Relation between hemoglobin a(1c) and outcomes in heart failure patients with and without diabetes mellitus

Abstract

In patients with diabetes mellitus (DM) in the general population, elevated glycosylated hemoglobin (HbA(1c)) increases the risk for developing heart failure (HF). However, in patients with established HF, the association of HbA(1c) level with outcomes is not well established. The aim of this study was to investigate the relation between HbA(1c) and outcomes in patients with HF with and without DM. A total of 845 patients with advanced HF followed at the Ahmanson-UCLA Cardiomyopathy Center were studied, stratified by the presence (n = 358) or absence (n = 487) of DM and by DM-specific HbA(1c) quartiles (patients with DM: Q1 ≤6.4%, Q2 6.5% to 7.2%, Q3 7.3% to 8.5%, and Q4 ≥8.6%; patients without DM: Q1 ≤5.6%, Q2 5.7% to 6.0%, Q3 6.1% to 6.5%, and Q4 ≥6.6%). The primary outcomes analyzed were death and death or urgent heart transplantation. In the cohort with DM, 2-year event-free survival was 61% and 65% in Q3 and Q4 compared to 48% and 42% in Q1 and Q2 (p = 0.005). In the cohort without DM, there was no difference in outcomes by HbA(1c) quartile. Risk-adjusted analysis in the diabetic cohort showed significantly increased hazard ratios for death or urgent heart transplantation in Q1 and Q2 compared to Q4. For every unit HbA(1c) increase, there was a 15% decreased hazard ratio of death or urgent heart transplantation and all-cause mortality (p = 0.006 and p = 0.036, respectively). In the cohort without DM, multivariate models revealed similar hazard ratios among HbA(1c) quartiles. In conclusion, in this cohort of patients with advanced HF, higher HbA(1c) levels were associated with improved outcomes in patients with DM. This relation was not observed in patients without DM. Further investigations into mechanisms underlying the relation between HbA(1c), DM, and survival in advanced HF are warranted.

Figure 1

Survival outcomes of advanced heart failure patients by HbA1c Quartiles. 1a. Whole Cohort: 2 Year Survival Free from Death/UTx by HbA1c Quartile (Q1 49.6%, Q2 55.3%, Q3 47.5%, Q4 60.4%) 1b. Whole Cohort: 2 Year Survival Free from All-Cause Mortality by HbA1c Quartile (Q1 70.2%, Q2 77.3%, Q3 65.7%, Q4 71.2%) 1c. DM+: 2 Year Survival Free from Death/UTx by HbA1c Quartile (Q1 47.9%, Q2 41.5%, Q3 60.7%, Q4 65.3%) 1d. DM+: 2 Year Survival Free from All-Cause Mortality by HbA1c Quartile (Q1 62.5%, Q2 53.5%, Q3 72.9%, Q4 74.4%) 1e. DM−: 2 Year Survival Free from Death/UTx by HbA1c Quartile (Q1 50.4%, Q2 60.6%, Q3 51.1%, Q4 49.9%) 1f. DM−: 2 Year Survival Free from All-Cause Mortality by HbA1c (Q1 69.8%, Q2 84.2%, Q3 77.1%, Q4 71.1%)