By Dr. Rebecca Castillo, M.D.
Doctors treating diabetic patients from all over the world attended a recent conference in Philadelphia, USA, wherein top experts discussed new developments in the management of diabetes and its complications on the heart, kidneys and other vital organs, including the arterial system of the body.
Dubbed as the Heart in Diabetes (HID), it was a unique conference which gathered world-renowned clinical leaders in diabetes and cardiovascular disease, and more than 1o local practitioners attended the meeting. Emerging clinical data and research, focusing on the management of the heart and kidney in diabetes was tackled giving the attendees important clinical insights on how to manage their diabetic patients better.
Diabetes is a multi-organ problem wherein the longstanding diabetic patients already presents with complications in the heart, brain, kidneys, eyes, arteries in the legs and elsewhere. Because of the multi-organ involvement, various specialists usually handle the diabetic patient and the goal of HID, which is now on its third run, is to align cardiologists, endocrinologists, diabetologists, neurologists, ophthalmologists, nephrologists and other interested medical professionals in their understanding and development of appropriate and comprehensive clinical management plans, especially for very high risk patients.
Heart failure or HF is one of the causes of disability and deaths in patients with diabetes. In fact, as discussed during the HID meeting, many diabetic patients now present with HF more commonly, than with a heart attack (myocardial infarction or MI).
“The incidence of HF in type 2 diabetes has increased to the point where it has become more common as the initial presentation of CVD (cardiovascular disease) in these patients than acute MI,” stated David Fitchett, MD, a cardiologist at St. Michael’s Hospital in Toronto, who was one of the invited faculty of HID.
He explained that physicians must be conscious in finding out if their diabetic patients have HF or not, particularly in women, who have a fivefold risk of HF; and also in elderly patients wherein the incidence is around 30 percent. That means in elderly diabetic patients, three out of 10 would have HF whether they suspect it or not. The obese diabetics are also at higher risk, particularly young, male, obese diabetics.
Many diabetic patients don’t suspect they have HF, and just dismiss their symptoms like easy fatigability, shortness of breath when engaging in physical activities, difficulty of breathing when lying down, as nonspecific and just part of the aging process.
Patients should always consult their doctors if they have these symptoms for early diagnosis and treatment.
Although HF is traditionally defined as weakness of the heart muscles to pump blood, it has now been shown that there is another type of HF which is frequently undiagnosed early particularly in diabetics. This is HF with preserved ejection fraction (HFpEF). When usual tests are done in this patients, they don’t seem to have HF but studies now show they occur frequently. The problem is that unlike in those with pump failure or HF with reduced ejection fraction (HFrEF), there is yet no known effective treatment form HFpEF. And because of this lack of effective treatment and its frequently being undetected, it can lead to a deterioration of the diabetic patient’s quality of life, and subsequent premature death.
Many experts including Dr. Fitchett have reported that the upward trend of HFpEF is alarming and has to be recognized by both physician and patient. Dr. Fitchett added that the relative incidence of HFrEF is apparently declining, while HFpEF is increasing. He explained that most experts are projecting that soon, around 65 percent of patients hospitalized with HF will have HFpEF. There may be no effective direct treatment for HFpEF but treatment of risk factors and comorbidities like diabetes, hypertension, smoking and obesity will certainly be beneficial.
“But it’s important to recognize that in comparison to HFrEF, comorbidity is a very important association both in the development of the disease and in its progression,” said Dr. Fitchett. He added that predisposing risk factors or comorbidities in HFpEF include metabolic syndrome (diabetes, hypertension, cholesterol problems), overweight and obesity, renal dysfunction, hypertension and coronary artery disease, which could all be found in patients with diabetes.
Although no drug has been shown to effectively improve HFpEF, there’s good data (STENO 2 study) showing that intensive risk factor therapy reduced HF hospitalization in diabetic patients by 50 percent during a 20-year period since randomization, said Dr. Fitchett.
There’s also a new class of antidiabetic drugs called SGLT2 inhibitors, which could improve HFrEF, and it may possibly lower the incidence of HFpEF. Dr. Fitchett however noted that although the studies on SGLT2 inhibitors have shown a similar reduction of HF hospitalization in diabetic patient, the studies didn’t really include consistent measures of EF and other echocardiographic parameters.
So for now, prevention of HFpEF and other complications of diabetes would consist of adequate control of blood sugar, blood pressure, cholesterol levels and maintenance of ideal body weight. This remains our best bet to stave off the disease and its complications.