Acute heart failure in patients with diabetes mellitus: Clinical characteristics and predictors of in-hospital mortality

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Abstract

Objective/methods

ALARM-HF was an in-hospital observational survey that included 4953 patients admitted for acute heart failure (AHF) in six European countries, Mexico and Australia. This article is a secondary analysis of the survey which evaluates differences in clinical phenotype, treatment regimens and in-hospital outcomes in AHF patients with diabetes mellitus (DM) compared to non-diabetics. The data were collected retrospectively by the investigators, and the diagnosis of AHF (reported at discharge) was based on the definition and classification of ESC guidelines, while the diagnosis of DM was based on medical record (past medical and medication history).

Results

This sub-analysis demonstrates substantial differences regarding both baseline features and in-hospital outcome among diabetic and non-diabetic AHF patients. Diabetic patients (n = 2229, 45%) presented more frequently with acute pulmonary edema (p < 0.001) than non-diabetics, had more often acute coronary syndrome (p < 0.001) as precipitating factors of AHF, and multiple comorbidities such as renal dysfunction (p < 0.001), arterial hypertension (p < 0.001), anemia (p < 0.001) and peripheral vascular disease (p < 0.001). All-cause in-hospital mortality of diabetics was higher compared to non-diabetics (11.7% vs 9.8%, p = 0.01). The multivariate analysis revealed that older age (p = 0.032), systolic blood pressure < 100 mm Hg (p < 0.001), acute coronary syndrome and non compliance as precipitating factors (p = 0.05 and p = 0.005, respectively), history of arterial hypertension (p = 0.022), LVEF < 50% (p < 0.001), serum creatinine > 1.5 mg/dl (p = 0.029), absence of life saving therapies such as ACE inhibitors/ARBs (p < 0.001) and beta-blockers (p = 0.014) at admission, as well as absence of interventional treatment by PCI (p < 0.001), were independently associated with adverse in-hospital outcome.

Conclusion

Diabetics with AHF have higher in-hospital mortality than non-diabetics despite their intensive treatment regimens (regarding care for HF and ACS), possibly due to underlying ischemic heart disease and the presence of multiple comorbidities.

Introduction

Heart failure (HF) and diabetes mellitus (DM) are both common clinical entities that frequently coexist in the same patient population. The prevalence of diabetes ranges from 4 to 7% in the general population, whilst reaches 11–47% in patients with heart failure, according to several clinical studies [1], [2], [3], [4], [5], [6], [7]. Despite the increased incidence of this comorbidity in HF patients, data regarding clinical profile and prognosis of this subgroup are still inadequate. Most clinical trials have demonstrated a worse outcome, established mainly in patients with left ventricular systolic dysfunction [1], [8], [9], [10], [11], [12]. However, the increased morbidity and mortality, related to diabetes, may be also attributed to other comorbidities observed in this HF patient population, such as renal dysfunction and anemia, which on the other hand may be owing to DM [13]. Additionally, clinical and prognostic interactions between diabetes and HF should be further studied in patients with preserved ejection fraction (EF) [14].

Acute Heart Failure Global Survey of Standard Treatment (ALARM-HF) is an international registry that included patients hospitalized for acute heart failure (AHF) [15], [16]. Distinct clinical presentations, management strategies, and outcomes of AHF were described and compared in order to evaluate the utility of European Society of Cardiology (ESC) guidelines in clinical practice [17]. Our analysis aims to identify the clinical profile, treatment strategies and in-hospital mortality of acute heart failure (AHF) patients with diabetes mellitus that were enrolled in the ALARM-HF registry. Moreover, the identification of predictors of in-hospital mortality in this subgroup may promote further monitoring and possible interventions in diabetic patients that have some of these predictors at baseline. This kind of analysis has not previously been described, to the best of our knowledge.

Section snippets

Methods

ALARM-HF is a retrospective observational survey of hospitalized patients for AHF in 9 countries (6 European, Turkey, Mexico and Australia) [15]. The 4953 enrolled patients were admitted to either Cardiology Departments (67%) or Intensive Care Units (ICU) (33%) of 666 representative hospitals according to geographic region, hospital sector (public versus private), type (academic versus non-teaching status) and magnitude (by number of beds). The increased rate of ICU admissions (1/3 of the total

Results

The overall population of patients with AHF included in the ALARM-HF registry has already been classified and presented along with data concerning clinical characteristics, treatment, and outcomes [15], [18], [19]. This population consisted of 4953 patients hospitalized for AHF in nine countries (700 in Spain, 679 in Italy, 623 in UK, 628 in Turkey, 617 in Germany, 601 in Mexico, 588 in France, 255 in Greece, and 262 in Australia) in Europe, Latin America, and Australia among October 2006 and

Discussion

Diabetes mellitus is a common comorbid condition of HF patients with prevalence that varies from 6 to 25% in subjects with left ventricular systolic dysfunction, 12–30% in those with symptomatic HF, and up to 40% in patients hospitalized with HF [2], [5], [6], [7], [13], [20], [21]. This retrospective sub-analysis of the ALARM-HF survey demonstrates that 45% of hospitalized patients with AHF had history of diabetes mellitus. Similar prevalence has been reported in the Acute Decompensated Heart

Conflicts of interest statements for all authors

JP, AM, JD, FVB, and FF reported being consultant for and received research grants from Abbott, Chicago, IL, USA.

Acknowledgment

The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [48].

References (48)

  • P.A. Poole-Wilson et al.

    Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol or Metoprolol European Trial (COMET): randomised controlled trial

    Lancet

    (2003)
  • B. Pitt et al.

    Effect of losartan compared with captopril on mortality in patients with symptomatic heart failure: randomised trial-the losartan heart failure survival study ELITE II

    Lancet

    (2000)
  • S. Yusuf et al.

    Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-preserved trial

    Lancet

    (2003)
  • P.G. Shekelle et al.

    Efficacy of angiotensin-converting enzyme inhibitors and beta-blockers in the management of left ventricular systolic dysfunction according to race, gender, and diabetic status: a meta-analysis of major clinical trials

    J Am Coll Cardiol

    (2003)
  • S.J. Haas et al.

    Are beta-blockers as efficacious in patients with diabetes mellitus as in patients without diabetes mellitus who have chronic heart failure? A meta-analysis of large-scale clinical trials

    Am Heart J

    (2003)
  • S. Smooke et al.

    Insulin-treated diabetes is associated with a marked increase in mortality in patients with advanced heart failure

    Am Heart J

    (2005)
  • I. Gustafsson et al.

    Influence of diabetes and diabetes-gender interaction on the risk of death in patients hospitalized with congestive heart failure

    J Am Coll Cardiol

    (2004)
  • R. Lee et al.

    Impact of diabetes mellitus on survival in South East Asian patients with congestive heart failure due to left ventricular systolic dysfunction

    Int J Cardiol

    (2010)
  • J.M. Brophy et al.

    A multivariate model for predicting mortality in patients with heart failure and systolic dysfunction

    Am J Med

    (2004)
  • C.W. Yancy et al.

    Clinical presentation, management, and in-hospital outcomes of patients admitted with acute decompensated heart failure with preserved systolic function: a report from the acute decompensated heart failure national registry ADHERE database

    J Am Coll Cardiol

    (2006)
  • W.T. Abraham et al.

    Predictors of in-hospital mortality in patients hospitalized for heart failure

    J Am Coll Cardiol

    (2008)
  • E.H. Gilbert et al.

    Chart reviews in emergency medicine research: Where are the methods?

    Ann Emerg Med

    (1996)
  • D. Badcock et al.

    The quality of medical record review studies in the international emergency medicine literature

    Ann Emerg Med

    (2005)
  • L.G. Shewan et al.

    Ethics in the authorship and publishing of scientific articles

    Int J Cardiol

    (2010)
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