusses the role of diabetologists in comorbid heart failure in diabetes

PHILADELPHIA — During a presentation from the Heart in Diabetes conference, Vivian A. Fonseca, MD, professor of medicine at Tulane University in New Orleans, discussed the role of a diabetologist in treating comorbid heart failure in diabetes and in improving care for patients in this subgroup.

According to Fonseca, one-third to one-half of patients with heart failure and reduced ejection fraction (HFrEF) have type 2 diabetes, and diabetes with HF is associated with a 70% to 80% increase in mortality as well as higher rates of hospitalization and longer length of stay.

"This is a highly prevalent problem. This distinction (between HFrEF and heart failure with preserved ejection fraction) is important as to how you choose drug therapy in these patients,” Fonseca said. “I’m going to give you a slightly different perspective and talk about how we should be addressing these problems in diabetes clinics and primary care clinics.”

In his presentation, Fonseca discusses several areas of concern that need further study when looking at HF patients with diabetes.

Pathophysiologic construct and HF drivers

There are pathophysiological abnormalities such as insulin resistance, obesity, activated renin-angiotensin-aldosterone system (RAAS), increased aldosterone and sympathetic stimulation inflammation that exist among these patients that are often overlooked.

"These are all endocrine abnormalities that we are not actively thinking about when we are seeing a patient with what we think is mild diabetes in an unfit, obese person coming to the clinic," Fonseca said. “These people don't exercise and, sometimes, we advise them to exercise, and we put it down as being unfit, but is it that they can't do a 6-minute walk test because they've got early heart failure?"

Fonseca discussed the underuse of biomarkers among primary care physicians and endocrinologists.

“How many of us in primary care or diabetes clinics do [basic metabolic panel]?” he asked. “We just don't do it, and maybe we should be doing this a little more.”

A lack of guideline information

According to Fonseca, the available guidelines for treating HF patients with diabetes must be expanded upon.

He discussed guideline recommendations such as angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for patients with a history of myocardial infarction or acute coronary syndrome, as well as the use of statins to prevention cardiovascular events.

“The basis of management and prevention of these patients includes things that we already knew,” he said.

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Choosing appropriate treatment

Further study of HF in patients with diabetes will aid physicians in choosing the best treatment for these patients, Fonseca said.

The presentation findings suggested that metformin was associated with reduced mortality and hospitalization, but the use of the drug is relatively contraindicated.

Additionally, the study results showed that the use of thiazolidinediones was linked to lower incidence of HF, and the effects of HF may be exacerbated by the drug.

SGLT2 may be the best choice for therapy, but its effect on HFrEF requires further evaluation, Fonseca said.

“I agree that SGLT2 inhibitors are the best option for people with HF and diabetes, but the impact of the drug in the early stages of the disease is still unknown,” he said.

Although the role of endocrinologists in the treatment of patients with diabetes with HF incidence is a developmental process, Fonseca said early detection is critical for the optimal management of these patients to avoid late-stage treatment.

“We should be trying to identify and characterize these patients early so that we can choose appropriate therapies, both from the diabetes perspective and from the HF perspective.” – by Dave Quaile

Reference:

Fonseca AF. Congestive Heart Failure in Diabetes. Presented at: Heart in Diabetes Medical Conference; July 14-16, 2017; Philadelphia.

Disclosure: Fonseca reports receiving funding from Amgen, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Johnson & Johnson, Takeda.