Diabetes and microvascular complications predict outcomes in HFpEF

The Prognostic Significance of Diabetes and Microvascular Complications in Patients With Heart Failure With Preserved Ejection Fraction

Literature - Sandesara PB, O’Neal WT, Kelli HM, et al. - Diabetes Care 2017; published online ahead of print

Background

Almost half of patients with heart failure with preserved ejection fraction (HFpEF) also have diabetes mellitus (DM), which is associated with nearly a twofold increase in morbidity and mortality in these patients [1-3]. Diabetes is, however, not a uniform disorder, and the risk of adverse CV outcomes may vary with disease severity (e.g., presence of microvascular complications).

In this analysis of the TOPCAT study [4], the prognostic significance of DM and its microvascular complications was evaluated in 3,385 patients with symptomatic HF and an EF ≥45%. The microvascular complications included neuropathy, nephropathy, and retinopathy, and the study outcome was the composite of CV mortality, aborted cardiac arrest, or HF hospitalization

Main results

During a median follow-up of 3.4 years, a total of 1,524 hospitalizations, 437 hospitalizations for HF, 516 deaths, and 330 CV deaths occurred. 1109 Patients (32%) of the patients included in this analysis had diabetes.
An increased risk for hospitalization (HR 1.54, 95% CI 1.25, 1.89; P-trend <0.001), HF hospitalization (HR 1.97, 95%CI 1.38, 2.80; P-trend <0.001), death (HR 1.73,
95%CI 1.22, 2.45; P-trend = 0.0017), and CV death (HR 1.70, 95% CI 1.09, 2.65, P-trend = 0.018) was observed in patients with diabetes and microvascular complications as compared with patients without diabetes. Patients with diabetes without microvascular complications also showed a higher risk of these events but to a lesser extent.
When the analysis was limited to DM participants who reported prior hospitalization for HF, a higher risk of re-hospitalization for HF was observed in patients with as compared with those without microvascular complications (HR for DM without microvascular complications: 1.40; 95% CI: 1.01 - 1.96; HR for DM plus microvascular complications: 1.78; 95% CI: 1.18 - 2.70; P-trend = 0.0036).
In a secondary analysis (model corrected for multiple CV risk factors and medications) limited to persons with DM, a higher risk of hospitalization (with no complications as references: HR: 1.29 for those with 1 complications, HR: 1.57 for those with ≥2 complications, P-trend <0.001), HF hospitalization (HR: 1.20 [non-significant) and HR: 1.63 respectively, P-trend = 0.0063), and death (HR: 1.24 [non-sign) and HR: 1.49 respectively, P-trend = 0.037) was observed with a higher number of microvascular complications.
The risk of CV death did not increase with a higher number of microvascular complications (non-significant HR: 1.31 and 1.27 for 1 and ≥2 microvascular complications, respectively, P-trend = 0.45).

Conclusion

In the TOPCAT study, diabetes and its microvascular complications carried important prognostic information regarding adverse outcomes in HFpEF patients. In addition, the microvascular disease burden predicts HF re-hospitalization in this high-risk group. These findings show that additional preventive strategies to reduce morbidity and mortality in HFpEF patients with DM are needed.

References

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