outcomes in the management of heart failure patients with T2DM - PowerPoint PPT Presentation

Real world practices and outcomes in the management of heart failure patients with T2DM Carolyn Lam, MD Singapore May 25, 2019 - Athens, Greece

Real world practices & outcomes in the management of HF patients with T2DM Carolyn S.P. Lam MBBS, PhD, FRCP, FAMS, FESC, FACC Senior Consultant Cardiologist, National Heart Centre Singapore Director, Clinical & Translational Research Office at NHCS Professor, Duke-National University of Singapore Affiliate Member, SingHealth Duke-NUS Institute of Precision Medicine (PRISM) Rosalind Franklin Fellow, University Medical Centre Groningen Scientific Advisor to the Clinical Trials Coordinating Centre (CTCC) at SingHealth

Prevalence of HF Europe: 15M Prevalence of HF US: 6M Global Prevalence of HF burden China: 4.5M of HF. India: 1.3 - 4.6M Japan: 1M Southeast Asia: 9M

Prevalence of DM Europe: 60M Prevalence of DM US: 29M Global Prevalence of DM burden China: 98M of DM. India: 65M Southeast Asia: 72M 60% of the world’s diabetics are in Asia Numbers in Southeast Asia expected to ↑ 70.6% by 2035

Singapore. est. 2015 Total population : 5,604,000 Unique racial admixture Chinese, Malay, Indian, Other World Health Organization. Available at: http://www.who.int/countries/sgp/en.

Interaction between regional income level & ethnicity on risk factor burden in HFrEF. 5,31 (higher vs lower income) Age-adjusted odds ratio 4,17 2,97 2,88 2,66 2,61 0,97 0,96 0,70 Chinese Indian Malay Coronary artery disease Hypertension Diabetes Lam CS Eur Heart J 2016

Epidemiologic transition. 1960’s Today

Asian vs Whites. Sin Singapore Asi sians vs s Swedish whit ites Bank, … Lam. JACC HF 2016

Prospective ASIAN-HF observational study: Registry. ~ 7000 Asian patients with Stage C HF With detailed characterization and adjudicated outcomes. Multinational & Multicenter 11 regions in 46 sites. La Lam CS Eur J Hear art Fail 2013 13

Comorbidity clusters in ASIAN-HF. Young Ischemic Elderly/AF Metabolic Lean Diabetic Korea Japan Malaysia Singapore Malaysia India Hong Kong Malaysia Singapore China Japan Hong Kong Indonesia Thailand Philippines India Taiwan Characteristics Characteristics Korea Characteristics • • Male patients with CAD Most often diabetic with • Few comorbidities. Characteristics Characteristics and ischemic aetiology low BMI. • More often HFrEF • Eldest with AF and high rates • High prevalence of obesity, • of HF More often HFpEF • Eccentric hypertrophy of previous stroke hypertension and diabetes • • More often HFrEF Concentric hypertrophy • Best outcomes • More often HFpEF • More often HFpEF • • Eccentric hypertrophy Worst outcomes and • Best effect of medication • Concentric remodeling • Concentric remodeling 2 nd worst outcomes • quality of life Tromp J… Lam CS PLOS Med 2018

Lean diabetic phenotype of HF in Asia. Asi sian wom omen wit ith HF HF ar are e pr predisposed Chandramouli C et al Eur J Heart Fail 2018

Lean diabetic phenotype of HF in Asia. Com Compared to to men, , Asi sian wom omen wit ith HF HF wer ere mor ore lik ikely to to ha have • DM despite a lean BMI • greater burden of CKD • more concentric LV geometry • worse outcomes with DM Chandramouli C et al Eur J Heart Fail 2018

Real world practices & outcomes DM in 40% of 5276 HFrEF (age 61 ± 11y; duration of DM 10 ± 8y) Patients with (vs without) DM were less likely to be prescribed RAASi (74% vs 77%, P =0.02) and MRAs (55% vs 61%, P < 0.01) Anti-diabetic agents prescribed: metformin (54%), SUs (53%), insulin (24%), DPP4i (17%), TZDs (0.4%), with wide regional variation Chia YMF Eur J Heart Fail 2019

Real world practices & outcomes DM in 40% of 5276 HFrEF (age 61 ± 1y composite outcome in 26% 11y; duration of DM 10 ± 8y) vs 17% of patients with vs without DM (P <0.01) Patients with (vs without) DM were less likely to be prescribed Only metformin RAASi (74% vs 77%, P =0.02) and associated with ↓risk MRAs (55% vs 61%, P < 0.01) (23% vs 28%, P =0.02; Anti-diabetic agents prescribed: propensity adjusted HR 0.80 metformin (54%), SUs (53%), [0.64-1.01]) insulin (24%), DPP4i (17%), TZDs (0.4%), with wide regional variation Chia YMF Eur J Heart Fail 2019

International comparison (DM + HFrEF). Compared with ith US S pa patients, , the use use of of GDM DMT for or HFr FrEF was as lo lower in in pa patients s in in LI LI Asia Asian cou ountries In n bo both US S and and Asia, Asia, op opportunities s for or im improvement in in evidence-bas ased therapies s exi xist for or pa patients s with ith DM DM + + HFrEF Arnold SV Diabetes Obes Metab. 2018

The CVD-REAL 2 Study: DOI:10.1016/j.jacc.2018.03.009 Lower Risk of Cardiovascular Events and Death Associated with Initiation of SGLT-2 Inhibitors versus Other Glucose Lowering Drugs - Real World Data Hospitalization for HF Across Three Major World Regions with More Than 400,000 Patients: Hospitalization for HF Death + hospitalization for HF Kosiborod M, Lam CSP, et al J Am Coll Cardiol 2018

Asian Diabetes Outcomes Prevention Trial Cardiovascular events are the leading cause of death among patients with diabetes. Early identification of high risk Rationale diabetic (DM) patients for intensification of preventive therapy may prevent cardiovascular events. Aims Among biomarker (N-terminal pro-B-type natriuretic peptide, NT-proBNP)-identified high-risk type 2 DM patients without pre-existing cardiovascular disease*, to test if intensive preventive therapy (high dose renin-angiotensin- aldosterone system inhibitors [RAASi], beta-blockade, sodium-glucose co-transporter 2 inhibitors [SGLT2i]) may be associated with reduced cardiovascular events compared to standard of care. Design Prospective multinational randomized open-label, parallel group, active-controlled, two-arm, long-term morbidity and mortality trial involving 5 countries (Singapore, Malaysia, China, Taiwan, India; estimated 6 sites each) with patients followed for 2 years. Population Adults with type 2 DM without cardiovascular disease* and with NT-proBNP >125 pg/mL *Defined as known coronary stenosis >70%, reduced left ventricular ejection fraction <40%, or a history of myocardial infarction/ coronary revascularization/ heart failure hospitalization/ ischemic stroke/ prior lower limb amputation or angioplasty