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QUARTERLY FOCUS ISSUE: HEART FAILURE: HEART FAILURE AND DIABETES

Relationship of Hemoglobin A1C and Mortality in Heart Failure Patients With Diabetes

David Aguilar, MD^_*,,_*, Biykem Bozkurt, MD^_*,, Kumudha Ramasubbu, MD^_*, and Anita Deswal, MD, MPH^_*,,

^_* Winters Center for Heart Failure Research and Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
Section of Cardiology, Michael E. DeBakey V.A. Medical Center, Houston, Texas
Houston Center for Quality of Care and Utilization Studies, Michael E. DeBakey V.A. Medical Center, Houston, Texas

Manuscript received February 2, 2009; revised manuscript received April 3, 2009, accepted April 29, 2009.

^_* Reprint requests and correspondence: Dr. David Aguilar, Cardiovascular Division, Baylor College of Medicine, 1709 Dryden Street-BCM 620, Suite 500, Box 13, Houston, Texas 77030 (Email: daguilar{at}bcm.edu).

Objectives: This study was designed to examine the relationship between glycosylated hemoglobin (HbA1C) and adverse outcomes in diabetic patients with established heart failure (HF).

Background: Despite the common coexistence of diabetes and HF, previous studies examining the association between HbA1C and outcomes in this population have been limited and have reported discrepant results.

Methods: We assessed the association between increasing quintiles (Q1 to Q5) of HbA1C and risk of death or risk of HF hospitalization by conducting a retrospective study in a national cohort of 5,815 veterans with HF and diabetes treated in ambulatory clinics at Veterans Affairs medical centers.

Results: At 2 years of follow-up, death occurred in 25% of patients in Q1 (HbA1C 6.4%), 23% in Q2 (6.4% < HbA1c 7.1%), 17.7% in Q3 (7.1% < HbA1c 7.8%), 22.5% in Q4 (7.8% < HbA1c 9.0%), and 23.2% in Q5 (HbA1c >9.0%). After adjustment for potential confounders, the middle quintile (Q3) had reduced mortality when compared with the lowest quintile (risk-adjusted hazard ratio: 0.73, 95% confidence interval: 0.61 to 0.88, p = 0.001). Hospitalization rates for HF at 2 years increased with increasing quintiles of HbA1C (Q1: 13.3%, Q2: 13.1%, Q3: 15.5%, Q4: 16.4%, and Q5: 18.2%), but this association was not statistically significant when adjusted for potential confounders.

Conclusions: The association between mortality and HbA1C in diabetic patients with HF appears U-shaped, with the lowest risk of death in those patients with modest glucose control (7.1% < HbA1C 7.8%). Future prospective studies are necessary to define optimal treatment goals in these patients.

Key Words: diabetes • heart failure • glycosylated hemoglobin • HbA1C • prognosis

Abbreviations and Acronyms   EPRP = External Peer Review Program   GFR = glomerular filtration rate   HbA1C = glycosylated hemoglobin   HF = heart failure   LVEF = left ventricular ejection fraction   Q = quintile   VA = Veterans Affairs

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