Why Heart Failure Is an Underappreciated Complication of Diabetes

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Introduction 

This article is entirely based on the consensus report by the American Diabetes Association titled "Heart Failure: An Underappreciated Complication of Diabetes. A Consensus Report of the American Diabetes Association," published in Diabetes Care in 2022. The report was prepared by a multidisciplinary team of leading experts in endocrinology, cardiology, and internal medicine, with participation from the American College of Cardiology and prestigious institutions including the University of Michigan, Massachusetts General Hospital, Cleveland Clinic, Duke University, University of Virginia, and others. The expert team ensures a balanced, evidence-based, and up-to-date perspective reflecting the latest advances in medical science.

Here, you’ll find five practical questions and answers based entirely on the report, specifically tailored for people living with diabetes and heart failure. The questions have been selected to clarify real-world problems and offer solutions that patients typically face.

"Heart failure may be the first and most overlooked sign of cardiovascular disease in people with diabetes—early detection is a chance at a new life."

Experts Speak

Heart failure (HF) is emerging as one of the most common and underrecognized complications of diabetes, particularly in light of the dramatic global rise in type 2 diabetes. In recent years, a new consensus has taken shape among leading diabetes and cardiology specialists: diabetes doesn’t just increase the risk of cardiovascular disease—heart failure is often the very first manifestation of cardiovascular issues in people with diabetes.

This makes early detection, prevention, and modern treatment of HF critically important—not just for those with diabetes, but also for their families and healthcare providers.

Below are five key expert opinions and scientific conclusions from the American Diabetes Association and American College of Cardiology’s consensus report. Each section includes a guiding question or headline, explanation, and direct quotes from the source to provide helpful, evidence-based, and practical information for patients, caregivers, and healthcare professionals.

1. How common and dangerous is heart failure in people with diabetes?

Explanation: Diabetes increases the risk of developing HF by two to four times. Alarmingly, HF can occur even in individuals without high blood pressure, coronary artery disease, or other classic risk factors. Both the incidence and mortality rates are higher in people with diabetes, and HF is often the first sign of cardiovascular disease. 

Quote:

“Heart failure (HF) has been recognized as a common complication of diabetes, with a prevalence of up to 22% in individuals with diabetes and increasing incidence rates... HF may also be the first presentation of cardiovascular disease in many individuals with diabetes.”

“Results of several longitudinal observational studies... have shown a two- to four-fold increased risk of HF among men and women with diabetes or prediabetes compared with those without... HF was the most common first presentation of cardiovascular disease in individuals with T2D.”

2. What are the main risk factors for developing HF with diabetes? What can be managed?

Explanation: Duration of diabetes, poor blood sugar control, high blood pressure, abnormal lipid levels, overweight, kidney problems, and ischemic heart disease are among the major risk factors. These should be routinely monitored and managed during clinical visits. 

Quote:

“The risk factors for HF in both T2D and T1D include diabetes duration, poor glycemic control, uncontrolled hypertension, hyperlipidemia, higher BMI, microalbuminuria, renal dysfunction, ischemic heart disease, and peripheral artery disease... Current trends suggest control of modifiable risk factors is poor in those with diabetes, emphasizing the importance of careful review of each during clinical visits.”

3. Are there specific mechanisms—how does diabetes lead to heart muscle damage?

Explanation: Diabetic cardiomyopathy is now recognized as a distinct condition. Beyond classic atherosclerotic mechanisms, chronic inflammation, oxidative stress, altered cellular metabolism, and fat buildup in the heart muscle play major roles. These processes lead to pathological remodeling, fibrosis, and ultimately impaired heart function. 

Quote:

“The pathophysiology of HF in individuals with diabetes is complex... ‘Diabetic cardiomyopathy,’ defined as ventricular dysfunction in the absence of coronary artery disease (CAD) and hypertension, is an increasingly recognized entity. Several potential mechanisms contributing... include renin-angiotensin-aldosterone system (RAAS) activation, mitochondrial dysfunction, oxidative stress, inflammation, changes in intracellular calcium homeostasis, increased formation of advanced glycation end products, and myocardial energy substrate alterations including increased free fatty acid utilization...”

4. What do experts recommend for early detection of HF in people with diabetes?

Explanation: Annual testing of natriuretic peptides (BNP or NT-proBNP) and high-sensitivity troponin is recommended to detect early or developing heart failure. This allows timely use of proven preventive treatments. 

Quote:

“Among individuals with diabetes, measurement of a natriuretic peptide or high-sensitivity cardiac troponin is recommended on at least a yearly basis to identify the earliest HF stages and implement strategies to prevent transition to symptomatic HF... Measurement of a natriuretic peptide or high-sensitivity cardiac troponin on at least a yearly basis is recommended to identify the presence of stage B HF and to determine risk for progression to symptomatic HF.”

5. What are the current strategies for treatment and prevention of HF in people with diabetes?

Explanation: Treatment is multifaceted: managing blood glucose, blood pressure, and cholesterol, along with medications proven to work—ACE inhibitors, angiotensin receptor blockers, mineralocorticoid receptor antagonists, beta-blockers, and especially SGLT2 inhibitors. SGLT2 inhibitors are now recommended both to prevent and treat HF in people with diabetes, regardless of whether HF has already been diagnosed or if they’re simply at high risk. 

Quote:

“For those individuals with diabetes with symptomatic HFrEF, barring contraindication, the expected components of guideline-directed medical therapy include: 1) angiotensin receptor/neprilysin inhibitor (ARNI) or ACEi/ARB, 2) evidenced-based β-blocker, 3) MRA, and 4) SGLT2i. While the GDMT options for HFpEF are less well-defined, SGLT2i are now also recommended in HFpEF... SGLT2i as a clinically proven, effective therapy for HFpEF.”

Q&A Section

1. Can I have heart failure even if I don’t have classic heart disease like a heart attack or high blood pressure? 

Answer: Yes, it’s possible. In people with diabetes, heart failure can occur even without previous high blood pressure, heart attack, coronary artery disease, or valve disease. This is because diabetes on its own damages the heart through complex mechanisms, even when other risk factors are not present.

“Data also suggest HF may develop in individuals with diabetes even in the absence of hypertension, coronary heart disease, or valvular heart disease...”

2. What symptoms should I watch for to catch heart failure early? 

Answer: Common symptoms include shortness of breath during physical activity, waking up at night gasping for air (paroxysmal nocturnal dyspnea), rapid weight gain, swelling of the ankles and legs, fatigue, and nighttime swelling. In more advanced cases, symptoms can include chronic exhaustion and difficulty with daily tasks.

“Common symptoms and signs... typically reflect fluid retention and congestion, or those of low cardiac output. Generally, individuals with HFpEF present with symptoms similar to those of individuals with HFrEF, most commonly exertional dyspnea, fatigue, and edema.”

3. Are there specific tests I should get as a person with diabetes and heart failure? 

Answer: Yes. Experts recommend annual blood tests for natriuretic peptides (BNP or NT-proBNP) and/or high-sensitivity troponin. If heart failure is suspected, other routine tests are also advised: complete blood count, urinalysis, electrolytes, kidney and liver function, ECG, and echocardiography.

“Among individuals with diabetes, measurement of a natriuretic peptide or high-sensitivity cardiac troponin is recommended on at least a yearly basis... Recommended laboratory evaluations for patients with HF include natriuretic peptide, complete blood count, urinalysis, serum electrolytes, blood urea nitrogen, serum creatinine, glucose, fasting lipid profile, liver function, and thyroid-stimulating hormone. A chest X-ray and 12-lead electrocardiogram are also recommended.”

4. What lifestyle changes can realistically help improve my condition? Answer: The most important changes include:

• Physical activity – Regular, individually tailored exercise improves heart function and overall health.

• Weight control – Reducing body weight, especially waist circumference, lowers risk and improves quality of life.

• Limiting alcohol and quitting smoking – These reduce additional health risks.

• Balanced diet – Personalized eating plans focusing on more vegetables, fruits, fish, legumes, and reducing salt and saturated fats.

“Regular tailored exercise is recommended as it has been shown to be beneficial in individuals with diabetes and HF... Weight loss improves cardiometabolic risk factors and may lower risk for HF... Minimizing alcohol intake and avoidance of smoking are recommended.”

5. Are there social or practical factors I should discuss with my doctor to receive the best care? 

Answer: Yes. Experts emphasize that social determinants of health—such as financial stability, access to medications, nutritious food, housing, work conditions, and health literacy—greatly impact heart failure management in diabetes. Don’t hesitate to talk to your doctor about barriers such as affording food or meds, getting to appointments, or needing social support.

“Providers should actively screen and identify specific social determinants of health (SDOH) for all individuals with diabetes and HF such as job and food insecurity, health literacy, appropriate and secure housing, and access to health care and medication... with implementation of a comprehensive multidisciplinary team approach to mitigate the challenges that these individuals face in their quest for longitudinal care.”

Conclusion

Heart failure as a complication of diabetes requires a combination of the most advanced medical knowledge, timely diagnosis, and active patient engagement. As highlighted in the American Diabetes Association’s consensus report, awareness and proper understanding of the risks, symptoms, diagnostic tools, and treatment options are essential for improving quality of life and long-term outcomes. A team approach—including the patient, their loved ones, and a multidisciplinary medical team—is key to achieving the best possible results.

We hope this information will help you feel more confident and informed about today’s options for managing and preventing this often-overlooked, yet critically important, complication of diabetes.

Source: Pop-Busui R. et al. Heart Failure: An Underappreciated Complication of Diabetes. A Consensus Report of the American Diabetes Association, Diabetes Care, 2022;45:1670–1690. https://doi.org/10.2337/dci22-0014