One in three diabetics found to have undetected heart disease

By using biomarkers that detect heart disease, researchers found as many as one in three people with Type 2 diabetes (T2D) have subclinical cardiovascular disease (CVD). This raises the question of whether more screening is warranted in this patient population. “Our study is the first to demonstrate the high burden of early heart disease in U.S. adults with diabetes, 33%. We also highlight the potential usefulness of routine testing to monitor risk in these patients,” said study coauthor Michael Fang, assistant professor at the Johns Hopkins Bloomberg School of Public Health. The study, which used data from the National Health and Nutrition Examination Survey (NHANES) of participants who had valid measures of NT-proBNP, hs-cTnT and covariates, was published in the Journal of the American Heart Association. NHANES is a program of studies designed to monitor the health of the U.S. population and started in the 1960s. While a 2022 consensus report from the American Diabetes Association (ADA) recommended annual testing of hs-cTnT and NT-proBNP (both indicators of heart damage) to facilitate early detection, this study was needed to examine a nationally representative population. At the same time, the ADA screening recommendations “do not align with some other guidelines. For instance, cardiology guidelines do not currently recommend routine testing of cardiac biomarkers in the general population, citing the lack of clinical trial evidence,” Dr. Fang told the Medical Post in an email. Most studies from before the ADA recommendations were conducted on middle-aged or older white adults. But this study, using national data, was able to capture a more general population. Researchers used data on 10,304 nonpregnant adults aged 20 years or older with no self-reported CVD from 1999 through 2004. Of those, 9,273 had no diabetes (47.1% male) and 1,031 had diabetes. (51.1% male). More of the non-diabetics were younger and fell in the 20 to 44-year old age category (56.5% of non-diabetics versus 21.3% of the diabetics). A total of 31.3% of the non-diabetics versus 48.7% were aged 45 to 64, and 12.2% versus 30% were aged 65 or over. A larger portion of the diabetics, 53.3%, had BMI of 30 kg/m2 and over compared to only 28.7% of the non-diabetics. Mortality data were also attained. Diabetes was confirmed with HbA1c, and the duration of diabetes was taken into account in various analyses in the study. The NT-proBN and hs-cTnT levels were measured from stored serum samples between 2018 and 2020. Subclinical CVD was defined as having either elevated hs-cTnT 14 ng/L or more) or NT-proBNP (125 pg/mL or more) levels. The results showed that 7% of the cohort with no history of CVD had diabetes. But, in the overall cohort, people with diabetes were generally older and had a higher burden of cardiovascular risk factors. When it came to NT-proBN and hs-cTnT, the median levels of both biomarkers were significantly higher in those with diabetes, than in non-diabetics. In fact, the prevalence of any subclinical CVD, as evidence by elevated biomarkers, was roughly twice as high for adults with diabetes when compared to people without diabetes: 33.4% versus 16.1%. “Differences by diabetes status were especially pronounced for elevated hs-cTnT (19% versus 5%). The prevalence of having both elevated hs-cTnT and NT-proBNP levels was low but was significantly higher in adults with diabetes versus without diabetes (9% versus 3%),” the study said. Overall, the study showed that about one in three adults with diabetes had subclinical CVD, with 19% having elevated levels of hs-cTnT, 23% having elevated NT-proBNP, and 9% having elevations in both cardiac biomarkers. “We went into the study thinking that the percentage of adults with diabetes and early heart disease would be high… it was a bit jarring to see the actual number, that 33% prevalence,” Dr. Fang said. While screening all adults with diabetes would, in theory, have the biggest public health benefit it would not be a cost-efficient approach, he said. The assumption is that screening would lead to early intervention and treatment which would potentially delay and prevent CVD events. “Trial data would be the best way to test whether this would be the case,” Dr. Fang said. He added that “Clinicians and policymakers will need to come together and decide what the right balance is between cost and detection to determine this optimal age cutoff for possible screening.” In Canada, screening for troponin and NT pro BNP is not recommended, according to Dr. Kim Connelly, a cardiologist and an associate professor of Medicine at the University of Toronto. He is past chair of the Canadian Cardiovascular Society’s (CCS) Guidelines Committee. “At this stage we would prefer doctors do targeted assessment of these biomarkers (such as), troponin and NT pro BNP as opposed to routine screening,” he said. The Diabetes Canada clinical practice guidelines outline an approach to help identify people with disease, and offers ways to either treat CVD once it is apparent, or, importantly prevent it. “Those guidelines, as well as the recent CCS guidelines for the use of new antihyperglycemic agents, make it very clear that people should be screened routinely with a history, examination – and then testing if there is a concern regarding symptoms. The guidelines routinely recommend treatment to reduce risk, and clearly outline when to use treatments,” he said. “If the Canadian recommendations are followed, then there is no need for routine screening as doctors should have already identified, and started the correct treatment to reduce the risk,” said Connelly.

One in three diabetics found to have undetected heart disease

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