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Dr. Gregory Weiss provides perspective on recent data detailing the acceleration of heart failure progression associated with a diagnosis of diabetes mellitus.
Diabetes is a well-known risk factor for many types of cardiovascular disease (CVD). If left uncontrolled, diabetes increases the risk for atherosclerotic peripheral arterial and coronary disease while increasing the risk for heart attack, stroke, and death over time.
Decompensated heart failure, which by definition, dramatically limits activities of daily living while posing an imminent threat to life, is a common result in the progression of CVD. Although it has long been known that diabetes and heart failure are linked, the contribution diabetes plays in the progression of heart failure from the preclinical stage to the overt stages has been unclear. Recently, Justin Echouffl Tcheugui, MD, and colleagues at Johns Hopkins University to determine the extent to which unchecked diabetes mellitus contributes to the progression of heart failure in adults.1
To this end, the authors included over 4000 adults with preclinical stage A or B heart failure in their study.1 The primary outcome was progression of heart failure beyond stage B in relation to diabetes and glycemic control, which was defined by HbA1c values obtained during the study period.1 Subjects were obtained from the Atherosclerosis Risk In Communities Study (ARIC), a large longitudinal database funded by the National Institutes of Health and designed to describe the link between medical outcomes and atherosclerosis progression.1
The authors found that patients with preclinical heart failure and uncontrolled diabetes were prone to advance to symptomatic heart failure at a faster rate than those in control. In fact, uncontrolled diabetics in stage A and B heart failure were 1.5 and 1.8 times more likely to progress to overt heart failure, respectively.1
In addition to more rapid progression to symptomatic heart failure, uncontrolled diabetics became symptomatic at a younger age than those with controlled blood glucose levels.1 Two important takeaway messages can be identified in these results. Diabetes is closely linked to heart failure progression and diabetic patients are not being managed to the extent we are capable.
“Our results demonstrate the vulnerability of older adults with co-occurring diabetes and stage A or B heart failure,” authors wrote.1
The authors go on to highlight these results as an opportunity to promote preventative therapies with lifestyle modification and medication adherence being key to stopping the progression to symptomatic heart failure in diabetic patients with cardiovascular disease.1 While an association has been made here between more rapid progression to clinical heart failure in patients with uncontrolled diabetes, the pathophysiology behind that progression has yet to be clarified.
Tcheugui and colleagues agree that more study is needed to reveal the reason heart failure symptoms progress more rapidly and at an earlier age in diabetic patients with elevated HbA1c levels. However, this study shines a light on what a serious problem this is. Stage C and D heart failure are typified by dramatic reductions in the ability to perform activities of daily living without shortness of breath.
Later stages of heart failure require internal defibrillator implantation due to the high risk of sudden cardiac death. Quality of life is everything. There are far more preclinical heart failure patients out in the community than there are patients with overt heart failure symptoms. This means that the opportunity for us to improve the quality of life for a large population of at-risk patients is real and the task urgent.
Time and quality of life are at risk. While the typical heart failure patient is in the latter years of their lives early prevention can not only lengthen those years but also improve them. Early identification and treatment for diabetes are not new concepts. What the authors have done here is highlight the urgency with which we must act to identify patients at risk and intervene before it is too late. We as clinicians must first identify preclinical heart failure patients and then provide the education and treatment they need to steal back the years of high-quality life they deserve.