Real-world evidence on integrating natriuretic peptide testing in diabetes care

Natriuretic peptide testing in diabetes: evidence from two real-world studies

Speaker: Konstantin Schmidt, PhD. Scientific Communications Lead, Roche Diagnostics International

Welcome. Heart failure is one of the most prevalent and serious cardiovascular complications in individuals with diabetes. Alarmingly, heart failure can develop independently of traditional cardiovascular risk factors and often remains asymptomatic in its early stages. Moreover, concomitant presence of heart failure and diabetes was shown to lead to worse outcomes. It is therefore increasingly relevant to detect heart failure as early as possible in people with diabetes. Natriuretic peptides (NPs), specifically B-type natriuretic peptides — BNP and its N-terminal proBNP fragment: NT-proBNP — are key biomarkers released by the heart ventricles in response to cardiac wall stress, strain, or stretch, which is often caused by pressure or volume overload. Natriuretic peptides can therefore detect early signs of pre-heart failure or stage B heart failure, and are an integral part of the universal definition of heart failure. International clinical societies such as the American Diabetes Association (ADA) recommend routine testing of natriuretic peptides in people with diabetes to allow for early heart failure detection even before symptomatic stages. However, implementation of such early testing efforts in daily clinical practice is still lagging behind. Today, we will review two recent publications: Pop-Busui et al., published in Diabetes Care, and Chatur et al., published in JACC: Heart Failure. Both studies are large-scale, real-world data analyses that highlight the value of natriuretic peptide testing in people with diabetes. 

Pop-Busui and colleagues analyzed the Optum Market Clarity database, looking at over 116,000 adults with type 1 and type 2 diabetes who had no prior history of heart failure and had NP testing results available. Overall, 24% developed incident heart failure or death over a median follow-up period of 26 months. 67% of individuals were tested with BNP and 33% were tested with NT-proBNP. Roughly 40% of people with diabetes showed elevated levels of natriuretic peptides. Elevated BNP and NT-proBNP values were significantly associated with reduced heart failure-free survival among individuals with type 1 and type 2 diabetes. Moreover, when adjusting for clinical and demographic factors, elevated natriuretic peptides remained highly prognostic for both type 1 and type 2 diabetes. Moderately elevated levels, meaning NT-proBNP of 125 to 300 picograms per milliliter, or BNP of 50 to 100 picograms per milliliter, doubled the risk of incident heart failure or death. For patients with markedly elevated levels, meaning NT-proBNP of over 300 picograms per milliliter or a BNP of over 100 picograms per milliliter, the risk of heart failure or death was up to four and a half times higher than in those with normal levels. Crucially, this study is the first large-scale dataset on type 1 diabetes showing the association between elevated NP levels and adverse outcomes. Historically, much of our cardiovascular focus has been on type 2 diabetes, but this real-world data proves that natriuretic peptide testing is an equally vital early indicator of cardiovascular risk in type 1 diabetes and underlines the prognostic value of natriuretic peptides in people with diabetes. 

But how is this translated to routine clinical practice? Here, Chatur and colleagues looked at this in a recent article published in JACC: Heart Failure. They analyzed the TriNetX Commercial Claims database, looking at nearly 22,000 patients with newly diagnosed diabetes. Natriuretic peptide screening was infrequent, occurring only in 9% of eligible individuals, or about 1 in 11 patients. However, among the 1,897 individuals who were tested, more than half had elevated natriuretic peptide levels meeting the thresholds suggestive of stage B or pre-heart failure. Using a difference-in-difference analysis, it was demonstrated that patients who underwent biomarker screening had a significant increase in downstream cardiovascular preventive care, and NP testing led to higher rates of diuretic use, echocardiography, and specialist referrals to cardiologists. Following an elevated test result, clinicians were significantly more likely to initiate guideline-recommended risk-lowering therapies like ACE inhibitors, ARBs, and beta blockers. Heart failure is a severe, often silent threat for individuals with both type 1 and type 2 diabetes, and these two real-world database analyses underline the importance of natriuretic peptide testing as a risk stratification tool in this population. This is also why clinical associations such as the American Diabetes Association recommend yearly testing of natriuretic peptides in people with diabetes. However, current NP testing rates remain alarmingly low. But this data demonstrates that when we do test early, identification of high-risk patients is possible, allowing for early optimization of care. By adopting routine natriuretic peptide testing into standard diabetes care protocols, we can move from reactive heart failure treatment to proactive cardiovascular prevention. Thank you for watching this summary and for more details, please refer to the full publications by Pop-Busui et al. published in Diabetes Care and Chatur et al. published in JACC: Heart Failure.