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Salzano A, D'Assante R, Iacoviello M, Triggiani V, Rengo G, Cacciatore F, Maiello C, Limongelli G, Masarone D, Sciacqua A, Filardi PP, Mancini A, Volterrani M, Vriz O, Castello R, Passantino A, Campo M, Modesti PA, De Giorgi A, Arcopinto M, Gargiulo P, Perticone M, Colao A, Milano S, Garavaglia A, Napoli R, Suzuki T, Bossone E, Marra AM, Cittadini A. Progressive right ventricular dysfunction and exercise impairment in patients with heart failure and diabetes mellitus: insights from the T.O.S.CA. Registry. Cardiovasc Diabetol 2022; 21:108. [PMID: 35710369 PMCID: PMC9204878 DOI: 10.1186/s12933-022-01543-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/16/2022] [Indexed: 01/01/2023] Open
Abstract
Background Findings from the T.O.S.CA. Registry recently reported that patients with concomitant chronic heart failure (CHF) and impairment of insulin axis (either insulin resistance—IR or diabetes mellitus—T2D) display increased morbidity and mortality. However, little information is available on the relative impact of IR and T2D on cardiac structure and function, cardiopulmonary performance, and their longitudinal changes in CHF. Methods Patients enrolled in the T.O.S.CA. Registry performed echocardiography and cardiopulmonary exercise test at baseline and at a patient-average follow-up of 36 months. Patients were divided into three groups based on the degree of insulin impairment: euglycemic without IR (EU), euglycemic with IR (IR), and T2D. Results Compared with EU and IR, T2D was associated with increased filling pressures (E/e′ratio: 15.9 ± 8.9, 12.0 ± 6.5, and 14.5 ± 8.1 respectively, p < 0.01) and worse right ventricular(RV)-arterial uncoupling (RVAUC) (TAPSE/PASP ratio 0.52 ± 0.2, 0.6 ± 0.3, and 0.6 ± 0.3 in T2D, EU and IR, respectively, p < 0.05). Likewise, impairment in peak oxygen consumption (peak VO2) in TD2 vs EU and IR patients was recorded (respectively, 15.8 ± 3.8 ml/Kg/min, 18.4 ± 4.3 ml/Kg/min and 16.5 ± 4.3 ml/Kg/min, p < 0.003). Longitudinal data demonstrated higher deterioration of RVAUC, RV dimension, and peak VO2 in the T2D group (+ 13% increase in RV dimension, − 21% decline in TAPSE/PAPS ratio and − 20% decrease in peak VO2). Conclusion The higher risk of death and CV hospitalizations exhibited by HF-T2D patients in the T.O.S.CA. Registry is associated with progressive RV ventricular dysfunction and exercise impairment when compared to euglycemic CHF patients, supporting the pivotal importance of hyperglycaemia and right chambers in HF prognosis. Trial registration ClinicalTrials.gov identifier: NCT023358017
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Affiliation(s)
- Andrea Salzano
- IRCCS SYNLAB SDN, Diagnostic and Nuclear Research Institute, Naples, Italy
| | - Roberta D'Assante
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Italian Clinical Outcome Research and Reporting Program (I-CORRP), Naples, Italy
| | - Massimo Iacoviello
- Cardiology Unit, Department of Medical and Surgical Sciences, University of Foggia, 71122, Foggia, Italy
| | - Vincenzo Triggiani
- Interdisciplinary Department of Medicine-Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, University of Bari 'A Moro', Bari, Italy
| | - Giuseppe Rengo
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Istituti Clinici Scientifici Maugeri SpA Società Benefit (ICS Maugeri SpA SB) - IRCCS - Scientific Institute of Telese Terme, Telese Terme, BN, Italy
| | - Francesco Cacciatore
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Ciro Maiello
- Heart Transplantation Unit, Monaldi Hospital, Azienda Ospedaliera Dei Colli, Naples, Italy
| | - Giuseppe Limongelli
- Division of Cardiology, Monaldi Hospital, Azienda Ospedaliera Dei Colli, University of Campania Luigi Vanvitelli, Caserta, Italy
| | - Daniele Masarone
- Division of Cardiology, Monaldi Hospital, Azienda Ospedaliera Dei Colli, University of Campania Luigi Vanvitelli, Caserta, Italy
| | - Angela Sciacqua
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Pasquale Perrone Filardi
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy.,Mediterranea Cardiocentro, Naples, Italy
| | - Antonio Mancini
- Operative Unit of Endocrinology, Catholic University of the Sacred Heart, Rome, Italy
| | | | - Olga Vriz
- Heart Center Department, King Faisal Hospital & Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Roberto Castello
- Division of General Medicine, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Michela Campo
- Unit of Endocrinology and Metabolic Diseases, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Pietro A Modesti
- Dipartimento Di Medicina Sperimentale E Clinica, Università Degli Studi Di Firenze, Florence, Italy
| | - Alfredo De Giorgi
- Department of Medical Sciences, School of Medicine, Pharmacy and Prevention, University of Ferrara, Ferrara, Italy
| | - Michele Arcopinto
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Italian Clinical Outcome Research and Reporting Program (I-CORRP), Naples, Italy
| | - Paola Gargiulo
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Maria Perticone
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Annamaria Colao
- Clinical Medicine and Surgery Department, Federico II University, Naples, Italy
| | - Salvatore Milano
- Department of Laboratory Medicine, AOUP P. Giaccone, Palermo, Italy
| | | | - Raffaele Napoli
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Toru Suzuki
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester, Leicester, UK
| | - Eduardo Bossone
- Italian Clinical Outcome Research and Reporting Program (I-CORRP), Naples, Italy.,Cardiology Division, A Cardarelli Hospital, Naples, Italy
| | - Alberto M Marra
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Italian Clinical Outcome Research and Reporting Program (I-CORRP), Naples, Italy.,Center for Pulmonary Hypertension, Thoraxclinic at Heidelberg University Hospital, Heidelberg, Germany
| | - Antonio Cittadini
- Department of Translational Medical Sciences, Federico II University, Naples, Italy. .,Italian Clinical Outcome Research and Reporting Program (I-CORRP), Naples, Italy. .,Department of Translational Medical Sciences, Division of Internal Medicine and Metabolism and Rehabilitation, Federico II University of Naples, Via S. Pansini 5, Bld.18, 1stfloor, 80131, Naples, Italy.
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Khan S, Ahmad SS, Kamal MA. Diabetic Cardiomyopathy: From Mechanism to Management in a Nutshell. Endocr Metab Immune Disord Drug Targets 2020; 21:268-281. [PMID: 32735531 DOI: 10.2174/1871530320666200731174724] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 06/03/2020] [Accepted: 07/06/2020] [Indexed: 11/22/2022]
Abstract
Diabetic cardiomyopathy (DCM) is a significant complication of diabetes mellitus characterized by gradually failing heart with detrimental cardiac remodelings, such as fibrosis and diastolic and systolic dysfunction, which is not directly attributable to coronary artery disease. Insulin resistance and resulting hyperglycemia is the main trigger involved in the initiation of diabetic cardiomyopathy. There is a constellation of many pathophysiological events, such as lipotoxicity, oxidative stress, inflammation, inappropriate activation of the renin-angiotensin-aldosterone system, dysfunctional immune modulation promoting increased rate of cardiac cell injury, apoptosis, and necrosis, which ultimately culminates into interstitial fibrosis, cardiac stiffness, diastolic dysfunction, initially, and later systolic dysfunction too. These events finally lead to clinical heart failure of DCM. Herein, The pathophysiology of DCM is briefly discussed. Furthermore, potential therapeutic strategies currently used for DCM are also briefly mentioned.
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Affiliation(s)
- Shahzad Khan
- Department of Pathophysiology, Wuhan University School of Medicine, Hubei, Wuhan, China
| | - Syed S Ahmad
- Department of Bioengineering, Faculty of Engineering, Integral University, Lucknow, India
| | - Mohammad A Kamal
- King Fahd Medical Research Center, King Abdulaziz University, P.O. Box 80216, Jeddah 21589, Saudi Arabia
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Lee WS, Kim J. Diabetic cardiomyopathy: where we are and where we are going. Korean J Intern Med 2017; 32:404-421. [PMID: 28415836 PMCID: PMC5432803 DOI: 10.3904/kjim.2016.208] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 01/08/2017] [Indexed: 12/15/2022] Open
Abstract
The global burden of diabetes mellitus and its related complications are currently increasing. Diabetes mellitus affects the heart through various mechanisms including microvascular impairment, metabolic disturbance, subcellular component abnormalities, cardiac autonomic dysfunction, and a maladaptive immune response. Eventually, diabetes mellitus can cause functional and structural changes in the myocardium without coronary artery disease, a disorder known as diabetic cardiomyopathy (DCM). There are many diagnostic tools and management options for DCM, although it is difficult to detect its development and effectively prevent its progression. In this review, we summarize the current research regarding the pathophysiology and pathogenesis of DCM. Moreover, we discuss emerging diagnostic evaluation methods and treatment strategies for DCM, which may help our understanding of its underlying mechanisms and facilitate the identification of possible new therapeutic targets.
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Affiliation(s)
- Wang-Soo Lee
- Division of Cardiology, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jaetaek Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
- Correspondence to Jaetaek Kim, M.D. Division of Endocrinology and Metabolism, Department of Internal Medicine, Chung-Ang University Hospital, 102 Heukseok-ro, Dongjak-gu, Seoul 06973, Korea Tel: +82-2-6299-1397 Fax: +82-2-6299-1390 E-mail:
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Jia G, Jia Y, Sowers JR. Contribution of Maladaptive Adipose Tissue Expansion to Development of Cardiovascular Disease. Compr Physiol 2016; 7:253-262. [PMID: 28135006 DOI: 10.1002/cphy.c160014] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The overweight and obesity epidemic has led to an increase in the metabolic syndrome and associated cardiovascular disease (CVD). These abnormalities include insulin resistance, type 2 diabetes mellitus, vascular stiffness, hypertension, stroke, and coronary heart disease. Visceral white adipocyte tissue (WAT) expansion and associated fibrosis/stiffness of WAT promote insulin resistance and CVD through increases in proinflammatory adipokines, oxidative stress, activation of renin-angiotensin-aldosterone system, dysregulation of adipocyte apoptosis and autophagy, dysfunctional immune modulation, and adverse changes in the gut microbiome. The expansion of WAT is partly determined by activation of peroxisome proliferator-activated receptor gamma and mammalian target of rapamycin/ribosomal S6 kinase signaling pathways. Further, the chronic activation of these signaling pathways may not only induce adipocyte hypertrophy and fibrosis, but also contribute to systemic inflammation, and impairment of insulin metabolic signaling in fat, liver, and skeletal muscle tissue. Therefore, the interplay of adipocyte dysfunction, maladaptive immune and inflammatory responses, and associated metabolic disorders often coexist leading to systemic low-grade inflammation and insulin resistance that are associated with increased CVD in obese individuals. © 2017 American Physiological Society. Compr Physiol 7:253-262, 2017.
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Affiliation(s)
- Guanghong Jia
- Diabetes and Cardiovascular Research Center, University of Missouri School of Medicine, Columbia, Missouri, USA.,Harry S. Truman Memorial Veterans Hospital, Columbia, Missouri, USA
| | - Yan Jia
- Diabetes and Cardiovascular Research Center, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - James R Sowers
- Diabetes and Cardiovascular Research Center, University of Missouri School of Medicine, Columbia, Missouri, USA.,Department of Medical Pharmacology and Physiology, University of Missouri School of Medicine, Columbia, Missouri, USA.,Dalton Cardiovascular Center, University of Missouri School of Medicine, Columbia, Missouri, USA.,Harry S. Truman Memorial Veterans Hospital, Columbia, Missouri, USA
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Abstract
Insulin resistance, type 2 diabetes mellitus and associated hyperinsulinaemia can promote the development of a specific form of cardiomyopathy that is independent of coronary artery disease and hypertension. Termed diabetic cardiomyopathy, this form of cardiomyopathy is a major cause of morbidity and mortality in developed nations, and the prevalence of this condition is rising in parallel with increases in the incidence of obesity and type 2 diabetes mellitus. Of note, female patients seem to be particularly susceptible to the development of this complication of metabolic disease. The diabetic cardiomyopathy observed in insulin- resistant or hyperinsulinaemic states is characterized by impaired myocardial insulin signalling, mitochondrial dysfunction, endoplasmic reticulum stress, impaired calcium homeostasis, abnormal coronary microcirculation, activation of the sympathetic nervous system, activation of the renin-angiotensin-aldosterone system and maladaptive immune responses. These pathophysiological changes result in oxidative stress, fibrosis, hypertrophy, cardiac diastolic dysfunction and eventually systolic heart failure. This Review highlights a surge in diabetic cardiomyopathy research, summarizes current understanding of the molecular mechanisms underpinning this condition and explores potential preventive and therapeutic strategies.
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Affiliation(s)
- Guanghong Jia
- Diabetes and Cardiovascular Center, University of Missouri School of Medicine, D109 Diabetes Center HSC, One Hospital Drive, Columbia, Missouri, 65212, USA
| | - Vincent G DeMarco
- Diabetes and Cardiovascular Center, University of Missouri School of Medicine, D109 Diabetes Center HSC, One Hospital Drive, Columbia, Missouri, 65212, USA
| | - James R Sowers
- Diabetes and Cardiovascular Center, University of Missouri School of Medicine, D109 Diabetes Center HSC, One Hospital Drive, Columbia, Missouri, 65212, USA
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Mencarelli A, Cipriani S, Renga B, D'Amore C, Palladino G, Distrutti E, Baldelli F, Fiorucci S. FXR activation improves myocardial fatty acid metabolism in a rodent model of obesity-driven cardiotoxicity. Nutr Metab Cardiovasc Dis 2013; 23:94-101. [PMID: 21924881 DOI: 10.1016/j.numecd.2011.06.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Revised: 06/16/2011] [Accepted: 06/20/2011] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND AIMS Obesity-driven lipotoxicity is a risk factors for cardiovascular disease. The Farnesoid X Receptor (FXR) is a bile acids sensor and member of the nuclear receptor superfamily. Activation of FXR lowers plasma triacylglycerols and glucose levels through a mechanism that involves both the repression of key regulatory genes in the liver and the modulation of insulin sensitivity in peripheral tissues. In the present study we have investigated whether administering obese (fa/fa) Zucker rats, a genetic model of obesity associated with dyslipidemia and insulin resistance, with an FXR ligand protects against lipid-induced cardiomyopathy. METHODS AND RESULTS FXR is expressed in neonatal cardiomyocytes and the treatment with FXR agonists, chenodeoxycholic acid (CDCA), and GW4064, increased the mRNA expression of FXR and its canonical target gene, the small heterodimer partner (SHP), as well as proliferator-activated receptor alpha PPARα, acyl-CoA oxidase (AOX) and pyruvate dehydrogenase kinase (PDK-4). Feeding obese fa/fa rats with CDCA, 12 weeks, reduced hyperinsulinemia and hyperlipidaemia. The histological-pathological analysis of hearts demonstrated that treatment with the FXR ligand reduced lipid heart content decreased the rate of apoptosis, fibrosis scores and restored heart insulin signalling. Chronic CDCA administration, in the heart, induced PPARα and PPARα-regulated genes involved in β-oxidation. CONCLUSION FXR agonism exerts beneficial effects in a genetic model of lipid-induced cardiomyopathy. The striking benefit of this therapy on cardiac function in this model warrants an effort to determine whether a counterpart of this activity translates in human settings.
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Affiliation(s)
- A Mencarelli
- Dipartimento di Medicina Clinica e Sperimentale, University of Perugia, Facoltà di Medicina e Chirurgia, Via Gerardo Dottori n° 1, S. Andrea delle Fratte, 06132 Perugia, Italy.
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Cittadini A, Napoli R, Monti MG, Rea D, Longobardi S, Netti PA, Walser M, Samà M, Aimaretti G, Isgaard J, Saccà L. Metformin prevents the development of chronic heart failure in the SHHF rat model. Diabetes 2012; 61:944-53. [PMID: 22344560 PMCID: PMC3314362 DOI: 10.2337/db11-1132] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Insulin resistance is a recently identified mechanism involved in the pathophysiology of chronic heart failure (CHF). We investigated the effects of two insulin-sensitizing drugs (metformin and rosiglitazone) in a genetic model of spontaneously hypertensive, insulin-resistant rats (SHHF). Thirty SHHF rats were randomized into three treatment groups as follows: 1) metformin (100 mg/kg per day), 2) rosiglitazone (2 mg/kg per day), and 3) no drug. Ten Sprague-Dawley rats served as normal controls. At the end of the treatment period (12 months), the cardiac phenotype was characterized by histology, echocardiography, and isolated perfused heart studies. Metformin attenuated left ventricular (LV) remodeling, as shown by reduced LV volumes, wall stress, perivascular fibrosis, and cardiac lipid accumulation. Metformin improved both systolic and diastolic indices as well as myocardial mechanical efficiency, as shown by improved ability to convert metabolic energy into mechanical work. Metformin induced a marked activation of AMP-activated protein kinase, endothelial nitric oxide synthase, and vascular endothelial growth factor and reduced tumor necrosis factor-α expression and myocyte apoptosis. Rosiglitazone did not affect LV remodeling, increased perivascular fibrosis, and promoted further cardiac lipid accumulation. In conclusion, long-term treatment with metformin, but not with rosiglitazone, prevents the development of severe CHF in the SHHF model by a wide-spectrum interaction that involves molecular, structural, functional, and metabolic-energetic mechanisms.
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Affiliation(s)
- Antonio Cittadini
- Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University Federico II, Naples, Italy
| | - Raffaele Napoli
- Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University Federico II, Naples, Italy
| | - Maria Gaia Monti
- Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University Federico II, Naples, Italy
| | - Domenica Rea
- Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University Federico II, Naples, Italy
| | | | - Paolo Antonio Netti
- Interdisciplinary Research Centre on Biomaterials, University Federico II, Naples, Italy
- Center for Advanced Biomaterial for Health Care, Interdisciplinary Research Centre on Biomaterials, Italian Institute of Technology, Naples, Italy
| | - Marion Walser
- Department of Internal Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Mariateresa Samà
- Department of Clinical and Experimental Medicine, University A. Avogadro, Novara, Italy
| | - Gianluca Aimaretti
- Department of Clinical and Experimental Medicine, University A. Avogadro, Novara, Italy
| | - Jörgen Isgaard
- Department of Internal Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Luigi Saccà
- Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University Federico II, Naples, Italy
- Corresponding author: Luigi Saccà,
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MacDonald MR, Eurich DT, Majumdar SR, Lewsey JD, Bhagra S, Jhund PS, Petrie MC, McMurray JJV, Petrie JR, McAlister FA. Treatment of type 2 diabetes and outcomes in patients with heart failure: a nested case-control study from the U.K. General Practice Research Database. Diabetes Care 2010; 33:1213-8. [PMID: 20299488 PMCID: PMC2875425 DOI: 10.2337/dc09-2227] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Diabetes and heart failure commonly coexist, and prior studies have suggested better outcomes with metformin than other antidiabetic agents. We designed this study to determine whether this association reflects a beneficial effect of metformin or a harmful effect of other agents. RESEARCH DESIGN AND METHODS We performed a case-control study nested within the U.K. General Practice Research Database cohort in which diagnoses were assigned by each patient's primary care physician. Case subjects were patients 35 years or older, newly diagnosed with both heart failure and diabetes after January 1988, and who died prior to October 2007. Control subjects were matched to case subjects based on age, sex, clinic site, calendar year, and duration of follow-up. Analyses were adjusted for comorbidities, A1C, renal function, and BMI. RESULTS The duration of concurrent diabetes and heart failure was 2.8 years (SD 2.6) in our 1,633 case subjects and 1,633 control subjects (mean age 78 years, 53% male). Compared with patients who were not exposed to antidiabetic drugs, the current use of metformin monotherapy (adjusted odds ratio 0.65 [0.48-0.87]) or metformin with or without other agents (0.72 [0.59-0.90]) was associated with lower mortality; however, use of other antidiabetic drugs or insulin was not associated with all-cause mortality. Conversely, the use of ACE inhibitors/angiotensin receptor blockers (0.55 [0.45-0.68]) and beta-blockers (0.76 [0.61-0.95]) were associated with reduced mortality. CONCLUSIONS Our results confirm the benefits of trial-proven anti-failure therapies in patients with diabetes and support the use of metformin-based strategies to lower glucose.
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