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Cited by 708Diabetes Treatment and ManagementHeart Failure Treatment and ManagementCardiovascular Function and Risk Factors

The DOI matches its Crossref record; 193 of the 193 references it cites were found in a registry or an index; none of the 257 sources its claims cite is checked for support yet.

Type 2 Diabetes Mellitus and Heart Failure: A Position Statement from the Heart Failure Association of the European Society of Cardiology

Open access
Seferović, Petar M., Petrie, Mark C., Filippatos, Gerasimos S., Anker, Stefan D., Rosano, Giuseppe, Bauersachs, Johann, Paulus, Walter J., Komajda, Michel, Cosentino, Francesco, de Boer, Rudolf A., Farmakis, Dimitrios, Doehner, Wolfram, Lambrinou, Ekaterini, Lopatin, Yuri, Piepoli, Massimo F., Theodorakis, Michael J., Wiggers, Henrik, Lekakis, John, Mebazaa, Alexandre, Mamas, Mamas A., Tschöpe, Carsten, Hoes, Arno W., Seferović, Jelena P., Logue, Jennifer, McDonagh, Theresa, Riley, Jillian P., Milinković, Ivan, Polovina, Marija, van Veldhuisen, Dirk J., Lainscak, Mitja, Maggioni, Aldo P., Ruschitzka, Frank, McMurray, John J.V.·2018·European Journal of Heart Failure
DOI 10.1002/ejhf.1170
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Abstract

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.

Overview

AI snapshot

Written from the paper’s full text.

TL;DR

This Heart Failure Association of the European Society of Cardiology position statement reviews the frequent coexistence of type 2 diabetes mellitus (T2DM) and heart failure (HF), its adverse prognostic impact, and current treatment implications. It concludes that standard HF therapies are similarly effective in patients with and without T2DM, that some glucose-lowering drugs increase HF risk, and that SGLT2 inhibitors reduce HF hospitalization while dedicated HF trials are ongoing.

Key findings

  • T2DM is common in HF: 30–40% of patients overall, around 30% in chronic HF trials irrespective of HFrEF/HFpEF, around 40% in acute HF trials, and 40–45% in hospitalized HF registries. A meta-analysis of 381,725 patients with acute and chronic HF found T2DM independently associated with higher all-cause death (HR 1.28), CV death (HR 1.34), hospitalization (HR 1.35), and all-cause death or hospitalization (HR 1.41).
  • Incident HF is a major complication of T2DM: in 1.9 million patients with T2DM without overt CV disease followed for 5.5 years, incident HF occurred in 14.1%, more frequently than MI or stroke. T2DM was associated with HF incidence rate 30.9 vs. 12.4/1000 person-years (rate ratio 2.5), and in UKPDS HF incidence rose from 2.3 to 11.9/1000 person-years for HbA1c <6% vs. >10%.
  • HF therapies including ACE inhibitors, ARBs, beta-blockers, mineralocorticoid receptor antagonists, sacubitril/valsartan, ivabradine, ICD/CRT-D, CABG, and exercise training were similarly effective in patients with and without T2DM. However, patients with T2DM had double the risk of hyperkalaemia on candesartan, and renal function/potassium monitoring is recommended with ACE inhibitors/ARBs and MRAs.
  • Among glucose-lowering drugs, thiazolidinediones (rosiglitazone, pioglitazone) and saxagliptin increase HF hospitalization (saxagliptin HR 1.27, P=0.007) and are contraindicated in patients with HF or at risk of HF. SGLT2 inhibitors reduced HF hospitalization in CV outcome trials: empagliflozin HR 0.65 and canagliflozin HR 0.67; canagliflozin was associated with higher lower-limb amputation risk (6.3 vs. 3.4 per 1000 patient-years; HR 1.97). GLP-1 receptor agonists and sitagliptin had neutral effects on HF hospitalization.

Methods

  • Design: position statement/clinical consensus document from the Heart Failure Association of the European Society of Cardiology, providing advice and education on clinical management of patients with T2DM and HF.
  • Data: narrative synthesis of population-based studies, registries, randomized clinical trials, and meta-analyses, including tables of T2DM prevalence in HF, mortality risk, antidiabetic drug HF outcomes, and ongoing SGLT2 inhibitor HF trials.
  • Analysis: descriptive review and interpretation of existing evidence; no new primary data collection or formal systematic review/meta-analysis by the authors is reported.

Limitations

  • The paper states that there are no clinical trials of HF treatment that included only patients with T2DM, so available evidence comes from subanalyses of mixed populations; there are also no RCTs in HF for metformin, insulin, sulphonylureas, or GLP-1 receptor agonists, and no accepted definition of diabetic cardiomyopathy.
  • The paper notes marked regional variation in T2DM prevalence among HF patients and states that reasons for this warrant further international studies with shared study design and standardized data collection.
  • Evident from the text: this is a position statement rather than a systematic review, many conclusions rely on observational data and subgroup analyses, and several key trials of SGLT2 inhibitors in HF (e.g., EMPEROR-Reduced, EMPEROR-Preserved, Dapa-HF) were ongoing and not yet available.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1002/ejhf.1170

Cites

193 of 193 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Verification

Claims the paper makes

0 of 257 cited sources checked · 0 supported · 0 flagged

Show all 108 claims

  • It may state two separate claims as one. 41
  • Probably not a substantial claim. 12
51 of 51

  • The paper relies on this without support.

    There is no definition of diabetic cardiomyopathy.

    “There is no definition of diabetic cardiomyopathy, which makes studies of epidemiology, pathophysiology, natural history and associated clinical outcomes challenging.”

  • The paper relies on this without support.

    Hypoglycaemia is a concern in patients with T2DM treated with insulin or sulfonylureas.

    “Hypoglycaemia is a concern in patients with T2DM treated with insulin or sulfonylureas.”

  • The paper relies on this without support.

    Diuretics are usually required to treat the symptoms and signs of fluid overload in patients with HF.

    “Diuretics are usually required to treat the symptoms and signs of fluid overload in patients with HF.”

  • The paper relies on this without support.

    Insulin causes sodium and water retention.

    “insulin, which causes sodium and water retention”

  • The paper relies on this without support.

    Sulphonylureas are insulin secretagogues.

    “sulphonylureas which, as insulin secretagogues”
5 of 5

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Italian prevalence ratio is not threefold

    Minor

    The listed Italian prevalences are 30% in patients with heart failure and 13% in the comparison population. Their ratio is about 2.31, not three.

    Reported 3 · recomputed 2.307692

  • Medicare mortality estimate lies outside its confidence interval

    Minor

    Table 4 gives the White-patient hazard ratio as 1.22, but its stated 95% confidence interval runs from 1.24 to 1.25 and therefore excludes the estimate.

  • HFrEF mortality hazard-ratio range omits EchoCRT

    Minor

    The stated upper end of 2.0 is below EchoCRT's reported all-cause mortality hazard ratio of 2.08.

  • French study shows the opposite aetiology-specific mortality pattern

    Minor

    The text groups the French study with studies finding higher mortality only in non-ischaemic heart failure. Table 6 instead reports a confidence interval above 1 for heart failure secondary to CAD and an interval crossing 1 for other aetiologies.

4 of 4

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Metadata

Authors
Seferović, P. M., Petrie, M. C., Filippatos, G. S., Anker, S. D., Rosano, G., Bauersachs, J., Paulus, W. J., Komajda, M., Cosentino, F., de Boer, R. A., Farmakis, D., Doehner, W., Lambrinou, E., Lopatin, Y., Piepoli, M. F., Theodorakis, M. J., Wiggers, H., Lekakis, J., Mebazaa, A., Mamas, M. A., Tschöpe, C., Hoes, A. W., Seferović, J. P., Logue, J., McDonagh, T., Riley, J. P., Milinković, I., Polovina, M., van Veldhuisen, D. J., Lainscak, M., Maggioni, A. P., Ruschitzka, F., & McMurray, J. J. V.
Affiliations
  • University of Belgrade School of Medicine, Belgrade University Medical Center , Belgrade ,
  • British Heart Foundation (GB)
  • National and Kapodistrian University of Athens (GR)
  • Universitätsmedizin Göttingen (DE)
  • St George's, University of London (GB)
  • Royal Brompton Hospital (GB)
  • Amsterdam Cardiovascular Sciences (NL)
  • Institute of Cardiometabolism and Nutrition (ICAN), Pierre et Marie Curie University, Paris VI, La Pitié-Salpétrière Hospital , Paris ,
  • Karolinska University Hospital (SE)
  • University of Groningen, University Medical Centre Groningen, Department of Cardiology, Hanzeplein Groningen
  • Center for Stroke Research Berlin (DE)
  • Cyprus University of Technology (CY)
  • Volgograd Medical University, Cardiology Centre , Volgograd ,
  • Azienda Unità Sanitaria Locale Piacenza (IT)
  • Aarhus University Hospital (DK)
  • Hôpital Lariboisière (FR)
  • Keele University (GB)
  • Charité – Universitätsmedizin Berlin (DE)
  • University Medical Center Utrecht (NL)
  • University of Belgrade (RS)
  • University of Glasgow (GB)
  • King's College Hospital (GB)
  • Imperial College London (GB)
  • Department of Cardiology, University Medical Center Groningen, University of Groningen , Groningen ,
  • Department of Internal Medicine, and Department of Research and Education, General Hospital Murska Sobota , Murska Sobota ,
  • Research Center of the Italian Association of Hospital Cardiologists , Florence ,
  • University Hospital Zurich (CH)
ORCID
Venue
European Journal of Heart Failure
Publisher
Oxford University Press (OUP)
Published
2018-03-08
Volume
20
Issue
5
Pages
853-872
ISSN
  • 1388-9842 (ISSN-L)
  • 1879-0844
DOI
10.1002/ejhf.1170
OpenAlex
W2793795908
Cited by
708
References
193
Citations by year
2026: 47 · 2025: 63 · 2024: 106 · 2023: 85 · 2022: 88 · 2021: 89 · 2020: 91 · 2019: 103 · 2018: 34
FWCI
63.02
Type
journal article
Language
en
Open access
Licence
academic.oup.com/pages/standard-publication-reuse-rights (vor)
Locations
  • European Journal of Heart Failure (publishedVersion)
  • PubMed (publishedVersion)
  • Pure Amsterdam UMC (publishedVersion, cc-by)
  • St George's Online Research Archive (St George's University of London) (acceptedVersion)
  • Zurich Open Repository and Archive (University of Zurich) (acceptedVersion, other-oa)
  • ENLIGHTEN (Jurnal Bimbingan dan Konseling Islam) (acceptedVersion, cc-by-sa)
  • Research Bank (Australian Catholic University) (submittedVersion)
  • Utrecht University Repository (Utrecht University) (submittedVersion, other-oa)
  • Keele Research Repository (Keele University) (submittedVersion, cc-by)
  • Lancaster EPrints (Lancaster University) (submittedVersion)
  • IRIS Research product catalog (Sapienza University of Rome) (submittedVersion)
  • Amsterdam UMC (VU Amsterdam) - Institutional Repository (submittedVersion, other-oa)
  • University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion)
  • Zurich Open Repository and Archive (University of Zurich) (submittedVersion, other-oa)
  • Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
  • Zurich Open Repository and Archive (University of Zurich)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Failure Treatment and Management
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Function and Risk Factors
Keywords
type 2 diabetes, heart failure, heart failure with reduced ejection fraction, heart failure with preserved ejection fraction, heart failure hospitalization, cardiovascular mortality, metformin, sulfonylureas, insulin, GLP-1 receptor agonists, DPP-4 inhibitors, saxagliptin, thiazolidinediones, SGLT2 inhibitors, empagliflozin, canagliflozin, coronary artery disease, hypertension
MeSH terms
Cardiology, Diabetes Mellitus, Type 2, Europe, Heart Failure, Humans, Societies, Medical, Global Health, Comorbidity, Prevalence, Survival Rate

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