Diabetes and Progression of Heart Failure

Quick Takes

  • Diabetes is strongly associated with progression to overt heart failure.
  • Uncontrolled diabetes is a particularly strong risk factor for heart failure.
  • The risk for heart failure was highest among participants with preclinical stage B heart failure.

Study Questions:

Does diabetes influence the progression of preclinical heart failure (HF) stages to overt HF?


Data from the ARIC (Atherosclerosis Risk In Communities) study, a longitudinal study including 15,792 participants from four US communities (enrolled between 1987–1989), were used for the present analysis. Participants from study visit 5 (2011‐2013), with preclinical HF (stage A [n = 1,551] or stage B [n = 3,223]) comprised the study population. Participants were excluded if they had prevalent HF or missing data on HF or diabetes. For each preclinical HF stage, associations between diabetes or glycemic control (hemoglobin A1c [HbA1c] <7% vs. ≥7%) were examined in association with the progression of HF. Echocardiograms were used to assess indices of cardiac structure and function. The primary outcome of clinical HF was defined as a new diagnosis of definite or probable acute decompensated HF (clear evidence from symptoms, signs, imaging, or treatment of an acute exacerbation; worsening or new onset of symptoms; or other decompensated circulatory state) or chronic stable HF (evidence of compensated HF signs and symptoms controlled by therapy with no evidence of therapy augmentation or symptom worsening during the hospitalization).


A total of 4,774 participants were included in the present analysis (mean age 75.4 ± 5.1 years, 58% women, 20% Black), of which 1,454 (30%) had diabetes, 1,551 (32.5%) had stage A HF, and 3,223 (67.5%) had stage B HF. There were 470 HF events during 8.6 years of follow-up. In both preclinical HF stages, individuals with diabetes were more likely to be Black, use blood pressure or lipid-lowering medication, have higher levels of low-density lipoprotein (LDL) cholesterol or triglycerides, and have lower levels of high-density lipoprotein (HDL) cholesterol.

In stage A, individuals with diabetes were additionally more likely to be women, to use alcohol, and to have a lower systolic blood pressure than those without diabetes. Among individuals in stage B, those with diabetes were also more likely to have a lower estimated glomerular filtration rate. Stage B participants with HbA1C ≥7% experienced clinical HF at a younger age than those with controlled diabetes or without diabetes (mean age 80 years vs. 83 years vs. 82 years; p < 0.001). HbA1C ≥7% was more strongly associated with HF in stage B (hazard ratio [HR], 1.83; 95% confidence interval [CI], 1.33-2.51) compared with stage A (HR, 1.52; 95% CI, 0.53-4.38). In cross-categories of preclinical HF stage and HbA1c, participants with stage B and HbA1c ≥7% had an increased risk of HF progression compared with those with stage A without diabetes (HR, 7.56; 95% CI, 4.68-12.20).


The investigators concluded that among older adults with preclinical HF stages, uncontrolled diabetes was associated with a substantial risk of HF progression. These data suggest that targeting diabetes early in the HF process is critical.


These data support the need to prevent diabetes and control glucose among those with diabetes to reduce the risk for HF. As the authors suggest, further investigation is warranted to understand the possible benefits of therapies such as sodium-glucose cotransporter 2 (SGLT2) inhibitors in patients with preclinical HF, particularly those who meet the definition of stage B HF.

Clinical Topics: Diabetes and Cardiometabolic Disease, Dyslipidemia, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Hypertriglyceridemia, Lipid Metabolism, Nonstatins, Acute Heart Failure, Echocardiography/Ultrasound

Keywords: Atherosclerosis, Blood Pressure, Cholesterol, HDL, Cholesterol, LDL, Diabetes Mellitus, Echocardiography, Geriatrics, Glomerular Filtration Rate, Glucose, Glycated Hemoglobin A, Glycemic Control, Heart Failure, Primary Prevention, Sodium-Glucose Transporter 2 Inhibitors, Triglycerides

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