In heart failure, BHB utilization along with the rate-limiting enzyme in ketone oxidation are increased (26, 31), which could be a beneficial adaptive mechanism, since ketone oxidation is highly energy efficient compared to fatty acids (32), and is utilized in proportion to blood-levels (26), replace myocardial glucose uptake and increase myocardial blood flow (33), and can occur independent of insulin (34). This evidence concerns the gene INS and heart failure.