1. Your Approach to Heart failure and Arrhythmias in Diabetics Dr Mervat Aboulmaaty Professor of Cardiology Ain Shams University 2012

2. DIAGNOSIS OF HEART FAILURE … should be based on a combination of clinical symptoms of heart failure and signs of myocardial dysfunction. Systolic Diastolic The leading causes of chronic heart failure are hypertension and ischaemic heart disease

3. Diabetes and CV risk 1% increase of HbA1c increased risk of CVD DM increases CV risk 2-3 x Men 3-5x women Post prandial glucose than fasting glucose for CV risk prediction Glucometabolic perturbation carries a risk of CV mobidity and mortality in women 29% of children with DM 1 with nephropathy will develop CAD after 20 years compared to 2% of those without nephropathy

4. Potential contributors to the development of diabetic cardiomyopathy. Boudina S, Abel E D Circulation 2007;115:3213-3223 Copyright © American Heart Association

5. Prevalence of heart failure and glucose abnormalities There was a strong association between diabetes and heart failure. Prevalence of Heart Failure & DM is 0.5 in Men and 0.4 in women increases with age. Rekyjavik Study Heart failure was found in 12% of those with diabetes compared with only 3% in individuals without diabetes.

6. Heart failure and diabetes Prognosis DM is a serious prognostic factor for CV mortality in pts with LVD 2ry to CAD. Survival decreased significantly even after adjustment for CV risk factors and IHD

7. ACE-inhibitors Recommended as first-line therapy in diabetic patients with reduced LV dysfunction with or without symptoms of heart failure. Class I, Level of Evidence C. Monitor plasma glucose carefully in the early phase of the institution of an ACE-inhibitor

8. ACE-inhibitors SOLVD trial : similar effects of ENLAPRIL in DM and non DM ATLAS trial mortality reduction was as good in DM and non DM with high and low dose LISINOPRIL

9. Angiotensin-II-receptor blockers similar effects in heart failure as ACE- inhibitors and can be used as an alternative or even as added treatment to ACE-inhibitors. Class I, Level of Evidence C.

10. Beta Blockers BBs in the form of metoprolol, bisoprolol, and carvedilol are recommended as first-line therapy in diabetic patients with heart failure. Class I, Level of Evidence C. MERIT HF (Metoprolol) CIBIS II (Bisoprolol) COPENICUS & COMET (Carvedilol)

11. Diuretics Important for symptomatic treatment of patients with fluid overload due to heart failure. Class IIa, Level of evidence C. loop diuretics rather than diuretics which impair glucometabolic state

12. Aldosterone antagonists ….may be added to ACE-inhibitors, BBs, and diuretics in diabetic patients with severe heart failure. (improve longevity) Class IIb, Level of Evidence C. Kidney function & K : Diabetic Nephropathy

13. Insulin TTT in DM and HF is under debate INSULIN Increase myocardial blood flow Decrease heart rate Cause a modest increase in cardiac output. It has been shown to have beneficial effects on myocardial function, ?? associated with increased mortality. Further studies are needed

14. Thiazolidinediones (Insulin sensitizers) Because of a risk for fluid retention, and thereby worsening of heart failure symptoms, the use of these drugs are considered contraindicated in heart failure patients in New York Heart Association Class III–IV.

16. Arrhythmias: AF and sudden death

17. DM favors the occurrence of AF ALFA study : DM in chronic AF pts 13% Manitoba study : Age specific incidence of AF in 4000 Males DM + AF = relative risk of 1.8 Framingham Study: DM + AF = 1.4 in Males = 1.6 in Females

18. Anti-thrombotic therapy in diabetic patients with AF Aspirin and anticoagulant use as recommended for patients with AF should be strongly applied in diabetic patients with AF to prevent stroke. Class I, Level of Evidence C.

19. Anticoagulation is normally advised for patients with a CHADS2 score ≥ 2 (Gage, et al 2001) and may be considered for patients with a CHADS2 score = 1 C Congestive heart failure 1 H Hypertension (or treated hypertension) 1 A Age >75 years 1 D Diabetes 1 S2 Prior Stroke or TIA 2 Diabetes and stroke risk stratification schemes

20. Age< 65 yrs +0 65-74 yrs +1 ≥ 75 yrs +2 CHF History? +1 HTN History? +1 Stroke/TIA/Thromboembolism History? +2 Vascular Disease History? (previous MI, peripheral arterial disease or aortic plaque ) +1 Diabetes Mellitus? +1 Female? +1 CHA2DS2-VASc Score for AF Stroke Risk

21. Atrial fibrillation (AF) Atrial fibrillation (AF) Evidence comparing the efficacy of different anticoagulation regimens suggests an optimum INR target of 2.5 (Singer et al, 2008), which is more effective than lowintensity fixed dose warfarin plus aspirin (Stroke Prevention in Atrial Fibrillation III trial) (Stroke Prevention in Atrial Fibrillation Investigators, 1996). Therefore Patients with AF who require warfarin for the prevention of cardio-embolic should have an INR target of 2.5 (1A). Keeling D et al, Br J Haematol. 2011 Aug;154(3):311-24

22. DM and SCD Framingham Study DM increases Risk of SCD x4 in all age groups SCD is higher in DM Women > Men Nurse Health Study 121,000 women (30-55yrs, f/u 22yrs) SCD was first sign of HD in 69% DM 3x risk of SCD (HTN 2.5, obesity 1.6)

23. DM & SCD Honolulu Heart Program DM in Japanese American Men : F/U 23 yrs DM & GI increase RR of SCD than non DM Paris Prospective study DM is a strong risk factor for SCD in the French population

24. DM is a risk factor for SCD Diabetic patients have a higher incidence of cardiac arrhythmias, including ventricular fibrillation and sudden death Diabetic men and women have comparable coronary mortality DM and MI increases CVD and all cause mortality.Diabetic patients have a higher incidence of cardiac arrhythmias, including ventricular fibrillation and sudden death Diabetic men and women have comparable coronary mortality DM and MI increases CVD and all cause mortality.

25. DM & Mechanisms of SCD  Atherosclerosis  Microvascular disease (retinopathy & microalbuminemea)  Diabetic autonomic neuropathy  ECG of DM patients presents repolarization abnormalities manifesting as prolonged QT interval and altered T waves (K channel abnormalities)

26. Recommendations Control of glycaemia even in the pre-diabetic stage is important to prevent the development of the alterations that pre-dispose to sudden cardiac death. Class I, Level of Evidence C Microvascular disease and nephropathy are indicators of increased risk of sudden cardiac death in diabetic patients. Class IIa, Level of Evidence B

27. Thank you