Transcript 幻灯片 1 - shsmu.edu.cn

David McFadden M.D.
Mayo Clinic
 Heart failure (HF) affects ＞5 million persons and is
responsible for ＞250,000 deaths in the United States
annually.
 HF hospitalization rates in the United States increased by
nearly
33%
from
1990–2004,
in
contrast
to
a
contemporaneous decrease in hospitalization rates for
myocardial infarction of 8%.
 Diabetes mellitus and HF commonly coexist. With the
increasing prevalence of obesity and diabetes in the
United States, it can be expected that the population with
diabetes who have HF will also increase.
Framingham cohort
 an association between diabetes and the risk for incident
HF independent of differences in coexisting CAD or
hypertension.
 the proportion of HF cases in a population accounted for
by diabetes alone was 12% in women and 6% in men.
Cardiovascular Health Study
 Diabetes conferred a significantly higher independent risk
for incident HF in 5,888 older patients followed for an
average of 5.5 years (relative risk [RR], 1.78).
 The proportion of incident HF in the population due to
diabetes was greater than that due to renal dysfunction,
electrocardiographic left ventricular hypertrophy, or left
ventricular systolic dysfunction .
Kaiser Permanente database
 It corroborated the Framingham and CHS results
 Strikingly, the prevalence of HF in patients with diabetes
in this population exceeded 1 in 9.
In clinical trial populations
 Antihypertensive
and Lipid-Lowering Treatment to
Prevent Heart Attack Trial (ALLHAT), which enrolled
subjects aged ≥ 55 years with hypertension and ≥1 other
cardiovascular risk factor.
 Davis and colleagues found that patients with diabetes had
a nearly 2-fold risk for HF hospitalization or death after
adjustment for other risk factors (RR, 1.95).
 Not surprisingly, because of the strong association
between diabetes and HF, the 2 commonly coexist.
 unselected community-based samples of patients with HF
likely provide more accurate estimates of the prevalence
of diabetes in the population.
 In patients with incident HF in Olmsted County,
Minnesota, from 1979 –2000, the prevalence of diabetes
was 24%.
 In a nationally representative sample of Medicare
beneficiaries
hospitalized
with
principal
discharge
diagnosis of HF, Havranek and colleagues found a
prevalence of diabetes exceeding 38%.
diabetes is also a risk factor
for the progression of HF
Studies of Left Ventricular Dysfunction
(SOLVD) trial
 Das
and colleagues found that in patients with
asymptomatic ischemic cardiomyopathy, diabetes was a
risk factor for the development of HF symptoms (hazard
ratio [HR], 1.56), HF hospitalization (RR, 2.16), or the
composite of death or symptom development (HR, 1.50).
 This relation was not observed in patients with
nonischemic cardiomyopathies.
diabetes as an important predictor
of mortality in patients with HF
 Several studies, including clinical trials and community-
based samples, have identified diabetes as an important
predictor of mortality in patients with HF independent of
other prognostic factors, including comorbidity and
functional status.
 These studies collectively represent a wide range of
patients, including those hospitalized for HF, ambulatory
patients, those enrolled in clinical trials, and those with
and without LVSD.
those hospitalized for HF
 Gustafsson and his colleague did a study which was an
analysis of survival data comprising 5,491 patients
consecutively hospitalized with new or worsening HF and
screened for entry into the Danish Investigations of
Arrhythmia and Mortality on Dofetilide (DIAMOND).
those hospitalized for HF
Gustafsson et al. JACC Vol 43, No 5, 2004; 771-7
ambulatory patients
 All patients with HF and left ventricular systolic
dysfunction attending the outpatient clinic at our Veteran’s
Hospital between October 1999 and November 2000 were
enrolled in our study and followed prospectively.
Electronic medical records were accessed for data on
comorbid conditions, medications, echocardiogram results
and mortality information. Mean follow-up was 2.7 years.
 Some studies suggest that this association may vary
on the basis of patient sex or HF cause.
 Specifically, some investigators have found that
diabetes has greater prognostic importance in women
or in those with ischemic cardiomyopathies.
 In summary, diabetes and HF commonly coexist. Diabetes
is an important risk factor for the development of HF
independent of CAD, hypertension, and other potential
confounders of the association.
 Finally, diabetes is associated with the progression of and
with a higher rate of adverse outcomes from HF.
 These observations emphasize the need for the appropriate
application of interventions that improve outcomes in this
high-risk population.
Thank you!