2008 Clinical Practice Guidelines - Canadian Diabetes Association

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2008 CLINICAL PRACTICE GUIDELINES S122 32. Malmberg K, Ryden L, Efendic S, et al. Randomized trial of insulin-glucose infusion followed by subcutaneous insulin treatment in diabetic patients with acute myocardial infarction (DIGAMI study): effects on mortality at 1 year. J Am Coll Cardiol. 1995;26:57-65. 33. Malmberg K, Ryden L,Wedel H, et al; DIGAMI Investigators. Intense metabolic control by means of insulin in patients with diabetes mellitus and acute myocardial infarction (DIGAMI 2): effects on mortality and morbidity. Eur Heart J. 2005;26:650- 661. 34. Cheung NW, Wong VW, McLean M. The Hyperglycemia: Intensive Insulin Infusion in Infarction (HI-5) study: a randomized controlled trial of insulin infusion therapy for myocardial infarction. Diabetes Care. 2006;29:765-770. 35. Gustafsson I, Torp-Pedersen C, Kober L, et al. Effect of the angiotensin-converting enzyme inhibitor trandolapril on mortality and morbidity in diabetic patients with left ventricular dysfunction after acute myocardial infarction. Trace Study Group. J Am Coll Cardiol. 1999;34:83-89. 36. Borghi C, Bacchelli S, Esposti DD, et al; SMILE Study. Effects of the early ACE inhibition in diabetic nonthrombolyzed patients with anterior acute myocardial infarction. Diabetes Care. 2003;26:1862-1868. 37. Freemantle N, Cleland J, Young P, et al. Beta blockade after myocardial infarction: systematic review and meta regression analysis. BMJ. 1999;318:1730-1737. 38. Kjekshus J, Gilpin E, Cali G, et al. Diabetic patients and betablockers after myocardial infarction. Eur Heart J. 1990;11:43-50. 39. Dargie HJ. Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: the CAPRICORN randomised trial. Lancet. 2001;357:1385-1390. 40. Younis N, Burnham P, Patwala A, et al. Beta blocker prescribing differences in patients with and without diabetes following a first myocardial infarction. Diabet Med. 2001;18:159-161. 41. Alter DA, Khaykin Y, Austin PC, et al. Processes and outcomes of care for diabetic acute myocardial infarction patients in Ontario: do physicians undertreat? Diabetes Care. 2003;26:1427- 1434. 42. Franklin K, Goldberg RJ, Spencer F, et al. Implications of diabetes in patients with acute coronary syndromes. The Global Registry of Acute Coronary Events. Arch Intern Med. 2004;164: 1457-1463. 43. Eagle KA, Goodman SG,Avezum A, et al. Practice variation and missed opportunities for reperfusion in ST-segment-elevation myocardial infarction: findings from the Global Registry of Acute Coronary Events (GRACE). Lancet. 2002;359:373-377. 44. Ohman EM, Roe MT, Smith SC Jr., et al; CRUSADE Investigators. Care of non-ST-segment elevation patients: insights from the CRUSADE national quality improvement initiative. Am Heart J. 2004;148(5 suppl):S34-S39. 45. Norhammar A, Malmberg K, Ryden L, et al. Under utilisation of evidence-based treatment partially explains for the unfavourable prognosis in diabetic patients with acute myocardial infarction. Eur Heart J. 2003;24:838-844. 46. Yan RT, Yan AT, Tan M, et al; Canadian Acute Coronary Syndrome Registry Investigators. Underuse of evidence-based treatment partly explains the worse clinical outcomes in diabetic patients with acute coronary syndromes. Am Heart J. 2006;152:676-683. 47. Brogan GX Jr., Peterson ED, Mulgund J, et al.Treatment disparities in the care of patients with and without diabetes presenting with non-ST-segment elevation acute coronary syndromes. Diabetes Care. 2006;29:9-14.
Treatment of Diabetes in People With Heart Failure Canadian Diabetes Association Clinical Practice Guidelines Expert Committee The initial draft of this chapter was written by Malcolm Arnold MD FRCPC FRCP FACC KEY MESSAGES • Heart failure is still underrecognized and misdiagnosed. This has significant clinical implications, as the prognosis of untreated or undertreated heart failure is poor, yet very effective proven therapies are widely available to most physicians. • Diabetes can cause heart failure independently of ischemic heart disease by causing a diabetic cardiomyopathy. The incidence of heart failure is 2- to 4-fold higher in people with diabetes compared to those without. • Generally, heart failure in people with diabetes should be treated similarly to heart failure in those without diabetes, although comorbidities such as renal dysfunction may be more prevalent in people with diabetes and may influence heart failure drug doses and monitoring of therapy. INTRODUCTION Type 2 diabetes often occurs in association with other cardiovascular risk factors such as hypertension, dyslipidemia, smoking and obesity, which together are strongly associated with atherosclerosis, ischemic heart disease and left ventricular (LV) dysfunction. LV dysfunction can be clinically silent or associated with the typical clinical signs and symptoms of heart failure (e.g. peripheral edema, shortness of breath and fatigue), although the elderly may have atypical symptoms (1). These symptoms need to be differentiated from other conditions that may have similar presentations, such as chronic obstructive pulmonary disease, pneumonia, anemia, varicose veins, depression etc. HEART FAILURE IN PEOPLE WITH DIABETES The diagnosis of heart failure is made by association of typical clinical signs and symptoms with objective evidence such as that obtained from a chest X-ray, an echocardiogram or plasma natriuretic peptide testing (brain natriuretic peptide [BNP] and prohormone of BNP [NT-pro-BNP]) (1). Documentation of systolic and diastolic myocardial function is recommended at the time of diagnosis of heart failure or with a significant change in clinical stability. Heart failure can occur over the entire range of LV ejection fractions (LVEFs), from 60%.The measurement of plasma BNP and NT-pro-BNP, which are acutely released by ventricular myocytes when the myocardium is stretched due to increased filling pressures, may help make an accurate diagnosis where clinical uncertainty exists (2). However, the practising physician may still underrecognize and misdiagnose heart failure. This has significant clinical implications, as the prognosis of untreated or undertreated heart failure is poor, yet very effective proven therapies are widely available to most physicians. Diabetes is associated with increased prevalence of heart failure, both systolic (commonly defined as an LVEF 50%, but also referred to as preserved systolic function or preserved ejection fraction). However, the overlap between systolic and diastolic heart failure is considerable, and many people have a combination of systolic and diastolic dysfunction, although one is often reported to be predominant. Current tests such as echocardiography do usually fully characterize all aspects of systolic and diastolic dysfunction in individuals. It is recognized that diabetes can cause heart failure independently of ischemic heart disease by causing a diabetic cardiomyopathy (3). Epidemiological studies have shown that the incidence of heart failure is 2- to 4-fold higher in people with diabetes compared to those without diabetes (4,5).While an increase in glycated hemoglobin among individuals with diabetes is a recognized risk factor for heart failure (6-10), no study to date has demonstrated that improved glycemic control significantly reduces the incidence of heart failure (11). Microalbuminuria is also an independent risk factor for heart failure, especially in people with diabetes. In individuals with and without diabetes, increasing urinary albumin to creatinine ratio is associated with a stepwise increase (2- to 4-fold) in the risk of heart failure development (8,12). Angiotensinconverting enzyme (ACE) inhibitors significantly reduce urinary albumin excretion, and in large clinical trials of subjects with cardiovascular disease or diabetes they have been shown to lower the risk of new-onset heart failure (13-15). TREATMENT OF INDIVIDUALS WITH BOTH DIABETES AND HEART FAILURE In most heart failure clinical trials, diabetes is present in over one-third of subjects. In the large landmark clinical trials of heart failure, there is no evidence to suggest that treatment choices for heart failure should be different in subjects with diabetes compared to those without diabetes. No large, prospective trials of heart failure have tested different heart failure drugs or doses in subjects with diabetes vs. those with- S123 COMPLICATIONS AND COMORBIDITIES
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2008 Clinical Practice Guidelines - Canadian Diabetes Association

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