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ADA Notes Heart Failure as "Underappreciated Complication" of Diabetes

  • Authors: News Author: Mitchel L. Zoler, PhD; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 7/8/2022
  • Valid for credit through: 7/8/2023
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Target Audience and Goal Statement

This activity is intended for primary care physicians, endocrinologists, cardiologists, nurses, physician assistants, pharmacists, and other members of the healthcare team who treat and manage adults with diabetes mellitus.

The goal of this activity is for learners to be better able to diagnose and manage heart failure among patients with diabetes mellitus.

Upon completion of this activity, participants will:

  • Assess screening for heart failure among patients with diabetes mellitus
  • Evaluate the management of heart failure in the setting of diabetes mellitus
  • Outline implications for the healthcare team


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News Author

  • Mitchel L. Zoler, PhD

    Freelance writer, Medscape


    Mitchel L. Zoler, PhD, has no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine


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    Consultant or advisor for: GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

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  • Yaisanet Oyola, MD

    Associate Director, Accreditation and Compliance, Medscape, LLC


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  • Leigh Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC


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ADA Notes Heart Failure as "Underappreciated Complication" of Diabetes

Authors: News Author: Mitchel L. Zoler, PhD; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 7/8/2022

Valid for credit through: 7/8/2023


Clinical Context

Heart failure may not be the first cardiovascular complication of diabetes to come to mind, but the authors of the current consensus statement note that it is the most common initial presentation of cardiovascular disease in modern studies. Diabetes is associated with 2- to 4-fold increase in the risk for heart failure, and the prevalence of heart failure in diabetes is currently 22% and is rising. This is an even bigger public health problem considering that the global prevalence of diabetes has risen approximately 30% in the past decade.

The relationship between heart failure and diabetes is bidirectional. About 60% of patients with heart failure have evidence of insulin resistance. The risk for heart failure in diabetes appears particularly high for Black, Hispanic, and Native American adults. The current consensus guideline provides recommendations regarding the diagnosis and treatment of heart failure in the setting of diabetes.

Study Synopsis and Perspective

All US patients with diabetes should undergo annual biomarker testing to allow for early diagnosis of progressive but presymptomatic heart failure, and treatment with an agent from the sodium-glucose cotransporter 2 (SGLT2) inhibitor class should expand among such patients to include everyone with stage B heart failure ("pre-heart failure") or more advanced stages, according to a recommendation from an American Diabetes Association consensus report published June 1 in Diabetes Care.

The report notes that until now, "implementation of available strategies to detect asymptomatic [heart failure in patients with diabetes] has been suboptimal." The remedy for this is that, "among individuals with diabetes, measurement of a natriuretic peptide or high-sensitivity cardiac troponin is recommended on at least a yearly basis to identify the earliest [heart failure] stages and implement strategies to prevent transition to symptomatic [heart failure]."

Written by a 10-member panel chaired by Rodica Pop-Busui, MD, PhD, and endorsed by the American College of Cardiology, the document also set thresholds for levels of these biomarkers that are diagnostic for a more advanced stage (stage B) of heart failure in patients with diabetes but without heart failure symptoms:

  • A B-type natriuretic peptide (BNP) level of ≥50 pg/mL.
  • An N-terminal pro-BNP level of ≥125 pg/mL.
  • Any high-sensitivity cardiac troponin value that's above the usual upper reference limit set at above the 99th percentile.

'Inexpensive' Biomarker Testing

"Addition of relatively inexpensive biomarker testing as part of the standard of care may help to refine [heart failure] risk prediction in individuals with diabetes," the report says.

"Substantial data [indicate] the ability of these biomarkers to identify those in stage A or B [heart failure] at highest risk of progressing to symptomatic [heart failure] or death," which is useful because "the risk in such individuals may be lowered through targeted intervention or multidisciplinary care."

It is "impossible to understate the importance of early recognition of" heart failure, the authors declare. However, the report also cautions that, "using biomarkers to identify and in turn reduce risk for [heart failure] should always be done within the context of a thoughtful clinical evaluation, supported by all information available."

The report, written during March 2021 to March 2022, cites the high prevalence and increasing incidence of heart failure in patients with diabetes as the rationale for the new recommendations.

For a person with diabetes who receives a heart failure diagnosis, the report details several management steps, starting with an evaluation for obstructive coronary artery disease, given the strong link between diabetes and atherosclerotic cardiovascular disease.

It highlights the importance of interventions that involve nutrition, smoking avoidance, minimized alcohol intake, exercise, weight loss, and relevant social determinants of health, but focuses in greater detail on a range of pharmacologic interventions. These include treatment of hypertension for people with early-stage heart failure with an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker, a thiazide-type diuretic, and a mineralocorticoid receptor antagonist, such as spironolactone or the newer, nonsteroidal agent finerenone for patients with diabetic kidney disease.

Dr Busui, from the Division of Metabolism, Endocrinology, and Diabetes at the University of Michigan, Ann Arbor, and colleagues cite recent recommendations for using guidelines-directed medical therapy to treat patients with more advanced, symptomatic stages of heart failure, including heart failure with reduced or with preserved ejection fraction.

'Prioritize' the SGLT2-Inhibitor Class

The consensus report also summarizes the roles for agents in the various classes of antidiabetes drugs now available, with particular emphasis on the role for the sodium-glucose cotransporter 2 (SGLT2)-inhibitor class.

SGLT2 inhibitors "are recommended for all individuals" with diabetes and heart failure, it says. "This consensus recommends prioritizing the use of [SGLT2 inhibitors] in individuals with stage B [heart failure] and that [SGLT2 inhibitors are] an expected element of care in all individuals with diabetes and symptomatic" heart failure.

Other agents for glycemic control that receive endorsement from the report are those in the glucagonlike peptide 1 receptor agonist class. "Despite the lack of conclusive evidence of direct [heart failure] risk reduction" with this class, it gets a "should be considered" designation, based on its positive effects on weight loss, blood pressure, and atherothrombotic disease.

Similar acknowledgment of potential benefit in a "should be considered" role goes to metformin. However, the report turned a thumb down for both the class of dipeptidyl peptidase 4 inhibitors and the thiazolidinedione class and said that agents from the insulin and sulfonylurea classes should be used "judiciously."

The report did not identify any commercial funding. Several of the writing committee members listed personal commercial disclosures.

Diabetes Care. Published online June 1, 2022.[1]

Study Highlights

  • Heart failure may be discovered at Stage B of disease, which is characterized by evidence of structural heart disease, abnormal cardiac function, or elevated cardiac biomarkers, but not typical symptoms of heart failure. The report recommends evaluation of natriuretic peptide or high-sensitivity cardiac troponin levels at least annually among all patients with diabetes to detect presymptomatic heart failure.
  • Thresholds for the diagnosis of Stage B heart failure include brain natriuretic peptide levels of 50 pg/mL or more or an n-terminal-proBNP level of 125 pg/mL or more, or a high-sensitivity cardiac troponin level above the 99th percentile. Serial measurements of these chemistries can be particularly helpful if there is doubt regarding the possibility of heart failure.
  • Screening is recommended because more intensive interventions for elevated levels of natriuretic peptide without symptoms are associated with lower rates of symptomatic heart failure and hospitalization for heart failure.
  • Patients with evidence of heart failure should undergo baseline testing including a complete blood count, evaluation of renal and hepatic function, thyroid-stimulating hormone, and serum electrolyte levels, urinalysis, iron studies, and HbA1c. An electrocardiogram, chest X-ray, and echocardiography should also be performed.
  • Diet is important in the management of heart failure in the setting of diabetes. A low-potassium diet is recommended, as is avoidance of medications such as nonsteroidal anti-inflammatory drugs, which can raise potassium levels.
  • Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are the preferred agents for stage A or B heart failure, particularly if hypertension or albuminuria are present. Angiotensin-converting enzyme inhibitors or hydrochlorothiazide appear more effective than calcium channel blockers in preventing symptomatic heart failure.
  • Finerenone can reduce the progression of diabetic kidney disease while also preventing symptomatic heart failure.
  • For symptomatic heart failure, sacubitril/valsartan had replaced angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers as the treatment of choice. However, sacubitril/valsartan has been associated with higher rates of hypotension vs angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers.
  • Management of heart failure should include similar agents among patients with and without diabetes: beta blockers, sodium glucose cotransporter 2 inhibitors (SGLT2 inhibitors), and mineralocorticoid antagonists.
  • Statins should generally be applied to all patients with diabetes who are at least 40 years of age, with consideration for statins among younger adults as well. Statins are particularly important in the setting of heart failure.
  • Intensive glycemic control does not necessarily produce better heart failure outcomes. The relationship between HbA1c levels and mortality in cases of diabetes and heart failure is U-shaped, with the lowest risk for death at HbA1c levels of 7% to 8%.
  • Metformin may have an effect in reducing the risk for incident heart failure, whereas sulfonylureas appear to have the opposite effect.
  • Dipeptidyl peptidase-4 inhibitors and pioglitazone should not be used among patients with heart failure.

Clinical Implications

  • The current report suggests annual screening for heart failure among patients with diabetes, using natriuretic peptide or high-sensitivity troponin levels.
  • Treatment for heart failure is generally similar regardless of the presence of diabetes, with sacubitril/valsartan preferred over angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers among patients with reduced ejection fraction and SGLT2i applicable across different stages of heart failure. SGLT2i are a mainstay of treatment of diabetes in the setting of heart failure, although very strict glycemic control may harm patients with heart failure.
  • Implications for the healthcare team: The healthcare team should screen for cases of heart failure among patients with diabetes and institute prevention strategies and appropriate treatment that can improve outcomes over time.


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