HEART FAILURE (HF) AND DIABETES MELLITUS TYPE II (DM2)- a talk by Dr Viveka and Dr Wanganoo.
Summary by Dr SK Kapoor
1) HF more common in DM : hazard ratio 1.5 with prediabetes and 2.5 with DM2.
2) Worse prognosis- lower survival
DM2 leads to LV concentric remodeling , LVH, Impaired myocardial functioning
Symptoms: Reduced exercise tolerance, SOB, Edema
Treatment
1) Metformin for mild to moderate HF. (Recently allowed by FDA)
2) SU and Insulin –conflicting evidence of benefit
3) Thiozalidinediones (pioglitazone) harmful as fluid retention.
4) DPP-4 I have neutral effects. Saxa is harmful.
5) GLP1-RA (liraglutide and semaglutide) positive effects in MACE but neutral in HF.
6) SGLT-2 INH : (EMPA AND CANA) CONSISTENTLY POSITIVE EFFECTS ON HF HOSPITALIZATION REDUCTION (both in HFrEF and HFpEF). Beneficial In Atherosclerotic CVD.
7) If HF and CKD with/without CVD :Empa and Cana are recommended.
Dr Viveka’sadditional points: (for DM and HF)
1) High HbA1C raises cardio renal risks.
2) Each hospitalization increases the risk further.
3) Start early with SGLT-2 I drugs.
4) ARNI, BB, MRA, ACE-ARB constitute the 4 pillars of HF treatment. SGLT2-I can be considered the 5th.
5) Dapaglitazone does not cause hypoglycemia, has CV benefits and is helpful is preventing 1st and subsequent hospitalization for HF.
Dr Wangnoo’s points: (for DM only)
1) In 5 years IGT usually becomes overt DM.
2) Combo of drugs required because a) progressive disease b)sub optimal glycemic control c) Single drug may not control well d) ADA, ACC guidelines prove its benefits.
3) Insulin resistance (IR) causes raised C-peptide values and usually does not progress.
4) Insulin deficiency (SIDD- S for severe) has reduced C-peptide and is progressive.
5) Combination of IR and ID raise the possibility of CKD.
6) Asian phenotype is more liable to complications of DM.
7) Abdominal girth matters. Faulty lifestyle is a cause of early DM2.
8) Treatment is LSM, diet and exercise.If fails, start with metformin, add SU, DPP4-I, Pioglit, Voglibose or SGLT2-I according to the case.