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Chapter 28 Jonathan G. Howlett , John C. MacFadyen

Canadian Diabete s Association Clinical Practice Guidelines Treatment of Diabetes in People with Heart Failure. Chapter 28 Jonathan G. Howlett , John C. MacFadyen. Diabetes in Heart Failure Checklist. 2013.

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Chapter 28 Jonathan G. Howlett , John C. MacFadyen

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  1. Canadian Diabetes Association Clinical Practice GuidelinesTreatment of Diabetes in People with Heart Failure Chapter 28 Jonathan G. Howlett, John C. MacFadyen

  2. Diabetes in Heart Failure Checklist 2013 • Treat heart failure in patients with diabetes the SAME as you would a patient without diabetes • METFORMIN recommended if eGFR >30 mL/min • If eGFR <60 mL/min, use RAAS blockade carefully • Do NOT use thiazolidinediones

  3. Diabetes → Increased Risk of Heart Failure Independent of Ischemia • Diabetic cardiomyopathy • 2 to 4-fold increase incidence of heart failure in DM • Asymptomatic abnormalities of ventricular systolic and diastolic function, independent of ischemic heart disease or systemic hypertension • Independent risk factors for CHF • Elevated A1C • Microalbuminuria

  4. Use the same heart failure therapies in diabetes as you would in non-diabetes based on the Canadian Cardiovascular Society (CCS) Recommendations (www.ccsguidelineprograms.ca)

  5. Use Same Treatments as in Non-diabetes … • Beta-blocker for systolic heart failure if indicated • Same target drug dose as indicated by CCS • If eGFR <60 mL/min • Starting dose of ACEi/ARB should be halved with gradual up-titration • Monitor electrolytes, creatinine, blood pressure, weight within 7-10 days of starting

  6. Metformin Use in Heart Failure Patients • Tayside, Scotland (population 400,000) • n=422 with CHF and diabetes • Antihyperglycemic therapy: • Metformin alone n=68 • SU alone n=217 • Combination n=137 1.0 0.8 0.4 Cumulative mortality Sulfonylurea monotherapy 0.6 Metformin monotherapy + combination 0 0.2 Time (days) ACEi= Angiotensin-Converting Enzyme inhibitor; CHF = Chronic Heart Failure; MI = Myocardial Infarction; SU = Sulfonylurea 3000 5000 2000 4000 1000 0 Evans JM, et al. Am J Cardiol 2010;106:1006-10.

  7. Metformin Use in Heart Failure Patients • Veterans Affairs • 6,185 with CHF & DM • Oral antihyperglycemic: • With metformin (n=1,561) • Without metformin • Statistically adjusted for co-variables 1.00 0.95 0.85 Metformin Survival estimates 0.90 No metformin 0.75 0.80 p = 0.01 Death: 0.76 (0.63-0.92) p < 0.01 CHF hospitalization: 0.93 (0.74-1.18) p = 0.56 Total hospitalization: 0.94 (0.83-1.07) p = 0.35 Time (days) 300 500 600 700 200 400 100 0 Aguilar D, et al. Circ Heart Fail 2011;4:53-8.

  8. Use metformin in heart failure patients when eGFR >30 mL/min

  9. Recommendation 1 • Individuals with diabetes and heart failure should receive the same heart failure therapies as those identified in the evidence- based Canadian Cardiovascular Society heart failure recommendations (http://www.ccsguidelineprograms.ca)[Grade D, Consensus]

  10. Recommendation 2 • In people with diabetes and heart failure and an eGFR <60 mL/min, or if combined RAAS blockade is employed: • Starting doses of ACE inhibitors or angiotensin receptor II antagonists (ARBs) should be halved[Grade D, Consensus]. • Serum electrolytes and creatinine, blood pressure and body weight, as well as heart failure symptoms and signs, should be monitored within 7-10 days of any initiation or titration of therapy [Grade D, Consensus]

  11. Recommendation 2 (continued) • Dose-up titration should be more gradual (with monitoring of blood pressure, serum potassium and creatinine) [Grade D, Consensus]. • The target drug doses should be the same as those identified in the evidence-based Canadian Cardiovascular Society recommendations on heart failure (http://www.ccsguidelineprograms.ca), if well tolerated[Grade D, Consensus]

  12. Recommendation 3 • Beta blockers should be prescribed when indicated for systolic heart failure, as they provide similar benefits in people with diabetes compared with people without diabetes[Grade B, Level 2]

  13. CDA Clinical Practice Guidelines www.guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) www.diabetes.ca – for patients

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