(C)13,181 Less-stringent A1c goals (such as <8%) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid condi- tions, and those with longstanding diabetes in whom the general goal is difficult to attain despite diabetes self-management educa- tion, appropriate glucose monitoring, and effective doses of multiple glucose lowering agents including insulin. (B)13,181 The following recommendations are from Intensive Glycemic Control and the Prevention of Cardiovascular Events: Implications of the ACCORD, ADVANCE, and VA Diabetes Trials: a Position Statement of the American Diabetes Association and a Scientific Statement of the American College of Cardiology Foundation and the American Heart Association 181 : Microvascular disease: lowering A1c to below or approximately 7% has been shown to reduce microvascular and neuropathic complications of type 1 and type 2 diabe- tes. Therefore, the A1c goal for nonpregnant adults in general is <7%. ADA, A-level recom- mendation; ACC/AHA, Class I recommenda- tion (Level of Evidence A). Macrovascular disease: in type 1 and type 2 diabetes, randomized controlled trials of intensive versus standard glycemic control have not shown a significant reduction in CVD Table 7. Glycemic Goals in Patients With Diabetes Mellitus and HF Recommendations COR LOE Referenced Guideline References Lowering HbA1c to <7% or 7% is reasonable for many nonpregnant adults with HF. IIa A to reduce microvascular complications, B to reduce macrovascular complications More stringent HbA1c goals (eg, <6.5%), if can be achieved without significant hypoglycemia or other adverse effects of treatment, might be considered for patients with a short duration of diabetes mellitus, a long life expectancy, and no significant CVD. 