Heart Failure: An Underappreciated Complication of Diabetes

Publication Date: June 1, 2022


  • Measurement of a natriuretic peptide or high-sensitivity cardiac troponin on at least a yearly basis to identify possible presence of stage B HF and to prognosticate risk for progression to symptomatic stages of the diagnosis.
  • Implementation of individualized management regarding further testing and introduction or avoidance of treatments following abnormal natriuretic peptide or high-sensitivity cardiac troponin results.
  • Use of guideline-directed medical therapy (GDMT) similar to patients with HF and without diabetes, including am angiotensin receptor-neprilysin inhibitor (ARNI) (or ACEi/ARB if ARNI is not prescribed), evidence-based beta-blockers, mineralocorticoid receptor antagonists, and SGLT2i.
  • Use of metformin, GLP1RA or insulin in individuals with T2D at high risk for/with established HF and for whom additional glycemic control is needed.
  • Consideration of diabetes technologies, cardiac rehabilitation programs and weight loss strategies as part of overall efforts to optimize care.
  • Ensuring women, individuals with T1D, and those with high-burdened social determinants of health have access to and are offered the same management framework.


• Both T1D and T2D increase the risk of developing HF across the entire range of glucose levels, but HF may be more
prevalent in people with T1D compared with T2D.

• There is increased incidence rate of HF among people with diabetes even after adjustment for age and comorbidities.

• HF may be the first presenting cardiovascular complication in individuals with diabetes.


• Individuals with diabetes may develop “diabetic cardiomyopathy,” defined as left ventricular systolic or diastolic dysfunction in the absence of other causes (such as CAD or hypertension), with excess risk in women.

• Both HFpEF and HFrEF may be present in diabetes.

• The pathophysiology of HF in individuals with diabetes reflects complex interactions between numerous pathways with deleterious effects on myocardial remodeling and muscle function.


• Anyone with a diagnosis of diabetes and the risk factors shown in Fig. 1 is in the stage A category of HF.

• Many people with diabetes have stage B HF, defined as asymptomatic with at least one of the following: 1) evidence of structural heart disease, 2) abnormal cardiac function, 3) elevated natriuretic peptide levels or elevated cardiac troponin levels.

• Early diagnosis of HF could enable targeted treatment to prevent adverse outcomes.

• Measurement of a natriuretic peptide or high-sensitivity cardiac troponin on at least a yearly basis is recommended
to identify the presence of stage B HF and to determine risk for progression to symptomatic HF.

• Useful cutoff values for BNP (50 pg/mL), NT-proBNP (125 pg/mL), or high sensitivity cardiac troponin (>99th percentile upper reference limit) to determine HF risk are based on population- based data and/or clinical trials.

• The identification of an abnormal natriuretic peptide or high-sensitivity cardiac troponin should be part of individualized management decision plans.

• Clinicians should be aware of the multiple symptoms, signs, and physical findings in patients with HF.

• Recommended laboratory evaluations for patients with HF include natriuretic peptide, complete blood count, urinalysis, serum electrolytes, blood urea nitrogen, serum creatinine, glucose, fasting lipid profile, liver function, and thyroid-stimulating hormone. A chest X-ray and 12-lead electrocardiogram are also recommended.

• Imaging studies such as transthoracic echocardiography will add meaningful information to the evaluation of a patient with suspected or proven HF.

• When HF is diagnosed in individuals with diabetes, clinicians should evaluate for evidence of obstructive CAD as the cause.


• Periodic serum potassium monitoring and minimizing alcohol intake and avoidance of smoking are recommended.

• Regular tailored exercise is recommended as it has been shown to be beneficial in individuals with diabetes and HF.

• Weight loss improves cardiometabolic risk factors and may lower risk for HF.

• Providers should identify SDOH factors that might adversely affect an individual’s access to care (job and food insecurity, health literacy, access to housing, and safe environment) in order to mitigate their impact.

• ACEi and ARB are preferred agents in the management of stage A or B patients with either T1D or T2D and hypertension, especially in the presence of albuminuria and/or CAD.

• Treatment with a thiazide-type diuretic or an ACEi has been shown to be more effective than treatment with a calcium channel blocker in preventing progression to symptomatic HF, and their use is recommended for treatment of individuals with diabetes and hypertension.

• Among patients with diabetes and DKD without symptomatic HF, the use of finerenone, a nonsteroidal MRA, may reduce progression of DKD and lower risk for incident HF.

• Careful monitoring of serum potassium levels is needed with the use of MRA and other RAAS blockers.

• Recommendations for GDMT of individuals with HFrEF and diabetes are similar to those for HFrEF patients without diabetes and include ARNI, ACEi, or ARB, evidence-based b-blockers, MRA, and SGLT2i.

• Sacubitril/valsartan is the first-line therapy in individuals with diabetes and HFrEF and is preferred to ACEi or ARB.

• Among individuals with HFpEF it is reasonable to consider treatment with spironolactone or sacubitril/valsartan.

• In individuals with HFpEF, treatment with an SGLT2i is clinically proven therapy to reduce HF hospitalizations.

• Clinical practice guidelines recommend treating individuals with diabetes with statins based on age and background risk factors.

• Diabetes medications have differential effects on HF risk, and each individual’s cardiovascular risk factors should
be carefully reviewed and considered in selecting a therapeutic regimen for diabetes.

• SGLT2i are an expected element of care in all individuals with diabetes and symptomatic HF and should be used in individuals with high cardiovascular risk, including those with stage B HF.

• If additional glycemic control is needed for an individual with T2D at high risk for or with established HF, use of GLP-1RA, metformin, or both should befavored over sulfonylureas.

• DPP-4 inhibitors or TZDs are not recommended for patients with diabetes with stage B, C, and D HF.

• Insulin treatment could be added if additional glycemic control is indicated.

• Cardiac rehabilitation programs are underutilized for those with diabetes and HFrEF.

• Participation in cardiac rehabilitation is associated with improvement in exercise capacity and health status and possibly reduces mortality.

• Efforts to increase routine referral of eligible individuals to cardiac rehabilitation are encouraged.

• Metabolic surgery promotes improvements in risk factors relevant to HF and is directly associated with reduction in major cardiovascular events in those with HF and obesity and thus should be considered in these individuals to improve HF outcomes.

• The recommendations for advanced HF management, including automated ICD implantation and CRT, are similar to those for patients without diabetes.

• Hospitalization for decompensation or new-onset HF represents a pivotal moment in the disease journey of individuals with diabetes, as risk for adverse outcome rises substantially in this setting.

• During hospitalization, individuals with diabetes and HF should receive standard management per contemporary guidelines and consensus documents, which includes assessment for cause of acute HF and optimization of outpatient GDMT.

• Consider initiation or continuation of SGLT2i in the inpatient management for those with diabetes and acute HF.

• Diabetes worsens the clinical trajectory of individuals with HF.

• People with diabetes and HF should be educated about the likely trajectory of their heart disease, and management strategies that can improve their outcomes, to limit disease progression, including HF-related hospitalizations and death.

Recommendation Grading




Heart Failure: An Underappreciated Complication of Diabetes

Authoring Organization

Publication Month/Year

June 1, 2022

Document Type


Country of Publication


Document Objectives

Heart failure (HF) has been recognized as a common complication of diabetes, with a prevalence of up to 22% in individuals with diabetes and increasing incidence rates. Data also suggest that HF may develop in individuals with diabetes even in the absence of hypertension, coronary heart disease, or valvular heart disease and, as such, represents a major cardiovascular complication in this vulnerable population; HF may also be the first presentation of cardiovascular disease in many individuals with diabetes. Given that during the past decade, the prevalence of diabetes (particularly type 2 diabetes) has risen by 30% globally (with prevalence expected to increase further), the burden of HF on the health care system will continue to rise. The scope of this American Diabetes Association consensus report with designated representation from the American College of Cardiology is to provide clear guidance to practitioners on the best approaches for screening and diagnosing HF in individuals with diabetes or prediabetes, with the goal to ensure access to optimal, evidence-based management for all and to mitigate the risks of serious complications, leveraging prior policy statements by the American College of Cardiology and American Heart Association.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings


Intended Users

Nurse, nurse practitioner, physician, physician assistant


Assessment and screening, Treatment, Management, Prevention

Diseases/Conditions (MeSH)

D003920 - Diabetes Mellitus, D006333 - Heart Failure


diabetes, heart failure

Source Citation

Rodica Pop-Busui, James L. Januzzi, Dennis Bruemmer, Sonia Butalia, Jennifer B. Green, William B. Horton, Colette Knight, Moshe Levi, Neda Rasouli, Caroline R. Richardson; Heart Failure: An Underappreciated Complication of Diabetes. A Consensus Report of the American Diabetes Association. Diabetes Care 2022; dci220014. https://doi.org/10.2337/dci22-0014

Supplemental Methodology Resources

Data Supplement