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CDE Diabetes

Practice Exam: Treatment of Diabetes in People with Heart Failure (Chapter 28)

Heart failure is one of the most common and serious cardiovascular complications of diabetes, with up to 40% of people with heart failure having comorbid diabetes. The 2018 Clinical Practice Guidelines mark a significant paradigm shift, prioritizing the use of specific glucose-lowering agents that have been proven to reduce heart failure hospitalizations, while identifying others that may cause harm.

This practice exam tests your ability to navigate these critical therapeutic choices, ensuring you can select the safest and most effective regimens for this vulnerable patient population.

Key Concepts Covered in This Exam:

  • The SGLT2 Inhibitor Benefit: Understanding the recommendation to use SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin) in patients with clinical cardiovascular disease to specifically reduce the risk of heart failure hospitalization.

  • Agents to Avoid: Identifying Thiazolidinediones (TZDs) as agents that cause fluid retention and are associated with an increased risk of heart failure.

  • DPP-4 Inhibitor Caution: Recognizing the specific safety signal associated with saxagliptin, which was shown to increase the rate of hospitalization for heart failure in the SAVOR-TIMI 53 trial.

  • Epidemiology and Risk: Acknowledging that heart failure is a major driver of mortality in diabetes and that the presence of diabetes significantly worsens the prognosis for patients with established heart failure.

  • Neutral Agents: Knowing which other antihyperglycemic agents (such as most GLP-1 receptor agonists) have demonstrated safety—but not necessarily benefit—regarding heart failure outcomes.

1.

  1. Case: A diabetes educator is counseling a patient about the relationship between diabetes and heart failure. According to the guidelines, which is an independent risk factor for heart failure in diabetes?

2. According to the guidelines, what is the minimum eGFR required for adding an SGLT2 inhibitor in adults with type 2 diabetes and clinical CVD to reduce heart failure hospitalization risk?

3. Case: A patient with type 2 diabetes and heart failure is being initiated on an ARB. After initiation or titration, when should serum electrolytes, creatinine, BP, and body weight be monitored?

4.

  1. Case: A 70-year-old man with diabetes and heart failure with reduced EF is currently on metoprolol tartrate. Based on the evidence, which beta blocker has been shown to specifically improve glycemic control?

5. Case: A patient with type 2 diabetes and NYHA Class III heart failure asks about using pioglitazone. What is the recommendation?

6. Which biomarker strongly and consistently improved the prediction of heart failure in people with diabetes according to the ADVANCE study analysis?

7. According to the guidelines, what is the clinical significance of the finding that diabetes can cause heart failure independently of ischemic heart disease?

8. Which three beta blockers have been shown to reduce morbidity and mortality for people with heart failure, reduced EF and diabetes?

9. The guidelines note that people with diabetes derive what type of benefit from efficacious heart failure therapies compared to those without diabetes?

10. According to the guidelines, what is the increased risk of heart failure development associated with increasing urinary albumin to creatinine ratio (ACR)?

11. Case: A 58-year-old woman with type 2 diabetes, clinical CVD, and heart failure has an eGFR of 35 mL/min. Her glycemic targets are not being met. According to the guidelines, which SGLT2 inhibitor has demonstrated heart failure hospitalization reduction?

12. According to the guidelines, what proportion of subjects in heart failure clinical trials have diabetes?

13. According to the guidelines, what is the evidence regarding whether improved glycemic control significantly reduces the incidence of heart failure?

14. According to the guidelines, why should heart failure be considered under-recognized in clinical practice

15. According to the guidelines, what symptoms of heart failure should people with diabetes be educated about?

16. Case: A 65-year-old man with type 2 diabetes and NYHA Class II heart failure with reduced EF is being started on antihyperglycemic therapy. His eGFR is 45 mL/min. Which agent should be avoided?

17. Case: A quality improvement team is reviewing heart failure care for people with diabetes. The guidelines state that comorbidities affect therapy how?

18. Case: A 62-year-old woman with type 2 diabetes and mild heart failure (eGFR 35 mL/min) needs antihyperglycemic therapy. According to the guidelines, what is the recommendation regarding metformin?

19. Case: A healthcare team is discussing why people with diabetes and heart failure may have worse outcomes despite effective therapies being available. According to the guidelines, what is a key factor?

20. According to the guidelines, heart failure can occur over what range of left ventricular ejection fractions?

21. Case: A patient with diabetes and heart failure is being initiated on an ACE inhibitor. Their eGFR is 55 mL/min. What dose adjustment is recommended?

22. According to the guidelines, the incidence of heart failure is how much higher in people with diabetes compared to those without diabetes?

23. Heart failure with reduced ejection fraction (HFrEF) is commonly defined as LVEF of:

24. Case: A patient with type 2 diabetes is on saxagliptin and develops worsening heart failure symptoms. According to Health Canada guidance, what is the recommendation?