University of Belgrade School of Medicine, Belgrade University Medical Center, Belgrade, Serbia.
Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
Eur J Heart Fail. 2018 May;20(5):853-872. doi: 10.1002/ejhf.1170. Epub 2018 Mar 8.
The coexistence of type 2 diabetes mellitus (T2DM) and heart failure (HF), either with reduced (HFrEF) or preserved ejection fraction (HFpEF), is frequent (30-40% of patients) and associated with a higher risk of HF hospitalization, all-cause and cardiovascular (CV) mortality. The most important causes of HF in T2DM are coronary artery disease, arterial hypertension and a direct detrimental effect of T2DM on the myocardium. T2DM is often unrecognized in HF patients, and vice versa, which emphasizes the importance of an active search for both disorders in the clinical practice. There are no specific limitations to HF treatment in T2DM. Subanalyses of trials addressing HF treatment in the general population have shown that all HF therapies are similarly effective regardless of T2DM. Concerning T2DM treatment in HF patients, most guidelines currently recommend metformin as the first-line choice. Sulphonylureas and insulin have been the traditional second- and third-line therapies although their safety in HF is equivocal. Neither glucagon-like preptide-1 (GLP-1) receptor agonists, nor dipeptidyl peptidase-4 (DPP4) inhibitors reduce the risk for HF hospitalization. Indeed, a DPP4 inhibitor, saxagliptin, has been associated with a higher risk of HF hospitalization. Thiazolidinediones (pioglitazone and rosiglitazone) are contraindicated in patients with (or at risk of) HF. In recent trials, sodium-glucose co-transporter-2 (SGLT2) inhibitors, empagliflozin and canagliflozin, have both shown a significant reduction in HF hospitalization in patients with established CV disease or at risk of CV disease. Several ongoing trials should provide an insight into the effectiveness of SGLT2 inhibitors in patients with HFrEF and HFpEF in the absence of T2DM.
2 型糖尿病（T2DM）与心力衰竭（HF）并存，无论射血分数降低（HFrEF）还是射血分数保留（HFpEF），均较为常见（30-40%的患者），且与 HF 住院、全因和心血管（CV）死亡率风险增加相关。导致 T2DM 患者 HF 的最重要原因是冠状动脉疾病、动脉高血压和 T2DM 对心肌的直接不良影响。在 HF 患者中，T2DM 往往未被识别，反之亦然，这强调了在临床实践中积极寻找这两种疾病的重要性。T2DM 患者的 HF 治疗没有特定限制。针对一般人群 HF 治疗的试验的亚组分析表明，无论是否患有 T2DM，所有 HF 治疗均同样有效。关于 HF 患者的 T2DM 治疗，目前大多数指南建议将二甲双胍作为首选。磺脲类药物和胰岛素一直是传统的二线和三线治疗方法，尽管它们在 HF 中的安全性存在争议。胰高血糖素样肽-1（GLP-1）受体激动剂和二肽基肽酶-4（DPP4）抑制剂均不能降低 HF 住院风险。事实上，一种 DPP4 抑制剂，沙格列汀，与 HF 住院风险增加相关。噻唑烷二酮类（吡格列酮和罗格列酮）禁用于（或有风险发生）HF 的患者。在最近的试验中，钠-葡萄糖共转运蛋白-2（SGLT2）抑制剂恩格列净和卡格列净均显示出在有明确 CV 疾病或有 CV 疾病风险的患者中，HF 住院风险显著降低。几项正在进行的试验应该能够深入了解 SGLT2 抑制剂在没有 T2DM 的情况下对 HFrEF 和 HFpEF 患者的有效性。
