ESC Congress 2017 In Review -- Main Edition - 25

ESC Congress 2017

LVAD implantation is now an important option either
as destination therapy or as a bridge to transplantation.
Lastly, when medical treatment has failed and no device
can be indicated because of patient age, comorbidities
and/or right ventricular dysfunction, palliative care
must be considered.

Heart Failure in Patients With
Diabetes
Written by Nicola Parry

In a symposium on heart failure (HF) and diabetes,
speakers shared data from recent studies investigating
the effects of diabetes in the HF population.
Effect of CV Risk Factors on CV Mortality in
Patients Receiving Empagliflozin
The EMPA-REG OUTCOME was a randomised, doubleblind, placebo-controlled trial to assess the effect of
once-daily empagliflozin (at a dose of either 10 mg or
25 mg), a selective inhibitor of sodium glucose cotransporter 2, versus placebo on cardiovascular (CV) events
in 7,028 adults with type 2 diabetes mellitus (T2DM) at
high CV risk versus usual standard of care. The primary outcome was a composite of death from CV causes,
nonfatal myocardial infarction (MI; excluding silent MI),
or nonfatal stroke [Zinman B et al. N Engl J Med. 2015].
The trial showed significant reduction in CV mortality
and all-cause mortality with empagliflozin in patients with
T2DM and CV disease, with similar benefits at the 2 doses
of empagliflozin used.
There was a lower rate of the primary composite CV
outcome in patients with T2DM who received empagliflozin than in those who received placebo (10% in the
pooled empagliflozin group vs 12.1%; HR, 0.86; 95% CI,
0.74 to 0.99; P = .04). Although there were no significant
between-group differences in the rates of MI (4.8% vs
5.4%; HR, 0.87; 95% CI, 0.70 to 1.09; P = .23) or stroke
(3.5% vs 3.0%; HR, 1.18; 95% CI, 0.89 to 1.56; P = .26),
patients who received empagliflozin had significantly
reduced rates of death from CV causes (HR, 0.62; 95%
CI, 0.49 to 0.77; P < .001 and from all causes (HR, 0.68;
95% CI, 0.57 to 0.82; P < .001).
Although the mechanism of the mortality reduction is
unclear, David Fitchett, MD, University of Toronto, Toronto,
Canada, noted that empagliflozin treatment also resulted
in small reductions in blood pressure (BP) and HbA1c, and
small increases in LDL-C during the trial.
Dr Fitchett and colleagues therefore performed a
study to investigate how these risk factors affected the
reduction in mortality with empagliflozin versus placebo during the EMPA-REG OUTCOME trial [Zinman B et
al. Eur Heart J. 2017].

In Review

After adjusting for control of BP, LDL-C and HbA1c,
and for all 3 risk factors together there was no effect
on the point estimate of the hazard ratio for CV mortality (HR, 0.61; 95% CI, 0.48 to 0.76). Similarly, the
adjustment for the single factor and for the all 3 factors
together did not influence the point estimate of the hazard ratio for all-cause mortality (HR, 0.67; 95% CI, 0.56
to 0.81).
This suggests that reductions in CV mortality and
all-cause mortality in patients receiving empagliflozin in
the EMPA-REG OUTCOME trial were not driven by control of these CV risk factors during the study.
Effect of Diabetes on HFmrEF
Diabetes is associated with worse long-term survival
and is an independent predictor of mortality in patients
with HF relative to patients with diabetes without HF
[Johansson I et al. Eur Heart J. 2017], emphasised
Isabelle
Johansson,
MD,
Karolinska
Institute,
Stockholm, Sweden. However, she noted that data on
the recently introduced subtype of heart failure with
mid-range ejection fraction (HFmrEF) are still lacking.
Using data from the Swedish Heart Failure Registry,
Dr Johansson and colleagues therefore aimed to
investigate characteristics and prognostic implications
of T2DM in HFmrEF (left ventricular EF 40-49%) in a
contemporary HF population [Johansson I et al. Eur J
Heart Fail. 2014].
They found that 21% (n = 6,483) of the total HF
population had HFmrEF; and among those with HFmrEF,
24% (n = 1,562) had T2DM.
Compared with HFmrEF patients without T2DM, those
with T2DM had more comorbidities, especially ischaemic
heart disease, hypertension, and chronic kidney disease
(P < .0001 for all). They also had a worse survival rate
(adjusted HR for all-cause mortality, 1.51; 95% CI, 1.39 to
1.65; P < .0001) at a median follow-up of 4 years.
The investigators also compared HFmrEF patients
with those with preserved-range ejection fraction (HFpEF)
and reduced-range ejection fraction (HFrEF) subtypes.
Diabetes was an independent predictor of mortality in
all 3 types of HF, and increased the risk of mortality by
51% in HFmrEF (HR, 1.51; 95% CI, 1.39 to 1.65), 46% in
HFrEF (HR, 1.46; 95% CI, 1.39 to 1.54), and 32% in HFpEF
(HR, 1.32; 95% CI, 1.22 to 1.43).
They found similar characteristics and prognoses in
patients with HFmrEF or HFrEF who also had diabetes.
Thus, in the diabetes setting, Dr Johansson indicated
that introducing the HFmrEF has added limited information to the pre-existing 2 HF-subtypes, and may even
confuse clinicians.
Effect of Diabetes on Iron Status in HF
The effect of T2DM on iron status in HFrEF patients remains
unclear because although some studies have established

Official Peer-Reviewed Highlights From ESC Congress 2017

25



Table of Contents for the Digital Edition of ESC Congress 2017 In Review -- Main Edition

Contents
ESC Congress 2017 In Review -- Main Edition - Cover1
ESC Congress 2017 In Review -- Main Edition - Cover2
ESC Congress 2017 In Review -- Main Edition - 1
ESC Congress 2017 In Review -- Main Edition - 2
ESC Congress 2017 In Review -- Main Edition - Contents
ESC Congress 2017 In Review -- Main Edition - 4
ESC Congress 2017 In Review -- Main Edition - 5
ESC Congress 2017 In Review -- Main Edition - 6
ESC Congress 2017 In Review -- Main Edition - 7
ESC Congress 2017 In Review -- Main Edition - 8
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ESC Congress 2017 In Review -- Main Edition - 12
ESC Congress 2017 In Review -- Main Edition - 13
ESC Congress 2017 In Review -- Main Edition - 14
ESC Congress 2017 In Review -- Main Edition - 15
ESC Congress 2017 In Review -- Main Edition - 15A
ESC Congress 2017 In Review -- Main Edition - 15B
ESC Congress 2017 In Review -- Main Edition - 15C
ESC Congress 2017 In Review -- Main Edition - 15D
ESC Congress 2017 In Review -- Main Edition - 16
ESC Congress 2017 In Review -- Main Edition - 17
ESC Congress 2017 In Review -- Main Edition - 18
ESC Congress 2017 In Review -- Main Edition - 19
ESC Congress 2017 In Review -- Main Edition - 20
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ESC Congress 2017 In Review -- Main Edition - 31
ESC Congress 2017 In Review -- Main Edition - 32
ESC Congress 2017 In Review -- Main Edition - Cover3
ESC Congress 2017 In Review -- Main Edition - Cover4
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