Heart failure in diabetes

Red Flags

Acute decompensated HF in DM with hyperglycaemic crisis (DKA or HHS) — admit; insulin infusion plus IV diuresis under monitoring^[1]
DM patient with new dyspnoea on minimal exertion + leg oedema — screen for HF with NT-proBNP and echocardiography^[1]
Established HF + diabetes not on SGLT2 inhibitor — significant evidence-care gap; initiate at next visit unless contraindicated^[1]
T2DM with HFrEF on insulin and high-dose sulphonylurea — reassess; both increase HF hospitalisation; switch to SGLT2 inhibitor + GLP-1 RA combination^[1]

First-line treatment

Interventions

Multidisciplinary HF–diabetes care^[1]
Joint cardiology and endocrinology / diabetology review; structured nurse-led HF clinic where available

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Dapagliflozin or empagliflozin^[1]	SGLT2 inhibitor	10 mg PO once daily	—	First-line in HF + DM regardless of LVEF; cardio-renal protection independent of glycaemic effect
Sacubitril/valsartan (ARNI)^[1]	ARNI	49/51 mg PO BD, titrate to 97/103 mg BD	—	First-line in HFrEF + DM; replaces ACE-i where tolerated
Bisoprolol or carvedilol^[1]	Beta-blocker	Bisoprolol 1.25–10 mg daily; carvedilol 3.125–25 mg BD	—	Pillar 2 of HFrEF foundation therapy; carvedilol favoured in DM (insulin sensitivity)
Spironolactone or eplerenone^[1]	MRA	Spironolactone 12.5–50 mg daily	—	Pillar 3 in HFrEF; monitor K+ closely in DM with CKD
Semaglutide or dulaglutide^[1]	GLP-1 receptor agonist	Semaglutide 0.5–1 mg SC weekly; dulaglutide 1.5 mg SC weekly	—	Add for weight reduction and additional CV/renal benefit; especially valuable in HFpEF + obesity
Metformin^[1]	Biguanide	500–1000 mg PO BD	—	Safe in stable HF including HFrEF (counter to legacy concerns); first-line glucose-lowering

Dapagliflozin or empagliflozin^[1]

SGLT2 inhibitor

Adult: 10 mg PO once daily
Paediatric: —

First-line in HF + DM regardless of LVEF; cardio-renal protection independent of glycaemic effect

Sacubitril/valsartan (ARNI)^[1]

ARNI

Adult: 49/51 mg PO BD, titrate to 97/103 mg BD
Paediatric: —

First-line in HFrEF + DM; replaces ACE-i where tolerated

Bisoprolol or carvedilol^[1]

Beta-blocker

Adult: Bisoprolol 1.25–10 mg daily; carvedilol 3.125–25 mg BD
Paediatric: —

Pillar 2 of HFrEF foundation therapy; carvedilol favoured in DM (insulin sensitivity)

Spironolactone or eplerenone^[1]

MRA

Adult: Spironolactone 12.5–50 mg daily
Paediatric: —

Pillar 3 in HFrEF; monitor K+ closely in DM with CKD

Semaglutide or dulaglutide^[1]

GLP-1 receptor agonist

Adult: Semaglutide 0.5–1 mg SC weekly; dulaglutide 1.5 mg SC weekly
Paediatric: —

Add for weight reduction and additional CV/renal benefit; especially valuable in HFpEF + obesity

Metformin^[1]

Biguanide

Adult: 500–1000 mg PO BD
Paediatric: —

Safe in stable HF including HFrEF (counter to legacy concerns); first-line glucose-lowering

Safety-net

Continue SGLT2 inhibitor and HF medications during minor illness; pause SGLT2 only during severe vomiting or dehydration to avoid euglycaemic DKA^[1]
Recognise signs of euglycaemic DKA on SGLT2 inhibitor — nausea, abdominal pain, breathlessness despite normal glucose; seek same-day care^[1]
Weigh daily; weight gain >2 kg in 3 days warrants same-day medical review^[1]

Referral criteria

Acute decompensated HF or new cardiogenic shockEmergency department; ICU consideration^[1]
DM patient with new HF or markedly elevated NT-proBNPCardiology and HF service within 2 weeks^[1]
HF + DM on suboptimal therapy without SGLT2i, ARNI, or MRACardiology / diabetology for therapy intensification^[1]

Clinical summary

Joint cardiology–diabetology management of patients with concurrent heart failure and type 2 diabetes, prioritising SGLT2 inhibitors as foundation therapy.

References

1.RSSDI-ESI Clinical Practice Recommendations for Heart Failure in Diabetes (2023)