PracticeUpdate: Diabetes

EDITOR’S PICKS 14

Reduced Risk of Heart Failure With Intensified Multifactorial Intervention in Individuals With T2D and Microalbuminuria Diabetologia Take-home message • Previous studies have shown that patients with type 2 diabetes (T2D) are not only at higher risk for developing congestive heart failure (CHF), they also experience significantly worse outcomes in terms of morbidity and mortality. The Steno-2 study compared conventional multifactorial management of patients with T2D and microalbuminuria with intensified multifactorial intervention targeting known modifiable risk factors with lifestyle and medications. After 3.8 years of intervention, patients who received intensified treatment had a reduction in microvascular complications of around 50%, and, after 7.8 years of intervention, a 53% reduction was seen in the intensive treatment group for cardiovascular endpoints. In all, 42 patients from the intensive arm and 24 patients from the conventional treatment arm were able to be followed until 2014. Results of the study showed that the age- and gender-adjusted hazard ratio was 0.30 in the intensive therapy group compared with the conventional therapy group. This reduced risk was associated with a decreased incidence of myocardial infarction in the intensive therapy group, but that could not be the sole factor leading to decreased incidence of heart failure. In addition, the investigators found that the change in plasma NT-proBNP during the first 2 years was significantly associated with developing heart failure, and that those individuals in the conventional treatment arm had significantly higher NT-proBNP levels than the people in the intensive treatment group. • This study brings to light an important and commonly overlooked complication of T2D in patients, which is congestive heart failure. The study also demonstrates clearly that individualized treatment to reduce modifiable risk factors such as blood pressure, HbA1c, microalbuminuria, and cholesterol can significantly reduce the incidence of heart failure in patients with T2D, thus improving all-cause mortality. It is vital for endocrine clinicians to understand that treating T2D is more than just achieving good glycemic control, and other factors should be addressed to ensure the best outcomes. Jason Sloane MD

Abstract AIMS/HYPOTHESIS In type 2 diabetes mellitus, heart failure is a frequent, potentially fatal and often forgotten complication. Glucose-lowering agents and adjuvant therapies modify the risk of heart failure. We recently reported that 7.8 years of intensified compared with conventional mul- tifactorial intervention in individuals with type 2 diabetes and microalbuminuria in the Steno-2 study reduced the risk of cardiovascular disease and prolonged life over 21.2 years of follow-up. In this post hoc analysis, we examine the impact of intensified multifactorial intervention on the risk of hospitalisation for heart failure. METHODS One hundred and sixty individuals were randomised to conventional or intensified multi- factorial intervention, using sealed envelopes. The trial was conducted using the Prospective, Randomised, Open, Blinded Endpoints (PROBE) design. After 7.8 years, all individuals were offered intensified therapy and the study contin- ued as an observational follow-up study for an additional 13.4 years. Heart-failure hospitalisa- tions were adjudicated frompatient records by an external expert committee blinded for treatment allocation. Event rates were compared using a Cox regression model adjusted for age and sex. " …treating T2D is more than just achieving good glycemic control, and other factors should be addressed to ensure the best outcomes. "

RESULTS Eighty patients were assigned to each treatment group. Ten patients undergoing inten- sive therapy vs 24 undergoing conventional therapy were hospitalised for heart failure dur- ing follow-up. The HR (95% CI) was 0.30 (0.14, 0.64), p=0.002 in the intensive-therapy group compared with the conventional-therapy group. Including death in the endpoint did not lead to an alternate overall outcome; HR 0.51 (0.34, 0.76), p=0.001. In a pooled cohort analysis, an increase in plasma N-terminal pro-B-type natriuretic pep- tide (NT-proBNP) during the first two years of the trial was associated with incident heart failure. CONCLUSIONS/INTERPRETATION Intensified, mul-

tifactorial intervention for 7.8 years in type 2 diabetic individuals with microalbuminuria reduced the risk of hospitalisation for heart failure by 70% during a total of 21.2 years of observation. Reduced Risk of Heart Failure With Intensified Multifactorial Intervention in Individuals With Type 2 Diabetes and Microalbuminuria: 21 Years of Follow-up in the Randomised Steno-2 Study. Diabetologia 2018 May 30;[EPub Ahead of Print], J Oellgaard, P Gæde, P Rossing, et al.

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