Treatment of HF in Diabetic Patients
Treatment of HF in Diabetic Patients
Treatment of HF in Diabetic Patients
PATIENTS
Professor / Mohammed Ahmed Bamashmos
Professor of Internal Medicine and Endocrinology
Faculty of Medicine ( Sanaa University
PREVALENCE AND RISK FACTORS
the prevalence of HF in patients with DM is between 9% and 22%, which is 4 times higher than the general population, and the prevalence is even
higher in patients with DM who are ≥60 years old
HF cohorts, including both HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF), the prevalence of DM ranges
from 10% to 47%. The prevalence of DM is higher in patients hospitalized with HF, with some reports of >40%.
- hypertension
- smoking
- dyslipidemia , obesity
- FH
- IR , MS
PATHOGENESIS OF HF IN DIABETIC PATIENTS
DIAGNOSIS
Of newly diagnosed DM
Of HF in diabetic patients
TREATMENT
1- Treatment goal
2- treatment target
3- treatment types ;
A- Non pharmacological ;
B- Pharmacological
Classification of GLDs according to the beneficial effect in prevention and treatment of HF in Diabetic patients
- fluid retention
Indicated in stage D HF
2- SU ;
- it binds to second SUR (SUR2) is present on skeletal and cardiac muscle and, with stimulation of this receptor, the cardiac output
and cardiac workload are increased.83, 84 Studies regarding HF have been conflicting, with an increased frequency of HF usually being seen
with sulphonylureas when compared to metformin
3- Dipeptidyl-peptidase-4 (DPP-4) inhibitors ;
- they did not increase the major adverse cardiovascular event
- was associated with increased risk of HHF without an increase in CV death
sit gliptin have shown an increase in HF ranging from 21% to 84%. The Linagliptin in the Carmelina trials did not show an
increased risk of HHF, so this may not be a class effect.
pathological basis for the increased frequency of HF?
- they increase cyclic AMP in cardiomyocytes. This may lead to calcium overload in the myocardium, which may adversely
affect cardiac function.
- increase sympathetic nervous system activity which increases ventricular hypertrophy and increases the risk of arrhythmias.
- myocardial fibrosis.
DPP-4 inhibitors are therefore not recommended in patients with HF, stage B, C and D.
4- Thiazolidinedione ;
Disadvantage ;
- fluid retention
- increased body weight
Its not recommended in stage B, C , D heart failure
B- diabetic drug therapy with neutral effect on HF
1- Alpha glucosidase inhibitor
- reduction in MI
2- GLP1RA ;
Benefit
Reduce the risk for hospital for HF by 11%
Indication in HF ; Because of the effect of GLP-1RAs on multiple comorbidities, they should be used in patients with HF without any
anticipation of improvement or deterioration in HFrEF.116 Further evaluation of GLP-1RAs in the treatment of HFpEF is indicated
C-Diabetic drug therapy that may prevent or ameliorate HF
1- Metformin ; - protection of HF newer data have shown that patients utilizing metformin do have a survival benefit in HF when
compared to patients on other glucose-lowering regimens. Use of metformin is still contraindicated in patients with unstable or
acute HF.118
2- SGLT2I ;
- Benefit in heart failure ;
types and there benefit ;
Other novel drugs ;
1- Dual GLP1 I and GIP ( Tirzepatide ) Benefit in type 2 DM with HF ;
- induce weight loss, dose dependent reduction in BW of 15%, 19.5%, and 20.9% with 5-, 10-, and 15-milligram
doses, respectively, at 72 weeks in non-diabetic obese patients
-enhance hepatic lipid metabolism,
-normalize systemic insulin sensitivity, and reduce or even reverse metabolic dysfunction. The US FDA approved
tirzepatide as the first dual GLP-1 and GIP receptor agonist for the treatment of T2DM in 2022.
- greater reduction glycated hemoglobin levels than semaglutide
- does not increase the risk of HHF
-The apparent advantage of reducing glycated hemoglobin and BW of tirzepatide over GLP-1 RA has the potential
to impact the clinical management or prevention of HF
• 2- Dual SGLT2 and SGLT1 I (Sotagliflazon )
- reduce upregulation of SGLT1
-reduce glucose and HbA1C
- Prevent the development of HF in type 2 DM
- Reduce CV mortality and HHF
3- Bromocriptine ;
reduced fasting and postprandial glucose levels, corrected dyslipidemia, and improved cardiovascular outcomes bromocriptine
treatment for 52 weeks resulted in a 39% reduction in CV death-inclusive composite CV endpoints, including myocardial infarction,
stroke, hospitalized angina, HHF, coronary revascularization, and CV death
4- Imeglimin ;
A- Clinical assessment ;
- Measurement of BP
B- Laboratory assessment
Prevalence of obesity in type 2 DM ( 90% ) , in type 1 ( 28%) , In heart failure ( HFpEF 84% )
Classification ;
Pathogenesis
- Treatment of obesity in DM ;
- for prevention of HF ( Stage A , B ) Any increase in HbA1C by 1 is associated with increase CV mortality by 11-16%
for prevention of HF ( stage A , B) ; Chronic hyperglycemia through glycosylation of myocardial protein can cause myocardial protein
cross linking leading to increase fibrosis and higher risk of HF
B - insulin resistance ;
1- Prevalence ;
3- Treatment ;
C- Hypertension
D- dyslipidemia
E- endothelial dysfunction ;
E- Inflammation
2- select optimal antidiabetic drugs when life style and weight reduction fail to achieve optimal A1c target ;
who to select ;