Dr Vivek Baliga, Consultant Internal Medicine at Baliga Diagnostics discusses the management of 2 common problems in medical practice - heart failure and type 2 diabetes, including the link between the two. For more articles for patients, visit http://heartsense.in/author/dr-vivek-baliga-b/. For scientific articles and short reviews, visit http://drvivekbaliga.net/

1. Chronic Disease Management in
Heart Failure and Diabetes
Dr Vivek Baliga
Consultant Internal Medicine
Baliga Diagnostics Pvt Ltd

2. Introduction
• Heart failure and diabetes are closely inter-related conditions
• Diabetes increased the risk of heart failure by 6 - 8 fold
• Recent ATLAS trial found that the proportion of patients with diabetes
who develop HF is around 20%
• Can be 2 separate entities that are closely inter-related

3. Heart Failure

4. What is Heart Failure?
• Inability of the heart to work as an efficient pump
• Systolic heart failure - Poor contraction
• Diastolic heart failure - Poor relaxation
• Can be due to a number of causes
• Coronary artery disease
• Viral infections
• Pregnancy
• Hypertension
• Diabetes
• Congenital heart disease
• Drugs - alcohol, cocaine
• Idiopathic - No cause identified

5. How Common Is It?
• A 2013 update from the American Heart Association (AHA) estimated that
there were 5.1 million people with HF in the United States in 2006.
• Heart failure costs the nation an estimated $30.7 billion each year in USA
• There are an estimated 23 million people with HF worldwide
• Reliable estimates of heart failure are lacking in India because of the
absence of a surveillance programme to track incidence, prevalence,
outcomes and key causes of heart failure.

6. How Common Is It?
• The annual incidence of HF for patients with CHD ranges from 0.4% to 2.3%
per year
• This suggests that 1.2 – 6.9 lakh Indians could develop symptomatic HF due
to CHD every year

7. Definition Of Heart Failure

8. Classification of Heart Failure

9. Symptoms

10. Management - Investigations

11. Management - Investigations

12. Management - Investigations

13. Investigations - Summary

14. Investigations - Summary

15. Treatment - Stage A

16. Treatment - Stage B

17. Treatment - Stage B

18. Treatment - Stage B

19. Treatment - Stage C

20. Treatment - Stage C

22. Treatment - Stage C HFrEF

23. Treatment - Stage C HFrEF

24. Treatment - Stage C HFrEF

25. Treatment - Stage C HFrEF
• Digoxin may be used - Can reduce hospitalisation
• Nutritional supplements are not recommended
• Hormonal therapies other than to correct any deficiencies are not
recommended
• Avoid drugs such as certain painkillers, TZDs (glitazones) and certain
antiarrhythmics
• Omega 3 PUFA supplements may be of some benefit

26. Lifestyle
• Not much advice can be given that will alter long term prognosis.
• Patient understanding of the condition is essential
• Give advice on drugs prescribed - benefits and side effects
• Advice on device management - when to notify their doctor
• Avoid excessive fluid intake, follow advice of the doctor regarding this
during summer or during illness.
• Stop smoking
• Low salt diet
• Maintain a healthy body weight
• Avoid alcohol completely if possible
• Exercise to a point where it becomes only mildly difficult to breathe

27. Lifestyle
• Get a good night’s rest - sleep at 45 degrees
• Sexual activity is OK, provided there are no undue symptoms
• Medication for erectile dysfunction may be needed.
Information websites
http://www.heartfailurematters.org
http://www.heartsense.in

28. Device Therapy - ICD

29. Device Therapy - CRT

30. End of Life Care

31. End of Life Care

32. Challenges
• Challenges lie at the root causes of heart failure
• Regulations to limit the salt content of foods have a great potential to reduce
the burden of hypertension, CHD and subsequent incidence of HF across a
wide spectrum of the population
• Tobacco taxation that includes beedis and smokeless tobacco provides the
most powerful tool to immediately reduce consumption of tobacco and helps
decrease the overall CVD burden, including HF.

33. Challenges
• Strict lifestyle measures need to be adopted – Patient compliance is a
problem
• Delayed presentation many times – higher mortality
• Better survival with earlier treatment means increased rehospitalisation
rate – nearly 6 fold increase compared to those who are not hospitalised.
• Changing profile of patients – higher number of co-morbid factors
• Poor follow up care – lack of a structured community heart failure rehab
program

34. Solution?
• Better patient education – We seem to really lacking with respect to this.
• Using serial biomarkers – May not be very practical for cost reasons though
studies have shown reduced rehospitalisation rates as treatment can be
started early
• Telemedicine – Regularly call the patient, text messaging, apps etc.
• But who will follow up??

35. Diabetes Mellitus

36. What Is Diabetes?
‘High blood sugar’
Absent insulin secretion - Type I diabetes
Reduced insulin secretion
Reduced sensitivity of cells to insulin
Type II diabetes
DEFINITION
Fasting > 126 mg/dL
PPBG > 200 mg/dL
HbA1c > 6.5%
In patients with
symptoms of high
blood sugar, a random
> 200 mg/dL

37. Scope of the Problem
• The prevalence of diabetes increased tenfold, from 1.2% to 12.1%, between
1971 and 2000.
• It is estimated that 61.3 million people aged 20-79 years live with diabetes in
India (2011 estimates). This number is expected to increase to 101.2 million by
2030.
• 77.2 million people in India are said to have pre-diabetes.
• Indians get diabetes on average 10 years earlier than their Western
counterparts.

38. Scope of the Problem
• Lifestyle changes have lead to decreased physical activity, increased
consumption of fat, sugar and calories, and higher stress levels, affecting
insulin sensitivity and obesity.
• The annual cost for India due to diabetes was about $38 billion in 2011.
• According to the WHO, if one adult in a low-income family has diabetes, “as
much as 25% of family income may be devoted to diabetes care.”
• According to the World Economic Forum, cardiovascular disease, cancer,
chronic respiratory disease, diabetes and mental health conditions will cost
India 126 trillion rupees between 2012 and 2030.

39. Symptoms

40. Testing - Who To Test?
• Test all adults who are overweight (BMI ≥ 25) and have additional risk
factors
• Physical inactivity
• First degree relatives with diabetes
• Women with history of gestational diabetes
• Those with hypertension and high cholesterol
• Polycystic ovarian syndrome
• Previous A1c testing ≥ 5.7%
• Begin testing after age 45 years
• If normal, then repeat every 3 years at least (or more frequently)

41. Testing - What To Test?
• Fasting blood glucose - Checked after a minimum of 8 hours fasting
• Postprandial blood glucose - Checked 2 hours after a meal or after a 75
gm glucose load
• Hemoglobin A1c - Checked at any time
• Check kidney function including ultrasound abdomen
• Eye Check Up
• Nerve conduction studies
• Cardiovascular examination and testing if needed

42. Treatment
• Start with lifestyle changes - 150 min exercise/wk, weight loss of > 5%
• Different classes of drugs with different effects on blood glucose
• Stepwise approach is followed
• When choosing glucose-lowering medications for overweight or obese
patients with type 2 diabetes, consider their effect on weight.
• Metformin, if not contraindicated and if tolerated, is the preferred initial
pharmacological agent for type 2 diabetes.
• Consider initiating insulin therapy (with or without additional agents) in
patients with newly diagnosed type 2 diabetes and markedly symptomatic
and/or elevated blood glucose levels or A1C.

43. Treatment

44. Treatment

45. Prevention
• Patients with prediabetes should be referred to an intensive diet and
physical activity behavioural counselling program
• Targeting a loss of 7% of body weight and should increase their
moderate-intensity physical activity (such as brisk walking) to at least 150
min/week.
• Follow-up counselling and maintenance programs should be offered for
long term success in preventing diabetes.
• Metformin therapy for prevention of type 2 diabetes should be
considered in those with prediabetes, especially in those with BMI ≥ 35
kg/m2, those aged ≥ 60 years, and women with prior gestational diabetes
mellitus.

46. Prevention
• Screening for and treatment of modifiable risk factors for cardiovascular
disease is suggested.
• Diabetes self-management education and support programs are
appropriate venues for people with prediabetes to receive education and
support to develop and maintain behaviours that can prevent or delay the
onset of diabetes.
• Technology-assisted tools including Internet-based social networks,
distance learning, DVD-based content, and mobile applications can be
useful elements of effective lifestyle modification to prevent diabetes.

47. Diet
• Low fat intake - The quality of fat
consumed is more important than
the quantity (e.g.: Mediterranean
diets).
• Eat complex carbohydrates - Whole
grain
• Nuts and berries are great!
• Dairy products and red meat to a
minimum

48. Exercise
• Moderate exercise, such as brisk walking or other
activities of equivalent intensity, has been also
observed to improve insulin sensitivity and reduce
abdominal fat content in children and young adults
• 150 min/week of moderate-intensity exercise and
showed beneficial effect on glycaemia in those with
prediabetes
• Both resistance training and endurance exercise
appear to have beneficial effects on waist
circumference, insulin sensitivity, and thus diabetes
risk

49. Yoga
• Regular practice of yoga can help
reduce levels of stress, enhance
mobility, lower blood pressure and
improve overall wellbeing
• Reduces weight
• Long-term/more intensive yoga practice could have beneficial health
consequences by altering leptin and adiponectin
• Yoga offers a promising lifestyle intervention for decreasing weight-related
type 2 diabetes risk factors and potentially increasing psychological well-
being

50. Eyes, Feet and Nerves
• Optimizing glycemic control, blood pressure, and serum lipid control is
key to reducing the risk for and slowing the progression of diabetic
retinopathy
• Achieving glycemic control can effectively prevent or delay diabetic
peripheral neuropathy and may slow their progression in T2DM
• All patients with T2DM should have a foot examination annually using 10-
g monofilament testing plus pinprick sensation, vibration perception, or
ankle reflexes

51. Technology Assistance
• Mobile applications for weight loss and diabetes prevention have been
validated for their ability to reduce A1C in the setting of prediabetes
• The CDC’s Diabetes Prevention Recognition Program (DPRP)
http://www.cdc.gov/diabetesprevention/recognition/index.htm) has
begun to certify electronic and mobile health-based modalities as
effective vehicles

52. Apps
Calorie Counter
Pro
Diabetes Connect

53. Self Monitoring

54. Diabetes and Heart Failure
• Diabetic Cardiomyopathy
• Every 1% increase in HbA1c leads to an 8% increase in HF
• Requires the absence of CAD and the presence of LVH, fibrosis and
decreased compliance
• Cause is likely multi-factorial but clearly related to hyperglycaemia,
hyperinsulinemia, enhance FFA utilization, and oxidative stress
• Treatment involves strict sugar control with usual heart failure treatment
strategies
• High mortality - 50% die within 5 years

55. Conclusion
• Heart failure and diabetes are inter-related conditions that carry significant
morbidity and mortality together.
• Simple lifestyle measures can help prevent both conditions and reduce risk
significantly
• Challenges remain in patient compliance and the following of medical advice.
• Rehabilitation and advisory programs could potentially reduce disease
burden and improve outcomes.

56. THANK
YOU!!!