Report and study highlight risk of heart failure in patients with diabetes

The American Diabetes Association recently issued a consensus report on heart failure (HF), calling it an underappreciated complication of diabetes.

The report, published by Diabetes Care on June 1, was intended to provide clear guidance to clinicians on the best approaches for screening and diagnosing HF in diabetes and prediabetes patients “to ensure access to optimal, evidence-based management for all and to mitigate the risks of serious complications.” The report writing group included representation from the American College of Cardiology (ACC), and the report leverages prior policy statements by the ACC and American Heart Association.

The report recommended identifying patients with diabetes and no symptoms of HF and classifying them as either stage A (diabetes with risk factors including obesity, hypertension, hyperlipidemia, diabetic kidney disease, and coronary heart disease) or stage B HF (diabetes with structural/functional cardiac abnormalities or elevated natriuretic peptides or troponin).

Other noteworthy guidance includes:

• Measurement of a natriuretic peptide or high-sensitivity cardiac troponin on at least a yearly basis is recommended to identify the presence of stage B HF and to determine risk for progression to symptomatic HF.
• When HF is diagnosed in individuals with diabetes, clinicians should evaluate for evidence of obstructive coronary artery disease (CAD) as the cause.
• Angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) are preferred agents in the management of stage A or B HF patients with either type 1 or type 2 diabetes and hypertension, especially in the presence of albuminuria and/or CAD.
• Recommendations for guideline-directed medical therapy of individuals with HF with reduced ejection fraction (HFrEF) and diabetes are similar to those for HFrEF patients without diabetes.
• Sacubitril/valsartan is the first-line therapy in individuals with diabetes and HFrEF and is preferred to an ACE inhibitor or ARB.

The report also discusses additional medication considerations, cardiac rehabilitation, bariatric surgery, and hospital care for patients with HF and diabetes, among other topics.

A recent study, published by the Journal of the American College of Cardiology on June 6, further highlighted the association between diabetes and HF. It included 4,774 adults with preclinical (stage A or B) HF and found that, among those with stage B HF, progression to clinical HF occurred at a younger age in those with an HbA1c level ≥7% (mean age, 80 years vs. 83 years in those with well-controlled diabetes; P<0.001). The authors concluded that “uncontrolled diabetes was associated with substantial risk of HF progression” and “targeting diabetes early in the HF process is critical.”

An accompanying editorial said that the results reinforce the importance of poorly controlled diabetes as a HF risk factor. “Because the step up is steepest in those who are in stage B heart failure, any evidence of structural heart disease or an increase in biomarkers should alert clinicians to an impending heart failure risk. Such an approach may also aid in identifying patients who may derive the greatest absolute risk reduction from sodium-glucose transport protein 2 inhibitors, which have been shown in various trials to prevent incident heart failure in diabetes,” the editorialists wrote.