Diabetes and heart failure post-acute myocardial infarction: Important associations and need for evidence-based interventions

In this edition of the European Journal of Preventive Cardiology, Ritsinger et al. evaluated nearly 74,000 participants in the SWEDEHEART registry with acute myocardial infarction (AMI) who had coronary angiography performed between 2012 and 2017 to compare the incidence of heart failure and death after AMI in patients with and without diabetes. In this broad patient population from across Sweden, patients with diabetes had a hazard ratio (HR) of 1.52 (95% confidence interval (CI) 1.44–1.61) relative to patients without diabetes for developing heart failure after a first AMI event. The increased risk for patients with diabetes was more pronounced in patients with a history of myocardial infarction, history of heart failure, and presence of reduced left ventricular ejection fraction (LVEF). In addition, the finding of increased risk among patients with diabetes was still observed in those patients with LVEF of 50% or greater, no history of myocardial infarction, and no history of heart failure. Similar relationships were observed for all-cause mortality. Increased rates of heart failure among patients with diabetes have been well recognized from foundational studies such as the Framingham Heart Study, and the significantly increased morbidity and mortality among patients with comorbid diabetes and heart failure has been increasingly recognized. In the post-AMI setting there is a standard regimen strongly supported by empiric evidence from clinical trials that includes beta-blockers and angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers to improve cardiovascular outcomes including progression to heart failure; however, targeted options to prevent heart failure in patients with diabetes despite their markedly increased risk have been limited until recently. There is abundant evidence from the ADVANCE, ACCORD, and other studies of glycemic control in patients with diabetes that haemoglobin A1c (HbA1c) lowering itself does not improve cardiovascular outcomes including heart failure in particular. However, there is a growing body of evidence over the past few years that the glucagon-like peptide 1 receptor agonist (GLP1-RA) and sodium-glucose co-transportor-2 inhibitor (SGLT2i) classes of medications are effective in reducing composite atherosclerotic cardiovascular outcomes in patients with or at risk of atherosclerotic cardiovascular disease. In addition, preclinical studies suggested that the DPP4i class of medications may have cardiovascular benefits including for heart failure, but more recent trials have indicated no benefit for cardiovascular outcomes and trends to worse heart failure outcomes in some trials. Only the SGLT2i class has been shown consistently and robustly to prevent the development of heart failure and reduce heart failure admissions among patients with diabetes (EMPAREG OUTCOMES, CANVAS, DECLARE TIMI 58, DAPA-HF, CREDENCE trials). These findings have led to support from international governmental pharmaceutical regulating organizations such as the US Food and Drug Administration and the European Medicines Agency for the use of this class of medications in patients with diabetes with or at high risk of cardiovascular disease. Despite this indication, the rates of use of these medications remain lower than expected. Ritsinger et al. have underlined the critical importance of considering AMI as a strong risk factor for the development of heart failure in patients with diabetes (and patients without diabetes to a lesser extent), and demonstrate that the increased risk of heart failure after AMI remains present even in patients without a history