Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ KEY FEATURES +++ ESSENTIALS OF DIAGNOSIS ++ Diabetes mellitus type 2 Unexplained heart failure without hypertension, valvular disease, or large epicardial coronary artery disease Left ventricular hypertrophy with predominantly diastolic dysfunction by echocardiography +++ GENERAL CONSIDERATIONS ++ In addition to being a risk factor for macrovascular atherosclerosis, diabetes (especially type 2 diabetes) produces a microvascular disease that can involve the heart, leading to left ventricular hypertrophy and heart failure with preserved left ventricular systolic function Microvascular disease is associated with endothelial dysfunction Insulin sensitivity, lipid-lowering agents, and angiotensin-modulating drugs may improve endothelial function Because diabetics can have painless myocardial infarction, macrovascular coronary artery disease must be excluded in diabetics with heart failure Diabetes frequently coexists with hypertension, which can lead to left ventricular hypertrophy and heart failure Type 1 diabetes is associated with autoimmune myocyte death, which can lead to heart failure with reduced left ventricular systolic function +++ CLINICAL PRESENTATION +++ SYMPTOMS AND SIGNS ++ Dyspnea, fatigue Chest pain +++ PHYSICAL EXAM FINDINGS ++ Hypertension in some Left ventricular lift S3 or S4 +++ DIFFERENTIAL DIAGNOSIS ++ Atherosclerotic cardiovascular disease with silent infarction Hypertensive heart disease Other causes of heart failure +++ DIAGNOSTIC EVALUATION +++ LABORATORY TESTS ++ Glucose, hemoglobin A1c Lipid panel Liver function tests Creatinine, electrolytes B-type natriuretic peptide, troponin +++ ELECTROCARDIOGRAPHY ++ ECG findings: – Left ventricular hypertrophy – Left atrial abnormality +++ IMAGING STUDIES ++ Echocardiogram: – Left ventricular, left atrial enlargement – Systolic and diastolic dysfunction may be seen +++ DIAGNOSTIC PROCEDURES ++ Coronary angiography may be necessary to exclude macrovascular coronary artery disease +++ TREATMENT +++ CARDIOLOGY REFERRAL ++ Suspected cardiac disease +++ HOSPITALIZATION CRITERIA ++ Heart failure Significant tachyarrhythmias +++ MEDICATIONS ++ Tight control of blood glucose (hemoglobin A1c < 7.0%) Angiotensin-converting enzyme inhibitors titrated to achieve blood pressure < 130/85 mm Hg Correction of dyslipidemia Diuretics as needed Other heart failure treatment as required Aspirin 81 mg/day PO +++ THERAPEUTIC PROCEDURES ++ Percutaneous coronary revascularization may be indicated in some +++ SURGERY ++ Coronary bypass surgery may be required +++ MONITORING ++ ECG monitoring in hospital +++ DIET AND ACTIVITY ++ Diabetic diet plus low-sodium diet Exercise as tolerated +++ ONGOING MANAGEMENT +++ HOSPITAL DISCHARGE CRITERIA ++ Resolution of problem After successful procedure or ... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.