Recommend using new drugs for diabetes in heart failure patients

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The SAC and the FAC established a position regarding the use of glyphozins, based on the evidence on benefits for cardiovascular health.

Heart failure (HF) and type 2 diabetes mellitus (DM2) are two of the most frequent pathologies in the adult population. In Argentina, 12.7% of those over 18 years of age live with diabetes and heart failure (HF) is the leading cause of cardiovascular death. These are closely related diseases: the presence of a predisposes and aggravates the development of the other. In recent years, this strong association added a link from the therapeutic point of view: the new generation of drugs for type 2 diabetes demonstrated benefits for the heart, which is why specialists from the Argentine Society of Cardiology (SAC) and the Argentine Federation of Cardiology ( FAC) produced a document with recommendations for its use in patients with heart failure.

The document is based on evidence from clinical trials showing that new drugs for the treatment of type 2 diabetes (DM2), called iSGLT2 (such as empagliflozin, canagliflozin and dapagliflozin), have been shown to reduce both the hospitalization as mortality in cardiac patients with and without diabetes.

“As heart failure is a disease of large people, this condition can be present along with other health problems at the same time, one of them is type 2 diabetes. Both diseases have physiological mechanisms in common and also share risk factors , which makes many people have both pathologies at the same time, in fact, more or less 40% of people with heart failure have diabetes and the same is already showing excess glucose in the blood or has not yet received a diagnosis of diabetes. Only 20% of people with heart failure have a normal sugar metabolism, the rest have some type of disorder, “explains cardiologist Enrique Fairman.

Fairman is a member of the organizing committee of the 46th Argentine Congress of Cardiology -which will take place virtually from November 19 to 21-, an event in which he will be officially presented The document with taking position titled “Recommendations for the management of patients with heart failure. Use of new antidiabetic drugs in Heart Failure”.

The most important symptom of HF is shortness of breath, which is the one that mostly drives people to see a doctor. To that is added the fluid retention that causes edema in the legs, the same edema that at the pulmonary level causes shortness of breath. Coughing and a decrease in the amount of daily urine may also appear.

“If the person with heart failure also has diabetes, they have a much higher risk of mortality, and vice versa. In turn, the individual with HF has a higher risk of developing diabetes than one who does not. The main cause of death in diabetic people is cardiovascular disease, the diabetes and cardiovascular disease guidelines place great emphasis on the importance of having people with diabetes undergo cardiovascular monitoring, “added Fairman. People living with DM2 have more than double risk (112%) of suffering from HF compared to the general population.

The prognosis of people with heart failure has changed in the last three decades, because they developed life-prolonging drugs. Cardiologist Mirta Diez, also an organizer of the congress, points out that the latest advance has to do with the family of drugs iSGLT2 or “glyphosins”, which were designed for the treatment of diabetes, but which showed that they were not only safe from the cardiovascular view, but also reduced the hospitalization and mortality rate of people with diabetic and non-diabetic heart failure.

“This created a very deep intersection between diabetes and heart failure, because they are common diseases that can coexist and where each predisposes to the development of the other; now – in addition – they have common treatments. What was seen is that hospitalization is reduced on average by 30% and mortality in HF patients with and without diabetes drops by 14%, “added Fairman.

The doctor noted that there are two large studies that showed this, one called DAPA-HF, which had the distinctive feature of first evaluating an antidiabetic drug, dapagliphozin, as a treatment for heart failure in patients with and without type 2 diabetes. and showed that mortality is reduced by 18%. While another work, called EMPEROR, showed a reduction in mortality by 8%. When you do a meta-analysis, where both studies are included, you see an average of 14% reduction in cardiovascular mortality and 13% of all-cause mortality.

The iSGLT2 drugs reduce the reabsorption of glucose at the renal level – an effect independent of the action of insulin – and favor its elimination through the urine. In addition, its incidence on cardiovascular health is related to the ability to reduce blood pressure and weight. These drugs, which are contraindicated in type 1 diabetes, can be used alone or in combination with other drugs, including insulin. Among the reported adverse effects are ketoacidosis and genitourinary tract infections.

“This group of drugs that come from the field of diabetes, was shown to improve hospitalization for heart failure initially in diabetic patients. The results were so convincing that they were tested in the population with HF, with or without diabetes. In this scenario, they managed to reduce death cardiovascular disease and hospitalization for heart failure, in addition to achieving beneficial effects on kidney function. The clinical impact is that we have an additional treatment strategy for HF that has a mortality of 8 to 15% per year depending on the degree of severity, “said Diez.

For the specialist, the approach to heart failure involves two main pillars: on the one hand, patients have to adhere to hygienic-dietary measures such as salt restriction, smoking cessation, regular physical activity and receiving drug groups that have a benefit in cardiovascular mortality and hospitalization for HF, that is, those that slow down disease progression. These groups of drugs are the so-called renin angiotensin system inhibitors (ARNI, iECA or ARA II); beta blockers; mineralocorticoid receptor antagonists and now iSGLT2.

“The guidelines for the management of heart failure and the results of clinical studies show us with high level of evidence the treatments to follow. Now the challenge is to transfer this knowledge and evidence to the population. HF programs or clinics are required to educate patients, have standardized follow-ups and control the quality of care. Moreover, it remains a I challenge access to medication universally“concluded the cardiologist.

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