Evaluating the Heart Failure Risk in Type 2 Diabetes: Insights from 1.6 Million People in England

Type 2 diabetes mellitus (T2DM) is a growing global health concern, significantly increasing the risk of cardiovascular diseases, particularly heart failure. Heart failure can be classified into ischaemic and non-ischaemic forms, with the former typically linked to coronary artery disease and myocardial infarction, while the latter encompasses various other mechanisms, including diastolic dysfunction and hypertensive heart disease.

Recent epidemiological data suggest a declining trend in ischaemic heart disease (IHD) rates across numerous populations, potentially influencing heart failure presentations. Given the changing landscape of cardiovascular morbidity, it becomes critical to understand whether these trends also extend to heart failure phenotypes among individuals with diabetes.

This study investigates the relative risks of ischaemic and non-ischaemic heart failure in individuals diagnosed with T2DM, providing crucial data that could inform preventive healthcare strategies and resource allocation for this population.

Study Design

This observational study utilised the Clinical Practice Research Datalink (CPRD), which integrates primary care data with hospital admissions and mortality records. Participants included newly diagnosed adults with T2DM from January 2000 to December 2021. Each diabetic individual was matched with up to four non-diabetic individuals based on sex, birth year, and general practice.

Definitions were as follows: ischaemic heart failure was characterised as new heart failure diagnosed after or during an ischaemic heart disease event. Conversely, non-ischaemic heart failure referred to newly diagnosed heart failure without a preceding ischaemic event.

The incidence rates of heart failure types and hazard ratios were calculated using Poisson and Royston-Parmar models, with adjustments for various sociodemographic and clinical confounders.

Key Findings

A total of 1,621,090 individuals were included in the analysis, with a mean follow-up period of 5.8 years (interquartile range 2.6–10.3). Among the included subjects, 532,185 had a diagnosis of T2DM. The incidence of heart failure was significantly higher in the diabetic group, with 20,016 cases (3.8%); breakdown indicated 5,046 waschaemic heart failure and 14,970 non-ischaemic heart failure. Comparatively, the non-diabetic cohort exhibited 29,835 heart failure cases (2.7%).

Crucially, age-standardised incidence rates revealed non-ischaemic heart failure events occurring at a rate of 3.18 (95% CI: 3.09-3.27) per 1000 person-years for men with diabetes versus 2.08 (95% CI: 2.03-2.12) for men without diabetes. For women, the rates were 2.47 (95% CI: 2.39-2.54) compared to 1.57 (95% CI: 1.53-1.61). In terms of ischaemic heart failure, incidence rates were 1.57 (95% CI: 1.51-1.63) versus 0.95 (95% CI: 0.92-0.98) for men and 0.80 (95% CI: 0.76-0.84) versus 0.46 (95% CI: 0.44-0.48) for women.

Adjusted hazard ratios indicated that individuals with T2DM had a greater risk for both heart failure types. For ischaemic heart failure, hazard ratios were 1.36 (95% CI: 1.28-1.45) for men and 1.30 (95% CI: 1.20-1.42) for women. Non-ischaemic heart failure risks were lower at 1.12 (95% CI: 1.07-1.16) for men and 1.10 (95% CI: 1.06-1.14) for women, showing the relatively lower but still increased risk among diabetic patients.

These findings affirm the hypothesis that while diabetes increases the risk of heart failure in general, those affected by diabetes are more likely to develop non-ischaemic forms.

Expert Commentary

The given data highlights essential implications for clinical management and preventive strategies regarding heart failure among those with T2DM. The significant risk posed by non-ischaemic heart failure in the diabetic population should urge clinicians to consider comprehensive heart health monitoring and interventions focusing on lifestyle modifications and early screening practices tailored to diabetes.

While the study relies heavily on observational data, thus limiting causal conclusions, the robustness of the CPRD dataset warrants confidence in the observed associations. It’s essential to note that there exist potential biases related to diagnostic practices or recording completeness in primary care settings. Future studies could explore a more granular classification of non-ischaemic heart failures, alongside in-depth investigations into the underlying pathophysiological mechanisms.

Conclusion

The escalating rates of non-ischaemic heart failure among individuals with T2DM underscore a substantial unmet need for early intervention strategies aimed at preventing both heart failure forms. Clinicians must recognize the elevated risk for ischaemic heart failure, as it appears that post-event preventive measures may not be sufficiently robust amongst this demographic.

Future directives should emphasize enhancing awareness, preventive measures, and research into optimizing treatment frameworks that address both heart failure types in diabetic patients, thereby improving clinical outcomes and quality of life.

Reference

Panchal K, Lawson C, Shabnam S, Khunti K, Zaccardi F. Risk of Ischaemic and Non-Ischaemic Heart Failure in People With Type 2 Diabetes: Observational Study in 1.6 Million People in England. Diabetes Metab Res Rev. 2025 Sep;41(6):e70072. doi: 10.1002/dmrr.70072IF: 6.0 Q1 . PMID: 40722166; PMCID: PMC12304495.

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