Antidiabetic medications in patients with heart failure

Diabetes mellitus increases the mortality secondary to heart failure independent of hypertension and coronary artery disease. Several hypoglycemic agents are used to achieve glycemic control, of which several classes however still raise controversies in terms of safety in patients with concomitant heart failure: Metformin does not carry an increased risk of exacerbation in patients with stable heart failure, yet should be avoided in patients with unstable disease or chronic kidney disease. Sulfonylureas are neither associated with an increased mortality, nor do they seem to have deleterious effects on heart failure. Thiazolidinediones are relatively contraindicated in patients with New York Heart Association class III or IV disease secondary to concerns of fluid retention and heart failure exacerbation. Glucagon-like peptide 1 agonists have shown trends towards improvement of heart failure parameters. Dipeptidylpeptidase 4 inhibitors show an overall neutral outcome, although saxagliptin can possibly be associated with an increased risk of hospitalization for heart failure. The use of sodium-glucose co-transporter 2 inhibitors is associated with beneficial cardiovascular outcomes, and further studies are underway.