SUN-261 Unmasking Heart Failure With Insulin

Abstract Disclosure: T. Jain: None. K. Zulqadar: None. S. Ifthikhar: None. R. Sharma: None. N. Jaafar: None. S. Israr: None. A. Khan: None. Background: Insulin therapy for diabetes management can occasionally trigger rare complications like insulin edema, leading to rapid fluid retention and volume overload. We present a case where insulin initiation unmasked heart failure with preserved ejection fraction (HFpEF), highlighting the need for vigilance in managing insulin in at-risk patients. Case Presentation: A 63-year-old male with a history of atrial fibrillation (AF), hypertension and type 1 diabetes mellitus presented to emergency department (ED) with progressive shortness of breath, orthopnea, leg swelling and 42 lb weight gain in 11 days. On exam, he had jugular venous distension and anasarca. The patient was diagnosed with uncontrolled diabetes, with an HbA1c of 17%, and was initiated on a basal-bolus insulin regimen 11 days prior to presentation. In the ED, labs revealed normal troponin levels, an elevated pro- brain natriuretic peptide at 1462 pg /mL and EKG revealed AF with rapid ventricular response, Q waves in II, III, AVF and poor R wave progression. He was admitted for acute decompensated HF. A transthoracic echocardiogram demonstrated mild concentric left ventricular hypertrophy with an ejection fraction of 55% with no wall motion abnormalities, and indetermined diastolic function. Thyroid, liver and renal function testing was normal with no proteinuria. The patient reported a notable decrease in urine output since starting insulin therapy. Previously, he experienced polyuria, voiding large volumes every 2-3 hours. His symptoms were attributed to new-onset HFpEF following insulin therapy, which led to reduced polyuria but exacerbated fluid retention, worsening his heart failure symptoms. He received intravenous diuretics, resulting in symptom resolution and was discharged with a titratable diuretic regimen. Conclusion: This case highlights a rare complication of insulin therapy—rapid fluid retention leading to HF symptoms, even in patients without a prior HF diagnosis. Insulin edema is rare complication of insulin use that can cause variety of manifestations ranging from lower extremity edema to anasarca and heart failure1. Clinicians should be vigilant about this potential complication when starting insulin in patients with predisposing conditions. 1.Chelliah A, Burge MR. Insulin Edema in the Twenty-first Century: Review of the Existing Literature. Journal of Investigative Medicine. 2004;52(2):104-108. doi:10.1177/108155890405200218 Presentation: Sunday, July 13, 2025