Diabetes mellitus und Herzinsuffizienz

Abstract

The incidence of congestive heart failure (CHF) is increased and the prognosis decreased in the presence of diabetes mellitus. CHF treatment of diabetics does not differ from non-diabetics although the recommendations are only evidence level C, as they are mainly based on subgroup analyses of major controlled trials. However, these subgroup analyses indicate comparable benefits of diabetics with CHF from e. g. ACE inhibitors and beta-blockers. Likewise, similar recommendations apply for diabetics with CHF in regard to AICD implantation and cardiac resynchronization therapy. The antidiabetic treatment in patients with CHF has some limitations. The role of sulfonylurea drugs with regard to adverse cardiac events remains unclear. Several studies indicate a decreased rate of major adverse events by biguanide medication, whereas therapy with insulin seems to increase mortality risk of patients with CHF. However, this may be rather due to different stages of diabetes than due to a specific effect of the respective drug. Glitazones should be given only in patients in NYHA-class I and II, since these drugs may lead to fluid retention and thus increase the risk of worsening of CHF. Rosiglitazone is not suitable for patients with ischemic heart disease. As diabetes mellitus is frequently accompanied by renal failure, kidney function should be tightly controlled. This is particularly important for the antidiabetic treatment in order to avoid an increased risk of hypoglycemia. The pharmacokinetic and -dynamic properties of nearly all antidiabetic drugs change in patients with renal failure. Biguanides are contraindicated, whereas the dose of most other drugs should be adapted. However, gliquidone und repaglinide are suitable even in patients with marked renal failure. Experience with glitazones is limited. Therapy with short acting insulin is useful in higher stages of renal insufficiency.