Pilot Program To Improve Self Management of Patients with Heart Failure by Redesigning Care Coordination

Diabetes mellitus (DM) and heart failure (HF) are frequent co-morbidities that adversely affect each other’s prognosis. Patients with both DM and HF are treated with a spectrum of therapies ranging from “diet only” to oral hypoglycemic (notwithstanding the glitazone limitations in advanced (NYHA III-IV) HF), insulin or combination. Although adequate DM control remains a desirable goal, there is no consensus about what type of anti-diabetic therapy is better suited for HF patients. We identified 160 patients with systolic LV dysfunction (LVEF ! 50%) and type II DM from our chronic HF clinic. We investigated the relationship between glycemic control, chronic therapy for HF and diabetes and hospitalization for acutely decompensated HF (ADHF) within the past 3 years. Demographically, the majority of our patients (66%) were African-Americans, 58% were male and 53% were non-ischemic. Baseline LVEF was 276 4% and baseline HgbA1c was 8.36 2 g/dl. Outpatient anti-DM therapy ranged from “diet only” (15%), to oral medicines only (35%), insulin only (40%) and insulin combined with oral medicines (10%). Insulin users had significantly higher HgbA1c than non-users (8.7 6 2.3 vs. 7.8 6 2.2 g/dl, P! 0.05) There were no significant baseline differences between the group hospitalized for ADHF (n564) and those who did not (n596) with regard to age, gender, race, baseline HgbA1c, baseline LVEF or cardiovascular therapies. The distribution of DM therapy however demonstrated different trends with insulin monotherapy (45% vs. 37%, pw 0.08) or diet-control only (22% vs. 12%, pw0.08) being more common and metformin use -among all oral anti-diabetic therapiesbeing less common (14% vs. 26%, pw 0.06) among patients with a history of ADHF hospitalization. In our predominantly African-American population of type II diabetic patients with advanced systolic dysfunction, there was a notable trend of metformin therapy associated with freedom from ADHF hospitalization, independent of HgbA1c control. These data are concordant with studies suggestive that metformin should not be withheld from diabetic patients with HF and support a plausible cardio-protective role.