Functional class in patients with heart failure is associated with the development of diabetes

doi:10.1016/S0002-9343(02)01530-9

The American Journal of Medicine

Volume 114, Issue 4, March 2003, Pages 271-275

https://doi.org/10.1016/S0002-9343(02)01530-9 Get rights and content

Abstract

Purpose

Recent reports suggest that decreased functional capacity in patients with heart failure may be associated with abnormalities in glucose metabolism. We followed patients with coronary artery disease who participated in the Bezafibrate Infarction Prevention study to determine the incidence of diabetes by baseline functional status during a 7.7-year follow-up.

Methods

The sample comprised 2616 nondiabetic patients aged 45 to 74 years with a fasting blood glucose level <7 mmol/L (126 mg/dL). They were divided into three groups by New York Heart Association (NYHA) criteria: class I (n = 1986 patients), class II (n = 518), and class III (n = 112). The detection of a fasting blood glucose level ≥7 mmol/L during follow-up was defined as the criterion for the development of diabetes.

Results

The study groups had similar demographic and clinical characteristics, except that patients with symptomatic heart failure (NYHA class II or III) were more likely to have angina. During follow-up, diabetes developed in 259 patients (13%) in NYHA class I, 76 (15%) in class II, and 22 (20%) in class III (P for trend = 0.05). At the last visit, patients in NYHA class III were twice as likely (17% [n = 19]) to have fasting blood glucose levels ≥7 mmol/L as those in NYHA class I (7.8% [n = 154]) or class II (8.7% [n = 45]) (P = 0.005). In a multivariate analysis, NYHA class III was associated with a 1.7-fold (95% confidence interval [CI]: 1.1 to 2.6) increase in the rate of development of diabetes, but NYHA class II was not (hazard ratio = 1.0; 95% CI: 0.8 to 1.3).

Conclusion

Among patients with coronary artery disease, advanced heart failure (NYHA class III) is associated with a significantly increased risk of developing diabetes during a 6- to 9-year follow-up.

Section snippets

Subjects

Initially, 15,524 coronary patients were screened for participation in the Bezafibrate Infarction Prevention study, a randomized trial of bezafibrate versus placebo for the treatment of lipid abnormalities, which was performed at 18 university-affiliated hospitals (19). In brief, the inclusion criteria for men and women were age 45 to 74 years; and either a history of myocardial infarction no less than 6 months and not more than 5 years before enrollment, or stable angina pectoris confirmed by

Results

The sample included 1986 patients (76%) in NYHA class I, 518 patients (20%) in class II, and 112 patients (4%) in class III. The three groups were similar in age, sex, and most clinical characteristics (Table 1). The majority of the patients in all groups were men and had sustained a myocardial infarction in the past. A significantly higher proportion of patients in class II or III had angina. Fasting glucose and HDL cholesterol levels were somewhat higher among patients with advanced heart

Discussion

Diabetes, and even relatively mild glucose abnormalities, are strongly associated with cardiovascular morbidity and mortality 3, 23, 24, 25, 26, and diabetes is an independent risk factor for heart failure 12, 13, 14. However, only one previous study, in a group of elderly subjects, reported that heart failure was associated with the subsequent development of diabetes (17). Our results support that observation.

Advanced heart failure leads to increased insulin resistance, characterized by

References (32)

C.M. Burchfiel et al.
Incidence and predictors of diabetes in Japanese-American men. The Honolulu Heart Program
Ann Epidemiol
(1995)
W.B. Kannel et al.
Role of diabetes in congestive heart failurethe Framingham study
Am J Cardiol
(1974)
U. Goldbourt et al.
Rationale and design of a secondary prevention trial of increasing serum high-density lipoprotein cholesterol and reducing triglycerides in patients with clinically manifest atherosclerotic heart disease (the Bezafibrate Infarction Prevention Trial)
Am J Cardiol
(1993)
E.Z. Fisman et al.
Impaired fasting glucose concentrations in nondiabetic patients with ischemic heart diseasea marker for a worse prognosis
Am Heart J
(2001)
J.W. Swan et al.
Insulin resistance in chronic heart failurerelation to severity and etiology of heart failure
J Am Coll Cardiol
(1997)
A. Laws et al.
Insulin resistance and risk factors for coronary heart disease
Baillieres Clin Endocrinol Metab
(1993)
J.E. Manson et al.
Physical activity and incidence of non-insulin dependent diabetes in women
Lancet
(1991)
Diabetes Statistics. National Diabetes Information Clearinghouse. Bethesda, MD: National Institute of Diabetes and...
J.P. Burke et al.
Rapid rise in the incidence of type 2 diabetes from 1987 to 1996results from the San Antonio Heart Study
Arch Intern Med
(1999)
S.M. Grundy et al.
Diabetes and cardiovascular disease. A statement for healthcare professionals from the American Heart Association
Circulation
(1999)

A.H. Mokdad et al.

The continuing increase of diabetes in the US [letter]

Diabetes Care

(2001)

T. Drivsholm et al.

Increasing prevalence of diabetes mellitus and impaired glucose tolerance among 60-year-old Danes

Diabet Med

(2000)

A. von Eckardstein et al.

Risk for diabetes mellitus in middle-aged Caucasian male participants of the PROCAM studyimplications for the definition of impaired fasting glucose by the American Diabetes Association. Prospective Cardiovascular Munster

J Clin Endocrinol Metab

(2000)

L. Mykkanen et al.

Cardiovascular disease risk factors as predictors of type 2 (non-insulin-dependent) diabetes mellitus in elderly subjects

Diabetologia

(1993)

L.L. Moore et al.

Can sustained weight loss in overweight individuals reduce the risk of diabetes mellitus?

Epidemiology

(2000)

M.P. Vanderpump et al.

The incidence of diabetes mellitus in an English communitya 20-year follow-up of the Whickham Survey

Diabet Med

(1996)

Cited by (93)

Chapter 1: The Burden of Heart Failure
2024, American Journal of Medicine
Heart failure (HF) affects an estimated 6 million American adults, and the prevalence continues to increase, driven in part by the aging of the population and by increases in the prevalence of diabetes. In recent decades, improvements in the survival of patients with HF have resulted in a growing number of individuals living longer with HF. HF and its comorbidities are associated with substantial impairments in physical functioning, emotional well-being, and quality of life, and also with markedly increased rates of morbidity and mortality. As a result, the management of patients with HF has a substantial economic impact on the health care system, with most costs arising from hospitalization. Clinicians have an important role in helping to reduce the burden of HF through timely diagnosis of HF as well as increasing access to effective treatments to minimize symptoms, delay progression, and reduce hospital admissions. Prevention and early diagnosis of HF will play a fundamental role in efforts to reduce the large and growing burden of HF. Recent advances in pharmacotherapies for HF have the potential to radically change the management of HF, offering the possibility of improved survival and quality of life for patients.
Type 2 Diabetes Mellitus and Heart Failure, A Scientific Statement From the American Heart Association and Heart Failure Society of America
2019, Journal of Cardiac Failure
Citation Excerpt :
Among nondiabetic patients with HF enrolled in the CHARM Program (Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity)45 and EMPHASIS-HF (Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure),46 the incidence of DM was 28 and 21 per 1000 person-years, respectively, which is substantially higher than adults of similar age in the general population (9.4–10.9 per 1000 person-years for adults 45 and older).47 The predictors of incident DM among patients with HF include elevated body mass index and waist circumference, history of smoking, elevated glucose or HbA1c, higher systolic blood pressure, longer duration of HF, diuretic therapy, and higher New York Heart Association functional class.45,46,48,49 DM can contribute to the development of structural heart disease and HF via systemic, myocardial, and cellular mechanisms.
Type 2 diabetes mellitus is a risk factor for incident heart failure and increases the risk of morbidity and mortality in patients with established disease. Secular trends in the prevalence of diabetes mellitus and heart failure forecast a growing burden of disease and underscore the need for effective therapeutic strategies. Recent clinical trials have demonstrated the shared pathophysiology between diabetes mellitus and heart failure, the synergistic effect of managing both conditions, and the potential for diabetes mellitus therapies to modulate the risk of heart failure outcomes. This scientific statement on diabetes mellitus and heart failure summarizes the epidemiology, pathophysiology, and impact of diabetes mellitus and its control on outcomes in heart failure; reviews the approach to pharmacological therapy and lifestyle modification in patients with diabetes mellitus and heart failure; highlights the value of multidisciplinary interventions to improve clinical outcomes in this population; and outlines priorities for future research.
A comparison of the effects of selective and non-selective mineralocorticoid antagonism on glucose homeostasis of heart failure patients with glucose intolerance or type II diabetes: A randomized controlled double-blind trial
2018, American Heart Journal
Mineralocorticoid receptor antagonists (MRAs) decrease morbidity and mortality in patients with heart failure (HF). However, spironolactone, a non-selective MRA, has been shown to exert a harmful effect on glucose homeostasis. The objective of this multicenter, randomized, controlled, double-blind trial was to compare the effects of spironolactone to those of the selective MRA eplerenone on glucose homeostasis among 62 HF patients with glucose intolerance or type II diabetes.
Trial registration number:NCT01586442.
2018 consensus of the Taiwan Society of Cardiology and the Diabetes Association of Republic of China (Taiwan) on the pharmacological management of patients with type 2 diabetes and cardiovascular diseases
2018, Journal of the Chinese Medical Association
The global incidence and prevalence of type 2 diabetes have been escalating in recent decades. Patients with type 2 diabetes have an increased risk of atherosclerotic cardiovascular disease (ASCVD). About two-thirds of death in type 2 diabetes are due to ASCVD, including 40% from coronary heart disease (CHD), 15% from heart failure (HF), and 10% from stroke. The association between hyperglycemia and elevated CV risk has been demonstrated in multiple cohort studies. However, clinical trials of intensive glucose reduction did not significantly reduce macrovascular outcomes. It remains unclear whether the absence of demonstrable benefits is attributed to the inclusion of patients with far advanced ASCVD in whom a short treatment period is barely enough for CV protective effects to be shown, or complications associated with the treatment such as hypoglycemia hamper the beneficial effects to manifest, or simply glucose-lowering per se is ineffective.
Since the US FDA issued a mandate in December 2008 that every new anti-diabetic agent requires rigorous assessments of its CV safety, there have been more than 200,000 patients enrolled in a number of randomized controlled trials (RCTs), and around half of them have been completed and published. The results of these CV outcome trials are important for clinicians in their clinical practice, and also provide an opportunity for academic society to formulate treatment guidelines or consensus to provide specific recommendations for glucose control in various CV diseases.
The Taiwan Society of Cardiology (TSOC) and the Diabetes Association of Republic of China (DAROC), aiming to formulate a treatment consensus in type 2 diabetic patients with CVD, have appointed a jointed consensus group for the 2018 Consensus of TSOC/DAROC (Taiwan) on the Pharmacological Management of Patients with Type 2 Diabetes and CV Diseases. The consensus is comprised of 5 major parts: 1) Treatment of diabetes in patients with hypertension, 2) Treatment of diabetes in patients with CHD, 3) Treatment of diabetes in patients with stage 3 chronic kidney disease, 4) Treatment of diabetes in patients with a history of stroke, and 5) Treatment of diabetes in patients with HF. The members of the consensus group comprehensively reviewed all the evidence, mainly RCTs, and also included meta-analyses, cohort studies, and studies using claim data. The treatment targets of HbA1c were provided. The anti-diabetic agents were ranked according to their clinical evidence. The consensus is not mandatory. The final decision may need to be individualized and based on clinicians' discretion.
Diabetes, heart failure, and renal dysfunction: The vicious circles
2019, Progress in Cardiovascular Diseases
The prevalence of Type 2 diabetes mellitus (T2DM) has reached pandemic proportions. T2DM frequently causes macrovascular and/or microvascular pathologic changes and thereby increases the risks for the development of myocardial infarction, heart failure, stroke, renal failure, and reduced survival. This article describes the important interactions between T2DM, heart failure, and renal dysfunction, forming vicious circles. The interruption of these circles represents important therapeutic goals.
Chronic heart failure fosters the onset of type 2 diabetes mellitus
2023, Revista Colombiana de Cardiologia

View all citing articles on Scopus

View full text

Clinical studyFunctional class in patients with heart failure is associated with the development of diabetes

Abstract

Purpose

Methods

Results

Conclusion

Section snippets

Subjects

Results

Discussion

Ann Epidemiol

Am J Cardiol

Am J Cardiol

Am Heart J

J Am Coll Cardiol

Baillieres Clin Endocrinol Metab

Lancet

Rapid rise in the incidence of type 2 diabetes from 1987 to 1996results from the San Antonio Heart Study

Arch Intern Med

Diabetes and cardiovascular disease. A statement for healthcare professionals from the American Heart Association

Circulation

The continuing increase of diabetes in the US [letter]

Diabetes Care

Increasing prevalence of diabetes mellitus and impaired glucose tolerance among 60-year-old Danes

Diabet Med

Risk for diabetes mellitus in middle-aged Caucasian male participants of the PROCAM studyimplications for the definition of impaired fasting glucose by the American Diabetes Association. Prospective Cardiovascular Munster

J Clin Endocrinol Metab

Cardiovascular disease risk factors as predictors of type 2 (non-insulin-dependent) diabetes mellitus in elderly subjects

Diabetologia

Can sustained weight loss in overweight individuals reduce the risk of diabetes mellitus?

Epidemiology

The incidence of diabetes mellitus in an English communitya 20-year follow-up of the Whickham Survey

Diabet Med

Clinical study
Functional class in patients with heart failure is associated with the development of diabetes