Cardiologist’s View:

Diabetes &
Heart Failure
Dasdo Antonius Sinaga
Interventional Cardiologist
RS Awal Bros Pekanbaru
 Disease Burden:
Global 10 causes of death
 CVD is a significant global burden

7.4 million
due to
31% CHD
due to
CVD

6.7 million
due to
stroke

CHD, coronary heart disease; CVD,

Total global deaths
cardiovascular disease in 2012 ~56 million1
1. WHO. CVD Fact sheet N°317, Jan
2015.
http://www.who.int/mediacentre/factsh 3
eets/fs317/en/#
 Key manifestations of CV disease
Coronary
heart disease
Disease of blood vessels
supplying heart muscle1
Stroke
Caused by disruption of blood
supply to the brain1
Heart failure
Failure of the heart to pump
blood with normal efficiency
(sometimes called congestive
heart failure)2

Peripheral arterial
disease
Disease of blood vessels
supplying arms and legs1

CV, cardiovascular
1. World Health Organization 2015:
http://www.who.int/cardiovascular_diseases/en/cvd
_atlas_01_types.pdf ?ua=1;
2.
http://www.heart.org/HEARTORG/Caregiver/Res
4 ources/WhatisCardiovascularDisease/What-is-
Cardiovascular-Disease_UCM_301852_Article.jsp#
HF is a Global Health Problem with a Prevalence
of approx. 26 million Worldwide
Proportion of the population living with heart failure (HF) in individual countries across the world
Europe 1
France 2.2%
UK 1.3%

North America 1
Canada 1.5% Asia 1
USA 1.9% China* 1.3%
Japan 1.0%
Malaysia* 6.7%
Singapore* 4.5%
Middle East1
Oman* 0.5%

Latin America and Africa 1 Australasia 1

No population-based Australia 1.3%
estimates

*Estimates based on a single centre or hospital

5
Ponikowski P et al. Heart failure: Preventing disease and death worldwide. European Society of Cardiology, 2014.
www.escardio.org/static_file/Escardio/Subspecialty/HFA/WHFA-whitepaper-15-May-14.pdf (accessed Nov 2015)
 Diabetes and
Cardiovascular Disease
How is Diabetes damaging
the cardiovascular system?
(1) Endothelial dysfunction
 Endothelial dysfunction is common to
microvascular and macrovascular events

Myocardial infarction
Remodelling – hypertrophy
Heart failure

Peripheral artery disease

Remodelling – plaque TIA, stroke
Aortic aneurysm

Overt proteinuria
Microalbuminuria/mild insufficiency End-stage renal failure

Normal conditions Risk factors Subclinical organ factors Clinical events

Endothelial function
TIA, transient ischaemic attack
Versari D et al. Diabetes Care 2009;32(suppl 2):S314 9
Endothelial dysfunction drives
atherosclerotic progression

Atherosclerosis is accelerated in T2D by hyperglycaemia,

insulin resistance, inflammation and diabetic dyslipidaemia
T2D, type 2 diabetes
10
Figure adapted from Libby P. Circulation 2001;104:365
Zeadin MG et al. Can J Diabetes 2013;37:345e350
How is Diabetes damaging
the cardiovascular system?
(2) Inflammation
Diabetes  Inflammation
How is Diabetes damaging
the cardiovascular system?
(3) Hypercoaguable state
(3) Hypercoagubility
Pathophysiological of heart failure in diabetes
mellitus

Circulation. 2016 Jun 14;133(24):2459-502. doi: 10.1161/CIRCULATIONAHA.116.022194.

Clinical Update: Cardiovascular Disease in Diabetes Mellitus: Atherosclerotic Cardiovascular Disease
and Heart Failure in Type 2 Diabetes Mellitus - Mechanisms, Management, and Clinical
Considerations.
Low Wang CC , Hess CN , Hiatt WR 1, Goldfine AB2.15
1 1
 Diabetes and Heart Failure

Atherosclerosis
Diabetes
CAD Reduced Ejection
Mellitus
Fraction
& .
Other Risk Remodelling HEART
factors . FAILURE
Diabetic
Cardiomyopathy
 Diabetes is Common Among Patients with HF
Preserved Reduced
60 Ejection Ejection
Fraction Fraction
50 49 48

43 43
42 42
Prevalence of diabetes (%)

40
35
33 32
30

20

10

0 TO PCAT RELAX SO CRATES -P3 EPHESUS4 PARADIG SO CRATES-R 6 GWTG HF7 O PTIMIZE ADHERE
1 2 8 9
(n =477) (n =6642) M5 (n =456) (n =21,078)
(n =3345) (n =216) (n =8399) (n =46,612) (n =46,612
)

HFpEF RCT s HFrEF RCT s Registries

Prevalence of DM in HF is 25-30% overall, 40-45% in those hospitalized for HF

1 Pitt B
et al. N Engl J Med 2014;390:1383; 2 Redfield MM et al. JAMA 2013;309:1268; B et al. Eur Heart J 2016;38:1119; 4 Pitt B et al. N Engl J
Med 2003;348:1309; 5McMurray JJV et al. N Engl J Med 2014;371:993; 6 Gheorghiade M et al. JAMA 2015;314:2251; 7 Luo N et al. JACC Heart 17
Fail 2017;5:305; 8Greenberg BH et al. Heart J 2007;154:277.e12277.e8; 9Peacock F, et al. N Engl J Med 2008; 358:2117–2126.
PROGNOSTIC FACTOR
 Diabetes worsens heart failure
prognosis
Poorer HF survival with diabetes than without diabetes

1.0 LVEF ≥50% 1.0 LVEF <50%

Diabetes No diabetes Diabetes No diabetes

0.8 0.8
Survival proportion

0.6 0.6

0.4 0.4

RR=1.41 RR=1.73
0.2 0.2
p=0.0322 p<0.0001

0.0 0.0
0 2 4 6 8 10 12 0 2 4 6 8 10 12
Time (years) Time (years)

Kaplan–Meier survival curves of HF patients hospitalised with LVEF ≥50% (n=498) and <50% (n=754)
HF, heart failure; LVEF, left ventricular
ejection fraction
19
Varela-Roman A et al. Eur J Heart Failure
 Effects of Risk factors to worse
outcomes
FASTING Total Cholesterol Systolic
BLOOD GLUCOSE And non LDL Chol Blood Pressure
 It’s a clearcut relationship
between Diabetes and Heart Failure.

HOW TO MANAGE?
Level Kompetensi
 PRIMARY PREVENTION
Prevention of patient with risk factors who have not yet
developed cardiovascular disease

SECONDARY PREVENTION
Prevention of patient who have already had history of
CAD, Stroke or Peripheral arterial disease
Patient Education
Balanced Diet
 CARB !!!
Index Glycemic
 Food Composition
-
Carb – Protein - Fibre
PHYSICAL ACTIVITY

Recommendation
150 mins/week of
moderate intensity exercise

3 – 4 x /week
@ 30-40 mins
IMPROVING FUNCTIONAL CAPACITY
 LEAD by giving example
IG: @kedodorunpku
 MEDICATION

DM drugs that provenly reduce

cardiovascular events, especially heart failure.
 Summary –
My points of view as a cardiologist:

1. Diabetes leads micro- and macrovascular

damages, and causes heart failure through several
pathways.
2. Heart failure patients with diabetes have poorer
prognosis, by 2 – 3x compared to those without
diabetes.
3. Primary prevention is key; promote regular
physical exercise (150 mins per week) and healthy
diet.
4. Medicate appropriately.
THANK
YOU