Diabetes and the Heart

Transcription

1 Diabetes and the Heart Jeffrey Boord, MD, MPH Advances in Cardiovascular Medicine Kingston, Jamaica December 6, 2012

2 Outline Screening for diabetes in patients with CAD Screening for CAD in patients with diabetes Insulin resistance, diabetes, and heart failure Managing diabetes in heart failure patients

3 A 51 year old male with hypertension, obesity (BMI 32), and dyslipidemia presents to the emergency department with chest pain and is diagnosed with acute non-st elevation myocardial infarction He takes hydrochlorothiazide 25 mg daily and simvastatin 10 mg daily His admission labs: serum glucose 177 mg/dl creatinine 1.1 mg/dl cholesterol 190 mg/dl, HDL 32, Trig 270 LDL 104 mg/dl

4 Risk factors and Diagnostic Criteria for Diabetes (ADA Guidelines) Criteria for Diagnosis of Diabetes A1C 6.5% OR Fasting plasma glucose (FPG) 126 mg/dl (8 hr fast) OR 2 hour plasma glucose 200 mg/dl during a 75 gram oral glucose tolerance test (OGTT) OR OR Hyperglycemic symptoms and random plasma glucose 200 mg/dl Categories at increased risk for diabetes A1C % FPG mg/dl 2 hr glucose on OGTT mg/dl Risk factors for DM Hypertension HDL <35 or TRG >250 History of CVD Obesity Sedentary 1 st degree relative with DM High risk race/ethnicity (African American, Latino, Native American, Asian American, Pacific Islander) Women with gestational DM or who delivered baby > 9 lb PCOS Diabetes Care 2012; 35:S11-S63

5 Diabetes & Cardiovascular Disease Cardiovascular disease is the leading cause of death for people with diabetes In adults with diabetes: 68% die of heart disease or stroke the risk for stroke is two to four times higher 67% have high blood pressure smoking doubles the risk for heart disease National Diabetes Fact Sheet, CDC,

6 American Heart Association Hyperglycemia in ACS Recommendations* Glucose should be part of initial lab evaluation in all patients with ACS In patients admitted to the ICU with ACS, glucose should be monitored closely. Until further data are available, approximation of normoglycemia appears to be a reasonable goal (suggested mg/dl) as long as hypoglycemia is avoided IV insulin infusion is most effective for controlling glucose in ICU patients In non-icu setting glucose should be maintained <180 mg/dl with subcutaneous insulin regimens ACS patients with hyperglycemia but w/o prior DM should have further evaluation (fasting glucose, A1c, and/or post-discharge OGTT) Approximately 25-34% of patients with admitted for acute MI have undiagnosed diabetes Before discharge, plans for optimal outpatient glucose control should be determined in patients with diabetes *Circulation 2008; 117: Diab Care 2008;31:36-8 Diab Care 2003;26:2770-6

7 Measuring A1c in acute MI patients with Diabetes Assessment of A1c measurement or documentation of value (<3 mo) on Acute MI admission 47% of patients had A1c available Hospital assessment range 7-81% 39% good control (<7%) 36% poor control (7-9%) 25% very poor control (>9%) A1c assessment and glucose therapy intensification (GTI) Diab Care 2012, 35: Am J Card 2010, 105:

8 A= A1c and Antiplatelet Tx Appropriate glycemic control Aspirin, thienopyridine B= Blood Pressure ACEI or ARB (especially if DM, prior MI, CHF, nephropathy) Beta blocker for CHF, post-mi C= Cholesterol D= Diet E= Exercise and Lifestyle Cardiac Rehab when available Smoking cessation Weight reduction for obesity The ABCs

9 A 51 year old male with hypertension, obesity (BMI 32), and dyslipidemia with recent non-st elevation myocardial infarction A= B= C= ASA and clopidogrel A1c=7.7% > start metformin add Beta blocker and ACEI or ARB LDL=104, intensify statin regimen D, E= diet counseling, exercise prescription, weight loss

10 46 year old female with obesity, type 2 diabetes, hypertension, hypercholesterolemia presents to your office for follow up. Meds: metformin, lisinopril, pravastatin, HCTZ Her mother recently died of a heart attack at age 68 She feels well and denies any symptoms, but she asks if she should be screened for heart disease

11 Silent Myocardial Ischemia (SMI) in Diabetes 44% of all nonfatal Q-wave MIs found on ECG in a cohort of patients with type 2 diabetes were silent Diabetologia 2004; 47:395-9 Silent myocardial infarction accounted for 55% of all nonfatal MI events in DCCT/EDIC type 1 diabetes groups NEJM 2005; 353: % of asymptomatic type 2 DM patients with 2 additional risk factors have silent ischemia Diabetes Care 2005; 28: SMI by exercise stress testing is predictive of future cardiac events (OR=4.1) Diabet Med 2004; 21:

12 Screening for CAD in type 2 DM The notion of screening in asymptomatic patients is attractive given the high prevalence However, screening of patients must provide prognostic information that improves risk stratification (beyond conventional RF) For screening to be effective, an intervention must exist that can be differentially applied based on test results and that leads to better clinical outcomes J Clin Endocrinol Metab 97: , 2012

13 Screening for CAD in type 2 DM ADA Guideline: In asymptomatic patients, routine screening [i.e. stress testing] for CAD is not recommended, as it does not improve outcomes as long as CVD risk factors are treated Generally speaking, all high risk patients should get similar CV risk reduction therapy- this mitigates the benefit of screening Optimal medical therapy (OMT) has similar outcomes compared to revascularization in patients with DM and stable CAD (COURAGE, BARI-2D) Excludes severe LV dysfunction, high risk /multivessel disease More research is needed: balancing benefits, risks, and costs J Clin Endocrinol Metab 97: , 2012

14 Screening- a suggested approach Resting ECG is useful and appropriate in patients with type 2 DM and other risk factors Ask about exercise/activity tolerance regularly Have a low threshold for diagnostic stress testing in high risk patients with atypical symptoms Individualize risk factor management

15 Antiplatelet therapy: ADA Guidelines Consider aspirin therapy (75 162mg/day) as a primary prevention strategy in type 1 or type 2 diabetes at increased cardiovascular risk (10-year Risk >10%) includes most men >50 years or women >60 years of age with 1 or more additional RF Aspirin should not be recommended for CVD prevention for adults with diabetes at low CVD risk (10-year CVD risk <5%, such as in men <50 years and women <60 years with no major additional CVD risk factors) In patients in these age-groups with multiple other risk factors (e.g., 10-year risk 5 10%), clinical judgment is required Use aspirin therapy ( mg/day) as a secondary prevention strategy in those with diabetes with a history of CVD (or clopidogrel in aspirin intolerant) Diabetes Care 2012; 35:S11-S63

16 Why the change in guidelines for aspirin therapy for primary CV prevention in diabetes? No contemporary large single randomized controlled trial has shown clear benefit of ASA for primary prevention in patients with diabetes and no baseline CVD Meta-analysis of available trial data show trend towards benefit in prevention of CV events, but these are not conclusive CHD events risk ratio (95%CI) 0.91 (0.79, 1.05) Stroke risk ratio (95%CI) 0.85 (0.66,1.11) Need to integrate potential benefits and harms of aspirin therapy Excess GI bleeding risk ~1-5 per 1000 per year Excess Hemorrhagic stroke risk ~1 per 10,000 per year ADA/AHA/ACCF Scientific Statement- Aspirin for Primary Prevention of CV Events in People with Diabetes. Circulation June 22,

17 Diabetes and Heart Failure Prevalence of HF in diabetes patients is 9-22% Est. prevalence of asymptomatic diastolic dysfunction in DM is 52-60% Prevalence of diabetes in HF patients 23-44% in registry studies Patients with diabetes have a worse prognosis from HF, regardless of LVEF Predictors for HF: elevated BMI, renal dysfunction, insulin use/longer duration of diabetes Each 1% increase in A1c associated with 8% increased risk for HF Voors A, Heart 2011;97:

18 Kaplan-Meier estimates of the proportion of patients with hospitalization for CHF divided into classes of glycemia at baseline (log rank P<0.001). Held C et al. Circulation 2007;115:

19 Potential contributors to the development of diabetic cardiomyopathy Copyright American Heart Association Boudina S, Abel E D Circulation 2007;115:

20 Impaired Insulin Sensitivity and Mortality in HF Impaired insulin sensitivity is related to decreased exercise capacity Insulin resistance correlates with degree of HF in ischemic and nonischemic HF Insulin sensitivity predicts mortality in HF Higher IS Lower IS J Am Coll Cardiol 2005;46:

21 Diabetes therapy and HF Insulin resistance likely plays role in HF: associated with neurohormonal activation, endothelial dysfunction, oxidative stress, altered myocyte metabolism TZDs (rosiglitazone, pioglitazone) improve insulin sensitivity, but increase risk for development of clinical HF Metformin has been associated with better HF outcomes in retrospective cohort studies compared to those treated with sulfonylurea or insulin The relationship between metformin use and lactic acidosis in HF is debated- degree of excess risk (if any) is unclear

22 Clinical Diabetes Management in Heart Failure Decompensated/advanced heart failure can be associated with severe insulin resistance Acute hyperglycemia can be a herald for HF exacerbation Fluctuating renal function and congestive hepatopathy in decompensated HF can complicate diabetes management Insulin is the way to go for glycemic management in acute decompensated HF Though DPP4 inhibitors and GLP1 agonists are probably ok in HF, we do not yet have any good CV outcome data