Treatment of Diabetes in People with Heart Failure

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

Jonathan G. Howlett MD, FRCPC, FACC, FSCAI John C. MacFadyen MD, FRCPC

  • Key Messages
  • Recommendations
  • Figures
  • Highlights
  • Full Text
  • References

Key Messages

  • Heart failure is still under-recognized and misdiagnosed. This has significant clinical implications as the prognosis of untreated or undertreated heart failure is poor, and yet very effective proven therapies are widely available to most physicians.
  • Diabetes can cause heart failure independently of ischemic heart disease by causing a diabetic cardiomyopathy that may manifest in the setting of normal or reduced left ventricular ejection fraction. The incidence of heart failure is 2- to 4-fold higher in people with diabetes compared to those without and, when present, occurs at an earlier age.
  • Even though heart failure in people with diabetes should be treated similarly to heart failure in those without diabetes, they are less likely to receive appropriate therapies. The presence of diabetes should not affect the decision for treatment of heart failure.
  • Comorbidities, such as renal dysfunction and propensity for hyperkalemia, are more prevalent in people with diabetes and may influence heart failure drug doses and monitoring of therapy but not therapeutic targets.

Highlights of Revisions

  • The chapter now includes an expanded discussion on beta blocker use in people with diabetes and heart failure.


  1. 1.Individuals with diabetes and heart failure should receive the same heart failure therapies as those identified in the evidence-based Canadian Cardiovascular Society heart failure recommendations ( [Grade D, Consensus].
  2. 2.In people with diabetes and heart failure and an estimated glomerular filtration rate <60 mL/min, or if combined renin-angiotensin-aldosterone blockade is employed:
    • Starting doses of angiotensin-converting enzyme inhibitors or angiotensin receptor II antagonists (angiotensin receptor blockers) should be halved [Grade D, Consensus].
    • Serum electrolytes and creatinine, blood pressure and body weight, as well as heart failure symptoms and signs, should be monitored within 7–10 days of any initiation or titration of therapy [Grade D, Consensus].
    • Dose-up titration should be more gradual (with monitoring of blood pressure, serum potassium and creatinine) [Grade D, Consensus].
    • The target drug doses should be the same as those identified in the evidence-based Canadian Cardiovascular Society recommendations on heart failure (, if well tolerated [Grade D, Consensus].
  3. 3.Beta blockers should be prescribed when indicated for systolic heart failure, as they provide similar benefits in people with diabetes compared with people without diabetes [Grade B, Level 2 (1,2)].


  1. Bell DS, Lukas MA, Holdbrook FK, et al. The effect of carvedilol on mortality risk in heart failure patients with diabetes: results of a meta-analysis. Curr Med Res Opin 2006;22:287-96.
  2. Haas SJ, Vos T, Gilbert RE, et al. Are beta-blockers as efficacious in patients with diabetes mellitus as in patients without diabetes mellitus who have chronic heart failure? A meta-analysis of large-scale clinical trials. Am Heart J 2003;146: 848-53.


Reproduced with permission from Canadian Journal of Diabetes © 2013 Canadian Diabetes Association. To cite this article, please refer to For citation.

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