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The majority of therapeutic agents for heart failure have
similar or better efficacy in patients with diabetes than
in those without diabetes. As a general principle, patients
with diabetes, and especially those with concomitant hypertension,
represent a subgroup with a high incidence of coronary artery
disease and a greater degree of left ventricular dysfunction.
The cornerstone of heart failure treatment are ACE inhibitors,
although diuretics are commonly used to treat pulmonary congestion.
A recommended treatment algorithm exists for choice of pharmacological
therapy of people with left ventricular systolic dysfunction
(Table 1), which
takes into account the presence of symptoms, signs of fluid
retention, and the progression of the condition. However,
the majority of people with diabetes initially develop left
ventricular diastolic dysfunction. The recommendations that
exist for diastolic dysfunction are purely speculative as
there is no straightforward algorithm for the choice of pharmacological
therapy in this situation. This is because diastolic and systolic
dysfunction are not synonymous and often co-exist. Therefore
people with this condition are often excluded from clinical
trials [Remme and Swedberg,
2001].
In general, the treatment strategy seen in Table 2 is recommended
for people with diastolic dysfunction.
| Therapy |
Effect |
| ACE inhibitor |
Improve relaxation and cardiac distensibility
and also have an effect on regression of hypertrophy and
reduction in hypertension. |
| Diuretic |
For fluid overload. |
| Beta-blocker |
Lower the heart rate and increase the diastolic
period. |
| Calcium channel antagonist |
Lower the heart rate and increase the diastolic
period. |
Table 2. Diastolic dysfunction – recommended
treatment strategy [Remme
and Swedberg, 2001] |
As heart failure progresses, diuretics are prescribed in
increasing dosages but still the electrolyte balance becomes
increasingly difficult to maintain. It is therefore recommended
at this stage to add a thiazide to the existing loop diuretic,
enhancing diuresis and improving the heart failure. However,
in due course these electrolyte difficulties will become increasingly
more difficult to manage [Shaw,
1996].
In terms of surgical options, revascularisation is useful
in preventing myocardial infarction but offers little benefit
to the patient with heart failure [Shaw,
1996]. Cardiac transplantation is considered in young
patients with severe refractory heart failure and those with
severe end-stage heart failure [Gray
and Yudkin, 1997; Shaw, 1996]. However, the presence of
diabetes poses special difficulties and the presence of other
complications seriously affects mortality. In general, transplantation
is not considered as a treatment option available to people
with diabetes [Shaw, 1996].
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