Diabetes mellitus and chronic heart failure

Diabetes mellitus and chronic heart failure

Archives of Gerontology and Geriatrics 23 (1996) 277-281 ELSEVIER ARCHIVES OF GERONTOLOGY AND GERIATRICS Diabetes mellitus and chronic heart failur...

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Archives of Gerontology and Geriatrics 23 (1996) 277-281

ELSEVIER

ARCHIVES OF GERONTOLOGY AND GERIATRICS

Diabetes mellitus and chronic heart failure Paolo Fumelli*, Fabio Romagnoli, Giorgio Carlino, Cristiana Fumelli, Massimo Boemi Department of Diabetology, I.N.R.C.A., Via della Montagnola, 164, 1-60100 Ancona, Italy

Received 8 May 1996; revised 30 June 1996; accepted 3 July 1996

Abstract Cardiovascular disease has a high prevalence in diabetic patients. Diabetes mellitus is an important risk factor for atherosclerosis and coronary disease mainly through obesity, hyperlipidemia, insulin-resistance, hyperinsulinemia, hyperglycemia and altered homeostasis. The correlation between diabetes and chronic heart failure is not widely documented in the literature. According to the Framingham study, the incidence of cardiovascular morbidity per year is 39.1% in diabetic males and 17.2% in diabetic females; chronic heart failure afflicts 7.6% of diabetic males and 11.4% of diabetic females. Actual knowledge about pathophysiology suggests that cardiac involvement in diabetes is not only related to macrovascular injury but also to other factors, such as alterations of autonomic nervous system, that can contribute to diabetic cardiopathy. The present study evaluated the prevalence of chronic heart failure in an Italian diabetic population in order to discuss the rationale of the therapeutic strategies. Copyright © 1996 Elsevier Science Ireland Ltd Keywords: Diabetes mellitus; Heart failure; Ischemic heart disease

1. Introduction A c c o r d i n g to the F r a m i n g h a m study, the incidence o f cardiac failure is considerably higher in the diabetic p o p u l a t i o n (51.4% o f males and 50.5% females) than in the n o n diabetic population (Margolis et al., 1973; Brand et al., 1989; Wittels and * Corresponding author. 0167-4943/96/$15.00 Copyright © 1996 Elsevier Science Ireland Ltd. All rights reserved PI! S0167-4943(96)00736-4

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Gotto, 1994). These data suggest that cardiac damage is not only secondary to coronary disease but may also be related to a myocardiopathy being independent from the coronary macroangiopathy (Jaffe et al., 1984). In diabetes, the cardiac small vessel alterations revealed during pathohistological examination are similar to those found in other districts consisting of capillary microaneurysms and capillary basal membrane inspissation (Stone et al., 1989). However, diabetic microangiopathy is not a cause of ischemia, although the protein leakage, due to the increased permeability, may stimulate interstitial fibrosis, deposition of collagen and PAS-positive substances. During the recent years, a great number of studies have been conducted both with invasive and non-invasive procedures, to demonstrate functional alterations in a pre-clinical phase and in the absence of macroangiopathy. Although not unequivocally, these studies confirm a reduced left ventricular performance in diabetic patients, suggesting that an early cardiac inotropic deficiency may be a functional and reversible damage related to the metabolic alterations. The inadequate utilization of the energetic source results in a deficient inotropic function and consequent hemodynamic alterations. The nature of diabetic myocardiopathy results in a slow but progressive evolution toward a dilatative myocardiopathy and chronic heart failure. This evolution may be accelerated because of concurrent complications such as autonomic neuropathy and/or coronary disease. Diabetic myocardiopathy, although often asymptomatic, explains the peculiar incidence and prevalence of chronic heart failure in diabetes also when macroangiopathic complications are not present. The aim of the present study was evaluate the prevalence of chronic heart failure in a well characterized Italian diabetic population.

2. Patients and methods

A cohort of 4185 patients (2101 females and 2084 males) has been examined; 3725, 326 and 134 subjects suffered from type II, type I or secondary diabetes, respectively. They have been chosen among the 12000 diabetics assisted by our diabetic treatment unit, based on their completely computerized clinical documentation (Fumelli et al., 1995). Table I shows their distribution according to age. Table 1 Distribution of the population according to age and sex Age (y)

Females

Males

Total

<61) 61 70 71 80 81 90 >90 Total

400 700 699 296 10 2105

611 668 624 175 3 2080

lOll 1368 1323 471 13 4185

(19.0) (33.2) (33.2) (14.1} {0.5)

Note: Percent values are given m parentheses.

(29.4) (32.1) (30.0) {8.4) (0.1)

(24,1) (32.7t (31.6) (11.2) (0.3)

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Table 2 Distribution of the patients with chronic heart failure according to age and sex Age (y)

Females

Males

Total

<60 61-70 71-80 81-90 > 90 Total

26 (8.5) 57 (18.6) 125 (40.7) 97 (23.9) 2 (0.6) 307

9 (5.0) 49 (27.2) 79 (43.9) 43 (23.9) 0 180

35 (7.2) 106 (21.8) 204 (41.9) 140 (28.7) 2 (0.4) 487

Note: Percent values are given in parentheses. Diagnosis of chronic heart failure was established on the basis of clinical examination, resting electrocardiogram, echocardiography and/or patient history, when a specific and appropriate pharmacological treatment was documented. Sex, age, duration of diabetes and antidiabetic treatment have also been taken into account. 3. Results The total number of subjects affected by chronic heart failure was 487 (11.6% of the total number); female/male distribution was 307 (63.0%) and 180 (37.0%), respectively. The mean age was 75 _+ 9 y (SD) and mean duration of diabetes was 15 _+ 10 y (SD). The age-distribution showed an increased occurrence of cases of chronic heart failure with aging, and this phenomenon was more evident a m o n g females (Table 2). Hypertension was associated in 57.8% of the patients, and ischemic heart disease in 41.1% of them. Three patients were type I diabetics and two patients had a diabetes secondary to pancreatic disease. As regards treatment schedules, 294 (60%) patients were treated by oral hypoglycemic agents, 24 (5%) were treated only by diet, 66 (13%) were insulin-treated and 103 were under a mixed (oral drugs + insulin) treatment. Thus, the percentage of subjects treated by insulin (alone or associated to oral drugs) was considerably higher to that observed in the diabetic patients without chronic heart failure (3 5 versus 25%). 4. Discussion The pharmacological treatment of a diabetic patient affected by chronic heart failure has to (i) improve the glycemic assessment; and (ii) supply a therapy for the chronic heart failure. With regard to the first point, it is difficult to obtain an optimized control as demonstrated by the wider use of insulin treatment in diabetics with chronic heart failure (35%) than in diabetics without chronic heart failure (25%) (Gallus and Garancini, 1993). This problem should be related to the use of drugs such as diuretics that may increase glycemia and also to the drastic reduction of physical activity associated with the cardiac disease.

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Furthermore, glycemic control is central to the m a n a g e m e n t o f chronic heart failure as the ventricular performance improves when g o o d metabolic conditions are achieved (Wilson et al., 1991; Nesto et al., 1995). As regards the second point, a special care has to be dedicated in the choice o f diuretics (Regan, 1983). Thiazidic diuretics may impair glycemic control and cause or worsen hyperlipemia; diuretics acting on the ansa are to be preferred but care should be taken in order to avoid hypokalemia. This latter condition leads to a reduction in insulin secretion and predisposes to arrhytmias. In the condition o f insulin deficiency potassium-saving diuretics may impair the glycemic control as well. The use o f angiotensin converting enzyme (ACE)-inhibiting drugs, especially when associated with diuretics (activating renin-angiotensin system) should be considered as a more favorable option. In diabetes a u t o n o m i c neuropathy often involves the heart (Zoneraich et al., 1977; Nesto et al., 1990). Cardiac frequency is altered and this event modifies the myocardial compliance under stress conditions and the response to drugs. Usually cardiac frequency is increased with loss o f the circadian rhythm and this latter modification parallels that o f blood pressure. Alteration in blood pressure control may result in postural hypotension. Lactic acidosis may occur more frequently in patients affected by chronic heart t:ailure when treated by biguanides. Both these conditions increase hepatic lactic acid production (Zarich and Nesto, 1989). In conclusion, the occurrence o f dyspnoea and/or asthenia in diabetic patients in rest or during exercise, even in absence o f electrocardiographic, radiological or physical signs (Zarich and Nesto, 1989), especially in older patients or with a duration of diabetes over 15 y, should suggest a careful cardiological evaluation. The aim of therapy will be to improve cardiac function, interrupting a possible drug-related vitious circle between metabolic impairment and chronic heart failure.

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Nesto, R.W., Zarich, S.W. and Jacoby, R.M. (1995): Malattia cardiaca nel diabete. In: Joslin II Diabete Mellito, III Italian edition, pp. 836-851. Editors: C.R. Kahn and G.C. Weir. Mediserve, Milano (in Italian). Regan, T.J. (1983): Congestive heart failure in the diabetic. Ann. Rev. Med., 34, 161-168. Stone, P.H., Muller, J.E., Harwell, T., York, B.J., Rutherford, J.D., Parker, C.B., Turi, Z.G., Strauss, H.W., Wilerson, J.T. and Robertson, T. (1989): The effect of diabetes mellitus on prognosis serial left ventricular function after acute myocardial infarction: contribution of both coronary disease and diastolic left ventricular dysfunction to the adverse prognosis. J. Am. Coll. Cardiol., 14, 49-57. Wilson, P.W.F., Cupples, L.A. and Kannel, W.B. (1991): Is hyperglycemia associated with cardiovascular disease? The Framingham Study. Am. Heart J., 121, 586-590. Wittels, E.H. and Gotto, A.M. (1994): Aspetti clinici della malattia cardiaca ischemica nel diabete mellito. In: II Diabete Mellito: Trattato Internazionale. First Italian Edition, Vol. 4, pp. 1487-1508. Editors: K.C.G.M. Alberti, R.A. DeFronzo, H. Keen and P. Zimmet. Mediserve, Milano (in Italian). Zarich, S.W. and Nesto, R.W. (1989): Diabetic cardiomiopathy. Am. Heart J., 118, 1000-1012. Zoneraich, S., Zoneraich, O. and Rhee, J.J (1977): Left ventricular performance in diabetic patients without clinical heart disease: evaluation by systolic time intervals and echocardiography. Chest, 72, 748 751.