Monday, August 30, 2010

Diabetes and the Heart – More Questions than Answers?

I am currently attending the 2010 Scientific Meeting of the European Society of Cardiology, here in Stockholm.

In a session on diabetes and heart disease, Mamas Mamas from the University of Manchester, UK, reported that abnormal glucose tolerance (pre-diabetes or diabetes) is found in about 50% of unselected heart failure patients.

Importantly, only a small fraction of patients will have abnormal fastng glucose, suggesting that glucose tolerance tests are essential to determine abnormal glucose disposition in patients with heart disease.

Insulin resistance, in part due to decreased exercise capacity, may also be exacerbated in heart failure patients.

Longitudinal studies confirm the negative prognostic relevance of abnormal glucose tolerance in with a 35% increased risk in cardiovascular death with each 1% increase in HbA1c levels.

However, Mamas also noted that while the Diabetes Prevention Program, showed a marked reduction in the progression to diabetes with lifesyle intervention in individuals with pre-diabetes, the findings from this study did not suggest any reduction in heart failure or cardiovascular deaths.

Indeed, despite the wide recognition that diabetes is an important risk factor for heart disease, data on the prevention or improvement in cardiac function with diabetes treatment remains rather disappointing.

On a similar note, Clyde Yancy, Baylor University Medical Center, Dallas, TX, spoke on the issue of diabetic cardiomyopathy.

As Yancy pointed out, diabetic cardiomyopathy defined as significantly impaired cardiac function in diabetic patients in the absence of epicardial vascular disease, left-ventricular hypertrophy, valvular disease, or other causes of cardiomyopathy, makes it largely a diagnosis of exclusion.

The association between diabetic cardiomyopathy and diabetic retinopathy suggests that microvascular abnormalities may play a role.

However, there may also be direct metabolic effects of dysglycemia and hyperinsulinemia, resulting in lipotoxicity and generation of oxidative stress leading to apoptosis and fibrosis. This may well explain the findings of left-ventricular remodeling, myocardial fibrosis, collagen and lipid deposition with altered compliance and diastolic dysfunction, seen in patients with diabetic cardiomyopathy.

Animal studies show that increased glucose levels can increase expression of box-1 protein, involved in pro-inflammatory defense mechanisms. Blocking this response may, thus, prove a novel approach to preventing and treating cardiomyopathy.

This is important because, as noted previously by Mamas (and other speakers in this session), current anti-diabetic treatments do not appear to have the expected beneficial effects on heart function or macrovascular disease in patients with diabetes.

In the context of obesity management it is therefore perhaps important to recall the fact that one of the most impressive findings from bariatric surgery studies, is the remarkable reduction (upto 80%) of diabetes related mortality – something conventional diabetes treatments have yet to demonstrate.

Whether similar benefits can be seen with more moderate weight loss of course remains to be seen, nevertheless, it is certainly increasingly apparent that simply controlling blood glucose levels in patients with diabetes may not be the answer.

AMS,
Stockholm, Sweden

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2 Responses to “Diabetes and the Heart – More Questions than Answers?”

  1. Melba montgomery says:

    Thank you Dr Sharma, for this article; I have always found Diabetes very intriguing, all my family from both side have diabetes the only one who doesn’t have yet it’s me. The only thing I have done different is that I’m a runner; I hope it has helped. Thanks again for taking the time to share all your articles, I find them very educational. All the best! (I’m sorry for any grammar mistake; English is not my first language).

  2. katja sawitsky says:

    I have just read the book “thinking in circles about obesity” by Tarek Hamid and would highly recommend it, especially to any health professionals. I am not suprised by what you report today, Dr. Sharma. High blood sugar levels are a sign that there is something wrong in the system – in this case – the system is one of energy balance and metabolism. Diabetes, or prediabetes are biological markers that energy metabolism has gone amuk. It makes sense therefore, that addressing only one of the observable signs that something is wrong in the system – such as bringing down blood sugar, would not necessarily impact one of the consequences of a system defect, such as early mortality or heart disease. I think it is important to distinguish the differences between markers of something being wrong and the consequences of something being wrong. While as medical folks we tend to believe that diabetes is a disease, understanding things from a systems perspective, reveals that high blood sugar is just feedback from a broken system and overhaul of the system is required, not just attention to the feedback signs.

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Oct. 18, 2013 – Ottawa Citizen: "Encouraging more men to consider bariatric surgery is also important, since it's the best treatment and can stop diabetic patients from needing insulin, said Dr. Arya Sharma, chair in obesity research and management at the University of Alberta." Read article

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