Are you seeing people with
type 2 diabetes (T2D) exhibiting:
- Breathlessness
- Exhaustion
- Swollen legs or ankles?
T2D increases the risk of developing heart failure (HF) both directly, by impairing cardiac function, and indirectly, through associated diseases.1
Early diagnosis of HF and initiation of evidence-based treatments in people with T2D can reduce cardiac damage, improve quality of life and improve patient outcomes.2
4.4 million people in the UK are diagnosed with T2D.4
14% of people with T2D have been diagnosed with HF.5
Every week, T2D leads to 2300 new cases of HF.6
T2D and HF are increasingly common burdens. Observational studies have shown that people with T2D have a two- to threefold increased risk of developing HF compared with individuals without T2D independent of other risk factors such as:1,7
• hypertension
• obesity
• coronary disease
• other metabolic factors
• renal dysfunction
The recent Universal Definition and Classification of HF recognised T2D as a prime risk factor for incident HF, classifying individuals with T2D as being in Stage A.8
Despite this, an independent survey conducted on behalf of Roche Diagnostics showed that only 28% of healthcare professionals consider HF amongst their T2D patients.9
The Universal Definition and Classification of HF is as follows:8
Stages of heart failure
At risk of HF
People who are at risk for heart failure but do not yet have symptoms or structural or functional heart disease
Risk factors for people in this stage include hypertension, coronary vascular disease, diabetes, obesity, exposure to cardiotoxic agents, genetic variants for cardiomyopathy and family history of cardiomyopathy
Pre-HF
People without current or previous symptoms of heart failure but with either structural heart disease, increased filling pressures in the heart or other risk factors
Symptomatic HF
People with current or previous symptoms of heart failure
Advanced HF
People with heart failure symptoms that interfere with daily life functions or lead to repeated hospitalisations
Co-existence of T2D and HF is associated with worse symptoms and quality of life, a greater burden of HF hospitalisation, and higher mortality rates compared to people without T2D.10
- HF often manifests as the first cardiovascular (CV) event in people with T2D.11
- The incidence of heart failure occurs 10-15 years earlier in people without diabetes compared to those without diabetes.12
- A clear double link has been demonstrated between T2D and HF. People with T2D present an increased risk of new onset of HF as well as HF-related events. On the other hand, HF patients present an increased risk of new onset T2D. Both HF in T2D and T2D in HF are associated with a worse prognosis.1
- HF development, at any year since T2D diagnosis, was associated with the highest 5-year absolute and relative risk of death, and decrease in lifespan within 5 years, when compared with development of other cardiovascular or renal diagnoses.13
T2D and cardiac damage
Several pathophysiological mechanisms underlie the development of HF in T2D, as detailed in the figure below. These contribute to adverse cardiac remodelling and the development of clinical HF in T2D. Each of these mechanisms is a potential therapeutic target for prevention that can delay the development and progression of HF.13
Myocardial ischaemia
Inflammation
Endothelial dysfunction
Extracellular matrix remodelling
Adverse cardiac remodelling
Myocardial substrate switch
FA - fatty acids
Glu - glucose
Autonomic dysfunction
Neurohormonal and RAAS activation
Impaired Ca2+ handling
Diagnosing HF in people with T2D
What is NT-proBNP?
NT-proBNP is a form of natriuretic peptide (NP) released by cardiac tissue in response to volume and/or pressure overload that causes the walls of the heart to stretch. NPs promote natriuresis and diuresis and act as vasodilators, to help regulate this pressure.14
Why test for NT-proBNP?
NP levels can be assessed by measuring either B-type NP (BNP) or N-terminal pro-B-type NP (NT-proBNP). NT-proBNP is the NP test recommended by NICE for suspicion of chronic HF as it as a very high diagnostic sensitivity for HF, is more stable over time and testing in patients with symptoms delivers a fast route to ruling out HF as a diagnosis.15,16
High levels of NT-proBNP are associated with a poor prognosis. Patients with values >2,000 ng/l are at greater risk of death. High levels therefore indicate the need for urgent referral.15,16
Risk assessment in your patients with T2D
In recent years, the circulating NP biomarkers have become increasingly important in relation to HF and, when elevated in the absence of prevalent HF, identify individuals with “pre-HF” at risk for progression to symptomatic disease.8
NT-proBNP may be the earliest sign to detect HF in people with T2D before structural and functional changes become apparent on imaging.17,18
If you have had trouble accessing NT-proBNP or would like to speak to a local representative about using NT-proBNP in patients with T2D, please contact us and we’ll be happy to help.
Triage patients at need of urgent specialist assessment.16
Rule out heart failure and reduce pressure on echocardiography services.19
Support an earlier diagnosis that could reduce hospitalisations and improve quality and length of life.20
Early and accurate diagnosis of heart failure has the potential to reduce rates of misdiagnosis and GP appointments.21
The Pumping Marvellous Foundation (PMF) is the UK’s patient-led heart failure charity. Founder & CEO Nick Hartshorne-Evans, a heart failure patient whose experiences whilst rehabilitating, shaped the Foundation’s goals and principles to improve patient outcomes.
With patient resources available for download by healthcare professionals, Pumping Marvellous takes a patient-centric approach to heart failure diagnosis, ongoing management and care.
References
- Palazzuoli, A., Iacoviello, M. Diabetes leading to heart failure and heart failure leading to diabetes: epidemiological and clinical evidence. Heart Fail Rev 28, 585–596 (2023). https://doi.org/10.1007/s10741-022-10238-6
- Wang Y, et al. Early detection of heart failure with varying prediction windows by structured and unstructured data in electronic health records. Annu Int Conf IEEE Eng Med Biol Soc. 2015;2015:2530-3. doi: 10.1109/EMBC.2015.7318907. PMID: 26736807; PMCID: PMC5233460.
- Seferović PM, et al. Type 2 diabetes mellitus and heart failure: a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2018;20(5):853–72.)
- BHF. UK Factsheet 2024. Available online: https://www.bhf.org.uk/-/media/files/for-professionals/research/heart-statistics/bhf-cvd-statistics-uk-factsheet.pdf [Accessed June 2024]
- The Lancet Diabetes & Endocrinology (2014) https://www.thelancet.com/journals/landia/article/PIIS2213-8587(14)70219-0/fulltext#:~:text=Of%20people%20with%20type%202,1%25%5D%20of%206137%20patients [Accessed June 2024]
- Diabetes UK. How many people in the UK have diabetes? Available online: https://www.diabetes.org.uk/about-us/about-the-charity/our-strategy/statistics [Accessed June 2024]
- Ify R. Mordi, R. Thomas Lumbers, Colin N.A. Palmer, Ewan R. Pearson, Naveed Sattar, Michael V. Holmes, Chim C. Lang; on behalf of the HERMES Consortium, Type 2 Diabetes, Metabolic Traits, and Risk of Heart Failure: A Mendelian Randomization Study. Diabetes Care 1 July 2021; 44 (7): 1699–1705. https://doi.org/10.2337/dc20-2518
- Bozkurt B, Coats AJS, Tsutsui H, Abdelhamid M, Adamopoulos S, Albert N, et al. Universal Definition and Classification of Heart Failure: A Report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure. J Cardiac Fail. 2021;27(4):387–413.
- Buzzback online survey conducted on behalf of Roche Diagnostics. n= 110 GPs and Nurses in Great Britain. Data on file (August 2022)
- European Society of Cardiology (2019) https://onlinelibrary.wiley.com/doi/10.1002/ejhf.1673 [Accessed June 2024]
- Ceriello, A., Catrinoiu, D., Chandramouli, C. et al. Heart failure in type 2 diabetes: current perspectives on screening, diagnosis and management. Cardiovasc Diabetol 20, 218 (2021). https://doi.org/10.1186/s12933-021-01408-1
- Diabetes Care 2001;24(9):1614–1619
- Zareini B et al. Type 2 Diabetes Mellitus and Impact of Heart Failure on Prognosis Compared to Other Cardiovascular Diseases: A Nationwide Study. Circ Cardiovasc Qual Outcomes. 2020 Jul;13(7):e006260. doi: 10.1161/CIRCOUTCOMES.119.006260. Epub 2020 Jun 23. PMID: 32571092.
- Mueller, C.et al. (2019), Heart Failure Association of the European Society of Cardiology practical guidance on the use of natriuretic peptide concentrations. Eur J Heart Fail, 21: 715-731. https://doi.org/10.1002/ejhf.1494
- Taylor CJ, Moore J, O’Flynn N. Diagnosis and management of chronic heart failure: NICE guideline update 2018. Br J Gen Pract. 2019 May;69(682):265-266. doi: 10.3399/bjgp19X702665. PMID: 31023695; PMCID: PMC6478474.
- National Institute for Health and Care Excellence, 2018. Chronic heart failure in adults: diagnosis and management [online] Available from: https://www.nice.org.uk/guidance/ng106/resources/chronic-heart-failure-in-adults-diagnosis-and-management-pdf-66141541311685 [Accessed: June 2024]
- Magnusson M et al. Diabetes Care. 2004;27:1929-35
- Gallagher J et al. Cardiac Failure Review. 2017;3:83–85.
- Taylor et al. (2017) The REFER (REFer for EchocaRdiogram) study: a prospective validation and health economic analysis of a clinical decision rule, NT-proBNP or their combination in the diagnosis of heart failure in primary care. Southampton (UK): NIHR Journals Library; 2017 Apr. PMID: 28445025.
- Roalfe et al. (2022) Long term trends in natriuretic peptide testing for heart failure in UK primary care: a cohort study. European Heart Journal, Volume 43, Issue 9, 1 Pages 881–891.)
- National Institute for Health and Care Excellence [NG106], 2020. Reducing inappropriate use of NT pro BNP: A Quality Improvement project. Available from: https://www.nice.org.uk/sharedlearning/reducing-inappropriate-use-of-nt-pro-bnp-a-quality-improvement-project [Accessed: June 2024]
- Kenny et al. (2019). Heart Failure in Type 2 Diabetes Mellitus. Impact of Glucose-Lowering Agents, Heart Failure Therapies, and Novel Therapeutic Strategies. Circulation Research. 2019;124:121–141.
- Bottle et al. (2018) Routes to diagnosis of heart failure: observational study using linked data in England. Heart. 104(7):600-605.