The Management of Patients with Heart Failure and Diabetes
Abstract
Patients with diabetes are at higher risk of developing heart failure compared to the general population. Diabetes itself confers a worse prognosis in patients with heart failure. In this chapter, we review the shared epidemiology of heart failure and diabetes, explore the mechanisms that lead to heart failure in diabetics including impaired myocardial glucose utilization and dysregulation of the neurohormonal system, and lastly focus on the intricacies of managing heart failure in the setting of diabetes. The section covers the impact of various diabetes pharmacotherapies such as metformin, glucagon-like peptide-1 receptor agonists, and sodium-glucose cotransporter 2 inhibitors (SGLT-2) on heart failure outcomes. We highlight the success of the SGLT-2 inhibitors empagliflozin and dapagliflozin in improving cardiovascular outcomes and heart failure risk among high-risk patients with diabetes. Empagliflozin and dapagliflozin reduce heart failure hospitalizations and mortality in patients with heart failure and reduced ejection fraction even in the absence of diabetes. As such, SGLT-2 inhibitors are increasingly prescribed by cardiovascular specialists, who need to be aware of contraindications such as genital and urinary infections, euvolemic diabetic ketoacidosis, volume depletion, and advanced kidney disease. Not all diabetic medications are beneficial in heart failure; thiazolidinediones and dipeptidyl peptidase-4 (DPP-4) inhibitors should be avoided.
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