Glucose-lowering therapy in type 2 diabetes with heart failure vs high HF risk: missed opportunities for prognosis-modifying treatment
V Medovchshikov, N Yeshniyazov, D Kurmangaliyeva, S Azhgaliyeva, G Yussupova, M Balabayeva, Z H Iskakova, D Murzagaliyeva, E Khasanova, G Kurmanalina, B Zholdin, Z KobalavaAbstract
Purpose
To evaluate outpatient glucose-lowering therapy and key contraindications to its use in patients with type 2 diabetes mellitus (T2DM) and diagnosed heart failure (HF) and in those at high risk of HF.
Methods
This single-center prospective study enrolled 737 patients aged ≥40 years with established cardiovascular disease who were hospitalized for cardiology indications at a city clinical hospital. All participants underwent ADA-based screening for disorders of glucose metabolism; previously diagnosed T2DM was identified in 25.1% (n=185). The present analysis focused on patients with previously diagnosed T2DM, stratified into diagnosed HF versus no diagnosed HF with high/very high 5-year HF risk by ABC-HF scale. We assessed cardiovascular comorbidity, outpatient glucose-lowering therapy at admission, and key absolute contraindications to glucose-lowering medications.
Results
Among patients with previously diagnosed T2DM (n=185), clinical HF was present in 60.5%, while 29.7% had high/very high HF risk by ABC-HF; the remaining patients without HF had low/intermediate risk (9.8%) and were not included in the between-group comparison. The median ABC-HF total score was 10 (8; 12). Compared with high/very high-risk patients, those with clinical HF were older (72.0±10.3 vs 64.5±11.4 years; p<0.001), had higher atrial fibrillation prevalence (49.1% vs 18.2%; p<0.001), and more frequent chronic kidney disease (66.1% vs 41.8%; p=0.003) and obesity (64.0% vs 52.8%; p=0.042) (Fig. 1). HbA1c levels were comparable between groups and overall consistent with moderate glycemic control (Fig. 1). Outpatient regimens more often included insulin and less often included metformin in HF (Fig. 2). Outcome-modifying agents, most notably SGLT2 inhibitors, were rarely used in both groups, with no significant between-group differences. Absolute contraindications, primarily related to renal dysfunction, were more frequent in clinical HF (Fig. 2).
Conclusions
Outpatient glucose-lowering therapy in T2DM patients with diagnosed HF or high HF risk is frequently discordant with contemporary recommendations: insulin is used more often and metformin less often in HF, while agents with proven prognostic benefit (including SGLT2 inhibitors) were infrequently prescribed irrespective of HF status. Although CKD may partly constrain therapeutic choices, it does not fully explain the low uptake of outcome-modifying drug classes. Integrating HF risk stratification (ABC-HF) into glucose-lowering treatment algorithms and strengthening multidisciplinary cardiometabolic care are warranted.Figure 1For image description, please refer to the figure legend and surrounding text.Figure 2For image description, please refer to the figure legend and surrounding text.