From the Guidelines
Diabetes mellitus significantly increases the risk of heart failure through multiple interconnected mechanisms, and therefore, it is crucial to manage diabetes and cardiovascular risk factors to prevent heart failure. High blood glucose levels damage blood vessels and heart muscle directly, causing structural changes that impair cardiac function 1. Insulin resistance, common in type 2 diabetes, forces the heart to work harder and contributes to left ventricular hypertrophy. Diabetic patients often develop coronary artery disease due to accelerated atherosclerosis, which can lead to heart attacks and subsequent heart failure. Diabetic cardiomyopathy, a condition specific to diabetes, causes heart muscle dysfunction independent of coronary artery disease. Additionally, diabetes frequently coexists with other heart failure risk factors like hypertension, obesity, and kidney disease, creating a perfect storm for cardiac damage.
Key Mechanisms and Risk Factors
- High blood glucose levels damage blood vessels and heart muscle
- Insulin resistance contributes to left ventricular hypertrophy
- Accelerated atherosclerosis leads to coronary artery disease and heart attacks
- Diabetic cardiomyopathy causes heart muscle dysfunction
- Coexistence with other heart failure risk factors like hypertension, obesity, and kidney disease
Management and Prevention
- Tight glucose control is essential for prevention, as demonstrated by recent clinical trials 1
- Management of other cardiovascular risk factors, such as hypertension and hyperlipidemia, is also crucial
- SGLT2 inhibitors, such as empagliflozin, canagliflozin, and dapagliflozin, are recommended to lower the risk of heart failure hospitalization in patients with diabetes 1
- Metformin and GLP1-RAs may be considered for diabetes treatment in patients with heart failure, while thiazolidinediones and saxagliptin are associated with an increased risk of incident heart failure and are not recommended 1
Recent Evidence and Guidelines
- The 2024 standards of care in diabetes emphasize the importance of screening for asymptomatic heart failure in people with diabetes 1
- The 2019 ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases recommend SGLT2 inhibitors to lower the risk of heart failure hospitalization in patients with diabetes 1
From the Research
Causation between Diabetes Mellitus and Increased Risk for Heart Failure
The relationship between diabetes mellitus and heart failure is complex, with several mechanisms contributing to the increased risk of heart failure in diabetic patients. Some of the key factors include:
- Hyperglycemia, which can lead to cardiomyopathy and increase the risk of coronary heart disease 2, 3
- Shared risk factors such as coronary artery disease, hypertension, and dyslipidemia 4, 5
- Direct cardiotoxic effects of type 2 diabetes mellitus 5
- Metabolic abnormalities, including insulin resistance and diminished insulin secretory response 3
Pathophysiology of Diabetic Cardiomyopathy
Diabetic cardiomyopathy is a condition in which the heart muscle is damaged due to high blood sugar levels, leading to impaired systolic and diastolic function. The pathophysiology of diabetic cardiomyopathy is not fully understood, but it is thought to involve:
- Toxic effects of hyperglycemia on the heart muscle 2, 3
- Increased oxidative stress and inflammation 6
- Impaired insulin signaling and glucose metabolism in the heart 3
Treatment and Prevention of Heart Failure in Diabetic Patients
Several treatments have been shown to be effective in preventing or improving outcomes in heart failure patients with diabetes, including:
- Sodium-glucose cotransporter 2 (SGLT2) inhibitors, which have been shown to reduce hospitalization for heart failure and cardiovascular death 4, 6, 5, 3
- Metformin, which has been shown to modestly improve outcomes in patients with heart failure 4
- Novel lifesaving medications such as sacubitril/valsartan, which have a favorable metabolic profile and lower the incidence of cardiogenic diabetes 3