Some observational studies have demonstrated that in- sulin use may be associated with a greater risk of devel- oping incident HF in patients with diabetes mellitus.175 In diabetic patients with established HF, observational studies have also demonstrated an association between insulin use and increased mortality,114,176,177 although these findings are potentially limited by unmeasured confounding factors, and not all observational studies have demonstrated this increased hazard.140 Given that individuals who require insulin for type 2 diabetes mel- litus are more likely to have a longer diabetes mellitus duration and severity, the use of insulin may be a marker of more advanced disease and a high-risk group rather than a direct contributor to increased HF events and in- creased mortality in patients with HF. In a recent large, randomized, controlled trial of 12537 patients with im- paired fasting glucose, impaired glucose tolerance, or early type 2 diabetes mellitus and cardiovascular risk factors, patients were randomized to insulin glargine or In this prospective study, rates of car- diovascular outcomes (including HF events) were similar in the insulin-glargine and standard care groups.178 Sodium-glucose cotransporter 2 inhibitors are a newer class of glucose-lowering medications with sev- eral compounds currently approved for diabetes mellitus Sodium-glucose cotransporter 2 in- hibitors promote the renal excretion of glucose, thereby causing osmotic diuresis. In a recent trial in patients with diabetes and cardiovascular risk, empagliflozin, an inhibitor of sodium glucose cotransporter 2, when added to standard care, was shown to reduce cardio- vascular death, all-cause mortality, and HF hospitaliza- tions. Hospitalization for HF was reduced by 35%; 10% of the patients had pre-existing HF. Consistent effects of empagliflozin were observed across subgroups de- fined by baseline characteristics, including patients with versus without HF. 