Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
DIABETES AS SIGNIFICANT DIABETES AS SIGNIFICANT 
COMORBIDITY IN ACUTE HEART COMORBIDITY IN ACUTE HEART 
FAILURE FAILURE 
C...
Acute heart failureAcute heart failure and diabetes and diabetes
Clinical considerationsClinical considerations
Survival for combined outcome (HF death
or hospitalization) by diabetic status
Aguilar et al. Am J Cardiol 2010;105:373–377
Clinical characteristics in AHF patients 
in different registries
Farmakis D, et al. Rev Esp Cardiol. 2015;68(3):245-8.
Seferovic et al. Clin Chem Lab Med 2014; 52(10): 1437–1446
AHF in diabetics vs non-diabetics:
Clinical features and profil...
Comorbidities in acute heart Comorbidities in acute heart 
failure (failure (diabeticdiabetics vss vs non-diabetic non-dia...
Registry of the management of patients 
treated for acutely decompensated heart 
failure in >200 US hospitals 
 
§ Multice...
• Acute Heart Failure Global Survey of Standard Treatment 
(ALARM-HF) – in-hospital observational survey
• 4593 patients h...
Age and functional status in Age and functional status in 
patients with AHF (patients with AHF (diabeticdiabeticss  vs.vs...
Clinical presentations and Clinical presentations and 
precipitating factors in patients with precipitating factors in pat...
Cardiogenic shock develops more often Cardiogenic shock develops more often 
among diabetics with acute MIamong diabetics ...
Prognostic impact of diabetes in Prognostic impact of diabetes in 
acute decompensated heart failureacute decompensated he...
Strong predictors of survival in DM patientsStrong predictors of survival in DM patients
SBPSBP ≤≤100mmHg100mmHg – surviva...
Insulin-Dependent Diabetes Is AssociatedInsulin-Dependent Diabetes Is Associated
With Increased Mortality in Patients With...
0 1 2 3 4 5 6 7 8
20
40
60
80
100
Nondiabetic subjects without prior MI
Diabetic subjects without prior MI
Nondiabetic sub...
In-hospital outcome In-hospital outcome in acute heart in acute heart 
failure (failure (diabeticdiabetics vss vs non-diab...
Positive predictors
n Beta/blockers * (p= 0.014)
n ACEi/ARBs* (p <0.001)
n PCI (p <0.001)
Negative predictors
n Age (p=0.0...
nn Multinational cohortMultinational cohort
nn 6,212 patients with AHF6,212 patients with AHF
nn Europe, USA, Asia, Africa...
Hyperglycemia is a predictor of
poor outcome in AHF
Arch Intern Med. 2009;169(5):438-446
InHospitalMortality(%)
Average Po...
Multivariate analysis of factors associated Multivariate analysis of factors associated 
with 30-Day mortality in a fully ...
30-Day Mortality rates according to 
the level of glucose
Cumulative hazard for 
death associated with 
hyperglicemia in A...
Risk of death and elevated blood 
glucose level in presence/absence 
of DM on admission
Mebazaa A, et al. J Am Coll Cardio...
30-day mortality and hyperglycemia: 30-day mortality and hyperglycemia: 
Comparison among various continentsComparison amo...
Umpierrez GE et al. J Clin Endocrinol Metab. 2002;87:978-982.
Hyperglycemia Is an independent marker of in-
patient mortal...
Hyperglicemia and AHF:Hyperglicemia and AHF:
Treatment targetsTreatment targets
Myocardial remodelling in HFPEF
Importance of comorbidities for systemic proinflammatory state
Paulus WJ, Tschöpe C. J Am ...
Kidney function is a key factor in Kidney function is a key factor in 
AHF worsening in diabetes AHF worsening in diabetes 
Differences in therapeutic modalities Differences in therapeutic modalities 
of AHF during hospitalizationof AHF during ho...
Glucose control in AHF with T2D oftenGlucose control in AHF with T2D often
unknown or untreated at dischargeunknown or unt...
tt Short acting insulinShort acting insulin
tt MMetformin and etformin and 
sulfonylureas (after sulfonylureas (after 
cli...
§ Diabetes is frequently
associated with AHF
§ AHF and diabetes are
frequently associated with
CAD and several co-
morbidi...
From Cradle to Grave (Michael Johnson, 2007)
CARDIODIABETIC CONTINUUM
Co-morbidities in AHF : Diabetes
Co-morbidities in AHF : Diabetes
Co-morbidities in AHF : Diabetes
Co-morbidities in AHF : Diabetes
Co-morbidities in AHF : Diabetes
Co-morbidities in AHF : Diabetes
Upcoming SlideShare
Loading in …5
×

Co-morbidities in AHF : Diabetes

273 views

Published on

Co-morbidities in AHF : Diabetes

Published in: Healthcare
  • Suffer from Kidney Disease? how his patients avoid dialysis? Aussie Naturopath tells all... click here to find out how ★★★ https://tinyurl.com/y5392ufy
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • The Big Diabetes Lie Download Link➤➤http://book723.com/z/thebigdiabeteslie
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

Co-morbidities in AHF : Diabetes

  1. 1. DIABETES AS SIGNIFICANT DIABETES AS SIGNIFICANT  COMORBIDITY IN ACUTE HEART COMORBIDITY IN ACUTE HEART  FAILURE FAILURE  Chair of Internal medicine, Belgrade University School of Medicine Board member, Heart Failure Association of the ESCBoard member, Heart Failure Association of the ESC Prof. Petar M. Seferović, MD, PhD, FESC, FESC Corresponding member of Serbian Academy of Sciences and Arts President, Heart Failure Society of Serbia
  2. 2. Acute heart failureAcute heart failure and diabetes and diabetes Clinical considerationsClinical considerations
  3. 3. Survival for combined outcome (HF death or hospitalization) by diabetic status Aguilar et al. Am J Cardiol 2010;105:373–377
  4. 4. Clinical characteristics in AHF patients  in different registries Farmakis D, et al. Rev Esp Cardiol. 2015;68(3):245-8.
  5. 5. Seferovic et al. Clin Chem Lab Med 2014; 52(10): 1437–1446 AHF in diabetics vs non-diabetics: Clinical features and profiles
  6. 6. Comorbidities in acute heart Comorbidities in acute heart  failure (failure (diabeticdiabetics vss vs non-diabetic non-diabetics)s) CV comorbiditiesCV comorbidities in  in diabetesdiabetes nn Chronic HFChronic HF (p (p<0.0001<0.0001)) nn CADCAD (p (p<0.0001<0.0001)) nn CardiomyopathyCardiomyopathy (p (p<0.0001<0.0001)) nn Periferal vascular diseasePeriferal vascular disease (p (p<0.0001<0.0001)) nn Obesity, dyslipidemiaObesity, dyslipidemia (p (p<0.0001<0.0001)) nn Arterial hypertensionArterial hypertension (p (p<0.0001<0.0001)) NNon-CV comorbidities in on-CV comorbidities in diabetesdiabetes nn Chronic renal diseaseChronic renal disease (p (p<0.0001<0.0001)) nn AnemiaAnemia (p (p<0.0001<0.0001)) nn COPDCOPD (p (p<0.0001<0.0001)) Parissis JT, et al. Int J Cardiol. 2012;157(1):108-13. 
  7. 7. Registry of the management of patients  treated for acutely decompensated heart  failure in >200 US hospitals    § Multicenter  § Observational  § Open label § Electronic web-based § >150,000 pts •Average age:  72.5 years •Women: 52% •Ischemic etiology (CAD): 60% •Renal insufficiency: 30% •Diabetes: 44% •Preserved LV systolic function:  ~50% •Atrial fibrillation:  31% The ADHERE Registry (Acute Decompensated Heart Failure National Registry)
  8. 8. • Acute Heart Failure Global Survey of Standard Treatment  (ALARM-HF) – in-hospital observational survey • 4593 patients hospitalized for AHF, 45% diabetics • Europe, Mexico, Australia • DM compared to non-DM patients: clinical phenotype                                      treatment regimes              in-hospital outcome Parissis JT, et al. Int J Cardiol. 2012;157(1):108-13. 
  9. 9. Age and functional status in Age and functional status in  patients with AHF (patients with AHF (diabeticdiabeticss  vs.vs.   non-diabeticnon-diabetics)s) Clinical Clinical  characteristicscharacteristics Diabetics Diabetics  (N=2229, (N=2229, 45%45%)) Non diabetics Non diabetics  (N=2724, 55%)(N=2724, 55%) pp Age (y)Age (y) <0.0001<0.0001 <55<55 56-8056-80 >80>80 10.2%10.2% 76.8%76.8% 12.7%12.7% 20.3%20.3% 62.7%62.7% 16.8%16.8% Functional status before admission 0.0330.033 NYHA I-IINYHA I-II NYHA III-IVNYHA III-IV 9.1%9.1% 71.8%71.8% 12.0%12.0% 69.9%69.9% Parissis JT, et al. Int J Cardiol. 2012;157(1):108-13. 
  10. 10. Clinical presentations and Clinical presentations and  precipitating factors in patients with precipitating factors in patients with  AHF (AHF (diabeticdiabeticss  vs.vs. non-diabetic non-diabetics)s) Clinical characteristicsClinical characteristics DiabeticsDiabetics Non diabeticsNon diabetics pp ClinicalClinical presentationpresentation <0.0001<0.0001 <0.0001<0.0001 <0.0001<0.0001 Acutely Acutely  decompensated decompensated CHFCHF Acute de novo HFAcute de novo HF Pulmonary edemaPulmonary edema 69.1%69.1% 30.9%30.9% 39.3%39.3% 59.6%59.6% 40.4%40.4% 34.7%34.7% Precipitating factors <0.0001<0.0001 <0.0001<0.0001 ACSACS Valvular heart diseaseValvular heart disease 44.1%44.1% 11.1%11.1% 30.9%30.9% 15.3%15.3% Parissis JT, et al. Int J Cardiol. 2012;157(1):108-13. 
  11. 11. Cardiogenic shock develops more often Cardiogenic shock develops more often  among diabetics with acute MIamong diabetics with acute MI Lindholm MG, Eur J Heart Fail 2005
  12. 12. Prognostic impact of diabetes in Prognostic impact of diabetes in  acute decompensated heart failureacute decompensated heart failure Burger AJ, Am J Cardiol 2005 The Vasodilation in the Management of Acute Congestive HF (VMAC) trial
  13. 13. Strong predictors of survival in DM patientsStrong predictors of survival in DM patients SBPSBP ≤≤100mmHg100mmHg – survival rate 74%, SBP 101-120mmHg – survival rate 92%– survival rate 74%, SBP 101-120mmHg – survival rate 92% SBP 121-159mmHg – survival rate 96%, SBP ≥160mmHg – survival rate 96%SBP 121-159mmHg – survival rate 96%, SBP ≥160mmHg – survival rate 96% Log rank=213.7, p<0.001 Parissis JT, et al. Int J Cardiol. 2012;157(1):108-13. 
  14. 14. Insulin-Dependent Diabetes Is AssociatedInsulin-Dependent Diabetes Is Associated With Increased Mortality in Patients With AdvancedWith Increased Mortality in Patients With Advanced Heart FailureHeart Failure 624 patients with advanced HF and systolic dysfunction. Smooky and Fonarow, AHJ 2005. P=0.0002 No DM DM, no insulin DM, insulin 0 20 40 60 80 100 0 1 2 3 4 5 6 7 8 9 10 11 12 Months Survival(%)
  15. 15. 0 1 2 3 4 5 6 7 8 20 40 60 80 100 Nondiabetic subjects without prior MI Diabetic subjects without prior MI Nondiabetic subjects with prior MI Diabetic subjects with prior MI Years Survival (%) Diabetes and AHF  Diabetes and AHF   Etiology of HF vs. risk of death Etiology of HF vs. risk of death  Haffner SM et al. NEJM 1998;339:229–234 Patients with DM but no CHD experience a similar rate of death as  patients without DM but with CHD
  16. 16. In-hospital outcome In-hospital outcome in acute heart in acute heart  failure (failure (diabeticdiabetics vss vs non-diabetic non-diabetics)s) OutcomeOutcome DiabeticsDiabetics Non diabeticsNon diabetics pp DeathDeath 11.7%11.7% 9.8%9.8% 0.010.01 Functional status on dischargeFunctional status on discharge 0.0160.016 NYHA I-IINYHA I-II 64%64% 67%67% NYHA III-IVNYHA III-IV 36%36% 33%33% Parissis JT, et al. Int J Cardiol. 2012;157(1):108-13. 
  17. 17. Positive predictors n Beta/blockers * (p= 0.014) n ACEi/ARBs* (p <0.001) n PCI (p <0.001) Negative predictors n Age (p=0.032) n SBP<100mmHg (p<0.001) n Non compliance (p=0.005) n Arterial hypertension (p=0.022) n Cr >1.5mg/dl (p=0.029) n LVEF <50% (p <0001) n Lenth of stay in CCU (p= 0.021) * Before admission Predictors of in-hospital outcome Predictors of in-hospital outcome  of patients with diabetes and of patients with diabetes and AHFAHF Parissis JT, et al. Int J Cardiol. 2012;157(1):108-13. 
  18. 18. nn Multinational cohortMultinational cohort nn 6,212 patients with AHF6,212 patients with AHF nn Europe, USA, Asia, AfricaEurope, USA, Asia, Africa nn EElevated blood glucose at admission levated blood glucose at admission  to predict to predict all-cause mortality by 30 all-cause mortality by 30  daysdays Mebazaa A, et al. J Am Coll Cardiol. 2013;61(8):820-9. 
  19. 19. Hyperglycemia is a predictor of poor outcome in AHF Arch Intern Med. 2009;169(5):438-446 InHospitalMortality(%) Average Post-admission Glucose
  20. 20. Multivariate analysis of factors associated Multivariate analysis of factors associated  with 30-Day mortality in a fully adjusted with 30-Day mortality in a fully adjusted  modelmodel Mebazaa A, et al. J Am Coll Cardiol. 2013;61(8):820-9. 
  21. 21. 30-Day Mortality rates according to  the level of glucose Cumulative hazard for  death associated with  hyperglicemia in AHF Blood glucose concentration at admission –  powerful predictor in AHF Mebazaa A, et al. J Am Coll Cardiol. 2013;61(8):820-9. 
  22. 22. Risk of death and elevated blood  glucose level in presence/absence  of DM on admission Mebazaa A, et al. J Am Coll Cardiol. 2013;61(8):820-9. 
  23. 23. 30-day mortality and hyperglycemia: 30-day mortality and hyperglycemia:  Comparison among various continentsComparison among various continents
  24. 24. Umpierrez GE et al. J Clin Endocrinol Metab. 2002;87:978-982. Hyperglycemia Is an independent marker of in- patient mortality in patients with undiagnosed diabetes In-hospital Mortality Rate (%) Newly Discovered Hyperglycemia Patients With History of Diabetes Patients With Normoglycemia P < 0.01 P < 0.01
  25. 25. Hyperglicemia and AHF:Hyperglicemia and AHF: Treatment targetsTreatment targets
  26. 26. Myocardial remodelling in HFPEF Importance of comorbidities for systemic proinflammatory state Paulus WJ, Tschöpe C. J Am Coll Cardiol 2013;62(4):263-71
  27. 27. Kidney function is a key factor in Kidney function is a key factor in  AHF worsening in diabetes AHF worsening in diabetes 
  28. 28. Differences in therapeutic modalities Differences in therapeutic modalities  of AHF during hospitalizationof AHF during hospitalization TherapyTherapy DMDM non-DMnon-DM pp Beta-blockersBeta-blockers DigoxinDigoxin Oral/TTS nitratesOral/TTS nitrates CCBCCB AspirinAspirin ClopidogrelClopidogrel Nitrates i.v.Nitrates i.v. DopamineDopamine AdrenalineAdrenaline 49.7%49.7% 32.0%32.0% 31.0%31.0% 0.9%0.9% 61.7%61.7% 21.4%21.4% 48.6%48.6% 14.6%14.6% 2.6%2.6% 45.0%45.0% 27.3%27.3% 20.6%20.6% 2.0%2.0% 53.4%53.4% 16.2%16.2% 35.1%35.1% 11.7%11.7% 4.3%4.3% 0.0010.001 <0.001<0.001 <0.001<0.001 0.0020.002 <0.001<0.001 <0.001<0.001 <0.001<0.001 0.0030.003 0.0020.002 InterventionalInterventional CABGCABG PCIPCI 3.8%3.8% 15.3%15.3% 2.2%2.2% 10.8%10.8% 0.0010.001 <0.001<0.001 Parissis JT, et al. Int J Cardiol. 2012;157(1):108-13. 
  29. 29. Glucose control in AHF with T2D oftenGlucose control in AHF with T2D often unknown or untreated at dischargeunknown or untreated at discharge
  30. 30. tt Short acting insulinShort acting insulin tt MMetformin and etformin and  sulfonylureas (after sulfonylureas (after  clinical stabilization, clinical stabilization,  no severe renal no severe renal  dysfunction)dysfunction) tt Avoid glitazonesAvoid glitazones tt New antiglycemic New antiglycemic  drugs minor?drugs minor? Acute heart failure: Acute heart failure:  Hyperglycemic control Hyperglycemic control  strategystrategy
  31. 31. § Diabetes is frequently associated with AHF § AHF and diabetes are frequently associated with CAD and several co- morbidities § Diabetics with AHF have higher in-hospital and long term mortality/morbidity § Age, low LVEF, renal function, low SBP, ACS and absence of life saving therapies were more frequent in high risk group Acute heart failure and diabetes: frequently associated Conclusions
  32. 32. From Cradle to Grave (Michael Johnson, 2007) CARDIODIABETIC CONTINUUM

×