https://diabetes.acponline.org/archives/2019/06/14/3.htm

AHA offers new guidance on treating diabetes and heart failure

A scientific statement from the American Heart Association and the Heart Failure Society of America describes new approaches to medications, lifestyles, and the importance of multidisciplinary care that includes physicians and other clinicians.


A recent scientific statement on diabetes and heart failure summarizes the epidemiology, pathophysiology, and impact of diabetes on outcomes in heart failure; reviews pharmacological therapy and lifestyle modification; highlights the value of multidisciplinary interventions to improve clinical outcomes; and outlines priorities for future research.

The scientific statement from the American Heart Association and the Heart Failure Society of America notes that the prevalence of diabetes among patients with heart failure ranges from 10% to 47% and the prevalence of heart failure among patients with diabetes is between 9% and 22%. Prevalence is even higher in patients with diabetes who are age 60 years and older. The scientific statement was published online June 6 by Circulation.

Although hyperglycemia with or without diabetes is associated with increased risk for heart failure, data suggest that intensive glycemic control in patients with established diabetes does not reduce the risk, according to the scientific statement. Optimal glycemic targets for patients with diabetes and heart failure should be individualized to reflect comorbidity burden, including the severity of heart failure, and to balance the benefits likely to be achieved by lowering HbA1c with the potential risks, the statement said.

The benefits of glucose-lowering therapy should also be balanced against a patient's life expectancy, because there is nearly a 10-year lag to benefit from intensive glycemic control. Because of the lack of heart failure-specific data to guide HbA1c goals, the scientific statement suggested a target HbA1c range of 7% to 8% for most patients with heart failure, consistent with diabetes clinical practice guidelines for patients with diabetes and serious comorbidities. For patients with advanced, stage D heart failure who are not pursuing mechanical circulatory support or transplantation, less stringent goals may be appropriate, the statement said.

The statement reviewed evidence on drugs for diabetes and offered clinical considerations on each class. For example, the statement said that although metformin was previously contraindicated in heart failure because of concerns regarding the rare risk of lactic acidosis, multiple observational studies have suggested a survival benefit. Metformin and sodium-glucose cotransporter-2 inhibitors (the first class to demonstrate reduced risk of heart failure hospitalization) are preferable to sulfonylureas in patients with or at high risk for heart failure. These two classes are also preferred to insulin if adequate glycemic control can be maintained. Thiazolidinediones are not recommended in patients with heart failure and may increase the risk of heart failure events in patients without heart failure. Glucagon-like peptide-1 receptor agonists are safe to use but don't help prevent heart failure in at-risk patients and should be used with caution in patients with reduced ejection fraction. The risk-benefit balance for most dipeptidyl peptidase-4 inhibitors does not justify their use in patients with or at risk for heart failure, the statement said.

Lifestyle management should be integral to the care of patients with diabetes and heart failure, the scientific statement continued. Exercise is safe and beneficial in patients with heart failure and diabetes and can improve functional capacity. “Cardiac rehabilitation programs represent an excellent avenue to encourage exercise participation in patients with diabetes and heart failure. Referral is critical and represents a primary barrier to cardiac rehabilitation enrollment,” according to the statement. Intentional weight loss can improve exercise capacity in obese patients with heart failure, including those with diabetes. Weight loss through calorie restriction combined with exercise is effective in patients with heart failure with preserved ejection fraction, the statement said.

The statement concluded, “Because both diabetes and heart failure are chronic diseases, integrated care that actively engages patients, family, and providers is key to optimizing both quality and quantity of life. Whether novel ambulatory or remote monitoring strategies can aid in this collateral benefit remains to be determined.”