Review article: Diabetes mellitus and heart failure--an overview of epidemiology and management

Impact of Diabetes on Outcomes After Transcatheter Mitral Valve Repair in Heart Failure: COAPT Trial

OBJECTIVES

This paper sought to determine whether diabetes influences the outcomes of transcatheter mitral valve repair (TMVr) in patients with heart failure (HF) and secondary mitral regurgitation (SMR).

BACKGROUND

Diabetes is associated with worse outcomes in patients with HF.

METHODS

The COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With functional Mitral Regurgitation) trial randomized HF patients with 3+ or 4+ SMR to MitraClip plus guideline-directed medical therapy (GDMT) versus GDMT alone. Two-year outcomes were evaluated in patients with versus without diabetes.

RESULTS

Of 614 patients, 229 (37.3%) had diabetes. Diabetic patients had higher 2-year rates of death than those without diabetes (40.8% vs 32.3%, respectively; adjusted P = 0.04) and tended to have higher rates of HF hospitalization (HFH) (HFH: 50.1% vs 43.0%, respectively; adjusted P = 0.07). TMVr reduced the 2-year rate of death consistently in patients with (30.3% vs 49.9%, respectively; adjusted HR: 0.51; 95% CI: 0.32 to 0.81) and without (27.0% vs 38.3%, respectively; adjusted HR: 0.57; 95% CI: 0.39-0.84) diabetes (P_interaction = 0.72). TMVr also consistently reduced the 2-year rates of HFH in patients with (32.2% vs 54.8%, respectively; adjusted HR: 0.41; 95% CI: 0.28-0.58) and without (41.5% vs 59.0%, respectively; adjusted HR: 0.54: 95% CI 0.35-0.82) diabetes (P_interaction = 0.33). Greater movements in quality-of-life (QOL) and exercise capacity occurred with TMVr than with GDMT alone, regardless of diabetic status.

CONCLUSIONS

Among HF patients with severe SMR in the COAPT trial, those with diabetes had a worse prognosis. Nonetheless, diabetic and nondiabetic patients had consistent reductions in the 2-year rates of death and HFH and improvements in QOL and functional capacity following TMVr treatment using the MitraClip than with maintenance on GDMT alone. (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation [COAPT]; NCT01626079).

Cardiovascular outcomes of vildagliptin in patients with type 2 diabetes mellitus after acute coronary syndrome or acute ischemic stroke

AIMS/INTRODUCTION

The cardiovascular (CV) outcomes of vildagliptin - a dipeptidyl peptidase-4 inhibitor - in patients with type 2 diabetes mellitus after acute coronary syndrome or acute ischemic stroke are unclear.

MATERIALS AND METHODS

We analyzed data from the Taiwan National Health Insurance Research Database on 3,750 type 2 diabetes mellitus patients with acute coronary syndrome or acute ischemic stroke within 3 months between 1 August 2011 and 31 December 2013. Clinical outcomes were evaluated by comparing 1,250 participants receiving vildagliptin with 2,500 propensity score-matched participants. The primary composite outcome included CV death, non-fatal myocardial infarction and non-fatal stroke.

RESULTS

The primary composite outcome occurred in 122 patients (9.8%) in the vildagliptin group and 263 patients (10.5%) in the control group (hazard ratio [HR] 0.90, 95% confidence interval [CI] 0.72-1.11) with a mean follow-up period of 9.9 months. No significant between-group differences were observed for CV death (HR 0.93, 95% CI 0.56-1.52), non-fatal myocardial infarction (HR 0.79, 95% CI 0.46-1.36) and non-fatal stroke (HR 0.96, 95% CI 0.74-1.24). The vildagliptin group was at similar risks of hospitalization for heart failure (HF) or coronary intervention to the control group (P = 0.312 and 0.430, respectively). For patients with HF at baseline, the risk of hospitalization for HF was similar between the vildagliptin and control groups (HR 1.04, 95% CI 0.57-1.88).

CONCLUSIONS

Among patients with type 2 diabetes mellitus after a recent acute coronary syndrome or acute ischemic stroke, treatment with vildagliptin was not associated with increased risks of CV death, non-fatal myocardial infarction, non-fatal stroke and hospitalization for HF.

Short- and Long-term Prognosis of Patients With Acute Heart Failure With and Without Diabetes: Changes Over the Last Three Decades

OBJECTIVE

We studied differences in long-term (i.e., 10 year) prognosis among patients with acute heart failure (HF) with and without diabetes over the last three decades. In addition, we investigated whether the degree of prognostic improvement in that period was comparable between patients with and without diabetes.

RESEARCH DESIGN AND METHODS

This prospective registry included all consecutive patients aged 18 years and older admitted to the Intensive Coronary Care Unit with acute HF in the period of 1985-2008. A total of 1,810 patients were included; 384 patients (21%) had diabetes. The outcome measure was the composite of all-cause mortality, heart transplantation, and left ventricular assist device implantation after 10-year follow-up.

RESULTS

The 10-year outcome in patients with diabetes was significantly worse than in those without diabetes (87% vs. 76%; adjusted hazard ratio [HR] 1.17 [95% CI 1.02-1.33]). Patients admitted in the last decade had a significantly lower 10-year event rate than patients admitted in the first two decades, both among patients without diabetes (adjusted HR 0.86 [95% CI 0.75-0.99]) and patients with diabetes (adjusted HR 0.80 [95% CI 0.63-1.00]).

CONCLUSIONS

The long-term outcome of patients with diabetes is worse than that of patients without diabetes. However, the long-term prognosis improved over time in both groups. Importantly, this improvement in long-term prognosis was comparable in patients with and without diabetes. Despite these promising results, more awareness for diabetes in patients with acute HF is necessary and there is still need for optimal treatment of diabetes in acute HF.

A Review of the External Validity of Clinical Trials with Beta-Blockers in Heart Failure

BACKGROUND

Beta-blockers (BBs) are the mainstay prognostic medication for all stages of chronic heart failure (CHF). There are many classes of BBs, each of which has varying levels of evidence to support its efficacy in CHF. However, most CHF patients have one or more comorbid conditions such as diabetes, renal impairment, and/or atrial fibrillation. Patient enrollment to randomized controlled trials (RCTs) often excludes those with certain comorbidities, particularly if the symptoms are severe. Consequently, the extent to which evidence drawn from RCTs is generalizable to CHF patients has not been well described. Clinical guidelines also underrepresent this point by providing generic advice for all patients. The aim of this review is to examine the evidence to support the use of BBs in CHF patients with common comorbid conditions.

METHODS

We searched MEDLINE, PubMed, and the reference lists of reviews for RCTs, post hoc analyses, systematic reviews, and meta-analyses that report on use of BBs in CHF along with patient demographics and comorbidities.

RESULTS

In total, 38 studies from 28 RCTs were identified, which provided data on six BBs against placebo or head to head with another BB agent in ischemic and nonischemic cardiomyopathies. Several studies explored BBs in older patients. Female patients and non-Caucasian race were underrepresented in trials. End points were cardiovascular hospitalization and mortality. Comorbid diabetes, renal impairment, or atrial fibrillation was detailed; however, no reference to disease spectrum or management goals as a focus could be seen in any of the studies. In this sense, enrollment may have limited more severe grades of these comorbidities.

CONCLUSIONS

RCTs provide authoritative information for a spectrum of CHF presentations that support guidelines. RCTs may provide inadequate information for more heterogeneous CHF patient cohorts. Greater Phase IV research may be needed to fill this gap and inform guidelines for a more global patient population.

Sexual function of patients with heart failure: facts and numbers

Approximately 60% to 87% of patients with heart failure (HF) report sexual problems, and numbers as low as 31% of HF patients younger than 70 have normal sexual function. When compared with healthy elders, the amount of perceived sexual dysfunction might be similar (around 56%), but patients with HF are reporting more erectile dysfunction (ED) and also perceive that their HF symptoms (20%) or HF medication (10%) is the cause for their problems. The prevalence of ED is highly prevalent in men with cardiac disease and reported in up to 81% of cardiac patients, compared with 50% in the general older population. In total 25-76% of women with HF report sexual problems or concerns. The physical effort related to sexual activity in cardiac patients can be compared to mild to moderate physical activity. The related energy expenditure of sexual activity falls in the range of three to five metabolic units (METs), which can be compared to the energy needed to climb three flights of stairs, general housework, or gardening. Information about sexual activity is often overlooked by health care professionals treating HF patients. Advice and counselling about this subject are needed to decrease worries of patients and partners, avoid skipping medication because of fear for side effects, or prevent inappropriate use of potency enhancing drugs or herbs.

Gender Discrepancy in Diabetic Patients Hospitalized With Heart Failure: Does Age Matter?

BACKGROUND

Gender discrepancy in the cardiovascular diseases has been evaluated in several studies. We studied the impact of gender disparity on the presentation and outcome of diabetic heart failure (DHF) patients.

METHODS

A retrospective analysis was conducted including all DHF patients admitted to the Heart Hospital between 1991 and 2013. Patients' demographics, presentation, management, and hospital outcomes were analyzed and compared based on gender and age.

RESULTS

Out of 8266 HF patients, 4684 (56.7%) were diabetic, of whom 1817 (39%) were females. Mean age was comparable in both genders. DHF female patients were more likely to be hypertensive (79% vs. 65%, P = 0.001) and obese (13% vs. 4.6%, P = 0.001). DHF females were less likely to receive beta-blockers and angiotensin-converting-enzyme inhibitors/angiotensinogen-receptor blockers (25% vs. 30%, P = 0.001, 54% vs. 57%, P = 0.01, respectively), but were more likely to be on insulin therapy (21% vs. 16%, P = 0.001). In-hospital atrial fibrillation (P =0.90), ventricular tachycardia (P = 0.07), stroke (P = 0.45), and cardiac arrest (P = 0.26) were comparable. Overall in-hospital mortality was comparable in both genders (P = 0.83). In age ≤50 years, male gender was associated with a 3-fold increase in death (13% vs. 4%, P = 0.01), however, this mortality difference disappeared in DHF patients aged >50 years (P = 0.62).

CONCLUSIONS

In DHF, female gender is characterized by having a high prevalence of metabolic syndrome components. Also, females are more likely to have better Left ventricular ejection fraction but less likely to receive cardiovascular evidence based medications. There is no significant difference in the overall hospital mortality between both genders, however, in the younger age; males have a significantly higher mortality.

Prevalent Diabetes Mellitus: Mortality and Management in Norwegian Heart Failure Outpatients

Objectives: Heart failure (HF) patients with diabetes mellitus experience poor prognosis. We assessed the independent predictive effect of prevalent diabetes mellitus on all-cause mortality in HF outpatients. Furthermore, we investigated if optimized HF medication differed in diabetic versus nondiabetic patients. Methods: From 6,289 patients included in the Norwegian HF registry during 2000-2012, 724 diabetic HF outpatients were propensity-score-matched with nondiabetic HF outpatients (1:1), based on 21 measured baseline variables. Baseline characteristics, measured comorbidities and medication were balanced in the matched sample. Results: Diabetes was not an independent predictor of all-cause mortality in the propensity-matched analyses (hazard ratio 1.041; 95% confidence interval 0.875-1.240). No interactions were found between the prognostic impact of diabetes and the strata renal function, systolic function or etiology of chronic HF. Diabetic HF outpatients were independently prescribed higher doses of β-blockers and loop diuretics (both p < 0.001) and were more prone to receive statins (p = 0.003) than nondiabetics. Conclusions: Prevalent diabetes mellitus was not an independent predictor of all-cause mortality in HF outpatients. Explanations other than tight glycemic control should be assessed to improve the prognosis of diabetic HF outpatients. The more intensive, optimized HF medication for diabetic HF outpatients may, to a certain degree, explain our results.

Predicting cardiovascular risk in type 2 diabetes: the heterogeneity challenges

Type 2 diabetes mellitus has reached epidemic proportions around the world, and the increase in cardiovascular risk attributable to diabetes estimated to range from 2- to 4-fold poses grave public health concern. Though in some contexts type 2 diabetes has been equated with coronary heart disease equivalent risk, there is considerable evidence that incremental cardiovascular risk does not uniformly affect all people with type 2 diabetes. This heterogeneity in cardiovascular risk is multifactorial and only partially understood but is a key consideration for our understanding of the nexus of diabetes and cardiovascular disease and for the development of optimal and individualized cardiovascular risk reduction strategies. This review provides a brief synopsis of the concept of cardiovascular risk heterogeneity in diabetes, including epidemiologic evidence, discussion of established and potential determinants of heterogeneity, and clinical, research, and regulatory implications.

Efficacy and safety of ivabradine in patients with chronic systolic heart failure and diabetes: an analysis from the SHIFT trial

AIMS

To evaluate clinical profiles and outcomes in patients with systolic heart failure (HF) with or without diabetes, and the efficacy and safety of ivabradine (heart rate-lowering agent) with respect to diabetic status.

METHODS AND RESULTS

This is a post hoc analysis on patients in SHIFT, a randomized controlled trial in adults in sinus rhythm with systolic HF, left ventricular ejection fraction ≤35%, and resting heart rate ≥70 b.p.m. Patients were randomized to ivabradine (titrated to 7.5 mg bid) or placebo. Diabetic status was established by medical history at baseline. The primary composite endpoint (PCE) was cardiovascular death or hospitalisation for worsening HF. Of 6505 patients, 30% had diabetes, 32% of whom used insulin. The PCE was more frequent in patients with diabetes [adjusted hazard ratio (HR) 1.18, 95% confidence interval (CI) 1.07-1.31; p = 0.001], as was hospitalization for worsening HF (adjusted HR 1.28, 95% CI 1.13-1.44; P < 0.001), and was increased in patients treated with insulin (adjusted HR 1.43, 95% CI 1.23-1.66; P < 0.01 vs. non-diabetics). Ivabradine significantly reduced the PCE in patients with and without diabetes (adjusted HR 0.80, 95% CI 0.68-0.94 and HR 0.84, 95% CI, 0.75-0.95, respectively; interaction P was non-significant) vs. placebo. Adverse events were significantly more frequent in patients with diabetes (78%) than without (74%) (P < 0.001). Regardless of diabetic status, the incidence of serious adverse events was not significantly different between ivabradine and placebo.

CONCLUSIONS

Comorbid diabetes in chronic HF worsens the prognosis of systolic HF patients. Irrespective of diabetic status, ivabradine is effective and safe in these patients.

Elevated serum glucose levels and survival after acute heart failure: a population-based perspective

BACKGROUND

Limited data are available about the characteristics, treatment and survival in patients without diabetes mellitus (DM), previously diagnosed DM and patients with hyperglycaemia who present with acute decompensated heart failure (ADHF). Our objectives were to examine differences in these endpoints in patients hospitalized with ADHF.

METHODS

Patients hospitalized with ADHF during 1995, 2000, 2002 and 2004 comprised the study population.

RESULTS

A total of 5428 non-diabetic patients were hospitalized with ADHF, 3807 with diagnosed DM and 513 with admission hyperglycaemia. Patients with admission hyperglycaemia experienced the highest in-hospital death rates (9.9%) compared to those with diagnosed DM (6.5%) and non-diabetics (7.5%). Patients with diagnosed DM had the greatest risk of dying after hospital discharge.

CONCLUSIONS

Patients with elevated blood glucose levels at hospital admission are more likely to die acutely. After resolution of the acute illness, patients with previously diagnosed DM need careful monitoring and enhanced treatment.

Inhibitory effects of Cymodocea nodosa sulphated polysaccharide on α-amylase activity, liver-kidney toxicities and lipid profile disorders in diabetic rats

This study aimed to evaluate for the first time the effects of Cymodocea nodosa sulphated polysaccharide (CNSP) on the α-amylase activity, hyperglycaemia, liver-kidney functions, and pancreatic architecture of alloxan-induced diabetic rats. Animals were allocated into four groups of seven rats each, the body weight and blood glucose levels were estimated periodically for 2 months of treatment by gastric gavages route. The CNSP effect was confirmed by biochemical procedures and histological study. The inhibition of α-amylase activity and protection of pancreatic β-cells induced a decrease in the blood glucose levels and regulated the lipid profile in the plasma of the treated diabetic rats, which helped to maintain the homeostasis of blood lipid. Moreover, CNSP administration induced a significant decrease in the levels of lipid peroxidation in the pancreas, liver and kidney of diabetic rats and protects their functions attested by a decrease in the levels of toxicity parameters in blood.

The Bi-directional Impact of Two Chronic Illnesses: Heart Failure and Diabetes - A review of the Epidemiology and Outcomes

Heart failure and diabetes mellitus contribute significantly to the morbidity and mortality of the US population. The combined economic impact on the US health care system reaches nearly $300 billion. Much of this cost stems from the frequent hospital admissions and direct cost of managing the two diseases. The presence of diabetes significantly increases the risk of developing heart failure compared to the general population and diabetics with heart failure experience significantly higher mortality. Patients with heart failure have a high incidence of insulin resistance and are at increased risk of developing diabetes mellitus. Traditionally these two chronic illnesses have been managed in relative isolation. However the adverse effects of each disease has significant impact on the other. The combination of heart failure and diabetes mellitus significantly increases the morbidity and mortality compared to either in isolation. This paper reviews the epidemiology and impact of the bidirectional effects of these two chronic illnesses.

Sperm glucose transport and metabolism in diabetic individuals

Individuals with diabetes mellitus (DM) present marked reduction in sperm quality and higher DNA damage in spermatozoa, evidencing that this metabolic disorder impairs male fertility. These effects are related to defective testicular metabolic pathways and signaling, resulting in altered sperm metabolism. Spermatozoa metabolize several substrates to ensure energy supplies and any alteration in this feature compromise sperm quality. For ATP production, spermatozoa require substrate availability and the involvement of specific hexose membrane carriers. DM is known to modulate the spermatozoa substrate consumption and/or production due to altered glycolytic behavior. In fact, glucose uptake and metabolism is highly deregulated in diabetic individuals. Herein, we present an overview of the implications of DM in sperm glucose uptake and metabolism. The understanding of these processes is essential to identify key mechanisms associated with DM-related male (in)fertility. Moreover, it may contribute to the development of therapeutics to counteract the dysfunction induced by DM in sperm metabolism.

Heart failure in the Middle East

The clinical syndrome of heart failure is the final pathway for a myriad of diseases that affect the heart, and is a leading and growing cause of morbidity and mortality worldwide. Evidence-based guidelines have provided clinicians with valuable data for better applying diagnostic and therapeutic tools, particularly the overwhelming new imaging technology and other, often expensive, therapies and devices, in heart failure patients. In the Middle East, progress has recently been made with the development of regional and multi-centre registries to evaluate the quality of care for patients with heart failure. A new heart function clinic recently began operation and has clearly resulted in a reduced readmission rate for heart failure patients. Many Middle Eastern countries have observed increases in the prevalence of the risk factors for the development of heart failure, including diabetes mellitus, obesity, and hypertension, with heart failure in the Middle Eastern population developing earlier than it is in their Western counterparts by at least 10 years. The earlier onset of disease is the result of the earlier onset of coronary artery disease, highlighting the need for Middle Eastern countries to establish prevention programs across all age groups. The health systems across the Middle East need to be modified in order to provide improved evidence-based medical care. Existing registries also need to be expanded to include long-term survey data, and additional funding for heart failure research is warranted.

Interpreting adverse signals in diabetes drug development programs

Detection and interpretation of adverse signals during preclinical and clinical stages of drug development inform the benefit-risk assessment that determines suitability for use in real-world situations. This review considers some recent signals associated with diabetes therapies, illustrating the difficulties in ascribing causality and evaluating absolute risk, predictability, prevention, and containment. Individual clinical trials are necessarily restricted for patient selection, number, and duration; they can introduce allocation and ascertainment bias and they often rely on biomarkers to estimate long-term clinical outcomes. In diabetes, the risk perspective is inevitably confounded by emergent comorbid conditions and potential interactions that limit therapeutic choice, hence the need for new therapies and better use of existing therapies to address the consequences of protracted glucotoxicity. However, for some therapies, the adverse effects may take several years to emerge, and it is evident that faint initial signals under trial conditions cannot be expected to foretell all eventualities. Thus, as information and experience accumulate with time, it should be accepted that benefit-risk deliberations will be refined, and adjustments to prescribing indications may become appropriate.

Living with chronic kidney disease: related issues and treatment

Chronic kidney disease is becoming a major health concern in patients with diabetes and hypertension. Patients often present with no symptoms, and practitioners must understand and utilize the proper treatment and health promotion activities to identify, prevent, and reverse the serious implications of this disease.

Hypoglycemic and antilipidemic properties of kombucha tea in alloxan-induced diabetic rats

Background

Diabetes has become a serious health problem and a major risk factor associated with troublesome health complications, such as metabolism disorders and liver-kidney dysfunctions. The inadequacies associated with conventional medicines have led to a determined search for alternative natural therapeutic agents. The present study aimed to investigate and compare the hypoglycemic and antilipidemic effects of kombucha and black tea, two natural drinks commonly consumed around the world, in surviving diabetic rats.

Methods

Alloxan diabetic rats were orally supplied with kombucha and black tea at a dose of 5 mL/kg body weight per day for 30 days, fasted overnight, and sacrificed on the 31st day of the experiment. Their bloods were collected and submitted to various biochemical measurements, including blood glucose, cholesterol, triglcerides, urea, creatinine, transaminases, transpeptidase, lipase, and amylase activities. Their pancreases were isolated and processed to measure lipase and α-amylase activities and to perform histological analysis.

Results

The findings revealed that, compared to black tea, kombucha tea was a better inhibitor of α-amylase and lipase activities in the plasma and pancreas and a better suppressor of increased blood glucose levels. Interestingly, kombucha was noted to induce a marked delay in the absorption of LDL-cholesterol and triglycerides and a significant increase in HDL-cholesterol. Histological analyses also showed that it exerted an ameliorative action on the pancreases and efficiently protected the liver-kidney functions of diabetic rats, evidenced by significant decreases in aspartate transaminase, alanine transaminase, and gamma-glytamyl transpeptidase activities in the plasma, as well as in the creatinine and urea contents.

Conclusions

The findings revealed that kombucha tea administration induced attractive curative effects on diabetic rats, particularly in terms of liver-kidney functions. Kombucha tea can, therefore, be considered as a potential strong candidate for future application as a functional supplement for the treatment and prevention of diabetes.

Diabetic neuropathy and heart failure: role of neuropeptides

Cardiovascular autonomic neuropathy (CAN), in which patients present with damage of autonomic nerve fibres, is one of the most common complications of diabetes. CAN leads to abnormalities in heart rate and vascular dynamics, which are features of diabetic heart failure. Dysregulated neurohormonal activation, an outcome of diabetic neuropathy, has a significant pathophysiological role in diabetes-associated cardiovascular disease. Key players in neurohormonal activation include cardioprotective neuropeptides and their receptors, such as substance P (SP), neuropeptide Y (NPY), calcitonin-gene-related peptide (CGRP), atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP) and C-type natriuretic peptide (CNP). These neuropeptides are released from the peripheral or autonomic nervous system and have vasoactive properties. They are further implicated in cardiomyocyte hypertrophy, calcium homeostasis, ischaemia-induced angiogenesis, protein kinase C signalling and the renin-angiotensin-aldosterone system. Therefore, dysregulation of the expression of neuropeptides or activation of the neuropeptide signalling pathways can negatively affect cardiac homeostasis. Targeting neuropeptides and their signalling pathways might thus serve as new therapeutic interventions in the treatment of heart failure associated with diabetes. This review discusses how neuropeptide dysregulation in diabetes might affect cardiac functions that contribute to the development of heart failure.

Mild anaemia is associated with increased all-cause mortality in heart failure

AIM

To evaluate the association of anaemia with increased long-term morbidity and mortality in hospitalised heart failure (HF) patients.

METHODS AND RESULTS

We analysed medical records of a random sample of 1000 patients admitted to tertiary care hospitals from 1996 to 2006 with a principal diagnosis of HF. Anaemia (WHO criteria) on admission was present in 45.2% of HF patients. Multivariate analysis identified anaemia as an independent predictor of 5-year mortality with a hazard ratio (HR) of 1.44 (95%CI 1.20-1.73) compared to non-anaemic patients, and a rate ratio of 1.85 (95%CI 1.72-2.02) for unplanned all-cause readmission and 1.22 (95%CI 1.16-1.29) for HF readmission within 5 years. Compared to patients in the highest gender-specific Hb quartile, those with mild anaemia (Hb 11.3-13.0 g/dL in males, 11.0-12.4 g/dL in females) had an adjusted HR of 1.32 (95%CI 1.01-1.71) for 5-year mortality. Anaemia and chronic kidney disease were independent (additive) predictors of survival, whereas anaemia interacted with prevalent diabetes (p for interaction=0.006), such that patients with both conditions had an adjusted mortality HR of 2.18 (95%CI 1.48-3.22) compared to those with diabetes only.

CONCLUSION

Mild anaemia is common in hospitalised HF patients and is an independent predictor of 5-year all-cause mortality in HF.