Comorbidity burden should be taken into account when determining an optimal glycemic target in the context of both T2D and HF. Based on current HF-specific data, a target HbA1c range should be 7% to 8% for most patients with T2D and HF.1
T2D Therapies and Their Impact on HF
The preferred treatment for T2D in the absence of contraindications is metformin. According to the literature, observational studies suggest that metformin is associated with reduced mortality in patients with HF vs controls, despite previously being contraindicated in HF. The scientific statement suggests that use of metformin is reasonable in patients with T2D who are at risk for or have established HF. Patients with acute conditions associated with lactic acidosis, however, should discontinue use.1
Insulin is a required therapy in many patients with T2D, either alone or in combination with other diabetes drugs. Based on findings from the ORIGIN trial (Outcome Reduction With Initial Glargine Intervention, ClinicalTrials.gov Identifier: NCT00069784) as well as other observational studies, insulin can be associated with weight gain and hypoglycemia and should be used with caution and close monitoring in patients with T2D at risk for or with HF. Metformin and sodium-glucose cotransporter 2 inhibitors are preferable to insulin.1
Sodium-glucose cotransporter 2 inhibitors are the first class of diabetes drugs to demonstrate a reduced risk for HF in patients with T2D and are a good choice for patients with both conditions. However, the AHA does not yet recommend their use given that appropriately powered clinical trials have not been completed.1
Recommended Management Strategies for T2D and HF
It is recommended patients with both T2D and HF receive pharmacologic and collaborative management regimens designed for their unique risk profile. In addition to medication adherence, these patients may need to have dietary modification, weight and stress management, physical activity, and individualized decision making incorporated into their treatment regimens.1
Team-based care is an essential aspect of managing T2D and HF and typically involves the multidisciplinary efforts put forth by physicians and advanced practice providers, nurses, pharmacists, dietitians, social workers, and community health workers. It is crucial that all members of the healthcare team coordinate to develop and follow individualized patient plans.1
Another integral component of care is lifestyle management, particularly as it relates to nutrition and physical activity, both of which can contribute to optimal glycemic control.1
According to the AHA/HFS statement, several questions regarding concomitant T2D and HF remain unanswered. To approach these questions, well-powered clinical trials and population-based studies will be necessary.1
“Because both [T2D] and HF are chronic diseases, integrated care that actively engages patients, family, and providers is key to optimizing both quality and quantity of life,” the committee wrote. “Whether novel ambulatory or remote monitoring strategies can aid in this collateral benefit remains to be determined.”1
- Dunlay SM, Givertz MM, Aguilar D, et al. Type 2 diabetes mellitus and heart failure: a scientific statement from the American Heart Association and Heart Failure Society of America [published online June 6, 2019]. Circulation. doi:10.1161/CIR.0000000000000691
- Centers for Disease Control and Prevention. National diabetes statistics report, 2017: estimates of diabetes and its burden in the United States. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Accessed June 5, 2019.
- Kannel WB, McGee DL. Diabetes and cardiovascular disease: the Framinghamstudy. JAMA. 1979;241:2035-2038.
This article originally appeared on The Cardiology Advisor