Cosmi Franco, Cosmi Deborah
Dipartimento Cardiovascolare, Ospedale di Cortona.
G Ital Cardiol (Rome). 2011 Dec;12(12):796-803. doi: 10.1714/996.10824.
Glucose-lowering treatment in patients with type 2 diabetes and heart failure is controversial. Metformin is clearly contraindicated when such diseases coexist. Conversely, no contraindications have been established for insulin in this subset of patients, even though several observational and retrospective studies have shown increased mortality and worsening heart failure. Data from the literature have demonstrated that in this patient population, which accounts for one third of all cases of heart failure, metformin reduces mortality by 14-35%. In patients with a glomerular filtration rate >30 ml/min who do not show dehydration, shock, sepsis, severe liver disease or hypoxemia, the administration of metformin doses <2 g/day was associated with a null risk of lactic acidosis. The positive effects of metformin are correlated with the reduction in insulin resistance, which is responsible for both the onset and development of heart failure in diabetic patients. Insulin can provoke severe hypoglycemia and fluid retention, resulting in negative effects. Further randomized and prospective studies are warranted to address these controversial issues in such a large population with high mortality and morbidity rates. Longitudinal studies would be crucial to the understanding of the optimal therapy and for stratification of patients according to the severity of heart failure.
2型糖尿病合并心力衰竭患者的降糖治疗存在争议。当这两种疾病并存时，二甲双胍显然是禁忌的。相反，在这类患者中，胰岛素尚无禁忌证，尽管多项观察性和回顾性研究显示死亡率增加且心力衰竭恶化。文献数据表明，在占所有心力衰竭病例三分之一的这一患者群体中，二甲双胍可使死亡率降低14% - 35%。在肾小球滤过率>30 ml/min且无脱水、休克、脓毒症、严重肝病或低氧血症的患者中，给予每日剂量<2 g的二甲双胍与乳酸酸中毒风险为零相关。二甲双胍的积极作用与胰岛素抵抗的降低相关，而胰岛素抵抗是糖尿病患者心力衰竭发生和发展的原因。胰岛素可引发严重低血糖和液体潴留，从而产生负面影响。有必要开展进一步的随机前瞻性研究，以解决这一高死亡率和高发病率的庞大人群中的这些争议性问题。纵向研究对于理解最佳治疗方法以及根据心力衰竭的严重程度对患者进行分层至关重要。
