Heart failure in the patient with diabetes: Epidemiology, aetiology, prognosis, therapy and the effect of glucose‐lowering medications

Abstract

In people with type 2 diabetes the frequency of heart failure (HF) is increased and mortality from HF is higher than with non-diabetic HF. The increased frequency of HF is attributable to the cardiotoxic tetrad of ischaemic heart disease, left ventricular hypertrophy, diabetic cardiomyopathy and an extracellular volume expansion resistant to atrial natriuretic peptides. Activation of the renin-angiotensin-aldosterone system and sympathetic nervous systems results in cardiac remodelling, which worsens cardiac function. Reversal of remodelling can be achieved, and cardiac function improved in people with HF with reduced ejection fraction (HFrEF) by treatment with angiotensin-converting enzyme inhibitors and β-blockers. However, with HF with preserved ejection fraction (HFpEF), only therapy for the underlying risk factors helps.Blockers of mineralocorticoid receptors may be beneficial in both HFrEF and HFpEF. Glucoselowering drugs can have a negative effect (insulin, sulphonylureas, dipeptidyl peptidase-4 inhibitors and thiazolidinediones), a neutral effect (α-glucosidase inhibitors and glucagon-like peptide-1 receptor agonists) or a positive effect (sodium-glucose co-transporter-2 inhibitors and metformin).antidiabetic drug, GLP-1 analogue, heart failure, insulin therapy, SGLT2 inhibitor, thiazolidinediones 1 | INTRODUCTION Heart failure (HF) results from structural and/or functional impairment of ventricular filling and/or ejection 1 and it is a common and serious comorbidity of type 2 diabetes. 2 In the present review we document the increased incidence of HF, and the reasons for this increase, as well as its poor prognosis in patients with diabetes.The potential therapies to both prevent and treat HF are discussed, in addition to the positive and negative effects of glucoselowering medications.Several reviews on this important subject have been recently published 3-7 ; however, this is a rapidly evolving field. An important limitation has been that HF was not a primary endpoint in most cardiovascular (CV) outcome trials, and it has been the most heterogeneously distributed outcome. | EPIDEMIOLOGYAs long ago as the Framingham Heart Study, HF was shown to be twice as common in men with diabetes and five times more common in women with diabetes between the ages of 45 and 74 years when compared with age-matched non-diabetic controls, and, in those aged ≤65 years, there was a fourfold increase in the prevalence of HF in men with diabetes and an eightfold increase in women with diabetes. 8In almost 10 000 patients with type 2 diabetes enrolled in a Health Maintenance Organization, 12% had HF at entry. Independent risk factors for the presence of HF were older age, longer duration of diabetes, use of insulin and lower body mass index (BMI). 9 In addition, those with type 2 diabetes who did not have HF at entry developed HF at a rate of 3.3% per year. The Reykjavik Study reported a 12% prevalence of HF in people with diabetes compared with 3% in people

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