Treatment of heart failure in patients with diabetes mellitus

Heart Failure and Diabetes: Collateral Benefit of Chronic Disease Management

To test the hypothesis that a focus on heart failure (HF) care may be associated with inadequate diabetes care, the authors screened 78 patients (aged 64+/-11 years; 69% male) with diabetes enrolled in an HF disease management program for diabetes care as recommended by the American Diabetes Association (ADA). Ninety-five percent of patients had hemoglobin A1c levels measured within 12 months, and 71% monitored their glucose at least once daily. Most patients received counseling regarding diabetic diet and exercise, and approximately 80% reported receiving regular eye and foot examinations. Mean hemoglobin A1c level was 7.8+/-1.9%. There was no relationship between hemoglobin A1c levels and New York Heart Association class or history of HF hospitalizations. Contrary to the authors' hypothesis, patients in an HF disease management program demonstrated levels of diabetic care close to ADA goals. "Collateral benefit" of HF disease management may contribute to improved patient outcomes in diabetic patients with HF.

Chronic Heart Failure–Related Interventions After Starting Rosiglitazone in Patients Receiving Insulin

STUDY OBJECTIVE

To determine whether rosiglitazone is associated with the onset or worsening of chronic heart failure (CHF) when administered to patients with type 2 diabetes mellitus who receive insulin.

DESIGN

Retrospective cohort analysis.

SETTING

Veterans Affairs medical center.

SUBJECTS

One hundred thirty-nine patients who received insulin for treatment of type 2 diabetes mellitus and had rosiglitazone added to their drug regimens.

INTERVENTION

Medical records were reviewed for 6 months before and 6 months after each patient's first rosiglitazone prescription. Records were assessed for the diagnosis of CHF and documented patient complaints of CHF symptoms requiring a medical intervention (unscheduled primary care or emergency room visit, start or dosage adjustment of CHF pharmacotherapy, or hospitalization).

MEASUREMENTS AND MAIN RESULTS

A diagnosis of CHF was documented in Thirty-five (25%) patients in the preindex period (before receiving rosiglitazone) versus 42 (30%) in the postindex period (after receiving rosiglitazone). Fifty (36%) patients received a medical intervention for CHF signs or symptoms in the postindex period compared with only 20 (14%) in the preindex period (p<0.0001). Of the 50 patients requiring a medical intervention in the postindex period, 33 (66%) had not required an intervention in the preindex period. The most common symptom was lower extremity edema; this occurred in 25 (18%) patients in the preindex period and 50 (36%) patients in the postindex period (p<0.0001).

CONCLUSION

More patients were diagnosed with CHF during the 6 months after rosiglitazone was added to their drug regimens than in the previous 6 months, when these patients received insulin but not rosiglitazone. In addition, more medical interventions related to CHF occurred after administration of rosiglitazone. Data from this study appear to support the Food and Drug Administration's warning of an increased risk of cardiac failure in patients receiving concurrent treatment with rosiglitazone and insulin.

Are β-blockers as efficacious in patients with diabetes mellitus as in patients without diabetes mellitus who have chronic heart failure? A meta-analysis of large-scale clinical trials

BACKGROUND

Diabetes mellitus is a frequent comorbid condition in patients with chronic heart failure (CHF) and confers a worse prognosis. Furthermore, although patients with CHF derive considerable benefit from beta-blockers, these agents are thought by many physicians to be contraindicated in patients with diabetes mellitus. Most published studies on beta-blockers in CHF have been unable to reach definitive conclusions about the mortality benefits of these agents in patients with diabetes mellitus. We therefore performed a meta-analysis of beta-blocker trials that reported mortality outcomes in patients with diabetes mellitus who had CHF to pool all available trial evidence on the benefits (or otherwise) of these agents in this setting.

METHODS

All-cause mortality data on patients with diabetes mellitus were obtained from all completed beta-blocker CHF randomized placebo-controlled trials involving >100 patients exposed to beta-blockers, in which outcomes in patients with diabetes mellitus were described. When events were not directly reported, risk ratios (RRs) were derived from analysis of figures and other manuscript data. Results were pooled with the Mantel-Haenszel method.

RESULTS

A total of 24.6% of patients were reported to have diabetes mellitus in the 6 studies analyzed (Australia and New Zealand [ANZ]-Carvedilol, Beta-blocker Evaluation of Survival Trial [BEST], Carvedilol US Trials, Cardiac Insufficiency Bisoprolol Study [CIBIS-II], Carvedilol Prospective Randomized Cumulative Survival Trial [COPERNICUS], and Metoprolol Controlled-release Randomized Intervention Trial in Heart Failure [MERIT-HF]). Patients with diabetes mellitus had increased mortality rates overall compared with subjects without diabetes mellitus (RR, 1.25; 95% CI, 1.15-1.36; P <.001). Compared with placebo, beta-blocker therapy for CHF was beneficial in patients with diabetes mellitus (RR, 0.84; 95% CI, 0.73-0.96; P =.011) and in subjects without diabetes mellitus (RR, 0.72; 95% CI, 0.65-0.79; P <.001). The absolute risk reduction in mortality with beta-blocker therapy was greater in patients with heart failure but without diabetes mellitus than in patients with diabetes mellitus (P =.023).

CONCLUSIONS

Patients with diabetes mellitus and CHF appear to derive prognostic benefit from beta-blocker therapy, although the magnitude of that benefit is somewhat less than that observed in subjects without diabetes mellitus.

Prevalence, predictors, and prognostic implications of improvement in left ventricular systolic function and clinical status in patients >70 years of age with recently diagnosed systolic heart failure

In recent years, several clinical trials conducted on selected middle-aged patients have documented the positive effects of new pharmacologic and nonpharmacologic treatment on chronic heart failure (HF). More recently, some investigators reported cases of elderly patients who had improved clinical conditions and left ventricular (LV) systolic function, but neither the prevalence nor the clinical variables associated with this phenomenon have ever been characterized in this population. To assess the prevalence and the predictors of "improvement" of HF, we prospectively analyzed 87 patients with a recent diagnosis of HF and LV systolic dysfunction, aged >70 years, who were consecutively admitted to our center for functional class impairment (New York Heart Association class III and IV). After discharge, patients underwent clinical and echocardiographic evaluations every 6 months. During follow-up (17 +/- 9 months) improvement was documented in 31 subjects (36%). The variables associated with improvement in the multivariate analysis were the absence of diabetes (odds ratio [OR] 5.1, 95% confidence interval [CI] 1.3 to 19.9, p = 0.007), history of arterial hypertension (OR 3.9, CI 1.3 to 11.1, p = 0.01), and beta-blocker therapy (OR 3.4, CI 1.1 to 10.8, p = 0.03). An improvement in clinical status and LV systolic function is not infrequently observed in patients >70 years of age who have a recent diagnosis of HF. This behavior occurs prevalently in patients receiving beta-blocker therapy who have a history of arterial hypertension, and is inversely related to the presence of diabetes mellitus.