There seems to be synergy between diabetes and hypertension in the development of structural myocardial changes. This may explain why aggressive antihypertensive therapy, in particular when combined with cholesterol control, has particular value in diabetics in terms of heart failure, stroke, and coronary events.
A comprehensive approach is required to prevent or at least postpone the development of heart failure in diabetics. This strategy should comprise aggressive normalization of blood glucose using insulin, especially in diabetics with myocardial infarction, as well as p-block-er and ACE-inhibitor therapy. Revascularization and strategies to improve outcome after coronary interventions in diabetic patients are also needed. Physical training also improves insulin resistance and glucose levels. Compromised left ventricular function may precede the development of congestive heart failure by a considerable period of time. More aggressive metabolic care at an early stage of the disease may delay myocardial restructuring and atheromatosis. Improved metabolic care may also decrease the thrombogenicity that characterizes diabetes.
ACE inhibition improves myocardial remodeling and insulin resistance, prevents progression of diabetes, and reduces future vascular events. In the CAPtopril Prevention Project (CAPPP), cardiovascular events and total mortality fell by over 40% in diabetics receiving captopril vs conventional treatment. In the United Kingdom Prospective Diabetes Study (UKPDS), tight control with atenolol or captopril significantly decreased diabetes-related end points and death, as well as stroke and microvascular complications.
Patients must be identified at an earlier disease stage. Cardiologists and diabetologists must combine their efforts in screening at-risk patients and deploying preventive measures.
Prevention of endothelial dysfunction
Endothelial dysfunction is a pathophysiological insult that occurs early in the course of cardiovascular disease, initiating a cascade of events that can lead to atherosclerosis, ischemia, and/or left ventricular dysfunction. The Heart Outcomes Prevention Evaluation (HOPE) study included patients with coronary artery disease, peripheral vascular disease, diabetes, and dyslipidemia, but no baseline left ventricular dysfunction or heart failure, ie, patients at high risk of major cardiovascular events. After randomization to ramipril or placebo, the study was terminated prematurely because of significant reductions in death due to cardiovascular causes, stroke, and other major cardiovascular events (revascularization procedures and heart failure).
Prevention of postinjury deterioration ACE inhibitors
ACE inhibitors are effective in preventing clinical heart failure in patients with asymptomatic ventricular dysfunction and in reducing mortality in those with overt heart failure. Their benefits in terms of hemodynamics and postinfarction remodeling make ACE inhibitors effective agents in patients with and without viable myocardium.
The Survival And Ventricular Enlargement (SAVE), Acute Infarction Ramipril Efficacy (AIRE), and TRAn-dolapril Cardiac Evaluation (TRACE) trials uniformly showed that in patients with recent myocardial infarction and left ventricular dysfunction ACE inhibition decreased all-cause mortality and the risk of severe heart failure by 20% to 30%.
The Studies Of Left Ventricular Dysfunction (SOLVD) Prevention included patients with a remote ischemic or nonischemic insult and an ejection fraction <35% with no or minimal symptoms of heart failure. Enalapril had no significant effect on all-cause mortality, but decreased the risk of hospitalization for heart failure by 36% and the combined risk of death and hospitalization for heart failure by 20%.
(3-Blockers have anti-ischemic activity and decrease the risk of reinfarction. These effects slow the development and progression of ischemic heart failure. Their hemodynamic effects, including decreases in afterload and wall stress, may also slow progression of ventricular dysfunction. As shown in the Carvedilol Post-Infarct Survival Control in Left Ventricular Dysfunction (CAPRICORN) study, carvedilol reduces the high rate of mortality and other major coronary events in patients with left ventricular dysfunction after acute myocardial infarction.
Revascularization improves left ventricular dysfunction, as well as mortality and morbidity. Identifying and treating viable myocardium is a realistic option in managing ischemic heart failure. Relative mortality reduction after revascularization in stable angina is greatest in the patients with left ventricular dysfunction, and greater than with medical therapy.
management; asymptomatic left ventricular dysfunction; screening; hypercholesterolemia; myocardial infarction; hypertension; diabetes; prevention