Heart Failure: The Overlooked Diabetes Complication
Key takeaways:
- People with type 1 and type 2 diabetes are at a significantly increased risk of developing heart failure compared to those without diabetes.
- Heart failure is a serious but manageable condition – early detection and treatment can greatly improve outcomes.
- Lifestyle changes, medications, and regular monitoring are key to protecting heart health in people with diabetes.
Heart failure is quietly becoming one of the most urgent public health threats of our time, especially for people living with diabetes. Roughly 8.7 million Americans are expected to develop heart failure by 2030, and over 11 million by 2050.
Dr. Adrian F. Hernandez, a cardiologist and executive director of the Duke Clinical Research Institute, described this rise as a “tidal wave,” driven largely by aging populations and the continued prevalence of obesity and diabetes, which are major risk factors for developing heart failure.
“If we don’t bend the curve, we really have a gloomy forecast for 2050,” Hernandez said.
Despite these alarming trends, heart failure remains widely misunderstood. Many people may mistake it for a heart attack or other forms of heart disease. But heart failure is a chronic, progressive condition that can limit quality of life and lead to hospitalization or death if not managed properly.
And for those with diabetes, the risk isn’t just higher – it’s more complex.
By understanding what heart failure is, how it relates to diabetes, and what symptoms to watch for, people can take steps to prevent or manage the condition and help slow the rise of this growing crisis.
What is heart failure and what causes it?
Heart failure happens when the heart can’t pump enough blood to the rest of the body. Unlike a heart attack, which happens suddenly due to a blocked artery, heart failure usually develops over time as the result of other health problems that strain or damage the heart.
The heart may become too weak or too stiff to pump blood properly, which can cause fluid to build up in the body and make it harder for cells to get the oxygen and nutrients they need. The most common causes of heart failure include:
- High blood pressure, which forces the heart to work harder than normal.
- Coronary artery disease, which is when narrowed arteries reduce blood flow to the heart muscle. If fatty deposits or cholesterol build up in the arteries, this is known as atherosclerosis.
- Type 2 diabetes, which affects blood vessels and can directly harm the heart.
- Obesity, which increases the risk of both diabetes and heart disease.
- Previous heart attacks, which may weaken the heart muscle.
- Heart valve problems, infections, or certain genetic conditions.
Other risk factors for heart failure include sleep apnea, lung disease, smoking, and excessive alcohol use. While there are lifestyle changes that individuals can make to reduce their risk of developing heart failure, recognizing the symptoms and seeking out treatment early are key steps that can help slow the progression of heart failure and reduce the risk of serious complications.
Signs and symptoms of heart failure
At first, people may not experience any physical symptoms because the body has ways of trying to compensate – the heart may become bigger and develop more muscle mass, or it could try to pump faster. Eventually, though, the heart’s decreased ability to pump blood causes fluid to build up in other parts of the body, including the legs and lungs, which can make walking and breathing difficult.
The American Heart Association recommends knowing the following signs of heart failure so that you can tell your health care professional:
- Shortness of breath (most commonly occurs during activity, but can also happen at rest)
- Persistent coughing or wheezing (that may produce white or pink, blood-tinged mucus)
- Swelling in the legs, ankles, or feet, fingers, or stomach
- Fatigue and weakness that may occur with everyday activities
- Decreased appetite and nausea
- Confusion or feelings of disorientation
- Increased heart rate or heart palpitations
- Sudden weight gain or loss
If you are experiencing any of the above symptoms, ask your healthcare professional if you can be tested for heart failure.
Diagnosing heart failure
To check for heart failure, healthcare providers often start with a physical exam and questions about your symptoms, lifestyle, and medical history. They may ask when symptoms started, how bad they are, and whether anything makes them better or worse. They’ll also want to know if you have a family history of heart disease or other conditions like diabetes, and what medications or supplements you take.
The main test used to diagnose heart failure is an echocardiogram, which is a painless ultrasound that shows how well the heart is pumping. Other scans, like chest x-rays, MRIs, or CT scans, can give more detailed images of the heart and blood flow. Doctors may also use an electrocardiogram to look at the heart’s electrical signals, as well as biomarkers such as B-type natriuretic peptide (BNP). All of this information helps them understand the cause, type, and severity of heart failure, and how best to treat it.
If you are already diagnosed with heart failure, it's important to track your symptoms (like changes in weight, blood pressure, heart rate, and fluid intake) and let your care team know about any sudden changes.
What is the connection between heart failure and diabetes?
Understanding what puts someone at higher risk for heart failure is just as important as recognizing its symptoms. According to the ADA’s 2025 Standards of Care, people with type 2 diabetes are at least twice as likely to develop heart failure as those without. People with type 1 diabetes are also at a much greater risk. But why is this?
The main link comes down to how diabetes affects the body over time. High blood sugar from insulin resistance in type 2 diabetes can damage blood vessels, making it harder for the heart to work properly. In addition, diabetes often leads to chronic inflammation, which can weaken the heart muscle and surrounding blood vessels over time. This makes it harder for the heart to pump blood efficiently, eventually leading to heart failure.
Another factor is that many of the key risk factors for heart failure are common in people with type 2 diabetes, such as high blood pressure, obesity, sleep apnea, and even certain diabetes medications. These all increase the strain on the heart and raise the risk of heart failure even more.
Dr. James Januzzi, a cardiologist at Harvard Medical School, emphasized just how strongly connected diabetes and heart failure are.
“Stage A represents individuals who are at risk for heart failure – by definition, a person with diabetes has Stage A heart failure,” he said.
In short, diabetes doesn't just affect blood sugar. It sets off a chain reaction in the body that puts extra stress on the heart. That’s why managing both blood sugar and heart health is so important for people living with diabetes.
Treatment of heart failure in people with diabetes
If you are diagnosed with heart failure, especially alongside diabetes, there are a range of treatment options to help you manage the condition and improve your quality of life.
Lifestyle changes like eating a heart-healthy diet, being physically active, quitting smoking, and managing stress are usually recommended as a starting point. However, medications are often needed as well. Finally, there are also devices that can be implanted in your chest if needed to help control your heart rhythm.
Several types of medications are used to treat heart failure. Updated guidelines from the American Heart Association note the importance of starting the following four medication classes early – and often, simultaneously:
- Mineralocorticoid receptor antagonists (MRAs) like spironolactone help block the effects of aldosterone, a hormone that can cause the body to retain sodium and water. These medications help reduce fluid buildup, improve heart function, and lower the risk of hospitalization.
- Beta blockers help slow down the heart and reduce the harmful effects of stress hormones like adrenaline from damaging the heart.
- Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) relax blood vessels, which makes pumping blood throughout the body easier for the heart. They also help lower blood pressure and reduce strain on the heart.
- SGLT2 inhibitors, such as dapagliflozin and empagliflozin, were originally developed as diabetes medications, but research has shown they also help reduce the risk of heart failure hospitalization – even in people without diabetes.
Additional medications may also be used, depending on your individual needs. These can include:
- Diuretics, or “water pills,” help remove excess fluid and salt from the body through urine. This reduces swelling (edema) and eases symptoms like shortness of breath.
- Inotropes help the heart contract more strongly and improve blood flow, though are typically reserved for advanced heart failure.
- Statins lower cholesterol and reduce the risk of heart attack or stroke.
- Nitrates for chest pain relief
- Blood thinners to reduce the risk of blood clots
In some cases, heart failure may interfere with the heart’s electrical system, leading to abnormal rhythms. If this happens, your doctor may recommend a device such as a pacemaker or an implantable cardioverter-defibrillator. These devices help coordinate your heartbeat and prevent life-threatening arrhythmias.
Emerging weight loss medications, such as semaglutide (Wegovy), have also been shown to have effects far beyond weight management. A recent study found that semaglutide improved biomarkers and reduced symptoms in people with obesity-related heart failure.
The bottom line
Heart failure is a growing and often overlooked threat, especially for people living with both type 1 and type 2 diabetes. But it doesn’t have to be inevitable. By understanding the connection between diabetes and heart failure, recognizing early symptoms, and working with your healthcare team to increase time in range and manage risk factors, you can take meaningful steps to protect your heart.
Managing heart failure in people with diabetes requires a comprehensive approach that includes lifestyle changes, medications, and sometimes medical devices. The good news is that with early treatment and the right combination of therapies, many people are able to improve their heart function, reduce symptoms, and live longer, healthier lives.
Learn more about heart failure and diabetes here: