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Current 30 - Update on the Staging and Management of Heart Failure in Diabetes



A 2022 consensus report from the American Diabetes Association provides detailed updates on the epidemiology, staging, and management 1   of heart failure (HF) as a complication of diabetes. Heart failure has a prevalence of up to 22% in people with diabetes, and may develop independently of other cardiovascular conditions, presenting as the first cardiovascular disease in this population.2, 3 

Stage A HF: People with diabetes who have one additional risk factor (e.g., hypertension, hyperlipidemia, diabetic kidney disease) (Figure 1). Controlling blood pressure and other risk factors may modify progression to later, symptomatic stages, though evidence supporting the use of angiotensin-converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARB) for risk factors other than diabetic kidney disease and coronary artery disease is limited.

Stage B HF, or “pre-HF”: Asymptomatic but with structural heart changes. Linked to higher cardiovascular and all-cause mortality. 

Yearly measurement of brain natriuretic peptide or high-sensitivity cardiac troponin is recommended in Stage A or B HF to determine the risk of progression and the need for further testing (Figure 1). Management should include ACEi/ARB and sodium-glucose cotransporter-2 inhibitors (SGLT2i), where possible, particularly in Stage B.

Stages C and D: Symptomatic. Management is similar to patients without diabetes,with additional emphasis on lifestyle for people with diabetes.

Pharmacotherapy and other management recommendations for all stages are included in Figure 2. 



  1. Pop-Busui R, Januzzi JL, Bruemmer D, et al. Heart failure: an underappreciated complication of diabetes. A consensus report of the American Diabetes Association. Diabetes Care. 2022;45(7):1670-1690.doi:10.2337/dci22-0014.
  2. Dunlay SM, Givertz MM, Aguilar D, et al. Type 2 diabetes mellitus and heart failure: a scientific statement from the American Heart Association and the Heart Failure Society of America: this statement does not represent an update of the 2017 ACC/AHA/HFSA heart failure guideline update. Circulation. 2019;140(7):e294–e324. doi: 10.1161/CIR.0000000000000691.
  3. Park JJ. Epidemiology, pathophysiology, diagnosis and treatment of heart failure in diabetes. Diabetes Metab J. 2021;45(2):146–157.doi: 10.4093/dmj.2020.0282.
  4. Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Am Coll Cardiol. 2017;70(6):776–803. doi: 10.1016/j.jacc.2017.04.025.


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