The mechanisms contributing to the greater degree of HF in individuals with diabetes mellitus are likely mul- tifactorial and include the commonly shared HF risk factors of hypertension, coronary artery disease, renal Figure 3. Restricted cubic spline analysis for Cox proportional hazards model. A, In patients with heart failure (HF) with mild to moderate left ventricular systolic dysfunction (left ventricular ejection fraction 30% and <50%) showing a nonlinear U-shaped association of systolic blood pressure (SBP) with increased all-cause mortal- ity at both the lower and upper ranges of SBP. The red line represents the estimated logarithmic hazard ratio (HR) of all-cause mortality; the blue lines represent the 95% pointwise confidence bands. B, In patients with HF with severe left ventricular systolic dysfunction (left ventricular ejection fraction <30%) showing a relatively linear association of SBP with all-cause mortality. The red line represents the estimated logarithmic HR of all-cause mortality; the blue lines represent the 95% pointwise confidence bands. HFrEF indicates heart failure with reduced ejection fraction; and EPRP, Veterans Affairs External Peer Review Program. Reprinted from Ather et al92 with permission from Elsevier. Copyright 2011, Mosby, Inc. Table 5. Recommendations for the Treatment of Diabetes Mellitus in Stage A HF: Asymptomatic Patients at Risk for HF Recommendations COR LOE Referenced Guideline References For patients with diabetes mellitus (who are all at high risk for developing HF), blood sugar should be controlled in accordance with contemporary guidelines. ACE inhibitors or ARBs can be useful to prevent HF in patients at high risk for developing HF who have a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension with associated cardiovascular risk factors. 