Type 2 diabetes mellitus and heart failure: a scientific statement from the American Heart Association and the Heart Failure Society of America: this statement does not represent an update of the 2017 ACC/AHA/HFSA heart failure guideline update

Dunlay, Shannon M.; Givertz, Michael M.; Aguilar, David; Allen, Larry A.; Chan, Michael; Desai, Akshay S.; Deswal, Anita; Dickson, Victoria Vaughan; Kosiborod, Mikhail N.; Lekavich, Carolyn L.; McCoy, Rozalina G.; Mentz, Robert J.; Piña, Ileana L.; On behalf of the American Heart Association Heart Failure and Transplantation Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; and the Heart Failure Society of America

doi:10.1161/cir.0000000000000691

Cited by 649Heart Failure Treatment and ManagementDiabetes Treatment and ManagementCardiovascular Function and Risk Factors

Type 2 diabetes mellitus and heart failure: a scientific statement from the American Heart Association and the Heart Failure Society of America: this statement does not represent an update of the 2017 ACC/AHA/HFSA heart failure guideline update

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Dunlay, Shannon M., Givertz, Michael M., Aguilar, David, Allen, Larry A., Chan, Michael, Desai, Akshay S., Deswal, Anita, Dickson, Victoria Vaughan +6 more·2019·Circulation

DOI 10.1161/cir.0000000000000691

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Abstract

Type 2 diabetes mellitus is a risk factor for incident heart failure and increases the risk of morbidity and mortality in patients with established disease. Secular trends in the prevalence of diabetes mellitus and heart failure forecast a growing burden of disease and underscore the need for effective therapeutic strategies. Recent clinical trials have demonstrated the shared pathophysiology between diabetes mellitus and heart failure, the synergistic effect of managing both conditions, and the potential for diabetes mellitus therapies to modulate the risk of heart failure outcomes. This scientific statement on diabetes mellitus and heart failure summarizes the epidemiology, pathophysiology, and impact of diabetes mellitus and its control on outcomes in heart failure; reviews the approach to pharmacological therapy and lifestyle modification in patients with diabetes mellitus and heart failure; highlights the value of multidisciplinary interventions to improve clinical outcomes in this population; and outlines priorities for future research.

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Treatment of obesity-related HFpEF with the GLP-1-based therapies semaglutide and tirzepatide achieves improvements in HF patient-reported health status and quality of life, functional capacity as measured by the 6-minute walk distance (6MWD), and freedom from worsening HF events, including HF hospitalizations.
“Treatment of obesity-related HFpEF with the GLP-1–based therapies semaglutide and tirzepatide achieves improvements in HF patient-reported health status and quality of life, functional capacity as measured by the 6-minute walk distance (6MWD), and freedom from worsening HF events, including HF hospitalizations.1,3,17,18”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [17]
The Clinical Considerations passage (page not specified) says there were no data to guide GLP-1 receptor agonist use in HFpEF and that large trials showed no reduction in HF hospitalization. The paper therefore does not report the claimed improvements with semaglutide and tirzepatide in obesity-related HFpEF; its assessment of the evidence available at the time is contrary to that attribution. (LLM, conf=0.90)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measured
Support from an interdisciplinary team can be particularly effective for facilitating lifestyle modification and weight loss.
“Support from an interdisciplinary team that may include nutritionists, kinesiologists, pharmacists, and mental health specialists, in addition to obesity medicine specialists, can be particularly effective for facilitating lifestyle modification and weight loss.17,18”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [17]
The Team-Based Care section (p. e312) endorses coordinated care that includes pharmacists and dietitians, and the Lifestyle Management section recommends lifestyle care for patients with diabetes and heart failure. The paper does not establish that interdisciplinary teams are particularly effective at producing weight loss, nor does it specify the full team listed in the citing sentence. (LLM, conf=0.84)
Experimental — accuracy not yet measured
Through these mechanisms, adverse SDOH lead to CKM risk factor development.
“Through these mechanisms, adverse SDOH lead to CKM risk factor development.16–20”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [17]
The Clinical Statements and Guidelines section says community and societal factors influence behavioral decisions and clinical outcomes in people with diabetes or heart failure. It does not say adverse social determinants cause the development of CKM risk factors; its discussion concerns people with existing conditions. (LLM, conf=0.76)
Experimental — accuracy not yet measured
Among patients with T2D and ASCVD, both SGLT2i and GLP-1-based therapy reduce MACE and CVD mortality, with SGLT2i having a principal impact on HF events and GLP-1-based therapy on atherosclerotic events.
“Both agents reduce MACE and CVD mortality, with SGLT2i having a principal impact on HF events and GLP-1–based therapy on atherosclerotic events.3,16,17”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [17]
The SGLT-2 Inhibitors section reports reductions in major cardiovascular events, cardiovascular death, and HF hospitalization with empagliflozin in patients with diabetes and cardiovascular disease. The GLP-1 Receptor Agonists section reports reductions in major cardiovascular events with liraglutide and semaglutide, cardiovascular death with liraglutide, and no HF-hospitalization benefit across four trials. The claim overgeneralizes these findings to both therapy classes: the statement says GLP-1 cardiovascular benefits are mostly beneficial but variable, and does not report a cardiovascular-mortality reduction for the class as a whole. (LLM, conf=0.87)
Experimental — accuracy not yet measured
Despite the lack of CVD event reduction, lifestyle modification with behavior change, healthy dietary modification, and physical activity, resulting in weight loss of 5% to 10%, causes improvements in CKM risk factors including remission of T2D, with the CKM benefits of lifestyle modification observed across a range of populations and geographic settings.
“Despite the lack of CVD event reduction, lifestyle modification with behavior change, healthy dietary modification, and physical activity, resulting in weight loss of 5% to 10%, causes improvements in CKM risk factors including remission of T2D,17,18 with the CKM benefits of lifestyle modification observed across a range of populations and geographic settings.19”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [17]
Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measured

SGLT2i appear to primarily reduce incident and worsening HF.
“SGLT2i appear to primarily reduce incident and worsening HF.17,37–44”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [17]
The Clinical Considerations section reports reduced heart-failure hospitalization in patients with diabetes, both with and without heart failure at baseline. That supports a preventive benefit and suggests a benefit in established heart failure, but the statement does not establish a general reduction in all incident or worsening heart failure; it says trials of treatment in patients without diabetes were still pending. (LLM, conf=0.84)
Experimental — accuracy not yet measured
These analyses suggest that SGLT2i therapy is not cost-effective at current drug prices (incremental cost-effectiveness ratio ≥$120,000 per QALY gained), but these analyses pooled individuals with and without diabetes, and there may be additional cardiovascular and kidney benefits in individuals with diabetes.
“These analyses suggest that SGLT2i therapy is not cost-effective at current drug prices (incremental cost-effectiveness ratio ≥$120 000 per QALY gained), but these analyses pooled individuals with and without diabetes, and there may be additional cardiovascular and kidney benefits in individuals with diabetes.”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [17]
Split into 2 atoms — 0 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 1 unverifiable. Expand the claim to see per-atom verdicts.
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MASLD is the pathophysiologic result of ectopic fat deposition, inflammation, and insulin resistance, which are central to CKM syndrome.
“MASLD is the pathophysiologic result of ectopic fat deposition, inflammation, and insulin resistance, which are central to CKM syndrome.16,17”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [17]
The PATHOPHYSIOLOGY OF DM AND HF section discusses insulin resistance, lipid accumulation, and inflammation in diabetes-related heart disease. It does not establish that these processes cause MASLD or describe them as central to CKM syndrome; those disease-specific parts of the claim are unsupported by this source. (LLM, conf=0.82)
Experimental — accuracy not yet measured
In patients with T2D and ASCVD, SGLT2i and GLP-1-based therapy significantly reduces the risk of MACE and cardiovascular mortality, promotes weight loss, and reduces progression of kidney disease.
“In patients with T2D and ASCVD, SGLT2i and GLP-1–based therapy significantly reduces the risk of MACE and cardiovascular mortality, promotes weight loss,34 and reduces progression of kidney disease”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [17]
Structured weight loss counseling can increase motivation to lose weight and engagement in weight loss efforts.
“The provision of structured weight loss counseling can increase motivation to lose weight and engagement in weight loss efforts.17”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [17]
The Lifestyle Management section discusses intentional weight loss and exercise capacity in patients with heart failure, while the Clinical Statements and Guidelines section discusses a broader self-care intervention. Neither passage addresses whether structured weight-loss counseling increases motivation or engagement in weight-loss efforts (searched: structured weight-loss counseling, motivation, behavioral intervention). Page numbers were not available in our copy. (LLM, conf=0.72)
Experimental — accuracy not yet measured
MBS is generally safe.
“While MBS is generally safe,17 the surgical and”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [17]
The Lifestyle Management passage discusses diet and exercise for weight loss in patients with heart failure, not the safety of metabolic and bariatric surgery (MBS). Searches of our copy for MBS, bariatric surgery, and surgical weight loss found no passage addressing its safety. (LLM, conf=0.75)
Experimental — accuracy not yet measured
Bupropion/naltrexone, phentermine/topiramate, and orlistat have shown efficacy in improving glycemia, and phentermine/topiramate and orlistat in reducing BP.
“Bupropion/naltrexone, phentermine/topiramate, and orlistat have all shown efficacy in improving glycemia, and the latter 2, in reducing BP.”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [17]
The References section (page not provided) mentions an orlistat pilot study in patients with heart failure, but gives no glycemia or blood-pressure results. Searches for bupropion, phentermine, and orlistat with glycemia and blood-pressure terms found no passage supporting the claimed effects of these drugs. (LLM, conf=0.76)
Experimental — accuracy not yet measured
Recent evidence suggests that counseling related to risk reduction for CKM syndrome in high-risk women should start in the prenatal period and continue until the completion of postpartum follow-up visits for the mother and baby.
“However, recent evidence suggests that counseling related to risk reduction for CKM syndrome in high-risk women should start in the prenatal period and continue until the completion of postpartum follow-up visits for the mother and baby.16–18”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [17]
The Clinical Considerations passages address counseling for patients with heart failure and diabetes, but not counseling high-risk women during pregnancy or postpartum follow-up. Searches for prenatal counseling and postpartum visits found no passage addressing the claimed timing or CKM-syndrome risk reduction. (LLM, conf=0.76)
Experimental — accuracy not yet measured
Clinical trials have indicated a lack of heterogeneity in the effects of each class of these cardioprotective glucose-lowering therapies between those who were and were not taking the other agent.
“Clinical trials have indicated a lack of heterogeneity in the effects of each class of these cardioprotective glucose-lowering therapies between those who were and were not taking the other agent.17–19,21”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [17]
The GLP-1 Receptor Agonists and SGLT-2 Inhibitors sections discuss cardiovascular trial outcomes for each class, but the passages found do not compare either class’s effects between patients taking and not taking the other. Searches for heterogeneity, interaction, concomitant use, and baseline use did not locate that comparison in our copy. (LLM, conf=0.73)
Experimental — accuracy not yet measured
CAC is associated with increased cardiovascular risk in patients with CKD and requires aggressive modification of this risk, and interpretation needs to be individualized in patients with CKD treated with dialysis or transplantation.
“Lastly, CAC is associated with increased cardiovascular risk in patients with CKD and requires aggressive modification of this risk,17 and interpretation needs to be individualized in patients with CKD treated with dialysis or transplantation.”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [17]
The 'Use of HF Medications With CKD' section discusses treatment risks in patients with diabetes and heart failure, but not CAC as a cardiovascular risk marker or aggressive modification of CAC-associated risk. Searches for CAC, coronary artery calcification, and dialysis or transplantation yielded no passage supporting the attributed claim. (LLM, conf=0.76)
Experimental — accuracy not yet measured
Prior studies performed using a US health care sector perspective and a lifetime analytic horizon noted that SGLT2i therapy was unlikely to be cost-effective for HFpEF, but that the incremental cost-effectiveness ratio was sensitive to the effect on mortality.
“Prior studies performed using a US health care sector perspective and a lifetime analytic horizon noted that SGLT2i therapy was unlikely to be cost-effective for HFpEF, but that the incremental cost-effectiveness ratio was sensitive to the effect on mortality.”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [17]
Split into 2 atoms — 0 confirmed, 0 partially supported, 0 disputed, 0 misattributed, 2 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measured
Two high-quality simulation model-based cost-effectiveness analyses evaluated the economic value of adding SGLT2i therapy to prior GDMT in adults with symptomatic HFpEF, but neither study reported subgroup analyses by diabetes status.
“Two high-quality simulation model–based cost-effectiveness analyses evaluated the economic value of adding SGLT2i therapy to prior GDMT in adults with symptomatic HFpEF, but neither study reported subgroup analyses by diabetes status.17,18”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [17]
The SGLT-2 Inhibitors section (p. e306) describes HFpEF outcomes trials as still underway, not two completed cost-effectiveness analyses. Searches for cost-effectiveness, simulation models, and diabetes-status subgroup analyses found no passage addressing the claimed economic studies. (LLM, conf=0.76)
Experimental — accuracy not yet measured
Lower eGFR, higher UACR, and higher CKD stages are associated with VTE development and worse outcomes.
“a lower eGFR, higher UACR, and higher CKD stages are associated with VTE development and worse outcomes.16–20”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [17]
The sections on HF medications with CKD and glucose-lowering medications with CKD discuss eGFR, albuminuria, renal outcomes, and treatment risks, but do not address VTE. Searches for VTE, venous thromboembolism, and the claimed CKD measures yielded no passage linking them to VTE development or outcomes. (LLM, conf=0.76)
Experimental — accuracy not yet measured
Transitional clinics for postpartum care after APOs have been studied in local, small trials.
“Transitional clinics for postpartum care after APOs (hypertensive disorders of pregnancy, GDM), including integration of maternal care at pediatric visits, patient navigation, BP monitoring, and use of electronic nudges for timely transition to primary care have been studied in local, small trials.17”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [17]
The Team-Based Care section (p. e312) discusses coordinated chronic-disease care, and the Clinical Statements and Guidelines section describes a pilot intervention for heart failure and diabetes self-care. Neither addresses postpartum transitional clinics or small trials after adverse pregnancy outcomes. Searches for postpartum care, gestational diabetes, pediatric visits, patient navigation, and electronic nudges found no passage supporting the claim. (LLM, conf=0.76)
Experimental — accuracy not yet measured
Poor psychological health (eg, depression, anxiety) is a risk enhancer for CKM syndrome.
“Poor psychological health (eg, depression, anxiety)17”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [17]
The 'DM as a Risk Factor for HF' section discusses diabetes, glycemic control, and heart-failure risk, not psychological health as a risk enhancer for CKM syndrome. Searches for depression, anxiety, psychological health, and CKM syndrome found no passage in our copy addressing that claim. (LLM, conf=0.74)
Experimental — accuracy not yet measured
Cutoffs provided for natriuretic peptide levels may have lower specificity, especially in older patients or in patients with AF or CKD.
“Cutoffs provided for natriuretic peptide levels may have lower specificity, especially in older patients or in patients with AF or CKD.”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [17]
The statement mentions higher NT-proBNP as a heart-failure risk marker (Clinical Statements and Guidelines; page not provided), but does not discuss the specificity of diagnostic natriuretic-peptide cutoffs. Searches for BNP and NT-proBNP cutoffs, age, atrial fibrillation, and CKD found no passage addressing the claimed reduction in specificity. (LLM, conf=0.74)
Experimental — accuracy not yet measured

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[89]89. Hayward RA, Reaven PD, Wiitala WL, Bahn GD, Reda DJ, Ge L, McCarren M, Duckworth WC, Emanuele NV; for the VADT Investigators. Follow-up of glycemic control and cardiovascular outcomes in type 2 dia- betes [published correction appears in N Engl J Med. 2015;373:198].
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WBC Count Predicts Heart Failure in Diabetes and Coronary Artery Disease Patients: A Retrospective Cohort Study
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“Weight loss, calorie restriction, and pharmacological drugs (i.e. glucose-lowering, hypolipidemic, and insulinsensitizing drugs) remain the available options to manage HF in obese individuals (Dunlay et al., 2019; Jindal et al., 2013).”
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Asymptomatic Diabetic Cardiomyopathy: an Underrecognized Entity in Type 2 Diabetes
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Erythropoietic Response After Intravenous Iron in Patients with Heart Failure and Reduced Ejection Fraction with and Without Background Treatment with Sodium–Glucose Cotransporter 2 Inhibitors
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Epidemiology of heart failure and long-term follow-up outcomes in a north-African population: Results from the NAtional TUnisian REgistry of Heart Failure (NATURE-HF)
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Type 2 diabetes mellitus and heart failure, a scientific statement from the American Heart Association and Heart Failure Society of America
Dunlay, S. M., Givertz, M. M., Aguilar, D., Allen, L. A., Chan, M., Desai, A. S., Deswal, A., Dickson, V. V., Kosiborod, M. N., Lekavich, C. L., et al. (2019) · Journal of Cardiac Failure · doi:10.1016/j.cardfail.2019.05.007 · Cited by 145 · see citing works
Self-citation
American Heart Association: Type 2 diabetes mellitus a risk factor for heart failure
Verdon, D. R. (2019)
AHA: Type 2 diabetes mellitus a risk factor for heart failure
Verdon, D. R. (2019)
Improving outcomes in patients with type 2 diabetes mellitus and chronic heart failure: New hope
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Diabetes Management in Patients with Heart Failure
Shen, J., & Greenberg, B. (2021) · Diabetes & Metabolism Journal · doi:10.4093/dmj.2020.0296 · Cited by 21 · see citing works

Authors: Dunlay, S. M., Givertz, M. M., Aguilar, D., Allen, L. A., Chan, M., Desai, A. S., Deswal, A., Dickson, V. V., Kosiborod, M. N., Lekavich, C. L., McCoy, R. G., Mentz, R. J., Piña, I. L., & On behalf of the American Heart Association Heart Failure and Transplantation Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; and the Heart Failure Society of America
Affiliations: Victoria University of Wellington (NZ)
ORCID: Dunlay, Shannon M.
Givertz, Michael M.
Aguilar, David
Allen, Larry A.
Chan, Michael
Desai, Akshay S.
Deswal, Anita
Dickson, Victoria Vaughan
Kosiborod, Mikhail N.
Lekavich, Carolyn L.
McCoy, Rozalina G.
Mentz, Robert J.
Piña, Ileana L.
Venue: Circulation
Publisher: Ovid Technologies (Wolters Kluwer Health)
Published: 2019-08-13
Volume: 140
Issue: 7
Pages: e294-e324
ISSN: 0009-7322 (ISSN-L)
1524-4539
DOI: 10.1161/cir.0000000000000691
OpenAlex: W2968633786
Semantic Scholar: d6c41ad2da811fe5460dc8dc4cb151316b250518
Cited by: 639
References: 278
Citations by year: 2026: 71 · 2025: 92 · 2024: 114 · 2023: 111 · 2022: 98 · 2021: 85 · 2020: 56 · 2019: 11
FWCI: 11.33
Type: journal article
Language: en
Update notices: correction (2019-09-16)
Open access: bronze
doi.org
Locations: Circulation (publishedVersion)
PubMed (publishedVersion)
Topics: Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Failure Treatment and Management
Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Function and Risk Factors
Keywords: type 2 diabetes, heart failure, comorbidities, pathophysiology, pharmacotherapy, lifestyle modification, multidisciplinary intervention, diabetes management, heart failure outcomes, morbidity and mortality
MeSH terms: American Heart Association, Cardiology, Diabetes Mellitus, Type 2, Heart Failure, Humans, Societies, Medical, United States, Practice Guidelines as Topic

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Type 2 diabetes mellitus and heart failure: a scientific statement from the American Heart Association and the Heart Failure Society of America: this statement does not represent an update of the 2017 ACC/AHA/HFSA heart failure guideline update

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