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Hypoglykämie und Herzrhythmusstörungen bei Patienten mit Diabetes Typ 2

Hypoglycemia and cardiac arrhythmia in patients with diabetes mellitus type 2

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Zusammenfassung

Hypoglykämien sind häufige und potenziell lebensbedrohliche Nebenwirkungen einer inadäquaten Diabetestherapie. Das gilt besonders für schwere Hypoglykämien bei Typ-2-Diabetes. Kardiale Komplikationen sind Ischämien mit Major-Ereignissen, Herzrhythmusstörungen und Herzinsuffizienz. Ältere, multimorbide Patienten mit Typ-2-Diabetes und Polypharmazie oder/und autonomer kardialer Neuropathie markieren eine „very high risk group“. Die Glykämiekontrollziele sind an das Hypoglykämierisiko anzupassen. Priorität hat eine stabile Glukosehomeostase ohne Hypoglykämien und rasche Blutzuckerschwankungen. Ältere Typ-2-Diabetiker haben eine um mehr als 20% höhere Prävalenz von Vorhofflimmern. Bei Blutzuckerwerten unter 3 mmol/l und einer Dauer über 30 min treten QT-Zeit-Verlängerungen und ventrikuläre Tachykardien auf mit erhöhtem Risiko für Kammerflimmern und plötzlichen Herztod. Diese Herzrhythmusstörungen erhöhen bei Diabetikern mit Herzinsuffizienz signifikant die Mortalität. Rasche Blutzuckerschwankungen (MAGE >5 mmol/l) erhöhen die Vulnerabilität des elektrischen Systems des Herzrhythmus. Besonders gefährdet sind ältere, polymorbide Typ-2-Diabetiker mit vorbestehender Koronarerkrankung und kardialer autonomer Neuropathie. Antihyperglykämische, orale Antidiabetika (Metformin, Acarbose, SGLT-2-Inhibitoren), DPPIV-Inhibitoren und GLP-1-Analoga haben ein niedrigeres Hypoglykämierisiko im Vergleich zu Sulfonylharnstoffen und Insulin. Rechtzeitige Insulintherapie mit Basalinsulin bei unzureichendem Effekt von Metformin ist effektiv, sicher und einfach. Die Glykämieziele und Antidiabetika sind individualisiert nach dem Risiko-Nutzen-Profil auszuwählen. Dabei kommt dem Hypoglykämierisiko eine oft unterschätzte Bedeutung zu.

Abstract

Hypoglycemia is a common and potentially life-threatening adverse effect of inappropriate diabetes treatment. Typical cardiac complications are ischemia with angina pectoris, myocardial infarction, stroke and arrhythmias, such as atrial fibrillation (AF), ventricular tachycardia and heart failure. Elderly multimorbid patients with type 2 diabetes and polypharmacy and/or cardiac autonomous neuropathy represent a very high risk group for cardiovascular complications associated with hypoglycemia. Targets for glycemic control have to be adapted to the risk of hypoglycemia with a priority of stable glucose homeostasis without rapid fluctuations. Elderly patients with diabetes have a >20% risk of AF. At blood glucose levels of <3 mmol/l with a duration of >30 min, prolongation of QTc time and ventricular tachycardia occur with an increased risk of ventricular fibrillation and sudden death. Ventricular arrhythmias and AF significantly increase mortality in patients with heart failure. Rapid fluctuations with a mean amplitude of glucose excursion (MAGE) >5 mmol/l promote vulnerability of electrical stability of the heart, particularly in frail patients with preexisting coronary heart disease and autonomic neuropathy. Antihyperglycemic agents, such as metformin, acarbose and sodium glucose cotransporter 2 (SGLT2) inhibitors have only a low risk of severe hypoglycemia. Dipeptidyl peptase 4 (DPP-IV) inhibitors and glucagon-like peptide 1 (GLP1) analogues as insulin secretagogues have a lower risk for hypoglycemia than sulfonylurea and insulin. Early basal insulin treatment in patients insufficiently controlled with metformin is efficient, safe and convenient. Targets for glucose control and HbA1c have to be individualized and the choice of drugs must be risk-adjusted. Risk of hypoglycemia should be used as guide in decision-making for safe treatment of diabetes.

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Einhaltung ethischer Richtlinien

Interessenkonflikt. M. Hanefeld, X. Ganz und C. Nolte geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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Authors and Affiliations

  1. Studienzentrum Prof. Hanefeld, GWT-TUD GmbH, Fiedlerstr. 34, 01307, Dresden, Deutschland

    M. Hanefeld & X. Ganz

  2. Praxis für Innere Medizin & Kardiologie Epidaurus, Dresden, Deutschland

    C. Nolte

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  1. M. Hanefeld
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Hanefeld, M., Ganz, X. & Nolte, C. Hypoglykämie und Herzrhythmusstörungen bei Patienten mit Diabetes Typ 2. Herz 39, 312–319 (2014). https://doi.org/10.1007/s00059-014-4086-1

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