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Heart Failure – The Overlooked Diabetes Complication, Part 2: Prevention and Management

Learn more about navigating heart failure, with recent insights from the 81st ADA Scientific Sessions – including the steps you can take to reduce your risk for heart failure and how to work with your health professional to manage this condition once you’ve been diagnosed.

Heart failure is one of the most common and deadly complications of diabetes, especially for people with type 2 diabetes. In this article, the second in our heart failure series, we explore insights on how you can prevent heart failure and the latest on treating this complication.

In part one of this series, we discussed the what and why of heart failure – including an explanation of what heart failure is, how it relates to diabetes, signs, symptoms, and screening, and how healthcare professionals test for this complication.

Heart failure happens when the heart can’t pump enough blood to the rest of the body. There are a number of reasons why heart failure can occur, including atherosclerosis and coronary artery disease, high blood pressure, previous heart attacks, or other conditions and structural issues that damage the heart muscle (like cardiomyopathy or heart valve problems). There are also two main types of heart failure:

  • When the heart muscle becomes stiff and the chambers in the heart cannot relax, but the heart is still able to pump more than half of the blood in the heart chamber to the rest of the body, this is called “heart failure with preserved ejection fraction,” or HFpEF.
  • When the heart muscle becomes weaker, and less than half of the amount of blood in the chamber is pumped out into the body with each heartbeat, this is called “heart failure with reduced ejection fraction,” or HFrEF.

People with diabetes are two to four times more likely to develop heart failure than people without, and having diabetes can increase a person's risk for repeated hospitalizations for heart failure. 

You can learn more about heart failure by checking out this helpful resource from the Know Diabetes By Heart initiative from the American Heart Association and the American Diabetes Association: “What is Heart Failure.”

Read on for how to prevent and treat this complication.

Are there steps that I can take to help prevent heart failure?

Ways to reduce your risk for developing heart failure are similar to the methods you probably use to manage your diabetes. This includes avoiding or quitting smoking, reducing your alcohol intake, decreasing your A1C and increasing your Time in Range, lowering blood pressure and cholesterol, being mindful of what you eat and losing weight for those with excess weight or obesity, and engaging in regular physical activity.

In addition to managing these risk factor, you and your healthcare team should also discuss the potential for medications to prevent heart failure – including SGLT-2 inhibitors and metformin. Click here to jump down to this section and learn more.

Can diet help prevent or manage my risk for heart failure?

Being very mindful of your diet and nutrition is a key way in which you can minimize your risk for heart failure. One way you can do this is to adjust your diet to be mindful of the other risk factors for this condition – this means changing your diet to better control your A1C, Blood pressure, and Cholesterol (commonly referred to as the “ABC’s of diabetes”).

  • A1C: A diet focused on keeping you in your target glucose and A1C ranges can help decrease your heart failure risk. This often means limiting the amount of fast-acting carbs, processed foods, and added sugars you are consuming and taking the appropriate medications to manage blood glucose levels. Check out our nutrition principles to learn more: “What to Eat with Diabetes.”
  • Blood Pressure: Diets that focus on reduced salt intake and are rich in whole grains, fruits, and vegetables and taking blood pressure medications can help you achieve your target blood pressure. Avoiding highly processed or packaged foods is also key as these are often high in added sugar and salt.
  • Cholesterol: It’s important to reduce the amount LDL cholesterol (“bad” cholesterol) in your blood. The best way to do this is to avoid foods that are high in saturated or trans fats because they can increase your cholesterol levels and to take a cholesterol-lowering medication if needed.

Unfortunately, there has been very little research conducted on specific dietary recommendations for people living with both diabetes and heart failure outside of the recommendations listed above. Emerging studies have suggested that the Mediterranean diet and DASH diets may improve outcomes for people with diabetes and heart failure. Both diets focus on eating more fruits and vegetables, nuts, legumes, whole grains and fish, and reducing the number of sweetened beverages and the amount of red and processed meat. In addition, low-carbohydrate or a very low-carbohydrate diet may also be another option.

Exercising with heart failure

Exercise and physical activity are a great way to decrease your risk for heart failure (and manage your diabetes). However, for people with diagnosed heart failure, exercising can be a bit complicated.

Exercise has clear benefits for helping the heart stay strong and slowing the progression of heart failure. But it’s important to know that heart failure, especially HFrEF, is often associated with a reduced ability to exercise safely for sustained periods of time, making some forms of exercise challenging or even dangerous.

Because of this, less strenuous activities such as walking are commonly recommended, and there may be benefits to strength or resistance training as well – remember to increase your activity level slowly and always warm up before beginning exercise and cool down when you are done. Since there are some risks that come with exercising with heart failure, such as sudden fatigue, shortness of breath, or fainting, it is crucial to discuss safe ways to approach physical activity with your health professional, especially before starting any new exercise program.

It may be important to check your blood pressure before and after exercising and to use a continuous glucose monitor (CGM) or a blood glucose meter (BGM) to keep track of your glucose levels during physical activity. Check with your healthcare professional about monitoring your blood pressure and blood sugar during exercise. In addition, pay attention during exercise for these warning signs:

  • Shortness of breath
  • Feeling dizzy or lightheaded
  • Chest pain, tightness, or pressure
  • Pain in your shoulders, arm, neck, or jaw
  • Skipped heart beats or uneven heart rate

If you notice these signs while active, slow down and rest. If they persist, contact your healthcare provider or call 911.

What treatments exist if I am diagnosed with heart failure?

If you are diagnosed with heart failure, there are different treatment options to help you manage the condition. Healthy lifestyle changes like those discussed above (changes in diet and exercise) are usually the first treatment options. There are also certain medication classes which can address specific issues associated with heart failure such as diuretics, beta blockers, ACE inhibitors, angiotensin-2 receptor blockers (ARBs), mineralocorticoid receptor antagonists (MRAs), and SGLT-2 inhibitors. Finally, there are also devices which can be implanted in your chest if needed to help control heart rhythm.

There are a number of different medicines that may be prescribed to help address and treat the underlying issues related to heart failure (such as high blood pressure):

  • Diuretics help the body get rid of excess salt and fluid through your urine in a process called diuresis. Diuretics can be used to prevent or reduce the build-up of salt and fluid (called edema) in the lungs, heart, legs, or other body tissues – a sign of underlying heart failure.
  • Beta blockers are often prescribed to help people manage high blood pressure and heart failure. They work by slowing down the heart and blocking your body’s “fight-or-flight” hormones (adrenaline and noradrenaline) from damaging the heart.
  • ACE inhibitors are another medicine often prescribed to help manage high blood pressure and heart failure. They relax and open your blood vessels which makes pumping blood throughout the body easier for the heart.
  • ARBs are very similar to ACE inhibitors. They relax your blood vessels and help lower your blood pressure.
  • Inotropic drugs may be used to treat HfrEF. These drugs help your heart contract (helping it pump blood), but they can also affect heart rate and resistance in your blood vessels.
  • Verquvo (vericiguat) is a new medicine for chronic heart failure called an oral soluble guanylate cyclase (sGC). This drug may help the heart pump blood and contract.
  • Other medications can also be prescribed depending on what your healthcare team thinks can provide the best treatment, including statins to lower cholesterol levels, nitrates for chest pain, or blood-thinning medicine to prevent blood clots.

In certain cases, heart failure can also affect the electrical signals in the heart that control heart rhythm. If this is the case, your healthcare provider may decide that a device such as a pacemaker or an implantable cardioverter defibrillators (ICDs) is needed to help maintain the coordination of the heart as it beats. ICDs, which are like pacemakers, are implanted near the heart and use electrical signals to help make sure the heart maintains a normal rhythm.

Diabetes medications and heart failure

Having diabetes and high blood pressure may increase your risk for experiencing heart failure, so it’s important to be aware of how your glucose lowering and blood pressure medications may increase or decrease your risk for heart failure – especially if you have other risk factors besides diabetes.

Two types of diabetes drugs in particular have been associated with increasing the risk of heart failure: DPP-4 inhibitors and thiazolidinediones (TZDs).

TZDs like Avandia (rosiglitazone) and Actos (pioglitazone) have been associated with an increased risk of heart failure. This is especially true if they increase weight and fluid retention, called edema, which can subsequently lead to heart failure.

DPP-4 inhibitors include a heart failure “warning” on its official label. This is based on heart failure risk observed for two specific DPP-4 inhibitors during clinical trials and observational studies, Nesina (alogliptin) and Onglyza (saxagliptin). Other DPP-4 inhibitors, most notably Januvia, have not shown an increased heart failure risk in studies, but a warning that heart failure has been observed in two other members of the DPP-4 inhibitor class (in Nesina (alogliptin) and Onglyza (saxagliptin)) has been added by the FDA as a precaution.

However, there are also exciting recent studies showing that some diabetes medications – namely SGLT-2 inhibitors – may have benefits for people with heart failure. At the 81st ADA Scientific Sessions we learned about these emerging studies and the recommendations for people with diabetes.

  • Dr. Biykem Bozkurt, a professor at the Baylor College of Medicine, delivered an overview on new insights into heart failure therapies focused on early and preventive treatments. In particular, SGLT-2 inhibitors are hugely important for preventing the progression of heart failure in people with “Pre-Heart Failure”
    • EMPA-REG OUTCOME: In this study of 7,020 people with type 2 diabetes and a high risk for cardiovascular disease, the use of Jardiance (empagliflozin) reduced the risk of heart failure by 35% compared to those on the placebo.
    • CANVAS: In this study of 10,142 people with type 2 diabetes and a high risk for cardiovascular disease, the use of Invokana (canagliflozin) reduced the risk of hospitalization for heart failure by 33% compared to those on the placebo.
    • DECLARE: In this study of 17,160 people with type 2 diabetes with or without atherosclerotic cardiovascular disease, the use of Farxiga (dapagliflozin) reduced the risk of hospitalization for heart failure by 27% compared to those on the placebo.
    • VERTIS CV: In this study of 8,246 people with type 2 diabetes and cardiovascular disease, the use of Steglatro (ertugliflozin) reduced the risk of hospitalization for heart failure by 30% compared to those on the placebo.
    • DAPA-HF: In this study of 4,744 with HfrEF, with or without diabetes, the use of Farxiga (dapagliflozin) reduced the risk of worsening heart failure or cardiovascular dearg by 26% compared to those taking a placebo
  • In another session, Dr. Muthiah Vaduganathan, a cardiologist at Brigham and Women’s Hospital, spoke to the potential for SGLT-2 inhibitors to treat HFpEF, which has been an area with few medication options. Two studies that will be releasing results soon (EMPEROR-Preserved and DELIVER) are looking at whether empagliflozin or dapagliflozin respectively may be able to help people with HFpEF with and without type 2 diabetes by reducing hospitalizations and improving quality of life.
    • Top-line results from EMPEROR-Preserved showed for the first time that a therapy (empagliflozin) can cut the risk of hospitalization and cardiovascular death for patients with HFpEF with or without type 2 diabetes. The long-awaited results will be presented in late August during the European Society of Cardiology 2021 conference.
  • Dr. Christina DeRemer, a professor at the University of Florida, College of Pharmacy, presented real world data on 13,006 people with type 2 diabetes and established heart disease that showed that, especially for heart failure, SGLT-2 inhibitors outperformed GLP-1 receptor agonists. The SGLT-2s reduced the risk for heart failure by 53% compared to the GLP-1s. It’s important to note, however, that GLP-1 receptor agonists also reduce your risk for heart failure compared to a placebo.

These presentations highlighted the benefits of using SGLT-2 inhibitors for preventing and treating heart disease in people with diabetes. Learn more about this class of medications and their positive heart benefits in our article: “What Are SGLT-2 Inhibitors and How Can They Help Your Heart?

Talk to your doctor about your risks for heart failure and what you can do to prevent this condition. If you have been diagnosed with heart failure and have diabetes, ask your doctor what treatment options may be available to you.

To learn more about heart failure check out part one in this series, “Heart Failure – The Overlooked Diabetes Complication, Part 1: What and Why?” or these helpful resources from the Know Diabetes By Heart initiative:

This article is part of a series to help people with diabetes learn how to support heart health, made possible in part by the American Heart Association and American Diabetes Association’s Know Diabetes by Heart initiative.