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Heart failure deserves more scrutiny as a
complication of type 2 diabetes
While much attention is given to the microvascular effects of type 2
diabetes, such as diabetic retinopathy, nephropathy, neuropathy; and
macrovascular consequences such as stroke, myocardial infarction, and
peripheral vascular disease, heart failure is a seventh and more sinister
complication that raises mortality.
T
his conclusion was based on an
in-depth session entitled, “Heart
Failure: The Frequent, Forgotten
and Often Fatal Complication of Type 2
Diabetes”.
David S.H. Bell, MD, of the University of Ala-
bama at Birmingham School of Medicine,
has performed clinical trials on the effects of
angiotensin II receptor blockers in patients
with diabetes and diastolic dysfunction. He
suggested that the evidence should pro-
pel endocrinologists to screen symptomatic
patients more rigorously and to consider
treating heart failure to mitigate the poor
outcomes often seen in these patients.
He said, “It’s not widely realized how
common this condition is. Between 40
and 45% percent of US patients with
diabetes suffer heart failure vs 12% of
nondiabetics. Mortality depends on the
degree of glycemic control.”
Dr Bell highlighted studies that examined
the complex effect of diabetes
and contributing factors to the
three causes of the heart fail-
ure, including coronary artery
disease, left ventricular hyper-
trophy (approximately 65% of
patients with type 2 diabetes),
and diabetic cardiomyopathy.
Richard E. Gilbert, MD, PhD,
FRCPC, of the University of
Toronto, Canada, noted that
anti-heart failure therapies such
as angiotensin-converting-
enzyme inhibitors and others
work similarly well in individuals
with diabetes as in thosewithout
diabetes. The glucose-lowering
drug dipeptidylpeptidase-4
inhibitor saxagliptin, however,
has been found to increase heart failure
in patients with diabetes.
An expert in kidney disease and diabetes
as major, independent risk factors for the
development of heart failure, Dr Gilbert
highlighted the relation between gly-
cemic control and heart failure risk. He
focused on evidence of the detrimental
and beneficial effects of various types of
hypoglycemic drugs.
Aaron I. Vinik, PhD, FCP, MACP, FACE, of
Eastern Virginia Medical School, Norfolk,
presented his research on autonomic
neuropathy, one of the most overlooked
complications of type 2 diabetes, contrib-
uting to the high incidence of heart failure.
Vascular damage extends to involuntary
nerves that stimulate the heart and blood
vessels, resulting in heart rate and vascu-
lar abnormalities.
Dr Vinik noted that autonomic system
dysfunction is a predictor of cardiovas-
cular risk and sudden death in patients
with type 2 diabetes. Autonomic dysfunc-
tion also occurs in prediabetes, offering
opportunities for early intervention. Impor-
tant technological advances in technology
during the past decade allow for identi-
fication of early stages of autonomic
dysfunction using objective, standardized
measurements.
PracticeUpdate Editorial Team
consistent with diabetic ketoacidosis.
Records were reviewed on 224 patients with
diabetic ketoacidosis and 151 individuals
with diabetes but not diabetic ketoacidosis
(beta-hydroxybutyrate <3.8 mmoL/L).
Among patients with diabetic ketoacido-
sis, serum bicarbonate was >18 mEq/L in
17%, consistent with previous reports. Urine
ketones were negative to trace in 21%,
and glucose was <250 mg/dL in 4%. Urine
ketones and serum bicarbonate were both
negative for diabetic ketoacidosis in 7%.
Among individuals who did not experience
diabetic ketoacidosis, 17% harbored small
to large urine ketones, 18% serum bicarbo-
nate ≤18 mEq/L, and 4%, both. Thus, 35% of
patients who experienced diabetic ketoac-
idosis as defined by beta-hydroxybutyrate
lacked one or more American Diabetic
Association diagnostic laboratory criteria.
Thirty-one percent who did not experi-
ence diabetic ketoacidosis fulfilled criteria
for diabetic ketoacidosis with respect to
serum bicarbonate, ketonuria, or both.
When patients with diabetes who are
admitted to the hospital are characterized
as suffering from diabetic ketoacidosis
or not based on admission beta-
hydroxybutyrate, substantial discordance
with American Diabetes Association
diagnostic criteria is observed.
Specifically, serum bicarbonate and
urine ketones were often at odds with
beta-hydroxybutyrate results. This is not
surprising, considering the limitations of the
urine ketone test and the fact that a serum
bicarbonate ≤18 mEq/L is not specific for
diabetic ketoacidosis.
The results argue in favor of the use of
serum beta-hydroxybutyrate to diagnose
diabetic ketoacidosis, at least in hospi-
tals with sufficient admissions for diabetic
ketoacidosis to justify test availability.
Dr Miles concluded that beta-hydroxybu-
tyrate measurement should not supersede
clinical judgment in the care of patients
with diabetic ketoacidosis, but the meas-
urement does add diagnostic rigor.
PracticeUpdate Editorial Team
If validated in other studies,
interventions may be
designed to reduce hospital
readmissions in this
population. Such
interventions could help save
the healthcare system
billions of dollars.
Anti-heart failure therapies
such as angiotensin-
converting-enzyme
inhibitors and others work
similarly well in individuals
with diabetes as in those
without diabetes.
© Photo by Jean Whiteside/AACE 2017
AACE 2017
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VOL. 1 • NO. 1 • 2017