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

Petar Seferovic
Mark C. Petrie
Gerasimos S. Filippatos
Stefan D. Anker
Giuseppe Rosano
J. Bauersachs
Walter J. Paulus
Michel Komajda
Francesco Cosentino
Rudolf A. de Boer
Dimitrios Farmakis
Wolfram Doehner
Ekaterini Lambrinou
Yuri Lopatin
Massimo F. Piepoli
Michael J. Theodorakis
Henrik Wiggers
John Lekakis
Alexandre Mebazaa
Mamas A. Mamas
Carsten Tschöpe
Arno W. Hoes
Jelena P. Seferovic
Jennifer Logue
Theresa McDonagh
Jillian P. Riley
Ivan Milinković
Marija Polovina
Dirk J. van Veldhuisen
Mitja Lainscak
Aldo P. Maggioni
Frank Ruschitzka
John McMurray


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.