Title : Advancing the care of heart failure and T2DM
Abstract:
Heart failure is a clinical syndrome caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or during stress.1 Heart failure poses a significant global disease burden, more than 60 million patients worldwide have heart failure. Approximately 50% of patients diagnosed with heart failure will die within 5 years 2-3 . There are 537 million patient with diabetes mellitus all over the world .4 People with diabetes have a 2- to 5-fold higher risk of developing HF 5 , On the other hand more than 30% of patients with heart failure also have diabetes. 6 Patients with heart failure and diabetes have a worse prognosis than those without diabetes 6 . Accord and advance trials showed that Intensive glycaemic control has not been shown to significantly impact the risk of HF. 7Specific glucoselowering medications have not been shown to improve heart failure outcomes, and some may actually have deleterious effects.8-10 Glucose in the blood is freely filtered by the glomerulus and reabsorbed again through proximal convoluted tube., The transport of glucose from the tubule into the tubular epithelial cells is accomplished by sodium- glucose cotransporters (SGLTs) family, SGLT2 in the proximal segment of the renal proximal tubule is responsible for 90% of glucose reabsorption and SGLT1 in the distal segment of the renal proximal tubule responsible for reabsorbtion the rest 10% of glucose. SGLT2 inhibitor is a new class of drugs to treat diabetes by inhibiting SGT2 decreases glucose reabsorption and increases urinary glucose excretion, improving glucose control in the diabetic patient. 14 At 2015 EMPA-REG OUTCOME trial showed that Empagliflozin in addition to reduction of HBa1c, reduced the 3MAC by 14% , CV death by 38% and HHF by 35%, 15 Then DECLARE-TMI58 trial showed that Dapagliflizon in addition to reduction of HBa1c, reduce HHF by 17%.16 So there are three questions to be answered : 1-Are the benefits of SGLT2i similar in patients With and without HF ? ( prevention and management of HF) 2-Are the benefits of SGLT2i similar in patients with and without Diabetes? 3- Are the benefits of SGLT2i similar in patients with HFrEF and HFpEF DAPA-HF assessing Dapagliflozin and EMPEROR-Reduced assessing Empagliflozin in Patients with Chronic HFrEF With or Without T2D showed that both Dapagliflozin and Empagliflozin reduced hospitalization HF or death from cardiovascular causes regardless of the presence or absence of diabetes with improvement of the quality of life .17,18 The results of these trials change the guidelines and FDA approved Dapagliflozin and Empagliflozin to be used in patients with HFrEF in diabetic and non-diabetic patients . In 2022 ADA recommended add SGLT2i to metformin irrespective to Hba1c target in patient with HErEF.21 EMPEROR-Preserved results showed that Empagliflozin demonstrated a clinically reduction in the composite primary endpoints of CV death or HHF in diabetic and non-diabetic patients with Heart failure with preserved Ejection Fraction.20 and DELEVER trial showed the same result for Dapagliflozen ,That is why the ADA guidelines in 2023 changed by recommended to start SGLT2i as the first line if patient has Heat failure either reduced or preserved. HF is often preventable by early detections of patients at risk and by early intervention. The importance of these approaches is emphasized by US guidelines that have incorporated a classification of HF that includes four stages. Stage A includes patients at risk for developing HF (such as patients with hypertension and diabetes). Stage B includes patients who have structural heart diseases but no current or previously recognized symptoms of HF. Stages C and D include patients with clinical HF and the relatively small group of patients who have become refractory to the usual therapies, respectively. This is why ADA guidelines 2024 added to new recommendations to include screening of adults with diabetes for asymptomatic heart failure by measuring natriuretic peptide levels to facilitate the prevention or progression to symptomatic stages of heart failure.
