Diabetes und Herzinsuffizienz: eine praxisorientierte, kritische Bestandsaufnahme

 

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Zusammenfassung

Patienten mit Typ-2-Diabetes weisen ein erhöhtes Risiko auf, Symptome einer Herzinsuffizienz zu entwickeln. Diese können zusammen mit einer reduzierten (HFREF, systolische Herzinsuffizienz) oder einer erhaltenen (‚preserved‘) linksventrikulären Funktion (HFPEF, diastolische Herzinsuffizienz) auftreten. Die Pathophysiologie beider Entitäten ist unterschiedlich und beinhaltet eine Störung des kardialen Metabolismus und gleichzeitig der koronaren Zirkulation. Obwohl Diabetes und Herzinsuffizienz oft gemeinsam miteinander auftreten, ist das Management dieser Patienten im Hinblick auf den spezifischen Nutzen oder mögliche Risiken einer antidiabetischen Therapie unzureichend untersucht. Aus diesem Grund sollten sowohl aus pathophysiologischer wie auch klinischer Sicht 1) Diabetiker mit Symptomen einer Herzinsuffizienz mit Hilfe von Herzecho und Gewebe-Doppler hinsichtlich der systolischen wie auch diastolischen linksventrikulären Funktion differenziert werden. 2) Die Herzinsuffizienz bei Diabetikern verdient aufgrund ihrer schlechten Prognose und ihrer Interaktionen ein besonderes Maß an Aufmerksamkeit. 3) Eine optimierte Blutzuckersenkung ist in Kombination mit einer Reduktion anderer kardiovaskulärer Risikofaktoren bewiesenermaßen bei systolischer Herzinsuffizienz sinnvoll und vermutlich ebenfalls nützlich beim Vorliegen einer diastolischen Herzinsuffizienz. 4) Antidiabetische Medikamente sollten spezifisch auf beide Entitäten ausgerichtet sein. Es existieren jedoch leider nur wenige prospektive kontrollierte Studien. Daher sollten zukünftige Interventionsstudien besonders auf die Reduktion klinischer Ereignisse und die Verbesserung der Lebenserwartung diabetischer Patienten mit verschiedenen Formen einer Herzinsuffizienz zielen.

Abstract

Patients with type 2 diabetes have an increased risk for developing symptoms of heart failure. These can be accompanied by a reduction of left ventricular ejection fraction (HFREF, systolic heart failure) or by a preserved function (HFPEF, diastolic heart failure). The pathophysiology of both entities is distinct and involves impairment of myocardial metabolism and coronary circulation alike. Although diabetes and heart failure often coincide, the management of these patients particularly with respect to the specific benefits or possible hazards of antidiabetic treatment is vague. Therefore, from a pathophysiological as well as clinical viewpoint, 1) diabetic patients with symptoms of heart failure have to be differentiated regarding systolic as well as diastolic left ventricular function by echocardiography and tissue doppler imaging. 2) Heart failure in diabetic patients needs similar attention due to a prognosis and interactions. 3) Optimized blood glucose lowering in combination with improvement of other cardiovascular risk factors is evident for HFREF and is assumed to be beneficial for HFPEF. 4) Antidiabetic medication has to be specifically adapted for both entities. As prospective, controlled studies are scarce, future interventional studies should specifically focus on clinical outcome in diabetic patients with different entities of heart failure.

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