Association of Diabetes Care & Education Specialists

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New Heart Failure Recommendations and the Impact on People with Diabetes

May 16, 2022

By John Bucheit, PharmD, BCACP, CDCES

People with diabetes are more than twice as likely to develop heart failure and approximately 50% of people with heart failure also have diabetes. In April 2022, the American College of Cardiology and American Heart Association released an update to the practice guidelines for heart failure. The new recommendations will surely impact people living with diabetes and the clinicians that work to optimize their cardiometabolic health. Below are the top four recommendations that every diabetes care and education specialist needs to know.

  1. Stay current on the new terminology for heart failure classification.
    Understanding the terminology is essential to determining medications to optimize outcomes.
    • Heart Failure Categories based on Left Ventricular Ejection Fraction (LVEF)
      • Heart Failure with Reduced Ejection Fraction (HFrEF)
        LVEF < 40%
      • New Heart Failure with Mildly Reduced Ejection Fraction (HFmEF)
        LVEF 41%-49%
      • Heart Failure with Preserved Ejection Fraction (HFpEF)
        LVEF > 50%
      • New Heart Failure with Improved Ejection Fraction (HFiEF)
        LVEF previously < 40% and follow-up measurements > 40%
    • Heart Failure Stages
      • Stage A: At Risk for Heart failure
        - No signs, symptoms, or structural abnormalities related to heart failure.
        - One or more risk factors present: hypertension, diabetes, obesity and family history.
      • Stage B: Pre-Heart Failure
        - No symptoms of heart failure, but one of the following is present: structural abnormalities, increased filling pressures or laboratory abnormalities (elevated natriuretic peptides or troponin levels).
      • Stage C: Symptomatic Heart Failure
        - Previous/current signs/symptoms of heart failure.
      • Stage D: Advanced Heart Failure
        - Substantial symptoms that effect daily living in addition to recurrent hospitalizations.
  2. Know diabetes-specific recommendations.
    For people with diabetes and heart failure, sodium glucose cotransport inhibitors (SGLT2-inhibitors) are recommended for hyperglycemia management and to reduce heart failure related-morbidity and mortality.
  3. Remember SGLT2-inhibitors are a new critical piece of guideline directed medical therapy (GDMT) for Stage C Heart Failure.
    Regardless of the type of heart failure (HFrEF, HFmEF, HFpEF, or HFiEF) SGLT2-inhibitors are indicated to reduce cardiovascular events and/or hospitalizations. Other medications to consider for GDMT are ACEi/ARBs, ARNI (sucubatril-valsartan), and mineralocorticoid receptor antagonists. Together, these medications reduce morbidity and mortality and the effects are additive as each class is prescribed based on patient toleration.
  4. Avoid certain diabetes medications in patients with heart failure. 
    Several medications for diabetes treatment can worsen heart failure and should be avoided. These medications include the thiazolidinediones (TZDs) or two agents from the dipeptidyl pepditase-4 inhibitors class (alogliptin and saxagliptin).

Access the guidelines to find more information and to learn more about the heart failure recommendations that impact people with diabetes. To learn more about the link between diabetes and heart health, you can also access ADCES resources on the topic at DiabetesEducator.org/CVD.


ADCES Perspectives on Diabetes Care

The Association of Diabetes Care & Education Specialists Perspectives on Diabetes Care covers diabetes, prediabetes and other cardiometabolic conditions. Not all views expressed reflect the official position of the Association of Diabetes Care & Education Specialists.

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HEALTHCARE DISCLAIMER: This site and its services do not constitute the practice of medical advice, diagnosis or treatment. Always talk to your diabetes care and education specialist or healthcare provider for diagnosis and treatment, including your specific medical needs. If you have or suspect that you have a medical problem or condition, please contact a qualified health care professional immediately. To find a diabetes care and education specialist near you, visit DiabetesEducator.org/Find.

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