Don't Wait for Symptoms! Annual Heart Failure Testing in Diabetes: New Recommendation

Neil Skolnik, MD


August 15, 2022

This transcript has been edited for clarity.

I'm Dr Neil Skolnik. Today we're going to talk about Heart Failure: An Underappreciated Complication of Diabetes. A Consensus Report of the American Diabetes Association, which was put together with designated representation from the American College of Cardiology.

The big news here is that early detection of presymptomatic heart failure utilizing annual screening with N-terminal pro B-type natriuretic peptide (NT-proBNP) or troponin is now recommended. It turns out that although we don't think about diabetes and heart failure the same way that we think about diabetes and vascular disease or microvascular complications of diabetes, heart failure is a very common complication of diabetes. Approximately 22% of all patients with diabetes eventually develop heart failure. In fact, it's two to four times more common in people with either type 1 or type 2 diabetes than in those without diabetes.

Risk factors for heart failure in both for type 1 and type 2 diabetes include duration of diabetes, poor glycemic control, uncontrolled hypertension, hyperlipidemia, higher body mass index (BMI), microalbuminuria, renal dysfunction, ischemic heart disease and peripheral vascular disease.

Heart failure classification includes stage A, which is people who are at risk for developing heart failure. That's essentially everyone with diabetes. Stage B, which is our focus today, can be thought of as presymptomatic heart failure or pre–heart failure. These are people who have an echocardiogram with evidence of structural heart disease, abnormal cardiac function, or elevated natriuretic peptide or cardiac troponin levels. Classification of heart failure includes symptomatic heart failure (stages C and D), which are the subjects of a different discussion.

The reason for these new guidelines is recent good randomized trial evidence showing that appropriate treatment of people at risk for heart failure who have elevated NT-proBNP levels (eg, people who have pre–heart failure or stage B heart failure) can reduce the risk for left ventricular dysfunction, newly diagnosed heart failure, and heart failure hospitalization.

That leads to the main recommendation of this consensus statement: annual testing of brain natriuretic peptide (BNP), NT-proBNP, or high-sensitivity cardiac troponin to identify the presence of stage B heart failure. The cutoff value for BNP is 50 pg/mL, and for NT-proBNP, it is 125 pg/mL.

Patients who are identified in this manner should receive an echocardiogram and then, based on the results of the echo, be treated with appropriate medications that include renin-angiotensin system blockade (either an angiotensin-converting enzyme [ACE] inhibitor or an angiotensin receptor blocker [ARB]), a sodium-glucose co-transporter 2 (SGLT-2) inhibitor, and other medications per the AHA/ACC heart failure guidelines, summarized here.

These are big, important new recommendations that are easy to implement and have the potential to make a big difference for our patients with diabetes. I'm Dr Neil Skolnik, and this is Medscape.

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