Modification of the of the cardiometabolic profile using combined therapy of the angiotensin receptor-neprilysin inhibitor and empagliflozin in comorbid patients with Chronic Heart Failure and type 2 Diabetes Mellitus

Chronic heart failure (CHF) and type 2 diabetes mellitus (DM2) and very common comorbidities with bidirectional, mutually aggravating courses. DM2 is known as an independent risk factor of cardiovascular complications whereas a higher CHF functional class is associated with increased risk of DM2. At present time, hypoglycemic drugs of the gliflozin class and the angiotensin receptor-neprilysin inhibitor (ARNI) are widely discussed in connection with their use in the treatment of patients with CHF and DM. The PARADIGM-HF study investigated effects of long-term treatment of CHF with reduced ejection fraction with presently the only representative of the ARNI class, a single supramolecular complex of valsartan-sacubitril. This medicine has already exceled enalapril at the effect not only on the incidence of nonfatal and fatal cardiovascular events but also on general mortality. Mean age of patients included into that study was 63.8±11.5 years; 21 % of them were females. In real-life clinical practice, physicians more frequently see older patients, and most of them are females, particularly with DM2. On the other hand, sodium-glucose cotransporter-2 inhibitors, including empagliflozin, significantly decreased the death rate and the frequency of CHF exacerbations in patients with DM2 and concomitant cardiovascular diseases, including CHF. This article describes a clinical case of initiating the valsartan-sacubitril treatment in combination with empagliflozin in an elderly female patient with congestive CHF with intermediate ejection fraction (EF) and comorbidities, including a history of myocardial infarction and DM2. Of interest is the rapid positive dynamics of clinical, laboratory (NT-proBNP) and instrumental (echocardiography) markers of CHF. At 3 months, the EF “recovered” from intermediate to preserved during the use of a comprehensive cardio-reno-metabolic approach. Both cardiologists and endocrinologists should definitely consider this approach in managing such patients since current cardiological drugs have additional pleiotropic metabolic effects whereas hypoglycemic drugs, in their turn, influence the cardiological prognosis.

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The chronic heart failure early stage predictors in type 2 diabetes mellitus

JOURNAL of SIBERIAN MEDICAL SCIENCES ◽

10.31549/2542-1174-2021-4-4-16 ◽

2021 ◽

pp. 4-16

Author(s):

D.V. Grazhdankina ◽

◽

A.A. Demin ◽

I.A. Bondar ◽

◽

...

Keyword(s):

Diabetes Mellitus ◽

Heart Failure ◽

Type 2 Diabetes ◽

Type 2 Diabetes Mellitus ◽

Chronic Heart Failure ◽

Ejection Fraction ◽

Left Ventricular ◽

Duration Of Diabetes ◽

Initial Symptoms

Introduction. Type 2 diabetes mellitus (T2DM) is considered to be the equivalent of cardiovascular disease due to its micro- and macrovascular complications. Insulin resistance and hyperinsulinemia, impaired glucose tolerance and fasting glucose, and their subsequent maladaptive responses lead to myocardial dysfunction several years before the onset of T2DM. Pathological changes in the cardiovascular system in T2DM can progress without any symptoms for a long time. Aim. To identify clinical, laboratory, echocardiographic predictors of the early manifestations of chronic heart failure (CHF) in patients with T2DM. Materials and methods. The study included 94 patients with T2DM with and without initial symptoms of CHF at the age of 40 to 65 years. All patients had obesity or excess body weight and arterial hypertension (AH), 37 patients had stable coronary heart disease (CHD). Patients underwent general clinical and laboratory examination, a 6-minute walk test (6MWT), echocardiography. The concentration of N-terminal pro-B-type natriuretic peptide (NT-proBNP ) was also determined. The patients were divided into 2 groups: without CHF symptoms (group 1, n = 54) and with initial symptoms of CHF (group 2, n = 40) and then these groups were compared. Results. Differences were revealed between the second and first groups in the duration of T2DM (10.5 vs 7.5 years, p = 0.02) and AH (15 vs 10 years, p = 0.009); the incidence of stable CHD (70 vs 16.7%, p < 0.0001); distance covered during 6MWT (375 vs 425 m, p < 0.0001); the median level of NT-proBNP (38.5 vs 27.2 pg/ml, p = 0.031); the left atrium (LA) size (4.4 vs 4.2 cm, p = 0.044); the left ventricular posterior wall thickness (PWT) (1.05 vs 0.95 cm, p = 0.02); the level of triglycerides (2.3 vs 1.6 mmol/l, p = 0.03) and the glomerular filtration rate (GFR) (74.1 vs 79.1 ml/min/1.73 m2, r = 0.04). The discriminant analysis revealed combination of factors associated with initial symptoms of CHF: the duration of CHD (taken as 0, if absent, p < 0.00001), PWT of the LV (p = 0.000007), GFR (p = 0.0009), the LA size (p = 0.005), the level of triglycerides (p = 0.03), the duration of T2DM (p = 0.046). The NT-proBNP level > 125 pg/ml was detected in 16% of patients with T2DM and correlated with the duration of diabetes over 10 years (p = 0.0085), the presence of stable CHD (p < 0.0001), and left ventricular mass index (p = 0.0005) and the ejection fraction of the LV (p < 0.0001). Conclusion. Predictors of the initial manifestations of chronic heart failure in patients with type 2 diabetes mellitus were the presence and duration of stable CHD, an increase in the PWT of the LV, the LA size, the level of triglycerides, and the duration of diabetes. An elevated level of NT-proBNP (more than 125 pg/ml) in patients with T2DM was detected in 16% of cases and was associated with the duration of diabetes for more than 10 years, presence of stable CHD, initial symptoms of CHF, left ventricular myocardial hypertrophy, and a lower left ventricular ejection fraction according to echocardiography.

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Influence of beta-blockers on mechanical dyssynchrony and cardiac remodeling in patients with ischemic chronic heart failure in the setting of revascularization

Research Results in Pharmacology ◽

10.3897/rrpharmacology.5.34073 ◽

2019 ◽

Vol 5 (1) ◽

pp. 1-13

Author(s):

Irina V. Askari ◽

Olga A. Osipova

Keyword(s):

Diabetes Mellitus ◽

Heart Failure ◽

Type 2 Diabetes ◽

Type 2 Diabetes Mellitus ◽

Chronic Heart Failure ◽

Ejection Fraction ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Average Dose

Introduction: Diastolic dysfunction (DD) and cardiac dyssynchrony (DS) are involved in the progression of chronic heart failure (CHF). A comparative analysis was conducted of the effect of a 6-month course of nebivolol and bisoprolol on DD, DS and metalloproteinase-9 (MMP-9) level in patients with ischemic chronic heart failure with preserved ejection fraction (HFpEF) and with midrange ejection fraction (HFmrEF), as well as in patients with comorbid type 2 diabetes mellitus (T2DM) in the setting of coronary artery bypass grafting (CABG) after 6 months of therapy. Materials and methods: The study included 308 patients with CHFFC I-II, left ventricular ejection fraction (LVEF) >40%, who had undergone CABG. The average dose of nebivolol in patients with DS 6 months later was 5.1±2.6 mg/day, and bisoprolol – 4.9±2.4 mg/day. Echocardiography (EchoCG) and evaluation of MMP-9 in blood plasma were performed. Mechanical myocardial asynchrony was determined by calculating the standard deviation of time to peak systolic myocardial velocity (TS-SD) and maximum segment delay (TS12) using a 6-basal and-midsegment model. Results and discussion: MMP-9 level in patients with CHF before CABG was 4.7 times higher (p<0.001). MMP-9 correlated with LVEF (r=-0.60, p<0.001), E/A (r=-0.49, p<0.001), DT (r=0.43, p<0.001), E` (r=-0.58, p<0.001) and DS: TS12 (r=0.54, p<0.001), TS-SD (r=0.49, p<0.001). The six-month course of nebivolol improved the values of DS: TS12 – by 30% (p<0.001), TS-SD – by 32% (p<0.01) and reduced the MMP-9 level by 11% (p<0.001). In patients with HFmrEF without DSnebivolol increased E/A by 19% (p<0.01), E` – by 16% (P<0.05), and decreased E/E’ by 9% (p<0.05), DT – by 12% (p<0.05). In patients with HFpEF and DM2, nebivolol reduced TS12 by 37% (p<0.01), TS-SD – by 29% (p<0.05) and MMP-9 – by 13% (p<0.05). Conclusion: The positive effect of nebivolol on the DS, DD of the LV in patients with HFpEF, HFmrEF and with comorbid type 2 diabetes mellitus. The six-month course of nebivolol decreased the MMP-9 level in patients with ischemic CHF after CABG, including patients with T2DM.

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