Clinical Phenotypes and In-hospital Management and Prognosis in Diabetic versus Non-diabetic Patients with Acute Heart Failure in ALARM-HF Registry

Transcription

1 Clinical Phenotypes and In-hospital Management and Prognosis in Diabetic versus Non-diabetic Patients with Acute Heart Failure in ALARM-HF Registry J T. Parissis, A. Mebazaa, V. Bistola, I. Ikonomidis, J. Delgado, F. Vilas-Boas, M. Anastasiou-Nana, D. Kremastinos, A. Mclean, F. Follath For ALARM-HF investigators

2 Disclosures Research grants by Abbott USA and Orion- Pharma as a member of steering committee of ALARM-HF Survey

3 Prevalence of Diabetes in Patients With Heart Failure: Clinical Trials Clinical Trial Diabetic Patients SOLVD 25.8% MERIT-HF 24.5% ELITE II 24.0% Val-HeFT 25.4% COPERNICUS 25.7% OPTIME-CHF (hospitalized) 44.2% VMAC (hospitalized) 47.0% SOLVD=Studies of Left Ventricular Dysfunction. MERIT-HF=Metoprolol Randomized Intervention Trial in Heart Failure. ELITE II=Evaluation of Losartan in the Elderly. Val-HeFT=Valsartan Heart Failure Trial. COPERNICUS=Carvedilol Prospective Randomized Cumulative Survival. OPTIME-CHF=Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure. VMAC=Vasodilation in the Management of Acute Congestive Heart Failure.

4 Relationship Between Diabetes and Heart Failure Prevalence: US population, 4%-6%; HF patients, 22%-48% Diabetes mellitus Heart failure

5 Insulin-Dependent Diabetes Is Associated With Increased Mortality in Patients With Advanced Heart Failure Survival (%) DM, no insulin No DM P= DM, insulin patients with advanced HF and systolic dysfunction. Smooky and Fonarow, AHJ Months

6 DM and mortality in HF: clinical trial populations Mac Donald et al. Eur Heart J 2008;29:

7 Heart Failure Due to Systolic Dysfunction and Mortality in Diabetes: Pooled Analysis of 39,505 Subjects Kamalesh and Cleopas, J Card Fail 2009;15:

8 DM and Hospitalizations in HF Kamalesh and Cleopas, J Card Fail 2009;15:

9 Pathopysiologic mechanisms Diabetic cardiomyopathy (microvasculopathy, fibrosis, cellular hypertrophy) Diastolic dysfunction (abnormal collagen deposition, abnormal calcium handling) Ischemic cardiomyopathy (MI, chronic ischemia)

10 Mechanisms of heart dysfunction in DM Mac Donald et al. Eur Heart J 2008;29:

11 Prevalence of DM in AHF registries

12 Prognostic Impact of Diabetes Mellitus in Patients With Acute Decompensated HF (VMAC Trial) Am J Cardiol 2005;95:1117

13 Influence of diabetes on characteristics and outcomes in patients hospitalized with HF Greenberg et al. Am Heart J 2007;154:277.e1-277.e8.

14 ALARM-HF: a view of AHF management across a wide variety of countries ALARM-HF Study - 9 Country Panel Analysis patient case share by country 66% cardiology 33% ICU Australia 5% Mexico 12% France 12% Germany 12% Top 5 EU = 65% Turkey 13% Greece 5% Italy 14% UK 13% Spain 14% ALARM-HF 9 Country (4,953 patients)

15 EHS HF II vs ALARM: Underlying CV comorbidities Acute heart failure patient CV co-morbidities: All AHF vs ADCHF vs Novo AHF patients 80% 70% 60% 50% 40% 30% 20% 10% 0% 72% 70% 66% 63% 49% 45% 38% 33% 54% 34% 31% 25% EHS HF II All AHF ADCHF De novo 39% 32% 30% 25% 24% 14% 13% most common co-morbidities = hypertension (70%), diabetes (45%) Sample = All AHF patients (4,953) vs ADCHF (3,161) vs De Novo AHF patients (1,792) Follath et al. Intensive Care Medicine 2010

16 Diabetics vs Non Diabetics in ALARM-HF: demographics Clinical characteristics Diabetics Non diabetics p value Age (years) < < % 20.3% % 62.7% > % 17.0% Sex Male 59.8% 64.5% Female 40.2% 35.5% J Parissis on behalf of ALARM Steering Committee

17 ESC Clinical classification in Diabetics vs Non-Diabetics (ALARM-HF) p <

18 Co-morbidities in diabetics vs nondiabetics with AHF Cardiovascular comorbidities Diabetics Non diabetics p value Chronic heart failure 41.6% 32.0% < CAD 35.5% 26.7% < Cardiomyopathy 10.5% 14.5% < Atrial fibrillation/flutter 24.5% 24.3% Peripheral vascular disease 11.6% 6.7% < Obesity 34.5% 19.9% < Dyslipidemia 53.0% 33.1% < Hypertension 81.6% 60.8% < Non cardiovascular comorbidities Chronic renal disease 29.5% 14.7% < Anemia 16.8% 12.4% < Depression 9.3% 7.9% <0.01 Dementia 4.6% 3.8% Hyponatremia 7.7% 4.8% < Asthma/COPD 29.3% 21.1% < J. Parissis on behalf of ALARM investigators

19 In-hospital Mortality of Diabetics vs Non-Diabetics With AHF (ALARM-HF) 12 11, ,5 p = Death 9,5 9 8,5 Diabetics Non diabetics

20 ACS as precipitating factor of AHF in Diabetics vs Non-Diabetics (ALARM-HF) p < Acute coronary syndrome Diabetics Non diabetics

21 AHF Therapies in Diabetics vs Non-Diabetics (ALARM-HF) p < p = 0.043

22 Treatment modalities in diabetics vs non-diabetics with AHF Interventional PCI 15.3% 10.8% < CABG 3.8% 2.2% ICD/CRTs 4.9% 4.7% IABP 5.0% 4.7% J. Parissis on behalf of ALARM investigators

23 Prognostic Factors in Diabetics with AHFS (ALARM-HF) Parameter OR 95%CI P Negative predictors Age SBP<100 mmhg < Precipitating factors: ACS Non compliance Cardiovascular comorbidities: Arterial hypertension Serum creatinine >1.5mg/dl LVEF<50% < Length of stay in the CCU Positive predictors Admission therapy: Beta-blocker ACEi/ARB < Nitrates PCI < J. Parissis on behalf of ALARM investigators

24 Conclusions Diabetes is highly prevalent in hospitalized patients with AHF. AHF patients with diabetes have more frequently underlying ischemic heart disease and multiple comorbidities. Diabetics with AHF have higher in-hospital mortality than non-diabetic patients despite their intensive treatment regimens. Age, LVEF, renal function, SBP, ACS and absence of life saving therapies at admission may identify high risk diabetics with AHF.