Heart Failure: The Most Important, Preventable, and Treatable Cardiovascular Complication of Type 2 Diabetes

Concerns about cardiovascular disease in type 2 diabetes have traditionally focused on atherosclerotic vasculo-occlusive events, such as myocardial infarction, stroke, and limb ischemia. However, one of the earliest, most common, and most serious cardiovascular disorders in patients with diabetes is heart failure (1). Following its onset, patients experience a striking deterioration in their clinical course, which is marked by frequent hospitalizations and eventually death. Many sudden deaths in diabetes are related to underlying ventricular dysfunction rather than a new ischemic event. As effective treatments for heart failure have emerged, the risk of sudden death has declined, even in the absence of an implantable cardioverter-defibrillator (2). Heart failure and diabetes are linked pathophysiologically. Type 2 diabetes and heart failure are each characterized by insulin resistance and are accompanied by the activation of neurohormonal systems (norepinephrine, angiotensin II, aldosterone, and neprilysin) (3). The two disorders overlap; diabetes is present in 35–45% of patients with chronic heart failure, whether they have a reduced or preserved ejection fraction. A similar prevalence of diabetes in acute heart failure is reported in this issue of Diabetes Care by van den Berge et al. (4). The interplay between diabetes and heart failure is particularly striking among those with heart failure and preserved ejection fraction, who typically have features of metabolic syndrome. As noted by Sandesara et al. (5) in this issue, the presence of diabetes markedly increases the risk of morbidity and mortality of patients with heart failure and preserved ejection fraction, particularly if the microvascular complications of diabetes are also present. There exists a relationship between the severity of type 2 diabetes and the risk of heart failure, but this …