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Heart failure screening in people with diabetes: clinical implementation in the US

Clinical implementation of heart failure screening in diabetes
Introduction

As incidence rates continue to rise, diabetes remains a significant global healthcare concern.3 There is a high prevalence of cardiovascular disease in people with diabetes, with a poor prognosis in those with HF compared to those without.1 As highlighted in the ADA consensus on diabetes and HF, the detection of HF in people with diabetes is of key importance, especially in early stages with structural disease but without symptoms.3  

Evidence shows that aminoterminal pro-B-type natriuretic peptide (NT-proBNP)-based screening can detect HF before the appearance of symptoms.4 The benefit of this screening has been shown in clinical trials; the PONTIAC trial5 demonstrated significant reduction in hospitalisations in people with diabetes, and the STOP-HF trial6 demonstrated reduced major adverse cardiovascular outcomes, as well as hospitalisations, in people with cardiovascular risk factors. The ADA consensus recommends that natriuretic peptides (or high-sensitivity cardiac troponin) are measured annually in diabetic patients to identify the earliest stages of HF and to prevent progression.3 The question that remains is how best to implement these guidelines in practice. There are several hurdles to overcome, such as optimal infrastructure, clinician education, and engagement of primary care practitioners.  

 

From guideline to clinical practice
 

Prof. Pop-Busui presented the strategy they have used to implement routine HF screening for people with diabetes at high risk of HF at the University of Michigan academic network. Together with the Michigan Medicine Diabetes Quality Council, they developed criteria to identify which individuals should be considered at high risk of developing HF, as well as a clinical decision support tool to aid the screening process.  The criteria for patient selection are as follows:

  • Patients need to be registered in the Diabetes Registry, which can be accessed by clinicians throughout the Michigan Healthcare system.
  • They must not have a diagnosis of congestive HF or be part of the MiChart HF Registry. 
  • Patients need to be ≥50 years of age, with at least one visit to Primary Care, Nephrology, Cardiology, or Metabolism, Endocrinology and Diabetes in the last year. 
  • They must have at least one additional risk factor: obesity (BMI>30), hypertension, diabetic kidney disease, or confirmed coronary artery disease.

For patients fitting these criteria a decision cascade is initiated via the developed decision support tool.  If a patient meets the above criteria, the system will first check for an NT-proBNP or BNP test result in the previous year.  If not, the provider is informed that the patient meets the criteria to be screened for HF and that they should order the indicated tests. If the NT-proBNP level is normal, no action is taken except to repeat the NT-proBNP testing annually. If the NT-proBNP levels are elevated, the clinician is guided on the appropriate actions to take. This includes guideline-directed treatment recommendations, optimal diabetes management, blood pressure and lipid control. The clinician is also directed to repeat NT-proBNP testing after six months and carry out an echocardiogram.

This is one of the first initiatives aiming to deliver a framework and guidance on how to implement HF screening in patients with diabetes in the US. These types of initiatives are critical in order to help improve cardiovascular outcomes in people with diabetes. 

Key facts

  • There is high prevalence of heart failure (HF) in people with diabetes,1 and they often have a poorer prognosis compared to non-diabetic HF patients, experiencing higher rates of hospitalisation and mortality.1,2
  • The American Diabetes Association (ADA) consensus report on diabetes and HF recommends routine screening for heart failure in diabetic patients in order to identify the onset of HF early and prevent its progression.3
  • In this presentation, Prof. Pop-Busui describes a pathway for implementing HF screening in high-risk diabetic patients as applied at the University of Michigan academic network.
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    References

    1. 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.
    2. 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.
    3. Pop-Busui R, et al. Heart Failure: An Underappreciated Complication of Diabetes. A Consensus Report of the American Diabetes Association. Diabetes care. 2022;45(7):1670-90. 
    4. Cosentino F, et al. 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Eur Heart J. 2020;41(2):255-323.
    5. Huelsmann M, et al. PONTIAC (NT-proBNP selected prevention of cardiac events in a population of diabetic patients without a history of cardiac disease): a prospective randomized controlled trial. JACC. 2013;62(15):1365-72.
    6. Ledwidge M, et al. Natriuretic Peptide–Based Screening and Collaborative Care for Heart Failure: The STOP-HF Randomized Trial. JAMA. 2013;310(1):66–74.