For over a decade, physicians
have watched with concern as diabetes rates have soared
in the general population. Unfortunately, diabetes may
be the least of their problems as two recent studies suggest
that patients with diabetes mellitus (DM) will likely
face a much more insidious threat to their health —
chronic heart failure (CHF).
"In the general population, the
prevalence of diabetes from 1989 to 1999 increased from
2.6% to 4.0% — a 54% increase. During the same
time, among patients with heart failure, the prevalence
of diabetes increased from 13% to 47% — a 360%
increase," report Drs Masoor Kamalesh and Girish Nair
of the Indiana University School of Medicine in the
March 10 issue of the International Journal of Cardiology.
The authors analyzed data from
34,633 CHF patients in 14 CHF clinical trials from 1989-99
for which the incidence of DM was recorded. The overall
incidence of DM was obtained from the Center for Disease
Control.
What then does this mean for primary
care physicians? Dr Kamalesh stresses that they must
"be aware that there is a strong association between
diabetes and congestive heart failure. This means that
when subjects with diabetes complain of shortness of
breath it would be prudent to assess left ventricular
systolic function as quickly as possible with an echocardiogram."
Dr Kamalesh also warns, "In subjects with diabetes,
diastolic dysfunction of the left ventricle is also
quite common."
PREDICTIVE
FACTORS
Another recent study led by Dr Giuseppe Coppola of the
University of Palermo found that elevated hs-CRP and
fibrinogen levels were predictive for cardiovascular
death or nonfatal cardiovascular events, including ischemic
stroke, myocardial infarction and critical limb ischemia.
Dr Coppola's research group followed
156 patients with type II DM, along with 156 sex- and
age-matched control subjects, for an average of five
years. Their findings were released online on March
23 in the International Journal of Cardiology.
Past studies on diabetes "have reported increased incidences
of cardiovascular diseases or increased diabetes complications
among subjects with high plasma levels of fibrinogen
and other markers of inflammation," explains Dr Coppola.
"Our study shows that, in patients with diabetes mellitus,
high plasma levels of hs-CRP [high sensitivity C-reactive
protein] and fibrinogen are significantly associated
with the presence of carotid atherosclerosis."
However, even when armed with a
useful prognostic indicator, doctors on the frontline
of diabetes and heart disease management still have
a tough job ahead of them. While both DM and CHF are
more common among the elderly, these patients, thanks
to better treatment, are living longer. But "the actual
prevalence of patients with CHF will not significantly
decrease in the near future," explain Drs Kamalesh and
Nair. So despite success in managing CHF, "greater efforts
should be made for prevention of diabetes in general
and subjects with diabetes should be specifically targeted
for preventing occurrence of CHF," they caution.
For now, "subjects with long standing
diabetes may benefit from an echocardiogram to assess
asymptomatic left ventricular dysfunction," suggests
Dr Kamalesh. In general, he feels that "aggressive management
of systolic dysfunction... improves symptoms and prolongs
life." Dr Coppola adds that in type II DM patients with
elevated levels of fibrinogen, hs-CRP and body mass
indices, anti-inflammatory therapies can reduce the
incidence of adverse cardiovascular events.
Int J Cardiol Mar 10, 2005;99(1):125-7
and published online Mar 23, 2005
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