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AACE: Fourth Complication From Type 2 Diabetes: Heart Failure

More rigorous screening called for to mitigate poor outcomes of this common condition.

While much attention is given to the microvascular effects of type 2 diabetes (T2D) – diabetic retinopathy, kidney disease, nerve damage – and the macrovascular consequences that include stroke, heart attacks, and peripheral vascular disease, there is a seventh and more sinister complication of diabetes that demands greater attention: heart failure leading to increased mortality.

We need to remember that people with diabetes do not die from diabetes but from cardiovascular disease. That was the message delivered yesterday by a trio of specialists during an in-depth symposium presented at the American Association of Clinical Endocrinologists’ 26th Annual Scientific and Clinical Congress. In the session “Heart Failure: The Frequent, Forgotten and Often Fatal Complication of Type 2 Diabetes,” Dr. David S.H. Bell, who has performed clinical trials on the effects of angiotensin II receptor blockers (ARBs) in diabetes patients with diastolic dysfunction, suggested the available evidence should propel endocrinologists to become more rigorous in screening for the complication with symptomatic patients and consider treating it to mitigate the poor outcomes often seen in these patients. “It’s not widely realized how common this condition is,” Dr. Bell noted. “Somewhere between 40 and 45 percent of people in this country with diabetes suffer heart failure versus 12 percent of non-diabetics. And depending on the degree of glycemic control, the worse the mortality is.”

Dr. Bell highlighted studies that examined the complex effect of diabetes and contributing factors to the three causes of the heart failure, including coronary artery disease, left ventricular hypertrophy (LVH, which occurs in approximately 65 percent of people with type 2 diabetes), and diabetic cardiomyopathy, a distinct pathology that is closely associated with the microvascular complications of diabetes. Paradoxically, while anti-heart failure therapies such as angiotensin-converting-enzyme inhibitors and others work similarly well in individuals with diabetes as compared to those without the disease, the glucose-lowering drug dipeptidylpeptidase-4 (DPP4) inhibitors saxagliptin has been found to cause an increase in heart failure in diabetes patients, said the second presenter of the session, researcher Dr. Richard E. Gilbert, PhD, FRCPC. Considered an expert in the knowledge of kidney disease and diabetes as major, independent risk factors for the development of heart failure, Dr. Gilbert highlighted the relation between glycemic control and heart failure risk, focusing on the state of knowledge regarding the detrimental and beneficial effects of the various types of anti-hyperglycemic drugs.

Dr. Aaron Vinik, PhD, FCP, MACP, FACE, and advisory board member for Diabetes in Control, presented details regarding his research on autonomic neuropathy, one of the most overlooked T2D complications contributing to the high incidence of heart failure in diabetes patients, in which damage to the body’s blood vessels extends to those involuntary nerves that stimulate the heart and blood vessels, resulting in heart rate and vascular abnormalities. Autonomic system dysfunction is a predictor of cardiovascular risk and sudden death in T2D patients, but also occurs in prediabetes, and thus offers opportunities for early intervention, Dr. Vinik noted.

Dr. Vinik added that important advances in technology during the past decade now make it possible to identify these early stages of autonomic dysfunction with the use of objective standardized measures, allowing earlier intervention when reversal of the condition is still possible.

Practice Pearls:

  • Autonomic neuropathy is one of the most overlooked T2D complications contributing to the high incidence of heart failure in diabetes patients.
  • The glucose-lowering drug dipeptidylpeptidase-4 (DPP4) inhibitors saxagliptin has been found to cause an increase in heart failure in diabetes patients.
  • Contributing causes of heart failure include coronary artery disease, left ventricular hypertrophy (LVH, which occurs in approximately 65 percent of people with type 2 diabetes), and diabetic cardiomyopathy.

26th AACE Annual Scientific & Clinical Congress in Austin, Texas on May 3-7, 2017