Article

Roundtable discussion on the value of NT-proBNP testing in patients with Type 2 Diabetes (T2D)

Risk stratification in Type 2 Diabetes

Professor Verma shares how patients with Type 2 Diabetes are at high risk of developing Heart Failure (HF) and have worse prognosis once they have HF established. Unmet need is to identify T2D patients at risk of HF development earlier and identify better tools for risk stratification, since the delay of cardioprotective measures increases risk of HF development. 

Professor Januzzi summarizes the use of biomarkers NT-proBNP and hs-cTnT as important measures for risk prediction and stratification in patients with and without T2D. T2D patients with elevated natriuretic peptides are at a higher risk of developing HF and elevated natriuretic peptides are associated with higher risk for HF hospitalization, major adverse cardiac events MACE, cardiovascular death and renal complications. Professor Januzzi concludes that better tools for risk prediction and stratification are urgently needed to identify patients at risk of developing HF earlier.

Professor Hülsmann discusses the latest data from the clinical trials DECLARE-TIMI 58 and PONTIAC I, which show the benefits of treatment optimisation or intensification in T2D patients with elevated natriuretic peptide levels. Additionally, Professor Hülsmann gives an overview of ongoing studies, PONTIAC II and ADOPT, that further investigate the effects of treatment optimisation, also using sodium/glucose cotransporter-2 inhibitors (SGLT2i, only ADOPT), in T2D patients with elevated NT-proBNP levels.

Professor Pandey gives an overview of the characteristics and benefits of available clinical risk scores for patients with diabetes, which analyze the risk of HF hospitalization (TIMI risk score), risk of incident HF (WATCH-DM) and a biomarker-based risk score. Professor Pandey presents a proposed approach for a clinical decision support tool, including both clinical and biomarker variables using the WATCH-DM risk score.

Professor Vaduganathan highlights that HF in T2D patients has a high economic burden, mostly driven by costs associated with HF hospitalisations. Professor Vaduganathan also highlights the importance of NT-proBNP screening in T2D patients as a cost-effective measure for risk stratification, notes that NT-proBNP is often not evaluated in current care of T2D patients and proposes a strategy of targeted HF prevention approaches in T2D patients using modern cardioprotective therapies (e.g. SGLT2i) guided by natriuretic peptide-based screening pathways.

Professor Ceriello provides a detailed overview of the current guidelines recommended by the European Society of Cardiology in 2021 in regards to diagnosis and treatment of HF, including guidance for patients with T2D who are at increased cardiovascular risk.

Professor Pop-Busui gives an overview of the guidelines that were recently released by the American Diabetes Association in 2022 on cardiovascular disease and risk management in diabetes patients, with a specific focus on HF. Professor Pop-Busui later discusses the gaps in clinical knowledge and use of biomarkers for screening and risk prediction of HF in diabetes patients, as well as limited implementation of guideline-directed medical therapy into clinical practice.

Using a clinical case, Professor Meune and Professor Cosson highlight the benefits of collaboration between diabetologists, endocrinologists and cardiologists when treating patients with diabetes. Both acknowledged the different discipline-specific approaches to patient treatment and provided real-world context on how a structured cross-disciplinary collaboration can achieve optimized patient treatment. They also shared that up to a third of patients in their METAB-HEART study have elevated NT-proBNP levels, underlining the importance of natriuretic peptide screening to identify patients at risk of HF development or for HF diagnosis. 

Diagnosis of heart failure

Professor Lam elaborates that HFpEF incidence and prevalence are currently increasing and that HFpEF is characterized by frequent hospitalisations and poor prognosis. Despite that HF diagnosis is often missed and patients often wait up to 5 years for a diagnosis of HF, highlighting the current challenges and need for objective criteria for HFpEF diagnosis and underlining the importance of simplified ESC 2021 guideline recommendations for HF diagnosis.

Professor Petrie highlights the importance of using ESC guideline-recommended medical therapies, i.e. angiotensin-converting enzyme inhibitors (ACE-I) / angiotensin receptor II blocker - neprilysin inhibitor (ARNI), beta blocker (BB), mineralocorticoid receptor antagonist (MRA) and sodium/glucose cotransporter-2 inhibitors (SGLT2i) in parallel in HFrEF patients as this has been shown to significantly reduce cardiovascular death and hospitalization. Professor Petrie also underlines the need for early diagnosis and screening to ensure effective treatment as early as possible, and recommends to follow the new ESC 2021 simplified pathway to diagnose patients with HF and refer patients to specialized teams / cardiologists for optimal treatment.

Key topics
  • Diabetes represents a high global burden, with 422 million adults living with the disease in 2014 (WHO), and prevalence is on the rise.1
  • Heart failure (HF) is one of the most common cardiovascular complications in Type 2 Diabetes Mellitus (T2D).2 These patients often have a poor prognosis with high rates of hospitalization and mortality.3
  • Effective cardioprotective therapies for HF(rEF) are available and recommended by international guidelines and have been shown to significantly reduce hospitalization and mortality.4,5,6
  • HF often goes undiagnosed or is diagnosed very late, so there is a need for increased disease awareness and education about signs, symptoms and diagnosis, to help identify HF earlier (e.g. in primary care).7,8 
  • The most important unmet medical needs identified in this roundtable discussion are early identification of T2D patients at risk of HF development, e.g. via screening efforts, and improved tools for risk stratification (e.g. NT-proBNP screening).9

 

At this roundtable, experts elaborate on:

  • Risk stratification in T2D:
    • The latest clinical data of HF in T2D patients 
    • The value of biomarker measurements as a means for HF diagnosis, risk stratification and treatment optimisation in patients with T2D
    • Clinical risk scores for HF risk stratification in comparison with biomarkers and economic evaluation of N-terminal pro-brain natriuretic peptide (NT-proBNP) screening for HF risk stratification
    • International guidelines for prevention, diagnosis and treatment of HF 
    • The intersection and cooperation between different specialties and associated practical clinical strategies 
  • Diagnosis of heart failure:
    • General recommendations on how to diagnose HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF)

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References

  1. World Health Organization. Diabetes. [Internet; cited 2022 August] Available from: https://www.who.int/news-room/fact-sheets/detail/diabetes
  2. McMurray JJ, et al. Heart failure: a cardiovascular outcome in diabetes that can no longer be ignored. Lancet Diabetes Endocrinol. 2014; 2(10): 843-51. 
  3. Burrows NR et al. Declining Rates of Hospitalization for Selected Cardiovascular Disease Conditions Among Adults Aged ≥35 Years With Diagnosed Diabetes, U.S., 1998–2014. Diabetes Care. 2018; 41(2): 293-302.
  4. UK National Health Service. Heart failure treatment. [Internet; cited 2022 August] Available from: https://www.nhs.uk/conditions/heart-failure/treatment/
  5. Heidenreich PA, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022; 145(18): e895–e1032.
  6. McDonagh TA, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2021; 42(36): 3599-726.
  7. Wong C, et al. Misdiagnosis of Heart Failure: A Systematic Review of the Literature. J Card Fail. 2021; 27(9):925-9.
  8. Bottle A, et al. Routes to diagnosis of heart failure: observational study using linked data in England. Heart. 2018 ;104(7): 600-605. 
  9. Pop-Busui et al  Heart Failure: An Underappreciated Complication of Diabetes. A Consensus Report of the American Diabetes Association Diabetes Care 2022;45:1670–1690 | https://doi.org/10.2337/dci22-0014