Diabetes Mellitus and Heart Failure With Preserved Ejection Fraction: Role of Obesity

Heart failure with preserved ejection fraction is a growing epidemic and accounts for half of all patients with heart failure. Increasing prevalence, morbidity, and clinical inertia have spurred a rethinking of the pathophysiology of heart failure with preserved ejection fraction. Unlike heart failure with reduced ejection fraction, heart failure with preserved ejection fraction has distinct clinical phenotypes. The obese-diabetic phenotype is the most often encountered phenotype in clinical practice and shares the greatest burden of morbidity and mortality. Left ventricular remodeling plays a major role in its pathophysiology. Understanding the interplay of obesity, diabetes mellitus, and inflammation in the pathophysiology of left ventricular remodeling may help in the discovery of new therapeutic targets to improve clinical outcomes in heart failure with preserved ejection fraction. Anti-diabetic agents like glucagon-like-peptide 1 analogs and sodium-glucose co-transporter 2 are promising therapeutic modalities for the obese-diabetic phenotype of heart failure with preserved ejection fraction and aggressive weight loss via lifestyle or bariatric surgery is still key to reverse adverse left ventricular remodeling. This review focuses on the obese-diabetic phenotype of heart failure with preserved ejection fraction highlighting the interaction between obesity, diabetes, and coronary microvascular dysfunction in the development and progression of left ventricular remodeling. Recent therapeutic advances are reviewed.