Heart Failure

GENERAL PRINCIPLES

HF is more common and carries a worse prognosis in persons with diabetes than in persons without diabetes. The hazard ratio for HF among those with prediabetes is 1.2-1.7 in different populations; while in persons with diabetes, the HR is about 2.5.

DIAGNOSIS

HF is suspected after an ischemic event, confirmed by echocardiography or during cardiac catheterization. Diabetes affects both the structure and function of the myocardium, leading to left ventricular concentric remodeling, hypertrophy, and impaired myocardial energetics. Symptoms include reduced exercise tolerance, shortness of breath, and edema.

TREATMENT

Guidelines do not recommend a different approach to the management of HF in persons with diabetes. Metformin is considered safe in mild to moderate HF and may be associated with better outcomes. Observational trial data and post hoc analyses of randomized clinical trials testing sulfonylureas and insulin have provided conflicting results. Thiazolidinediones are known to cause fluid retention and increase the risk of HF events. The DPP-4 inhibitors have neutral CV effects overall. Saxagliptin and alogliptin had increased risk of HF in large CVOTs; however, these effects have not been seen in retrospective analyses or observational cohorts. The GLP-1 receptor agonists have had neutral to positive effects on MACE endpoints but have had neutral effects in HF patients. The SGLT2 inhibitors have had consistently positive effects on HF hospitalization, including populations with HFrEF and HFpEF. The newest consensus statement from the European Association for the Study of Diabetes and the ADA recommends the preferential use of a GLP-1-RA (liraglutide, semaglutide, dulaglutide) or SGLT2 inhibitor (empagliflozin, canagliflozin) with proven CV benefit in individuals with atherosclerotic CVD. If HF and CKD are prominent in individuals with or without CVD, then SGLT2 inhibitors are the recommended agents.³⁷