I. Johansson

Is the prognosis in patients with diabetes and heart failure a matter of unsatisfactory management? : An observational study from the Swedish Heart Failure Registry

To analyse the long‐term outcome, risk factor panorama, and treatment pattern in patients with heart failure (HF) with and without type 2 diabetes (T2DM) from a daily healthcare perspective.

Risk factors, treatment and prognosis in men and women with heart failure with and without diabetes

Objective To test the hypothesis that risk factor pattern, treatment and prognosis differ between men and women with heart failure (HF) with and without diabetes in the Swedish Heart Failure Registry. Methods Patients with (n=8809) and without (n=27 465) type 2 diabetes (T2DM) included in the Swedish Heart Failure Registry (2003–2011) were followed for mortality during a median follow-up of 1.9 years (range 0–8.7 years). All-cause mortality, differences in background and HF characteristics were analysed in women and men with and without T2DM and with a special regard to different age groups. Results Of 36 274 patients, 24% had T2DM and 39% were women. In patients with T2DM, women were older than men (78 years vs 73 years), more frequently had hypertension, renal dysfunction and preserved ventricular function. Regardless of T2DM status, women with reduced ventricular function, compared with their male counterparts, were less frequently offered, for example, ACE inhibitors/angiotensin receptor II blockers (ARB). Absolute mortality was 48% in women with T2DM, 40% in women without; corresponding male mortality rates were 43% and 35%, respectively. Kaplan-Meier curves revealed shorter longevity in women with T2DM but female sex did not remain a significant mortality predictor following adjustment (OR 95% CI 0.90; 0.79 to 1.03). In those without T2DM, women compared with men lived longer; this pattern remained after adjustment (OR 0.72; 0.66 to 0.78). T2DM was a stronger predictor of mortality in women (OR 1.72; 1.53 to 1.94) than in men (OR 1.47; 1.34 to 1.61). Conclusions T2DM is a strong mortality predictor in men and women with HF, somewhat stronger in women. The shorter survival time in women with T2DM and HF related to comorbidities rather than sex per se. Evidence-based management was less prevalent in women. Mechanisms behind these findings remain incompletely understood and need further attention.

Type 2 diabetes and heart failure: Characteristics and prognosis in preserved, mid-range and reduced ventricular function

Objective: To study the characteristics and prognostic implications of type 2 diabetes in different heart failure entities from a nationwide perspective. Methods: This observational study comprised 30,696 heart failure patients prospectively included in the Swedish Heart Failure Registry (SwedeHF) 2003–2011 from specialist care, with mortality information available until December 2014. Patients were categorized into three heart failure entities by their left ventricular ejection fraction (heart failure with preserved ejection fraction: ⩾50%, heart failure with mid-range ejection fraction: 40%–49% and heart failure with reduced ejection fraction: <40%). All-cause mortality stratified by type 2 diabetes and heart failure entity was studied by Cox regression. Results: Among the patients, 22% had heart failure with preserved ejection fraction, 21% had heart failure with mid-range ejection fraction and 57% had heart failure with reduced ejection fraction. The proportion of type 2 diabetes was similar, ≈25% in each heart failure entity. Patients with type 2 diabetes and heart failure with preserved ejection fraction were older, more often female and burdened with hypertension and renal impairment compared with heart failure with mid-range ejection fraction and heart failure with reduced ejection fraction patients among whom ischaemic heart disease was more common. Type 2 diabetes remained an independent mortality predictor across all heart failure entities after multivariable adjustment, somewhat stronger in heart failure with left ventricular ejection fraction below 50% (hazard ratio, 95% confidence interval; heart failure with preserved ejection fraction: 1.32 [1.22–1.43], heart failure with mid-range ejection fraction: 1.51 [1.39–1.65], heart failure with reduced ejection fraction: 1.46 [1.39–1.54]; p-value for interaction, p = 0.0049). Conclusion: Type 2 diabetes is an independent mortality predictor across all heart failure entities increasing mortality risk by 30%–50%. In type 2 diabetes, the heart failure with mid-range ejection fraction entity resembles heart failure with reduced ejection fraction in clinical characteristics, risk factor pattern and prognosis.

Problems, Pitfalls and Encouraging Information on Patients with Diabetes and Heart Failure.

bleak when compared to those without diabetes, and hence, there is a need for improved treatment strategies in this unfavourable situation [6] . In this context, the report from the Norwegian Heart Failure Registry in this issue of Cardiolog y [7] , indicating that, following adjustment for comorbidities, outpatients with diabetes and heart failure have a similar prognosis to those without diabetes, is encouraging although surprising. In a recent national report from another Scandinavian country, Sweden, diabetes was indeed an independent predictor of mortality with an adjusted odds ratio of 1.60 (95% confidence interval 1.50–1.71) [5] . An important difference between these 2 studies is that the Norwegian report is based on outpatients, while the Swedish study reports on hospitalised patients and outpatients in specialist care. A contributory reason for the divergent findings may therefore be that the Norwegian population consisted of patients with less advanced disease. The age distribution gives support to this assumption, with a mean age of 69 years for patients with diabetes in the Norwegian study and of 74 years in the Swedish study. Moreover, the median survival was 64 months in the Norwegian patients with diabetes and heart failure compared to 42 months in the Swedish population. The very first report on the unfavourable relation between coronary artery disease and diabetes, including the dismal prognosis if combined with heart failure, was probably that by Sievers, Blomquist and Biörck in 1954 [1] . They did not receive the attention they deserved, and it is Kannel and his collaborators [2] who are usually referred to as the pioneers in this field due to their presentation of similar data from the Framingham Study about 20 years later. Sadly, it seems that the scenario has not changed over the years. Despite improved contemporary diabetes management, a recent analysis from the UK reported a 1.6fold risk increase of heart failure development in the presence of type 2 diabetes compared with the general population [3] . Common explanations for this increased risk are comorbidities like hypertension and coronary artery disease, but specific diabetes cardiomyopathy, including deranged myocardial metabolism and fibrosis, has also been suggested [4] . The present trend of improved survival following a myocardial infarction, even in people with diabetes, that leaves them alive but with coronary artery disease and myocardial injuries, may, in the future, increase the prevalence of diabetes in heart failure populations [5] . Unfortunately, the long-term prognosis for diabetes patients hospitalised for heart failure remains Received: February 23, 2016 Accepted: February 24, 2016 Published online: April 28, 2016

Contents Vol. 134, 2016

136 The Heart Valve Society 2nd Annual Meeting, March 17–19, 2016, New York City, N.Y., USA