Type 2 Diabetes Mellitus and Heart Failure with preserved Ejection Fraction – Development of Cardio-diabetology, a necessary step forward

Heart failure (HF) is a complex clinical syndrome that results from either functional or structural impairment of ventricles resulting in left ventricle (LV) dysfunction. The symptoms come from an inadequate cardiac output and failing to keep up with the metabolic demands of the body [1].

Diabetes mellitus increases the risk of HF up to 2-fold in men and 5-fold in women (since Framingan 1979). The association between diabetes and heart failure will worsen the prognosis of these patients, even in patients with heart failure with preserved ejection fraction (HFpEF). Currently, the need to screen for heart failure in patients with diabetes and how to do it are not defined. The incidence of HFpEF in patients with diabetes is underdiagnosed, however, approximately 50% of patients diagnosed with HEpEF have diabetes.

Early diagnosis has a significant impact on the prognosis, especially in patients with mild symptoms. The inter-relationship between clinical endocrinologists and cardiologists is essential today.

The pathophysiology for HF development in T2DM is complex. Besides the general HF risk factors like advancing age, ethnicity, genetic predisposition, hypertension, and smoking, T2DM increases the risk of ischemic HF through increased risk of coronary artery disease (CAD), as well as impacting directly the myocardium leading to structural and functional changes (diabetic heart disease)[2]. Observational data suggest an 8–16% increased risk of HF for each 1%-point increase in HbA1c [3]. Furthermore, T2DM is associated with obesity and visceral adiposity which is associated with impaired myocardial function and an increased risk of HF [4,5]. Additionally, T2DM is associated with an accelerated decline in renal function and increased risk for chronic kidney disease, which adversely influences the risk for HF outcome [6].

Structural cardiac changes seen in T2DM include increased interstitial fibrosis, increased left ventricular (LV) wall thickness, and often increased LV mass, alterations that contribute to but are not a prerequisite to, the development of functional myocardial impairments. As a consequence, diastolic dysfunction is the classical and most frequent early cardiac functional abnormality in T2DM patients [7]. The cumulative probability of the development of HF at 5 years for diabetic patients with diastolic dysfunction was 36.9% compared with 16.8% for patients without diastolic dysfunction (p<0.001).[8]

After clinical suspicion, specialized resting and stress echocardiography, as well as natriuretic peptides, will help confirm the diagnosis. These patients will have the benefit of new drugs such as SGLT2 that will undoubtedly improve the prognosis. [9]

It would be useful to promote a rapprochement between endocrinologists and cardiologists, early identification and treatment of patients with diabetes as well as early identification and treatment of patients with heart failure is vital in this era of the constant increase of non-communicable diseases in our environment.

Dr. Piter Martinez Benitez. Hung Vuong General Hospital

Dr. Chu Thi Ha My

References:

1. WRITING COMMITTEE MEMBERS, Yancy CW, Jessup M, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013;128(16):e240-e327. doi:10.1161/CIR.0b013e31829e8776
2. Fang ZY, Prins JB, Marwick TH. Diabetic cardiomyopathy: evidence, mechanisms, and therapeutic implications. Endocr Rev. 2004;25(4):543-567. doi:10.1210/er.2003-0012
3. Iribarren C, Karter AJ, Go AS, et al. Glycemic control and heart failure among adult patients with diabetes. Circulation. 2001;103(22):2668-2673. doi:10.1161/01.cir.103.22.2668
4. Neeland IJ, Gupta S, Ayers CR, et al. Relation of regional fat distribution to left ventricular structure and function. Circ Cardiovasc Imaging. 2013;6(5):800-807. doi:10.1161/CIRCIMAGING.113.000532
5. Aune D, Sen A, Norat T, et al. Body Mass Index, Abdominal Fatness, and Heart Failure Incidence and Mortality: A Systematic Review and Dose-Response Meta-Analysis of Prospective Studies. Circulation. 2016;133(7):639-649. doi:10.1161/CIRCULATIONAHA.115.016801
6. Ekundayo OJ, Muchimba M, Aban IB, Ritchie C, Campbell RC, Ahmed A. Multimorbidity due to diabetes mellitus and chronic kidney disease and outcomes in chronic heart failure. Am J Cardiol. 2009;103(1):88-92. doi:10.1016/j.amjcard.2008.08.035
7. Devereux RB, Roman MJ, Paranicas M, et al. Impact of diabetes on cardiac structure and function: the strong heart study. Circulation. 2000;101(19):2271-2276. doi:10.1161/01.cir.101.19.2271
8. From AM, Scott CG, Chen HH. The development of heart failure in patients with diabetes mellitus and pre-clinical diastolic dysfunction a population-based study [published correction appears in J Am Coll Cardiol. 2010 Nov 2;56(19):1612]. J Am Coll Cardiol. 2010;55(4):300-305. doi:10.1016/j.jacc.2009.12.003.
9. Pieske B, Tschöpe C, de Boer RA, et al. How to Diagnose Heart Failure With Preserved Ejection Fraction: The HFA–PEFF Diagnostic Algorithm: A Consensus Recommendation From the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). Eur Heart J 2019;40:3297-3317.

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