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© 2003 by the American Diabetes Association, Inc.
Reviews/Commentaries/Position Statements |
Heart Failure
The frequent, forgotten, and often fatal complication of diabetes
From the Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
Address correspondence and reprint requests to David S.H. Bell, MB, FACE, 1808 Seventh Ave. S., Rm. 813, Birmingham, AL 35294. E-mail: dbell{at}endo.dom.uab.edu
There is a high frequency of heart failure (HF) accompanied by an increased mortality risk for patients with diabetes. The poor prognosis of these patients has been explained by an underlying diabetic cardiomyopathy exacerbated by hypertension and ischemic heart disease. In these patients, activation of the sympathetic nervous system results in increased myocardial utilization of fatty acids and induction of fetal gene programs, decreasing myocardial function. Activation of the renin-angiotensin system results in myocardial remodeling. It is imperative for physicians to intercede early to stop the progression of HF, yet at least half of patients with left ventricular dysfunction remain undiagnosed and untreated until advanced disease causes disability. This delay is largely because of the asymptomatic nature of early HF, which necessitates more aggressive assessment of HF risk factors and early clinical signs. Utilization of ß-blockade, ACE inhibitors, or possibly angiotensin receptor blockers is essential in preventing remodeling with its associated decline in ventricular function. ß-Blockers not only prevent, but may also reverse, cardiac remodeling. Glycemic control may also play an important role in the therapy of diabetic HF. The adverse metabolic side effects that have been associated with ß-adrenergic inhibitors in the diabetic patient may be circumvented by use of a third-generation ß-blocker. Prophylactic utilization of ACE inhibitors and ß-blockers to avoid, rather than await, the need to treat HF should be considered in high-risk diabetic patients.
Abbreviations: ANG-II, angiotensin-II • ANP, atrial natriuretic peptide • ATLAS, Assessment of Treatment with Lisinopril and Survival • BNP, brain natriuretic peptide • CHF, chronic heart failure • CPT-1, carnitine palmityl transferase 1 • DIGAMI, Diabetes Insulin Glucose in Acute Myocardial Infarction • FFA, free fatty acid • HF, heart failure • MHC, myosin heavy chain • MI, myocardial infarction • RAS renin-angiotensin system • RESOLVD, Randomized Evaluation for Strategies of Left Ventricular Dysfunction • SERCA-2, sarcoplasmic reticular Ca2+ ATPase • SNS, sympathetic nervous system • SOLVD, Studies of Left Ventricular Dysfunction • TZD, thiazolidinedione
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