Treatment of type 2 diabetes patients with heart conditions

ABSTRACT

Introduction

While type 2 diabetes mellitus (T2DM) increases the risk of cardiac complications, diabetes treatment choices may increase or decrease the rates of cardiac events. In the present review, we comprehensively discussed the treatment options of diabetic subjects with cardiac conditions.

Areas covered

Current evidence related to diabetes treatment in cardiac situations has been reviewed. Clinical trials and meta-analyses on cardiac safety of anti-diabetic medicines are discussed. Treatment choices with proven benefits and those at least without associated increased cardiac risk were drawn from clinical trials; meta-analyses and cardiac safety studies in the recent medical literature were the basis of the suggestions in the present review.

Expert opinion

We can suggest that hypoglycemia and extreme hyperglycemia should be avoided in acute ischemic heart conditions. Certain diabetic treatment options, especially sodium-glucose cotransporter-2 (SGLT2) inhibitors, can reduce overall cardiovascular mortality and hospitalization due to heart failure. Therefore, we suggest that physicians should choose SGLT2 inhibitors as the first-line treatment option in diabetic patients with heart failure or those who have a high risk of heart failure development. T2DM increases the risk of atrial fibrillation (AF), and metformin and pioglitazone seem to reduce the risk of AF in diabetic population.

KEYWORDS:

• Type 2 diabetes mellitus
• cardiac conditions
• heart failure
• atrial fibrillation
• diabetes treatment

Article highlights

•- Losing tight glucose control is recommended in the elderly, in patients with advanced cardiac disease, during follow-up of acute coronary syndrome, in diabetics with a long duration of diabetes, and in subjects with multiple comorbidities. Although strict glucose control is not recommended in ACS, a positive correlation between blood glucose levels and ACS mortality exists.

•- HF risk was increased in patients with intensive treatment with pioglitazone. Diabetic subjects with heart failure (NYHA class 3–4) should not be treated with thiazolidinediones because of heart failure risk driven by the sodium and the fluid retention effect of these drugs.

•- More evidence is needed to recommend against insulin in diabetic patients with HF. On the other hand, metformin is a safe choice of diabetes treatment in HF patients unless the patient has acute decompensated HF or a GFR lower than 30 mL/min/1.73 m2.

•- The risk of HF may be exaggerated by sulfonylureas since they cause hypoglycemia. Therefore, other anti-diabetic medicines with low-risk profiles should be preferred over sulfonylureas in diabetic populations with heart failure.

•- Due to the controversial results of studies on the cardiovascular safety of DPP-4 inhibitors, they are not recommended as the first-line treatment options in diabetic patients with heart failure.

•- GLP1 analog treatment can be used safely in diabetics with heart failure; however, they appear not to reduce the risk of heart failure in diabetics with cardiac conditions.

•- SGLT2 inhibitors are the first-line drugs for diabetic subjects with heart failure and for those whose heart failure risk is high because they have proven effects in reducing cardiac mortality and heart failure risk.

•- Metformin and pioglitazone can be useful in diabetic patients with AF. Moreover, SGLT2 inhibitors and GLP-1 agonists are also safe medications in this manner.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.