outcomes in the management of heart failure patients with T2DM - - PowerPoint PPT Presentation

Real world practices and

• utcomes in the

management of heart failure patients with T2DM

Carolyn Lam, MD Singapore

May 25, 2019 - Athens, Greece

Real world practices & outcomes in the management of HF patients with T2DM

Carolyn S.P. Lam MBBS, PhD, FRCP, FAMS, FESC, FACC

Senior Consultant Cardiologist, National Heart Centre Singapore Professor, Duke-National University of Singapore Rosalind Franklin Fellow, University Medical Centre Groningen Director, Clinical & Translational Research Office at NHCS Affiliate Member, SingHealth Duke-NUS Institute of Precision Medicine (PRISM) Scientific Advisor to the Clinical Trials Coordinating Centre (CTCC) at SingHealth

Global burden

• f HF.

Prevalence of HF US: 6M Prevalence of HF Europe: 15M

Prevalence of HF China: 4.5M India: 1.3 - 4.6M Japan: 1M Southeast Asia: 9M

Global burden

• f DM.

Prevalence of DM US: 29M Prevalence of DM Europe: 60M

Prevalence of DM China: 98M India: 65M Southeast Asia: 72M

60% of the world’s diabetics are in Asia Numbers in Southeast Asia expected to ↑ 70.6% by 2035

Singapore.

World Health Organization. Available at: http://www.who.int/countries/sgp/en.

• est. 2015

Total population :

5,604,000

Unique racial admixture

Chinese, Malay, Indian, Other

Interaction between regional income level & ethnicity on risk factor burden in HFrEF.

0,70 2,61 0,96 2,97 4,17 2,66 0,97 5,31 2,88 Chinese Indian Malay Age-adjusted odds ratio (higher vs lower income) Coronary artery disease Hypertension Diabetes

Lam CS Eur Heart J 2016

Epidemiologic transition.

1960’s Today

Asian vs Whites.

Bank, … Lam. JACC HF 2016

Sin Singapore Asi sians vs s Swedish whit ites

ASIAN-HF Registry. Prospective

• bservational study:

~7000 Asian

patients with Stage C HF

With detailed characterization and adjudicated outcomes. Multinational & Multicenter 11 regions in 46 sites.

La Lam CS Eur J Hear art Fail 2013 13

Comorbidity clusters in ASIAN-HF.

Tromp J… Lam CS PLOS Med 2018

Elderly/AF

Characteristics

• Eldest with AF and high rates
• f previous stroke
• More often HFpEF
• Concentric remodeling

Hong Kong Japan Korea

Metabolic

Characteristics

• High prevalence of obesity,

hypertension and diabetes

• More often HFpEF
• Concentric remodeling

Malaysia Singapore Philippines Taiwan

Ischemic

Characteristics

• Male patients with CAD

and ischemic aetiology

• f HF
• More often HFrEF
• Eccentric hypertrophy
• 2nd worst outcomes

India Malaysia Indonesia

Lean Diabetic

Characteristics

• Most often diabetic with

low BMI.

• More often HFpEF
• Concentric hypertrophy
• Worst outcomes and

quality of life Singapore Malaysia Hong Kong

Young

Characteristics

• Few comorbidities.
• More often HFrEF
• Eccentric hypertrophy
• Best outcomes
• Best effect of medication

Japan Korea India Thailand China

Lean diabetic phenotype of HF in Asia.

Chandramouli C et al Eur J Heart Fail 2018

Asi sian wom

• men wit

ith HF HF ar are e pr predisposed

Lean diabetic phenotype of HF in Asia.

Chandramouli C et al Eur J Heart Fail 2018

Com Compared to to men, , Asi sian wom

• men

wit ith HF HF wer ere mor

• re lik

ikely to to ha have

• DM despite a lean BMI
• greater burden of CKD
• more concentric LV geometry
• worse outcomes with DM

Real world practices & outcomes

DM in 40% of 5276 HFrEF (age 61 ± 11y; duration of DM 10 ± 8y)

Patients with (vs without) DM were less likely to be prescribed RAASi (74% vs 77%, P =0.02) and MRAs (55% vs 61%, P <0.01)

Anti-diabetic agents prescribed: metformin (54%), SUs (53%), insulin (24%), DPP4i (17%), TZDs (0.4%), with wide regional variation

Chia YMF Eur J Heart Fail 2019

Real world practices & outcomes

DM in 40% of 5276 HFrEF (age 61 ± 11y; duration of DM 10 ± 8y)

Patients with (vs without) DM were less likely to be prescribed RAASi (74% vs 77%, P =0.02) and MRAs (55% vs 61%, P <0.01)

Anti-diabetic agents prescribed: metformin (54%), SUs (53%), insulin (24%), DPP4i (17%), TZDs (0.4%), with wide regional variation

Chia YMF Eur J Heart Fail 2019

1y composite outcome in 26% vs 17% of patients with vs without DM (P <0.01)

Only metformin associated with ↓risk

(23% vs 28%, P =0.02; propensity adjusted HR 0.80 [0.64-1.01])

International comparison (DM + HFrEF).

Compared with ith US S pa patients, , the use use of

• f GDM

DMT for

• r HFr

FrEF was as lo lower in in pa patients s in in LI LI Asia Asian cou

• untries

In n bo both US S and and Asia, Asia, op

• pportunities

s for

• r im

improvement in in evidence-bas ased therapies s exi xist for

• r pa

patients s with ith DM DM + + HFrEF

Arnold SV Diabetes Obes Metab. 2018

The CVD-REAL 2 Study:

Lower Risk of Cardiovascular Events and Death Associated with Initiation of SGLT-2 Inhibitors versus Other Glucose Lowering Drugs - Real World Data Across Three Major World Regions with More Than 400,000 Patients:

Kosiborod M, Lam CSP, et al J Am Coll Cardiol 2018

DOI:10.1016/j.jacc.2018.03.009

Hospitalization for HF Death + hospitalization for HF Hospitalization for HF

Rationale Cardiovascular events are the leading cause of death among patients with diabetes. Early identification of high risk diabetic (DM) patients for intensification of preventive therapy may prevent cardiovascular events. Aims Among biomarker (N-terminal pro-B-type natriuretic peptide, NT-proBNP)-identified high-risk type 2 DM patients without pre-existing cardiovascular disease*, to test if intensive preventive therapy (high dose renin-angiotensin- aldosterone system inhibitors [RAASi], beta-blockade, sodium-glucose co-transporter 2 inhibitors [SGLT2i]) may be associated with reduced cardiovascular events compared to standard of care. Design Prospective multinational randomized open-label, parallel group, active-controlled, two-arm, long-term morbidity and mortality trial involving 5 countries (Singapore, Malaysia, China, Taiwan, India; estimated 6 sites each) with patients followed for 2 years. Population Adults with type 2 DM without cardiovascular disease* and with NT-proBNP >125 pg/mL

*Defined as known coronary stenosis >70%, reduced left ventricular ejection fraction <40%, or a history of myocardial infarction/ coronary revascularization/ heart failure hospitalization/ ischemic stroke/ prior lower limb amputation or angioplasty

Asian Diabetes Outcomes Prevention Trial