Heart failure and diabetes: Understanding the bidirectional relationship

Mechanisms behind the high mortality rate in chronic Chagas cardiomyopathy: Unmasking a three-headed monster

Chagas disease is a neglected tropical disease caused by the parasite Trypanosoma cruzi. Chronic Chagas cardiomyopathy (CCC), the most severe form of target organ involvement in Chagas disease, is characterized by a complex pathophysiology and a unique phenotype that differentiates it from other cardiomyopathies, highlighting its worse prognosis compared to other aetiologies of heart failure. The three pathophysiological mechanisms with the largest impact on this differential mortality include rapidly progressive heart failure, a high incidence of stroke, and a high burden of ventricular arrhythmias. However, despite significant advances in understanding the unique molecular circuits underlying these mechanisms, the new knowledge acquired has not been efficiently translated into specific diagnostic and therapeutic approaches for this unique cardiomyopathy. The lack of dedicated clinical trials and the limited CCC-specific risk stratification tools available are evidence of this reality. This review aims to provide an updated perspective of the evidence and pathophysiological mechanisms associated with the higher mortality observed in CCC compared to other cardiomyopathies and highlight opportunities in the diagnostic and therapeutic approaches of the disease.

Type 2 diabetes mellitus negatively affects the functional performance of 6-min step test in chronic heart failure: a 3-year follow-up study

BACKGROUND

Type 2 diabetes mellitus (T2DM) and chronic heart failure (CHF) present a decrease in functional capacity due to the intrinsic nature of both pathologies. It is not known about the potential impact of T2DM on functional capacity when assessed by 6-min step test (6MST) and its effect as a prognostic marker for fatal and non-fatal events in patients with CHF.

OBJECTIVE

to evaluate the coexistence of T2DM and CHF in functional capacity through 6MST when compared to CHF non-T2DM, as well as to investigate the different cardiovascular responses to 6MST and the risk of mortality, decompensation of CHF and acute myocardial infarction (AMI) over 36 months.

METHODS

This is a prospective cohort study with 36 months of follow-up in individuals with T2DM and CHF. All participants completed a clinical assessment, followed by pulmonary function testing, echocardiography, and 6MST. The 6MST was performed on a 20 cm high step and cardiovascular responses were collected: heart rate, systemic blood pressure, oxygen saturation, BORG dyspnea and fatigue. The risk of mortality, acute myocardial infarction and decompensation of CHF was evaluated.

RESULTS

Eighty-six participants were included. The CHF-T2DM group had a significantly lower functional capacity than the CHF non-T2DM group (p < 0.05). Forced Expiratory Volume in one second (L), ejection fraction (%), gender and T2DM influence and are predictors of functional capacity (p < 0.05; adjusted R squared: 0.419). CHF-T2DM group presented a higher risk of mortality and acute myocardial infarction over the 36 months of follow-up (p < 0.05), but not to the risk of decompensation (p > 0.05).

CONCLUSION

T2DM negatively affects the functional performance of 6MST in patients with CHF. Gender, ejection fraction (%), FEV1 (L) and T2DM itself negatively influence exercise performance.

Impact of Sodium-Glucose Cotransporter 2 Inhibitors on Cardiovascular and Renal Outcomes in Heart Failure Patients With Type 2 Diabetes: A Literature Review

The management of heart failure (HF) in patients with type 2 diabetes has significantly evolved with the introduction of sodium-glucose cotransporter 2 (SGLT2) inhibitors. This article aims to consolidate existing knowledge on the efficacy of these inhibitors in managing HF in this patient population. Major medical databases, including PubMed, Scopus, and Web of Science, were reviewed, prioritizing research from the last decade. The results of this review highlight the mechanisms of action of SGLT2 inhibitors, their clinical benefits, challenges in patient management, and outcomes associated with their use. These medications were found to not only improve glycemic control but also offer significant cardiovascular and renal benefits, reducing cardiovascular mortality and major adverse cardiovascular events. However, challenges and knowledge gaps persist, particularly regarding long-term effects and safety in diverse populations. The conclusions of this review underscore the importance of updating clinical guidelines to incorporate these findings and propose the need for future research to address existing gaps and optimize the use of SGLT2 inhibitors in clinical practice.

Systematic Review of Left Ventricular Remodeling in Response to Hypoglycemic Medications: Assessing Changes in End-Systolic and End-Diastolic Diameters

Hypoglycemic medications are widely used in managing diabetes mellitus, with emerging evidence suggesting their role in cardiac reverse remodeling. This systematic review aims to quantitatively synthesize data regarding the impact of these medications on left ventricular end-diastolic diameter (LVEDD) and end-systolic diameter (LVESD), and to evaluate the clinical relevance of these changes in promoting favorable cardiac outcomes. We conducted a comprehensive search across PubMed, Scopus, and the Web of Science up to 22 April 2024, selecting studies based on inclusion criteria that focused on the impact of hypoglycemic medications on LVEDD and LVESD in patients with diabetes. Studies were selected through a rigorous process, adhering to PRISMA guidelines, and involving various designs including randomized controlled trials and observational studies. The main outcomes were changes in LVEDD and LVESD measured by validated cardiac imaging techniques. A total of ten studies met the inclusion criteria, involving a total of 1180 patients. Treatment durations ranged from 3 to 24 months. Significant improvements in cardiac dimensions were noted with some medications. For instance, Liraglutide treatment over three months significantly improved LVEF from 47.2% to 57.2% and reduced LVEDD and LVESD from 46.5 mm to 45.2 mm and 35.2 mm to 32.7 mm, respectively. In contrast, other medications like Sitagliptin showed minimal impact over 24 months. On average, hypoglycemic medications reduced LVEDD from 58.2 mm to 55.0 mm and LVESD from 48.3 mm to 44.3 mm, with a mean improvement in LVEF from 38.9% to 43.8%. Hypoglycemic medications contribute variably to cardiac reverse remodeling. Medications such as Liraglutide and Dapagliflozin demonstrate significant potential in improving cardiac dimensions and function, indicating their utility beyond glycemic control. This review highlights the need for tailored treatment approaches to maximize cardiac outcomes in patients with diabetes, suggesting a broader therapeutic role for these agents.

Systemic aging fuels heart failure: Molecular mechanisms and therapeutic avenues

Systemic aging influences various physiological processes and contributes to structural and functional decline in cardiac tissue. These alterations include an increased incidence of left ventricular hypertrophy, a decline in left ventricular diastolic function, left atrial dilation, atrial fibrillation, myocardial fibrosis and cardiac amyloidosis, elevating susceptibility to chronic heart failure (HF) in the elderly. Age-related cardiac dysfunction stems from prolonged exposure to genomic, epigenetic, oxidative, autophagic, inflammatory and regenerative stresses, along with the accumulation of senescent cells. Concurrently, age-related structural and functional changes in the vascular system, attributed to endothelial dysfunction, arterial stiffness, impaired angiogenesis, oxidative stress and inflammation, impose additional strain on the heart. Dysregulated mechanosignalling and impaired nitric oxide signalling play critical roles in the age-related vascular dysfunction associated with HF. Metabolic aging drives intricate shifts in glucose and lipid metabolism, leading to insulin resistance, mitochondrial dysfunction and lipid accumulation within cardiomyocytes. These alterations contribute to cardiac hypertrophy, fibrosis and impaired contractility, ultimately propelling HF. Systemic low-grade chronic inflammation, in conjunction with the senescence-associated secretory phenotype, aggravates cardiac dysfunction with age by promoting immune cell infiltration into the myocardium, fostering HF. This is further exacerbated by age-related comorbidities like coronary artery disease (CAD), atherosclerosis, hypertension, obesity, diabetes and chronic kidney disease (CKD). CAD and atherosclerosis induce myocardial ischaemia and adverse remodelling, while hypertension contributes to cardiac hypertrophy and fibrosis. Obesity-associated insulin resistance, inflammation and dyslipidaemia create a profibrotic cardiac environment, whereas diabetes-related metabolic disturbances further impair cardiac function. CKD-related fluid overload, electrolyte imbalances and uraemic toxins exacerbate HF through systemic inflammation and neurohormonal renin-angiotensin-aldosterone system (RAAS) activation. Recognizing aging as a modifiable process has opened avenues to target systemic aging in HF through both lifestyle interventions and therapeutics. Exercise, known for its antioxidant effects, can partly reverse pathological cardiac remodelling in the elderly by countering processes linked to age-related chronic HF, such as mitochondrial dysfunction, inflammation, senescence and declining cardiomyocyte regeneration. Dietary interventions such as plant-based and ketogenic diets, caloric restriction and macronutrient supplementation are instrumental in maintaining energy balance, reducing adiposity and addressing micronutrient and macronutrient imbalances associated with age-related HF. Therapeutic advancements targeting systemic aging in HF are underway. Key approaches include senomorphics and senolytics to limit senescence, antioxidants targeting mitochondrial stress, anti-inflammatory drugs like interleukin (IL)-1β inhibitors, metabolic rejuvenators such as nicotinamide riboside, resveratrol and sirtuin (SIRT) activators and autophagy enhancers like metformin and sodium-glucose cotransporter 2 (SGLT2) inhibitors, all of which offer potential for preserving cardiac function and alleviating the age-related HF burden.

Utility of Kansas City Cardiomyopathy Questionnaire (KCCQ) in Assessing Quality of Life among Patients with Heart Failure Undergoing Exercise Training Rehabilitation: A Systematic Review

This systematic review evaluates the effectiveness of the Kansas City Cardiomyopathy Questionnaire (KCCQ) in assessing quality of life improvements among patients with heart failure (HF) undergoing various forms of exercise training rehabilitation, including telemedicine and in-person modalities, across all stages of HF, irrespective of ejection fraction (EF) and clinical status. The aim was to collate evidence from studies employing the KCCQ as a measure of quality of life (QoL). A comprehensive search strategy was implemented across PubMed, Scopus, and Embase databases, adhering to the PRISMA guidelines, including literature up until October 2023. Inclusion criteria encompassed studies on patients diagnosed with HF undergoing exercise training rehabilitation assessed by KCCQ. Nine articles met the inclusion criteria, involving a total of 3905 patients from various global locations and conducted between 2012 and 2022. Results indicated significant heterogeneity in exercise interventions and patient characteristics. Notably, high-intensity interval training (HIIT) showed a marked improvement in KCCQ scores (from 68.0 to 80.0) compared to moderate continuous training (MCT) and control groups, underscoring its potential for enhancing QoL. Additionally, a significant improvement in the 6-min walking test (6MWT) outcomes was observed, with an average increase of 106 m (95% CI: 60, 152) in one study, reflecting physical capacity enhancements. However, the difference in KCCQ scores between intervention and control groups was not statistically significant in several studies. In conclusion, the KCCQ's effectiveness is highlighted by its ability to detect clinically meaningful improvements in QoL across diverse exercise modalities, including HIIT and MCT, tailored to the specific needs of HF populations. The consistent correlation between KCCQ score improvements and enhanced physical outcomes, such as the 6MWT, supports its reliability in capturing the nuanced benefits of exercise interventions on patient well-being.

A comprehensive review of heart failure: Unraveling the etiology, decoding pathophysiological mechanisms, navigating diagnostic modalities, exploring pharmacological interventions, advocating lifestyle modifications, and charting the horizon of emerging therapies in the complex landscape of chronic cardiac dysfunction

Heart failure (HF) poses a significant global health burden, necessitating a profound understanding of its multifaceted dimensions. This comprehensive review aims to unravel the etiology, decode pathophysiological mechanisms, navigate diagnostic modalities, explore pharmacological interventions, advocate lifestyle modifications, and chart the horizon of emerging therapies in the complex landscape of chronic cardiac dysfunction. The exploration of HF begins with an insightful journey into its diverse etiological factors, encompassing genetic predispositions, hypertension, and coronary artery disease. Delving into pathophysiological mechanisms, this review elucidates the intricate processes of cardiac remodeling, neurohormonal activation, and cellular dysfunction that underlie the progression of HF. Diagnostic modalities play a pivotal role in unraveling the mysteries of HF by examining advanced imaging techniques, biomarkers, and comprehensive clinical assessments. The pharmacological interventions section provides an in-depth analysis of traditional medications, such as diuretics and angiotensin-converting enzyme inhibitors, while highlighting the emergence of novel drug classes transforming HF management. Advocating lifestyle modifications emphasizes the crucial role of diet, exercise, smoking cessation, and alcohol moderation in enhancing patient outcomes. Lastly, the review delves into the promising horizon of emerging therapies, offering a glimpse into current research, innovative treatment approaches, and potential breakthroughs. As HF management faces challenges in patient compliance, healthcare access, and education, this comprehensive review aims to equip healthcare professionals and researchers with a holistic understanding of chronic cardiac dysfunction's intricacies. In conclusion, synthesizing key findings emphasizes the need for an integrated and multidimensional approach to effectively address the complex landscape of heart failure.