Diabetes combined with heart disease a growing problem in Europe
12 September 2007
Diabetes is becoming one of the major health problems
in both the European and US populations. It is frequently associated with
overweight, hypertension and high serum cholesterol levels, representing a
dangerous combination of risk factors for the development of heart and
Recent large surveys and registries in patients with heart failure,
including the Euro Heart Failure Surveys (EHFS) I and II, have shown that
diabetes in such patients was also present in 30-40% of cases.
This combination of disorders worsens the long-term health risks for
patients and complicates the management of those with acute and chronic
heart failure. Analysis of the EHFS II follow-up data documented for the
first time an increased early and late mortality in acute heart failure in
A similar association of diabetes with an adverse
outcome was found during the post-discharge period between 3 and 12 months.
Diabetes was also identified as an independent risk factor contributing to a
relative mortality increase of 26% at one year.
A higher mortality was also observed in diabetic patients with chronic
heart failure in the large scale betablocker trial comparing carvedilol and
metoprolol (COMET). However, not all surveys in chronic heart failure
recognised diabetes as an independent risk factor, probably because other
negative prognostic features, such as a markedly reduced left ventricular
ejection factor, low blood pressure and renal dysfunction had a greater
impact on long-term outcome.
The presence of diabetes also influences the
selection of optimal therapeutic measures in heart failure. Among the modern
cardiovascular drugs the angiotensin-converting enzyme inhibitors (ACEI) and
the angiotensin-receptor antagonists (ARA) are regarded as the most suitable
agents in such patients, since they do not increase blood glucose and reduce
the occurrence of new diabetes when compared to diuretics and some
betablockers. Furthermore, these drugs have also protective effects on the
kidneys against diabetic complications.
The choice of invasive cardiac
interventions to treat coronary artery disease in patients with and without
heart failure may also depend on the presence or absence of diabetes.
Coronary artery bypass in patients with multi-vessel coronary disease is
considered to be preferable to catheter interventions with regard to
long-term outcome. The rate of restenosis after percutaneous coronary
dilatation is higher in diabetics, although the use of modern drug eluting
stents can reduce this risk.
It has been shown that a strict blood sugar
control by insulin treatment reduces the rate of cardiovascular diseases in
diabetes. Whether the achievement of lower blood sugar values and reduction
of glycosilated haemoglobin levels by different means has always a
beneficial effect in patients with established cardiovascular diseases
remains a debated issue.
Recently, some publications have shown that a new antidiabetic drug,
rosiglitazone, which is superior to older drugs in correcting blood sugar,
causes fluid retention with signs of heart failure and may even have a
negative long term impact by increasing the rate of myocardial infarction
and of cardiovascular death. The mode of action of antidiabetic drugs could
therefore also be practically relevant.
The most important future task to
reduce the negative effects of diabetes in patients with heart failure and
coronary artery disease will be the prevention of its development by weight
reduction, physical exercise and early treatment of other metabolic risk
factors, in particular high cholesterol levels with appropriate drugs.
Source: The European Society of Cardiology (ESC)
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