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Heart failure screening in people with diabetes: How labs can impact patient care

Contributing lab leader: Dr. Ibrahim Hashim

Diabetes is a major global health concern, affecting more than 530 million people worldwide and accounting for more than USD$ 960 billion in healthcare expenditure. By 2045, the number of diabetes cases could soar to more than 780 million individuals. Diabetes is also a leading cause of mortality, with 6.7 million deaths reported in 2021.1

Beyond the traditional symptoms of diabetes, patients are also at a two-fold risk for developing heart failure. Diabetic heart failure can lead to significant structural deficits of the heart and pathophysiological features that can cause a greater risk of death and rehospitalization compared to non-diabetic patients with heart failure.2 In 2022, the American Heart Association (AHA), American College of Cardiology (ACC), and the Heart Failure Society of America (HFSA) released guidelines for heart failure, calling out the risk of heart failure in people living with diabetes.3

At this year’s annual Association for Diagnostics & Laboratory Medicine (ADLM) meeting, Dr. Ibrahim A. Hashim, Professor of Pathology, University of Texas Southwestern Medical Center, Parkland Hospital and Health System, discussed the need for labs to become more involved in patient clinical testing for diabetic heart failure, specifically to become the clinical interface within healthcare organizations and to address the new Standards of Care released by the American Diabetes Association (ADA) for biomarker screening.

Article highlights:
  • Diabetes is a major risk factor for developing heart failure, causing advocacy groups to recommend heart failure screening for people living with diabetes.
  • Routine screening for natriuretic peptides (BNP or NT-proBNP) in people living with diabetes is recommended to help identify heart failure risk as early as possible.
  • Through education and clinical alerts, lab leaders have the opportunity to directly impact patient care by informing providers and their patients with diabetes about the need for heart failure screening.
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The four stages of heart failure and the role of diabetes

According to the AHA/ACC/HFSA Guidelines for the Management of Heart Failure, there are four stages of heart failure:3

  • Stage A: At-Risk for Heart Failure
  • Stage B: Pre-Heart Failure
  • Stage C: Symptomatic Heart Failure
  • Stage D: Advanced Heart Failure


During Stage A, patients may be at risk but have no sign of heart damage or dysfunction. As patients progress to Stage B, there continue to be no clear physical or clinical symptoms, but other chemical signs are present, ranging from abnormal biomarker levels of natriuretic peptide – B-type natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP)– to early structural damage and mild dysfunction. The heart produces elevated levels of BNP and NT-proBNP when it experiences increased strain or workload required to effectively pump blood, as in heart failure. For more than a decade, NT-proBNP has been the gold-standard for testing for heart failure.4

As the condition worsens into Stage C, the patient starts to notice the physical symptoms of heart failure. The classic signs of heart failure become evident, along with more significant increases in biomarker levels and clear indications of heart structural deficits and prominent dysfunction. By Stage D heart failure, patients are dramatically incapacitated, affecting daily life and leading to recurrent hospitalizations.

According to Dr. Hashim, early screening for BNP or NT-proBNP in people living with diabetes is key for intervention before reaching later stages. "Identifying those individuals much earlier before it becomes clinically obvious, it's reversible. Intervention is easy, and this is a fantastic opportunity," said Dr. Hashim. 

As recommended by the ADA, this screening should be done early and at least annually in patients with diabetes to prevent Stage C symptomatic heart failure.5,6 However, according to Dr. Hashim, only 12% to 16% of these patients get heart failure screening within a primary care setting. Often, they get measured during an emergency room visit, meaning the patient is most likely already symptomatic and in the later stages of heart failure. This is where the lab can play an integral role in improving screening rates in patients with diabetes and assisting clinicians, offering insights into heart failure risk. 

The lab and diabetic heart failure screening

Since screening for BNP or NT-proBNP is extremely low, potentially due to lack of awareness or patient reluctance, labs have the opportunity to directly impact patient care. Increasing the frequency and accessibility of this biomarker test can dramatically decrease heart failure risk and offer clinicians a means of early detection and intervention.

According to Dr. Hashim, there are several ways labs can help clinicians apply the guidelines set forth by the ADA for heart failure screening in people with diabetes:

  • Education and training of healthcare professionals and patients
  • Developing and utilizing clinical decision support systems for alerts
  • Continuous feedback from providers and end users


“I'm a very strong proponent of moving the laboratory into that clinical interface. This is actually an outstanding opportunity for us to be out there helping clinicians, making sure that testing is being performed,” commented Dr. Hashim.

Closely monitoring test ordering and keeping healthcare providers updated on availability and sample requirements can help optimize biomarker testing. In turn, this can ensure timely interventions for patients, such as lifestyle modifications, medication adjustments, and specialist referrals.

In regards to the role of the lab, Dr. Hashim concluded, “This is an incredible opportunity for us to be at that intersection between clinical medicine and the laboratory to offer our support to these clinicians to implement such an incredible life-changing process that can prevent heart failure symptoms from ever becoming their [patients’] reality.”
 

If you would like to hear more from Dr. Hashim, click here to view his full presentation from ADLM 2024.

  1. International Diabetes Federation. (2021). Information available from https://diabetesatlas.org/ [Accessed October 2024]
  2. Kenny & Abel. (2019). Circ Res 124, 121-141. Paper available from https://www.ahajournals.org/doi/10.1161/CIRCRESAHA.118.311371 [Accessed October 2024]
  3. Heidenreich et al. (2022). Circulation 145, e895-e1032. Paper available from https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000001063 [Accessed October 2024]
  4. McKie and Burnett. (2016). JACC 68, 2437-2439. Paper available from https://www.jacc.org/doi/10.1016/j.jacc.2016.10.001 [Accessed October 2024]
  5. American Diabetes Association Professional Practice Committee. (2024). Diabetes Care 47, S179–S218. Paper available from https://diabetesjournals.org/care/article/47/Supplement_1/S179/153957/10-Cardiovascular-Disease-and-Risk-Management [Accessed October 2024]
  6. Pop-Busui et al. (2022). Diabetes Care 45, 1670–1690. Paper available from https://diabetesjournals.org/care/article/45/7/1670/147048/Heart-Failure-An-Underappreciated-Complication-of [Accessed October 2024]