Dr. Malkani is a Professor of Medicine at the University of Massachusetts Chan Medical School and specializes in diabetes and lipid care. We asked for his expert opinion on what he considers to be the most important developments in the last year regarding diabetes.
1. What do you consider the most important piece of evidence or guideline published in the past year?
I would like to highlight a newer guideline from the 2024 American Diabetes Association Standards of Care that addresses a common complication of diabetes frequently overlooked at the early stages and only diagnosed later when the patient is very symptomatic. This problem is heart failure, the risk of which is increased two- to four-fold in patients with diabetes. The guideline recommends screening early in the presymptomatic phase (stage B) with a blood biomarker: B-type natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP).
Here’s an excerpt from the 2024 American Diabetes Association Standards of Care:
- 0.39a Adults with diabetes are at increased risk for the development of asymptomatic cardiac structural or functional abnormalities (stage B heart failure) or symptomatic (stage C) heart failure. Consider screening adults with diabetes by measuring a natriuretic peptide (B-type natriuretic peptide [BNP] or N-terminal pro-BNP [NT-proBNP]) to facilitate prevention of stage C heart failure. B
- 10.39b In asymptomatic individuals with diabetes and abnormal natriuretic peptide levels, echocardiography is recommended to identify stage B heart failure. A
2. What’s your clinical “take” on this evidence or guideline?
I agree that diagnosis of heart failure at the presymptomatic stage (stage B) allows for early treatment and modification of risk factors to reduce the chance of progression to the later stages of symptomatic heart failure (stages C and D). Individuals with diabetes and early heart failure have a faster progression to more advanced stages of heart failure and poorer outcomes than those without diabetes. They are also more likely to require hospitalization. The screening tests (BNP, NT-proBNP) are relatively inexpensive blood tests and are easy to perform.
However, one needs to be aware of the limitations of these biomarkers. The BNP can be elevated without heart failure in persons with advanced age, chronic kidney disease, anemia, obstructive sleep apnea, pulmonary hypertension, atrial fibrillation, and sepsis. It can be falsely low in people with obesity. Also, it may be more cost effective to screen only those at the highest risk of heart failure, such as female patients or those with obesity, hypertension, dyslipidemia, kidney disease, and/or atherosclerotic coronary disease.
An abnormal screening test needs to be repeated or, if appropriate, followed with a confirmatory test such as echocardiography to confirm the presence of heart failure and assess the severity and type.
3. How will this publication influence your practice and patient care? Will it have a large or small impact on your daily decision-making?
This recommendation adds to the complexity of managing diabetes within a short office visit. Besides addressing glycemia control, one needs to address lipids, blood pressure, foot care and peripheral circulation, evaluation for liver fibrosis, renal and eye health, and now testing for heart failure. It takes a lot of time, organizational skills, and support to get this done. Even though the guidelines advocate testing everyone, one needs to use clinical judgment to order the appropriate screening tests at each visit.
4. Is there anything else you’d like to share about this topic that may not be covered or mentioned in this evidence?
Forty percent of people admitted for heart failure in the United States have coexisting diabetes. The mechanisms by which diabetes increases risk of heart failure are complex and include endothelial dysfunction in the heart microvasculature, sympathetic activation, a prothrombotic milieu, elevated free fatty acids, and the higher risk of atherosclerotic heart disease seen in diabetes. SGLT-2 inhibitors should be preferred for glycemic control, as they help reduce the progression of heart failure and kidney disease, which are intimately linked. They also reduce hospitalization and mortality in those with symptomatic heart failure. TZDs like pioglitazone should be avoided in those with heart failure. Blood pressure and lipid control and other therapies targeted to heart failure such as ACE-I/ARBs, beta-blockers, and mineralocorticoid receptor agonists may also be indicated.
Editors’ note: Because the risk of heart failure seems to be higher in people with both type 1 and 2 diabetes, the American Diabetes Association extends this screening recommendation to both groups. Values of ≥ 50 mg/mL for BNP and ≥ 125 mg/mL for NT-proBNP are considered abnormal. A time interval or frequency for screening is not specified in this recommendation.
For more information on this, see the follow-up section on management of heart disease in Management of Type 1 Diabetes Mellitus in Adults and Management of Type 2 Diabetes Mellitus in Adults.
