Diabetes imposes a heavy physical and socioeconomic burden on the patient, his/her family, and on society. Patients with advanced diabetes may have frequent trips to the hospital emergency room (ER), and may require confinement due to heart failure (HF) symptoms.
That’s why we usually instruct resident doctors assigned to the ER that when a known diabetic complains of shortness of breath or difficulty of breathing when exerting effort or when lying down, there might be an underlying heart problem, which requires further tests.
Although usually there’s heart enlargement (cardiomegaly) when HF is present, some diabetics may present with a type of HF in which the heart size may still be normal.
This is called diastolic HF, in contrast to systolic HF which usually presents with an enlarged heart.
Diastolic HF, which may be seen in patients with diabetes, hypertension and when there is thickening of the heart muscles (hypertrophy), is due to stiffness of the heart. It should relax during the second phase of the heart contraction called diastole, but in diastolic HF, it remains partially stiff, which can impair the contraction or pumping action of the heart.
Furthermore, it compresses the heart arteries supplying nutrition to the heart, which may render a portion of the heart muscles lacking in oxygen and nutrients, an imbalance of the circulation called ischemia.
For decades, the challenge to physicians treating diabetic patients was how to remedy this imbalance and prevent hospitalization due to HF.
Reduced hospitalization rate
A new study, presented at the American College of Cardiology (ACC) scientific sessions in Washington DC last week, showed that a relatively new class of drugs called sodium glucose cotransporter-2 inhibitor (SGLT-2i) can reduce the rate of hospitalization for diabetic patients and could even prolong life.
This confirms the findings of a landmark trial (Empa-Reg outcome trial), published two years ago, which also showed that a member of this class of drugs (empaglifloxin) can reduce deaths from any cause, heart-related deaths, and hospitalization for HF.
In the present real-world study across six countries in Europe and the United States, researchers looked at the outcomes between treatment with a SGLT-2i and other glucose-lowering drugs (oGLD), in terms of hospitalization for HF (HHF).
Dr. Mikhail Kosiborod presented the paper in the conference, attended by close to 30,000 heart specialists and scientists from all over the world, who braved the subzero temperature outside.
The patient records of 364,828 diabetic patients were analyzed, evenly representing both treatment groups. The mean age was 57 years old, and 56 percent were men. At baseline, 3 percent had HF, 13 percent had established cardiovascular disease mainly of the heart, brain and leg arteries; while 27 percent had small-vessel disease like eye, nerve and kidney problems.
The researchers reported that there was a reduction that favored the SGLT-2i in each of the six countries involved in the study.
Furthermore, in the SGLT-2i treated group, there was a lower death rate from any cause. They used statistical analyses, suggesting that the differences in both HHF and all-cause death were not due to chance or to any bias, either on the doctor’s side or patient’s side.
Usually, doctors require a more stringent design of clinical research called randomized controlled trial (RCT) in which both patients and doctors don’t know (double-blinded) what type of treatment all patients are receiving.
But considering the huge number of patients in this study by Dr. Kosiborod’s group, I would personally put some weight to the study findings.
In short, the fear of a shortened life span of diabetics due to heart complications, particularly heart failure, seems to have found its therapeutic match.
In addition to other life-extending medicines like cholesterol-lowering drugs (statins), blood thinners like aspirin, and artery-friendly drugs like angiotensin converting enzyme inhibitors or angiotensin receptor blockers, it’s not too remote that, soon, diabetics can finally take away the cardiovascular sword of Damocles hanging over their head.