Diabetes and Acute Coronary Syndrome

Glycaemic Control in Patients with Diabetes and Acute Coronary Syndrome

• Assess glycaemic status at initial evaluation in all patients with ACS.
• Frequently monitor blood glucose levels in patients with known diabetes or hyperglycaemia (glucose levels ≥11.1 mmol/L or ≥200 mg/dL).

Heart Failure Screening and Diagnosis in Patients with Diabetes

• Evaluate for heart failure by measuring BNP/NT-proBNP if suspected.
• Conduct a systematic survey for HF symptoms and/or signs of HF at each clinical encounter in all patients with diabetes.
• Perform diagnostic tests, including:
  • 12-lead ECG.
  • Transthoracic echocardiography.
  • Chest radiography (X-ray).
  • Routine blood tests for comorbidities, including full blood count, urea, creatinine and electrolytes, thyroid function, lipids, and iron status (ferritin and TSAT).

Heart Failure Treatments in Patients with Heart Failure with Reduced Ejection Fraction and Diabetes

• Recommend pharmacological treatment in patients with HFrEF (NYHA class II–IV) and diabetes, including:
  • SGLT2 inhibitors (dapagliflozin, empagliflozin, or sotagliflozin) to reduce the risk of HF hospitalization and death.
  • Sacubitril/valsartan or an ACE-I to reduce the risk of HF hospitalization and death.
  • Beta-blockers to reduce the risk of HF hospitalization and death.
  • MRAs to reduce the risk of HF hospitalization and death.
• Recommend device therapy with an ICD, CRT-P, or CRT-D in patients with diabetes, as in the general population with HFrEF.
• Recommend ARBs in symptomatic patients with HFrEF and diabetes who do not tolerate sacubitril/valsartan or ACE-Is, to reduce the risk of HF hospitalization and death.
• Recommend diuretics in patients with HFrEF and diabetes with signs and/or symptoms of fluid congestion to improve symptoms, exercise capacity, and HF hospitalization.

Treatment of Heart Failure Patients with Left Ventricular Ejection Fraction >40% and Diabetes

• Recommend empagliflozin or dapagliflozin in patients with T2DM and LVEF >40% (HFmrEF and HFpEF) to reduce the risk of HF hospitalization or CV death.
• Recommend diuretics in patients with HFpEF or HFmrEF and diabetes with signs and/or symptoms of fluid congestion to improve symptoms, exercise capacity, and HF hospitalization.

Glucose-Lowering Medications in Patients with Type 2 Diabetes with and without Heart Failure

• Recommend SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin, ertugliflozin, or sotagliflozin) in patients with T2DM with multiple ASCVD risk factors or established ASCVD to reduce the risk of HF hospitalization.
• Recommend SGLT2 inhibitors (dapagliflozin, empagliflozin, or sotagliflozin) in patients with T2DM and HFrEF to reduce the risk of HF hospitalization and death.
• Recommend empagliflozin or dapagliflozin in patients with T2DM and LVEF >40% (HFmrEF and HFpEF) to reduce the risk of HF hospitalization or CV death.

Glucose-Lowering Medications with Increased Risk of Heart Failure Hospitalization

• Pioglitazone is associated with an increased risk of incident HF in patients with diabetes and is not recommended for glucose-lowering treatment in patients at risk of HF (or with previous HF).
• The DPP-4 inhibitor saxagliptin is associated with an increased risk of HF hospitalization in patients with diabetes and is not recommended for glucose-lowering treatment in patients at risk of HF (or with previous HF).

Special Considerations in Patients with Heart Failure and Diabetes

• Recommend switching glucose-lowering treatment from agents without proven CV benefit or proven safety to agents with proven CV benefit.

Atrial Fibrillation in Patients with Diabetes

• Recommend opportunistic screening for AF by pulse taking or ECG in patients ≥65 years of age and in patients with diabetes.