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Eur J Heart Fail. 2018 May;20(5):853-872. doi: 10.1002/ejhf.1170. Epub 2018 Mar 8.

Type 2 diabetes mellitus and heart failure: a position statement from the Heart Failure Association of the European Society of Cardiology.

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University of Belgrade School of Medicine, Belgrade University Medical Center, Belgrade, Serbia.
Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
Department of Cardiology, National and Kapodistrian University of Athens Medical School, Athens University Hospital "Attikon", Athens, Greece.
Division of Cardiology and Metabolism - Heart Failure, Cachexia & Sarcopenia, Department of Cardiology (CVK); and Berlin-Brandenburg Center for Regenerative Therapies (BCRT); Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK) Berlin; Charité Universitätsmedizin Berlin, Germany; Department of Cardiology and Pneumology, University Medicine Göttingen, Göttingen, Germany.
Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy and Cardiovascular and Cell Science Institute, St George's University of London, London, UK.
NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK.
Department of Physiology and Institute for Cardiovascular Research VU, VU University Medical Center, Amsterdam, The Netherlands.
Institute of Cardiometabolism and Nutrition (ICAN), Pierre et Marie Curie University, Paris VI, La Pitié-Salpétrière Hospital, Paris, France.
Cardiology Unit, Department of Medicine, Karolinska University Hospital, Stockholm, Sweden.
University of Groningen, University Medical Centre Groningen, Department of Cardiology, Hanzeplein Groningen, The Netherlands.
Charité - Campus Virchow (CVK), Center for Stroke Research, Berlin, Germany.
Department of Nursing, Cyprus University of Technology, Limassol, Cyprus.
Volgograd Medical University, Cardiology Centre, Volgograd, Russian Federation.
Heart Failure Unit, Cardiac Department, Guglielmo da Saliceto Hospital, AUSL, Piacenza, Italy.
Endocrinology, Metabolism and Diabetes Unit, Evgenideion Hospital, University of Athens, Athens, Greece.
Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.
University Paris Diderot, Paris, France; and Department of Anaesthesia and Critical Care, University Hospitals Saint Louis-Lariboisière, Paris, France.
Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK.
Department of Cardiology, Campus Virchow Klinikum, Charite - Universitaetsmedizin Berlin, Berlin, Germany.
Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
Clinic of Endocrinology, Diabetes and Metabolic Diseases, Belgrade University Medical Center, Belgrade, Serbia.
Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.
Department of Cardiology, King's College Hospital, Denmark Hill, London, UK.
National Heart and Lung Institute Imperial College London, London, UK.
Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
Department of Internal Medicine, and Department of Research and Education, General Hospital Murska Sobota, Murska Sobota, Slovenia.
Research Center of the Italian Association of Hospital Cardiologists, Florence, Italy.
University Heart Centre, University Hospital Zurich, Zurich, Switzerland.
British Heart Foundation, Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.


The coexistence of type 2 diabetes mellitus (T2DM) and heart failure (HF), either with reduced (HFrEF) or preserved ejection fraction (HFpEF), is frequent (30-40% of patients) and associated with a higher risk of HF hospitalization, all-cause and cardiovascular (CV) mortality. The most important causes of HF in T2DM are coronary artery disease, arterial hypertension and a direct detrimental effect of T2DM on the myocardium. T2DM is often unrecognized in HF patients, and vice versa, which emphasizes the importance of an active search for both disorders in the clinical practice. There are no specific limitations to HF treatment in T2DM. Subanalyses of trials addressing HF treatment in the general population have shown that all HF therapies are similarly effective regardless of T2DM. Concerning T2DM treatment in HF patients, most guidelines currently recommend metformin as the first-line choice. Sulphonylureas and insulin have been the traditional second- and third-line therapies although their safety in HF is equivocal. Neither glucagon-like preptide-1 (GLP-1) receptor agonists, nor dipeptidyl peptidase-4 (DPP4) inhibitors reduce the risk for HF hospitalization. Indeed, a DPP4 inhibitor, saxagliptin, has been associated with a higher risk of HF hospitalization. Thiazolidinediones (pioglitazone and rosiglitazone) are contraindicated in patients with (or at risk of) HF. In recent trials, sodium-glucose co-transporter-2 (SGLT2) inhibitors, empagliflozin and canagliflozin, have both shown a significant reduction in HF hospitalization in patients with established CV disease or at risk of CV disease. Several ongoing trials should provide an insight into the effectiveness of SGLT2 inhibitors in patients with HFrEF and HFpEF in the absence of T2DM.


Glucose-lowering agents; Heart failure; Heart failure hospitalization; Heart failure treatment; Type 2 diabetes mellitus

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