Screening and diagnosing heart failure in individuals with diabetes

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Heart failure: a major but underappreciated complication in patients with diabetes - new ADA guidance

As part of the ‘Global diabetes burden calls for a holistic approach to advance patient empowerment and access to innovation’ session at the European Association for the Study of Diabetes (EASD) congress 2022, Professor Rodica Pop-Busui from the University of Michigan and President-Elect of the American Diabetes Association (ADA), highlighted the demand from various physician groups to understand how to screen and diagnose patients with diabetes for heart failure (HF). The recently published ADA/American College of Cardiology (ACC) consensus report1 aims to address this need - in her presentation, Professor Pop-Busui shared key highlights from the consensus report. 


Epidemiology of HF in patients with diabetes (from 00:01:26)

HF is a major and underappreciated complication of diabetes. In fact, HF is the most prevalent complication of diabetes, with a prevalence of up to 22% in patients with diabetes and with an increasing incidence rate.1 Professor Pop-Busui highlighted that the incidence and prevalence of HF in patients with type 1 and type 2 diabetes is higher compared with the general population.2 Further to this, diabetes has a significant impact on the prognosis of HF. In her talk, Professor Pop-Busui shared evidence that demonstrates increased hospitalizations and mortality in patients with HF and diabetes compared with those with HF without diabetes.2–5 In the REACH registry, the presence of diabetes was associated with a 33% higher risk of hospitalization for HF compared with the absence of diabetes (9.4% versus 5.9%; adjusted odds ratio, 1.33; 95% confidence interval, 1.18–1.50).4 Mortality was also markedly higher in patients with diabetes than in patients without diabetes (14.3% versus 9.9%; P<0.001).4


The mechanism of HF in diabetes (from 00:05:48)

A combination of factors, including endoplasmic reticulum stress, mitochondrial dysfunction, inflammation, microvascular disease, metabolic dysfunction in the heart (specifically, the imbalance between glucotoxicity and lipotoxicity), and cardiovascular autonomic neuropathy (CAN) are involved in the complex mechanism of HF in diabetes.1 Professor Pop-Busui highlighted that metabolic dysfunction and CAN are of particular importance in diabetes.1,6–8


Diagnosis and staging of HF in patients with diabetes (from 00:07:45)

Professor Pop-Busui stressed the importance of the clinical staging of HF as defined by the ACC/American Heart Association/Heart Failure Society of America in the universal definition and classification of HF: 9,10

  • Stage A (at risk): Patient with risk factors including diabetes, hypertension, coronary artery disease, and obesity, with no signs/symptoms of HF and no structural cardiac changes. Patient is at risk of developing HF
  • Stage B (pre-HF): Patient without current or prior signs/symptoms of HF with evidence of structural heart disease, abnormal cardiac function or elevated natriuretic peptide or cardiac troponin levels
  • Stage C (symptomatic HF): Patient with current or prior symptoms and/or signs of HF as a result of structural and/or functional cardiac abnormalities 
  • Stage D (advanced HF): Patient with severe symptoms and/or signs of HF at rest, recurrent hospitalizations despite guideline-directed medical therapies (GDMT), refractory or intolerant to GDMT and requiring advanced therapies, transplantation, mechanical circulatory support or palliative care

Professor Pop-Busui emphasized that it is not only cardiologists who should be familiar with the staging of HF, but other physicians also, including endocrinologists, nephrologists and those working in primary care. 

The ADA/ACC consensus report recommends management according to the Stages of HF in  diabetes patients. Professor Pop-Busui explained that in Stages A and B, prevention and diagnosis can be very effective. However, despite the potential for early intervention, a large number of patients with diabetes are only diagnosed at HF Stages C and D by cardiologists. With this in mind, Professor Pop-Busui highlighted that to improve patient care and outcomes, there must be a focus on the earlier stages of HF in order for effective strategies to be initiated to prevent or delay progression to Stages C and D. 


The role of NT-proBNP during early screening and diagnosis of HF (from 00:10:28)

Due to the lack of signs/symptoms at Stages A and B, biomarkers are important in order to identify patients at risk of HF and therefore requiring further clinical evaluation. Over the last several years, sensitive and specific biomarkers, such as N-terminal pro B-type natriuretic peptide (NT-proBNP), have been identified that can be used to predict future HF development and progression. Professor Pop-Busui highlighted a study by Clodi and colleagues11 that stratified patients using NT-proBNP levels combined with albuminuria to predict cardiovascular (CV) events in type 2 diabetes. The study demonstrated that NT-proBNP was a better predictor than albuminuria for identifying those at highest risk of developing more advanced HF.11 Professor Pop-Busui concluded that testing biomarker levels is an effective way of identifying patients at risk of HF.

The ADA/ACC consensus paper provides a stepwise approach to the screening and diagnosis of HF in patients with diabetes, with biomarkers playing an important role, especially in HF Stages A and B.1 If biomarkers are not elevated, assessment should be repeated annually. If elevated, imaging (i.e. echocardiogram or chest x-ray) should be performed to establish the diagnosis and the cause of clinical HF, providing information on cardiac structural and functional changes and etiology. 


Management of HF in patients with diabetes (from 00:14:04)

Professor Pop-Busui described the recommended pharmacologic treatment for patients with diabetes and HF by HF Stage.1 She emphasized that sodium/glucose cotransporter-2 inhibitors (SGLT2i) should be an expected element of care for all patients with diabetes and early stage HF. Besides SGLT2i for patients with HFrEF and diabetes, the ADA/ACC consensus report recommends angiotensin receptor/neprilysin inhibitors, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, evidence based ẞ-blockers, and mineralocorticoid receptor antagonists. For those with HFpEF and diabetes, the consensus recommends consideration of treatment with spironolactone or sacubitril/valsartan, while also noting that SGLT2i has been clinically proven to reduce HF hospitalizations. Professor Pop-Busui commented that HF GDMT continues to be underutilized in patients with diabetes. Beyond medical treatments, the ADA/ACC consensus report underlines the importance of access to medical care, lifestyle and social determinants in the management of HF in patients with diabetes.

Professor Pop-Busui concluded that a multidisciplinary approach is of great importance in the management of HF in patients with diabetes, with primary care physicians, nurse practitioners, diabetes educators, social workers, amongst others, required as part of the team.1 The ADA/ACC consensus report provides an algorithm describing how to screen, treat and follow-up patients at each HF Stage, providing a practical and clear approach for the management of HF in patients with diabetes.

Key facts
  • Compared with the general population, patients with diabetes are at much higher risk of developing heart failure (HF) and, if they already suffer from HF, their prognosis is poorer
  • Following high demand from various physician groups to understand how to diagnose and screen patients with diabetes for HF, a consensus document was developed by the American Diabetes Association (ADA)/American College of Cardiology (ACC) to address this need
  • Prof. Pop-Busui presents recommendations for management of HF in patients with diabetes stratified by Stage of HF, including how to screen, what clinical assessment is needed, how to diagnose, and what the medical management and therapy should include

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  1. Pop-Busui R,  et al. Heart failure: An underappreciated complication of diabetes: A consensus report of the American Diabetes Association. Diabetes Care. 2022;45:1670–90.

  2. McAllister DA, et al. Incidence of hospitalisation for heart failure and case-fatality among 3.25 million people with and without diabetes mellitus. Circulation. 2018;138:2774–86.

  3. Bertoni AG, et al. Heart failure prevalence, incidence, and mortality in the elderly with diabetes. Diabetes Care 2004;27:699–703.

  4. Cavender MA, et al. Impact of diabetes mellitus on hospitalization for heart failure, cardiovascular events, and death: outcomes at 4 years from the Reduction of Atherothrombosis for Continued Health (REACH) registry. Circulation. 2015;132:923–31.

  5. McMurray JJ, et al. Heart failure: a cardiovascular outcome in diabetes that can no longer be ignored. Lancet Diabetes Endocrinol. 2014;2:843–51.

  6. Brahma MK, et al. My sweetheart is broken: role of glucose in diabetic cardiomyopathy. Diabetes Metab J. 2017;41:1–9.

  7. Nakamura M and Sadoshima J. Cardiomyopathy in obesity, insulin resistance and diabetes. J Physiol. 2020;598:2977–93.

  8. Pop-Busui R, et al. Association between cardiovascular autonomic neuropathy and left ventricular dysfunction: DCCT/EDIC study (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications). J Am Coll Cardiol. 2013;61:447–54.

  9. Bozkurt B, 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 Card Fail. 2021;S1071–9164(21)00050-6.

  10. Yancy CW, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J AmColl Cardiol 2013;62:e147–239.

  11. Clodi M, et al. A comparison of NT-proBNP and albuminuria for predicting cardiac events in patients with diabetes mellitus. Eur J Prev Cardiol. 2012;19:944–51.