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Cardiovascular Outcomes and Diabetes Status in Patients With HFpEF
TAKE-HOME MESSAGE
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This study compared clinical characteristics, echocardiographic findings, and overall outcomes of patients with heart failure with preserved ejection fraction (HFpEF) with coexisting diabetes with those without diabetes. The participants with HFpEF with comorbid diabetes exhibited higher NT-proBNP levels, had more history of MI, more signs of congestion, poorer quality of life, and more cardiographic abnormalities compared with patients without diabetes.
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The authors concluded that improving outcomes in patients with HFpEF with diabetes will depend on further research into the specific mechanisms by which diabetes affects heart structure and function and directing interventions accordingly.
abstract
This abstract is available on the publisher's site.
Access this abstract nowBACKGROUND
In patients with HF and preserved ejection fraction (HFpEF), little is known about the characteristics of and outcomes in those with and without diabetes.
METHODS
We examined clinical and echocardiographic characteristics and outcomes in the Irbesartan in Heart Failure with Preserved Ejection Fraction trial (I-Preserve), according to history of diabetes. Cox regression models were used to estimate hazard ratios (HR) for cardiovascular outcomes adjusted for known predictors, including age, sex, natriuretic peptides, and comorbidity. Echocardiographic data were available in 745 patients and were additionally adjusted for in supplementary analyses.
RESULTS
Overall, 1134 of 4128 patients (27%) had diabetes. Compared to those without diabetes, they were more likely to have a history of myocardial infarction (28% vs. 22%), higher BMI (31kg/m(2) vs. 29kg/m(2)), worse Minnesota living with HF score (48 vs. 40), higher median NT-proBNP concentration (403 vs 320 pg/ml; all p<0.01), more signs of congestion but no significant difference in LVEF. Patients with diabetes had a greater left ventricular (LV) mass and left atrial area than patients without diabetes. Doppler E wave velocity (86 vs 76 cm/sec, p<0.0001) and the ratio of E/e' (11.7 vs 10.4, p=0.010) were higher in patients with diabetes. Over a median follow-up of 4.1 years, cardiovascular death or HF hospitalization occurred in 34% of patients with diabetes vs. 22% of those without diabetes; adjusted HR 1.75 (95% CI 1.49-2.05) and 28% vs. 19% of patients with and without diabetes died; adjusted HR 1.59 (1.33-1.91).
CONCLUSIONS
In HFpEF, patients with diabetes have more signs of congestion, worse quality of life, higher NT-proBNP levels, and a poorer prognosis. They also display greater structural and functional echocardiographic abnormalities. Further investigation is needed to determine the mediators of the adverse impact of diabetes on outcomes in HFPEF, and whether they are modifiable.
Additional Info
Disclosure statements are available on the authors' profiles:
Clinical and Echocardiographic Characteristics and Cardiovascular Outcomes According to Diabetes Status in Patients With Heart Failure and Preserved Ejection Fraction: A Report From the Irbesartan in Heart Failure With Preserved Ejection Fraction Trial (I-Preserve)
Circulation 2017 Jan 04;[EPub Ahead of Print], SL Kristensen, UM Mogensen, PS Jhund, MC Petrie, D Preiss, S Win, L Køber, RS McKelvie, MR Zile, IS Anand, M Komajda, JS Gottdiener, PE Carson, JJ McMurrayFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Diabetes is a potent risk factor for heart failure and portends worse prognosis among patients with prevalent heart failure, regardless of LVEF. However, the mechanisms responsible for this heightened risk are unclear, particularly when LVEF is preserved. In this study, Kristensen et al performed a well-designed post hoc analysis of the I-PRESERVE database to better characterize heart failure with preserved ejection fraction (HFpEF) in patients with diabetes compared with patients without diabetes. Among the 4128 patients enrolled in this large randomized controlled trial, the 1134 patients with diabetes had similar LVEF and NYHA functional class compared with those without diabetes. Despite this, diabetic patients had more frequent signs and symptoms of congestion, worse quality of life reflected in higher Minnesota Living with Heart Failure score, higher NT-proBNP levels, greater risk of the composite of cardiovascular death and heart failure hospitalization, and greater risk of all-cause mortality.
Using data from the 745 patients included in the I-PRESERVE echocardiographic substudy, the researchers provide potential mechanistic insights into these associations by showing that diabetic patients had higher LV mass index, E/e’ ratio, and left atrial volume, all suggestive of worse LV diastolic function in diabetic patients compared with nondiabetic HFpEF patients.
Further research is necessary to better define why diabetic patients with HFpEF do so much worse, and whether specific interventions can modify this risk. However, the findings of Kristensen et al advance our understanding of the unique clinical profile of HFpEF patients with diabetes and of potential mechanisms responsible for their heightened risk of adverse outcomes. These findings also alert the clinician to pay particular attention to identify and treat congestion in diabetic HFpEF patients, especially given the association of certain oral hypoglycemic agents with sodium and water retention.