Gitt A K, Bramlage P, Binz C, Krekler M, Deeg E, Tschöpe D
Medizinische Klinik B, Kardiologie, Herzzentrum Ludwigshafen, Ludwigshafen, Germany.
Herz. 2012 May;37(3):294-300. doi: 10.1007/s00059-012-3611-3.
Patients with type 2 diabetes and heart failure are considered to be at high risk for hypoglycaemic complications. There is a considerable uncertainty with respect to the appropriate choice of antidiabetic pharmacotherapy in patients with type 2 diabetes and comorbid heart failure. Little is known about comorbidity, hypoglycaemia rates and selected pharmacotherapy in diabetic patients with heart failure in clinical practice.
DiaRegis is a prospective registry in Germany including 3,810 patients with type 2 diabetes receiving antidiabetic treatment with oral mono or oral dual combination therapy in 2009/2010. Only patients for which adjustment of pharmacotherapy (including the introduction of insulin and GLP-1 analogues) was deemed necessary were enrolled. We examined the differences in comorbidity, hypoglycaemia and choice of anti-diabetic pharmacotherapy between diabetics with and without clinical heart failure in clinical practice in Germany.
For 3,746 patients, data on the presence of heart failure were available, median (IQR) age 65.9 (57.6-72.8) years and 46.8% were female. Patients with heart failure (n = 370; 9.9%) were older, had a higher BMI, were less physically active, and had more cardiovascular risk factors and a substantial comorbidity. Glycaemic control was comparable between groups. Of the patients with heart failure, 76.8% received metformin, 32.7% sulfonylureas, 2.2% glucosidase inhibitors, 4.3% glinides, 6.2% glitazones and 7.3% DPP-4 inhibitors at baseline before adjustment of therapy. In multivariate analyses, patients with heart failure received less metformin (odds ratio (OR) 0.58, 95% confidence interval (CI) 0.43-0.79) and sulfonylureas (OR 0.70, 95%CI 0.52-0.95) but not thiazolidinediones (OR 1.22, 95%CI 0.82-1.81) or other antidiabetic drugs. Hypoglycaemia was considerably more frequent in diabetic patients with heart failure than in those without (OR 1.96, 95%CI 1.47-2.61).
Patients with type 2 diabetes and heart failure had a substantially increased comorbidity burden compared to patients without heart failure. They more often suffered from episodes of hypoglycaemia, especially those requiring medical assistance. The diagnosis of heart failure did not impact the choice of antidiabetic pharmacotherapy in patients with type 2 diabetes. There was no differential use of thiazolidinediones despite evidence discouraging their use in patients with heart failure.
2型糖尿病合并心力衰竭患者被认为发生低血糖并发症的风险较高。对于2型糖尿病合并心力衰竭患者，抗糖尿病药物治疗的恰当选择存在相当大的不确定性。在临床实践中，对于糖尿病合并心力衰竭患者的合并症、低血糖发生率及所选药物治疗知之甚少。
DiaRegis是德国一项前瞻性登记研究，纳入了2009/2010年接受口服单药或口服双联抗糖尿病治疗的3810例2型糖尿病患者。仅纳入那些被认为有必要调整药物治疗（包括开始使用胰岛素和GLP-1类似物）的患者。我们研究了德国临床实践中合并和未合并临床心力衰竭的糖尿病患者在合并症、低血糖及抗糖尿病药物选择方面的差异。
3746例患者有心力衰竭相关数据，年龄中位数（四分位间距）为65.9（57.6 - 72.8）岁，46.8%为女性。心力衰竭患者（n = 370；9.9%）年龄更大，BMI更高，身体活动较少，有更多心血管危险因素及大量合并症。两组血糖控制情况相当。在心力衰竭患者中，76.8%在治疗调整前基线时接受二甲双胍治疗，32.7%接受磺脲类药物治疗，2.2%接受糖苷酶抑制剂治疗，4.3%接受格列奈类药物治疗，6.2%接受噻唑烷二酮类药物治疗，7.3%接受DPP - 4抑制剂治疗。多因素分析显示，心力衰竭患者接受二甲双胍（比值比（OR）0.58，95%置信区间（CI）0.43 - 0.79）和磺脲类药物（OR 0.70，95%CI 0.52 - 0.95）治疗的比例较低，但接受噻唑烷二酮类药物（OR 1.22，95%CI 0.82 - 1.81）或其他抗糖尿病药物治疗的比例无差异。糖尿病合并心力衰竭患者低血糖发生频率显著高于未合并心力衰竭患者（OR 1.96，95%CI 1.47 - 2.61）。
与未合并心力衰竭的患者相比，2型糖尿病合并心力衰竭患者的合并症负担显著增加。他们更常发生低血糖事件，尤其是需要医疗救助的低血糖事件。心力衰竭的诊断并未影响2型糖尿病患者抗糖尿病药物的选择。尽管有证据不鼓励心力衰竭患者使用噻唑烷二酮类药物，但该类药物的使用并无差异。
