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Heart failure strongest predictor of poor survival in type 2 diabetes

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November 17, 2017

Older adults with type 2 diabetes are at increased risk for death from cardiovascular complications, with the strongest associations found between survival and heart failure and vascular disease of the lower limbs, according to findings published in Diabetes Care.

Jean-Pierre Le Floch, MD, of the department of diabetology-endocrinology at Villecresnes Medical Hospital in France, and colleagues evaluated data from the GERODIAB study on 987 adults (median age, 77 years) with type 2 diabetes (diabetes duration, 16 years) to assess CV complications during a 5-year follow-up and the associations with 5-year mortality.

Among the cohort, 21% died. CV complications were the most common reason for death (34.3%).

Compared with the time of inclusion, at 5 years, more participants had evidence of coronary heart disease (> 40% vs. 30%), heart failure (approximately 20% vs. 9%), vascular disease of the cerebral vessels (approximately 26% vs. 15%) and vascular disease of the lower limbs (approximately 35% vs. 25%).

Poor survival was strongly associated with heart failure (P < .0001) and vascular disease of the lower limbs (P = .0004). CHD (P = .0056) and vascular disease of the cerebral vessels (P = .026) were mildly associated with poor survival.

The strongest predictor of poor survival was heart failure in multivariate models (HR = 1.96; 95% CI, 1.45-2.64).

“All the cardiovascular complications under study were significantly associated with survival, but their associations did not show the same value; heart failure and vascular disease of the lower limbs were very strongly associated with death, whereas coronary heart disease and vascular disease of the cerebral vessels showed only mild associations. ... Obvious conclusions should however be considered with caution, because many treatments can be used to improve the progression of coronary heart disease and/or vascular disease, whereas heart failure is not so easy to improve or prevent,” the researchers wrote. – by Amber Cox

Disclosures: The study was funded by unrestricted grants from Merck Serono and Novo Nordisk. The authors report no relevant financial disclosures.

itj+ Perspective

Alexander Turchin
Perspective

Prevalence of diabetes grows with age. As a result, the worldwide epidemic of diabetes makes an especially strong impact on older patients. Nevertheless, relatively little is known about treatment and complications of diabetes in this population. The study by Bauduceau and colleagues sheds welcome light on how diabetes affects these particularly vulnerable individuals.

In this large, population-based cohort, a large fraction of individuals had cardiovascular disease. Prevalence of CVD continued to increase rapidly as patients grew older. Mortality was high and was strongly associated with presence of CVD. These findings underscore the importance of focusing treatment of patients with diabetes on CV risk reduction.

The study also highlights the opportunities for improvement. In this high CV risk patient population, only 63% of patients were taking statins. Dearth of rigorous research on statin effects in older patients, which in turn has led to silence in the guidelines, has likely played a role. It is also notable that many patients were taking medications placing them at high risk for hypoglycemia, including sulfonylureas, glinides and insulin. Hypoglycemia, in turn, could increase CV risk. Several new classes of diabetes medications (mostly approved after the study was initiated) could both decrease the risk of hypoglycemia and also directly decrease the rate of CV events, making them potentially especially beneficial in this high-risk population. This study should therefore serve as a guidepost to both clinicians and researchers, pointing out how we could improve care of older patients with diabetes.

Alexander Turchin, MD, MS

Director of Quality in Diabetes,
Division of Endocrinology, Diabetes and Hypertension,
Brigham and Women’s Hospital

Disclosure: Turchin reports he is on the advisory boards for Merck and Monarch Medical Technologies and receives research grants from Eli Lilly and Sanofi.