Guidelines for Managing HF in Diabetes, Cardiorenal, and Metabolic Conditions

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Practice guidelines have been developed regarding management of patients with heart failure and diabetes, cardiorenal, and/or metabolic conditions.

A multidisciplinary team formulated consensus guidelines for the management of heart failure (HF) in the setting of diabetes mellitus (DM), cardiorenal, and/or metabolic (DCRM) conditions. These guidelines were published in the Journal of Cardiac Failure.

Guidelines are often formulated by organizations in silos. For these recommendations, a volunteer task force of investigators from The University of Mississippi Medical Center, Metabolic Institute of America, and Baylor University Medical Center sought to review guidelines from the American Diabetes Association, Kidney Disease Improving Global Outcomes, American College of Cardiology, and American Heart Association and form more holistic guidelines for the prevention and management of HF in the setting of DCRM.

Patients with DCRM are recommended to consume a diet high in fruits, vegetables, whole grains, and legumes; engage in 150 minutes or longer of moderate intensity aerobic activity with resistance weekly; sleep at least 7 hours of quality sleep per night; limit alcohol consumption to 1 or 2 drinks per day; and avoid all nicotine products. For sleep, patients with poor sleep should be screened for obstructive sleep apnea.

In general, DM is associated with increased risk for HF. Delaying DM progression may decrease risk and can potentially be achieved by weight loss, dietary modification, and pharmacologic therapy. Thiazolidinediones should be avoided among patients at risk for HF.

Hypertension is a significant, modifiable, risk factor for HF. Patients should maintain a blood pressure of less than 130/80 to minimize risk. For patients with hypertension and high blood pressure, the authors recommended for antihypertensive therapy use.

For DCRM patients with HF, the initial HF evaluation should include an etiology and severity assessment. In the outpatient setting, B-type natriuretic peptide (BNP) or N-terminal pro-BNP are useful for guiding therapy and predicting prognosis and severity. In the inpatient setting, natriuretic peptides and cardiac troponin should be used for prognosis prediction.

Disease management for patients with HF with reduced ejection fraction (EF; EF, £40%) comprises diuretics for congested patients plus quadruple therapy with angiotensin receptor-neprilysin inhibitors (ARNIs), beta-blockers, sodium glucose cotransporter 2 inhibitors (SGLT2is), and mineralocorticoid receptor antagonists (MRAs). For patients with HF with mildly reduced EF (EF, 41%-49%), patients should receive diuretics if congested and SGLT2is and consider triple therapy with ARNIs, beta-blockers, and MRAs. The patients with HF with preserved EF (EF, ³50%) should receive a diuretic if congested with SGT2is and consider ARNIs and MRAs.

The authors cautioned that patients with DCRM and comorbid HF have a high pill burden and complex dosing regimens. These patients require frequent consultations with a multidisciplinary team. An optimal balance in management of these patients is key to optimize outcomes.

“The high concurrency of DCRM conditions underscores the need for co-management of these conditions,” the study authors wrote. “Optimal management of DCRM conditions in patients with HF leads to better cardiovascular outcomes and reduced mortality. The integrated recommendations highlighted here and by the taskforce are targeted for subspecialty physicians as well as primary care physicians. Incorporation of these recommendations into practice is crucial in the optimal management of patients with HF.”

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Hamid A, Handelsman Y, Butler J. DCRM multispecialty recommendations in patients with heart failure. J Card Fail. Published online August 12, 2022. doi:10.1016/j.cardfail.2022.07.053