The Impact of Diabetes Ketoacidosis on Heart Failure: An Analysis of National Inpatient Sample Study 2016-2018

Objective : Heart failure (HF) is one of the common complications of diabetes mellitus. Patients with history of diabetes are associated with higher risk of mortality and hospitalization in patients with cardiovascular diseases. It is hypothesized that presence of DKA can be associated with poor outcomes in HF population. We conducted this study to evaluate the impact of DKA on HF.

Methods: We conducted a retrospective analysis of 3 years of the National Inpatient Sample (NIS) database, 2016 to 2018, and 2 years of Nationwide Readmission Database (NRD), 2018 to 2019. Study population were selected using ICD-10 diagnosis codes. Discharge-level weight analysis was used to produce a national estimate. We conducted multivariate regression analysis to calculate odds ratio with STATA 17. 

Results: 106,709,435 of HF patients and 314,840 of DKA patients were discharged during the study period. DKA was more prevalent in HF patients when it was compared to non-HF patients (0.32% v 0.29%). According to the further study within HF group, patients with DKA were younger (mean age 64.52 vs 71.53), higher risk of in-hospital mortality (6.52% v 4.74%), major cardiovascular events (14.77% v 9.53%), acute kidney injury (60.29% v 31.06%), deep vein thrombosis (2.52% v 2.25%) and longer length of stay (7.51 SD 0.088 vs 6.18 SD 0.004) than non-DKA patients. However, atrial fibrillation was less prevalent with DKA (16.14% v 27.87%).  After adjusting for age, sex, race, chronic kidney disease (CKD) and comorbid burden, DKA is associated with higher in-hospital mortality (OR 1.61, 1.48 – 1.74, p < 0.0001) and higher incidence of MACE (OR 1.56, 1.48-1.65, p < 0.0001) in HF population. DKA was associated with premature readmission in HF patients. Within HF patients, 16.69% (n=10,217) of DKA patients readmitted within 30 days compared to 14.72% (n=1,600,298) of patients without DKA. After adjusting for age, sex and CKD, DKA was associated with higher 30-days readmission in HF (OR 1.12, 1.08 – 1.15, p < 0.0001).

Discussion/Conclusion: Our study concludes that the presence of DKA is associated with poor outcomes and increases the risk of complications. The higher rate of readmission in HF population emphasizes the importance of proper post-hospitalization management. Further studies are needed to untangle the risk factors and develop a standard management of DKA in HF population.